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 [Illustration: LOUIS AGASSIZ "A natural law is as sacred as a moral principle"]

 CIVICS AND HEALTH

 BY

 WILLIAM H. ALLEN

 SECRETARY, BUREAU OF MUNICIPAL RESEARCH

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

 WITH AN INTRODUCTION

 BY

 WILLIAM T. SEDGWICK

PROFESSOR OF BIOLOGY IN THE MASSACHUSETTS INSTITUTE OF TECHNOLOGY

 GINN AND COMPANY BOSTON · NEW YORK · CHICAGO · LONDON

 ENTERED AT STATIONERS' HALL

 COPYRIGHT, 1909 BY WILLIAM H. ALLEN

 ALL RIGHTS RESERVED

 910. 4

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

INTRODUCTION

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

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

Our age is of another temper. It yearns for reality. It no longer restssatisfied with mere ideas, or words, or phrases. The modern Ulysseswould drink life to the dregs. The present age is dissatisfied with thevague assurance that the Lord will provide, and, rightly or wrongly, isbeginning to expect the state to provide. And while this desire forreality has its drawbacks, it has also its advantages. Our age doubtsabsolutely the virtues of blind submission and resignation, and criesout instead for prevention and amelioration. Disease is no longerregarded, as Cruden regarded it, as the penalty and the consequence ofsin. Nature herself is now perceived to be capable of imperfect work. Time was when the human eye was referred to as a perfect apparatus, butthe number of young children wearing spectacles renders that ideauntenable to-day. 

Meanwhile the multiplication of state asylums and municipal hospitals, and special schools for deaf or blind children and for cripples, speakseloquently and irresistibly of an intimate connection between civicsand health. There is a physical basis of citizenship, as there is aphysical basis of life and of health; and any one who will take thetrouble to read even the Table of Contents of this book will see thatfor Dr. Allen prevention is a text and the making of sound citizens asermon. Given the sound body, we have nowadays small fear for the soundmind. The rigid physiological dualism implied in the phrase _mens sanain corpore sano_ is no longer allowed. To-day the sound body generallyincludes the sound mind, and vice versa. If mental dullness be due toimperfect ears, the remedy lies in medical treatment of thoseorgans, --not in education of the brain. If lack of initiative or energyproceeds from defective aëration of the blood due to adenoids blockingthe air tides in the windpipe, then the remedy lies not in betterteaching but in a simple surgical operation. 

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

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

No one can read this volume, or even its chapter-headings, withoutsurprise and rejoicing: surprise, that the physical basis of effectivecitizenship has hitherto been so utterly neglected in America;rejoicing, that so much in the way of the prevention of incapacity andunhappiness can be so easily done, and is actually beginning to bedone. 

The gratitude of every lover of his country and his kind is due to theauthor for his interesting and vivid presentation of the outlines of asubject fundamental to the health, the happiness, and the well-being ofthe people, and hence of the first importance to every Americancommunity, 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 withspecial reference to alcohol and tobacco is made compulsory. To hygienealone, of the score of subjects found in our modern grammar-schoolcurriculum, is given statutory right of way for so many minutes perweek, so many pages per text-book, or so many pages per chapter. Forthe neglect of no other study may teachers be removed from office andfined. Yet school garrets and closets are full of hygiene text-booksunopened or little used, while of all subjects taught by five hundredthousand American teachers and studied by twenty million Americanpupils the least interesting to both teacher and pupil is that forcedupon both by state legislation. To complete the paradox, this leastinteresting subject happens also to be the most vital to the child, tothe home, to industry, to social welfare, and to education itself. 

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

Interviews with teachers and principals regarding the present apathy toformal hygiene instruction have brought out the following points thatmerit the serious consideration of those who are struggling for higherhealth standards. 

1. _There is many a slip 'twixt the making of a law and itsenforcement. _ If laws regarding hygiene instruction are not enforced, we should not be surprised. It has been nobody's business to seewhether and how hygiene is being taught. The moral crusade spent itselfin forcing compulsory laws upon the statute books of every state andterritory. Making a fetish of _Legislation_, the advocates ofanti-alcohol and anti-tobacco instruction failed to see the truth thatexperienced political reformers are but slowly coming tosee--_Legislation which does not provide machinery for its ownenforcement is apt to do little good and frequently will do much harm. _Machinery, however admirably adapted to the work to be done, will getout of order and become useless, or even harmful, unless constantlywatched and efficiently directed. Of what possible use is it to saythat state money may be withheld from any school board which fails toenforce the law regarding instruction in hygiene, if state officialsnever enforce the penalty? So long as the penalty is not enforced forflagrant violation, what difference does it make whether the reason isindifference, ignorance, or desire to thwart the law? Fortunately, itis easy for each one of us to learn how often and in what way thechildren in our community are being taught hygiene, and how the schoolsof our state teach and practice the laws of health. If either thespirit or the letter of the law regarding instruction in hygiene isbeing violated, we can measure the penalty paid in health and morals byour children and our community. We can learn whether law, text-book, curriculum, or teacher should be changed. We can insist upon discussionof the facts and upon remedies suggested by the facts. 

2. _Teachers give as one reason for neglecting hygiene, that they areoften compelled to struggle with a curriculum which requires more thanthey are able to teach and more than pupils are able to learn in thetime allowed. _ While an overcharged curriculum may explain, it surelydoes not justify, the violation of law and the dropping of hygiene fromour school curriculum. If there is any class of citizen who shouldteach and practice respect for law as law, it is the teacher. Parents, school directors, county and state superintendents, universitypresidents, social workers, owe it not only to themselves, but to theAmerican school-teacher, either to repeal the laws that enjoininstruction in hygiene or else so to adjust the curriculum thatteachers can comply with those laws. The present situation thatdiscredits both law and hygiene is most demoralizing to teacher, pupil, and community. Many of us might admire the man teacher who frankly sayshe never explains the evils of cigarettes because he himself is aninveterate smoker of cigarettes. But what must we think of the schoolsystem that shifts to such a man the right and the responsibility ofdeciding whether or not to explain to underfed and overstimulatedchildren of the slums the truth regarding cigarettes? If practice andprecept must be consistent, shall the man be removed, shall he changehis habits, shall the law regarding instruction in hygiene be changed, or shall other provision be made for bringing child and essential factstogether in a way that will not dull the child's receptivity?

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

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

If one illustration is better than ten lessons, if an open window isworth more than all that text-books have to say about ventilation, ifa seat adjusted to the child is better than an anatomical chart, thisdoes not mean that instruction in hygiene should cease. On thecontrary, it means that provision should be made for every teacher toopen windows, to adjust desks, to use the experience of individualchildren for the education of the class. If the rank and file ofteachers have not hitherto been sufficiently observant of physiologicaland hygienic facts, if they are unprepared from their own lives todetect or to furnish illustrations for the child, this again does notmean that the child should be denied the illustrations, but that theteacher should either have instruction and experience to inciteinterest and to stimulate powers of observation, or else be asked togive place to another teacher who is able to furnish suchqualifications. 

5. _Children, like adults, can be interested in other people, in rulesof conduct, in social conditions, in living and working relations moreeasily than in their own bodies. _ The normal, healthy child thinks verylittle of himself apart from the other boys and girls, the games, thestudies, the animals, the nature wonders, the hardships that come tohim from the outside. So true is this that one of the best means ofmitigating or curing many ailments is to divert the child's attentionfrom himself to things outside of himself that he can look at, hear, enjoy. The power to concentrate attention upon oneself is a sign eitherof a diseased body, a diseased mind, or a highly trained mind. To studyothers and to recognize the similarity between others and oneself is asnatural as the body itself. Teachers are consulting this line ofeasiest access to children's attention when they honor childrenaccording to cleanliness of hands, of teeth, of shoes. Human interestattaches to what parks or excursions are doing for sickly children, howwelfare work is improving factory employees, how smallpox is conqueredby vaccination, how insurance companies refuse to take risks upon thelives of men or women addicted to the excessive use of alcohol ortobacco. 

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

6. _Other people's habits of health influence our well-being quite asmuch, if not more, than our own. _ Because we are social beings, abilityto get along with our families, our friends, our employers, is--atleast so it seems to most of us--quite as important as individualhealth. For too many of us, living hygienically is absolutelyimpossible without inconveniencing and bothering the majority ofpersons with whom we live. I remember a girl in college, --a fresh-airfiend, --who every morning, no matter how cold, threw the windows wideopen. Then, with forty others, I thought this girl a nuisance as wellas a menace to health, but now, twenty years afterwards, I find myselfwanting to do the same thing. Professor Patten, the economist, whom Ishall quote many times because he is particularly interested in thepurpose of this book, was recently dining at my house and illustratedfrom his own health the importance of teaching hygiene so as to affectsocial as well as personal standards. "To be true to my own healthneeds, I ought to have declined nearly everything that has been offeredme for dinner, but in the long run, if I am going to visit, my eatingwhat is placed before me is better for society than making those whoentertain me feel uncomfortable. "

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

To live unhygienically where others live hygienically is quite asdifficult. Witness the speedy improvement of dissipated men whenboarding with country friends who eat rationally and retire early. Itmust have been knowledge of this fact that prompted the tramways ofBelfast to post conspicuous notices: "Spitting is a vile and filthyhabit, and those who practice it subject themselves to the disgust andloathing of their fellow-passengers. " It is almost impossible to haveindigestion, blues, and headache when one is camping, particularlywhere action and enjoyment fill the day. Our practical question is, therefore, not "What shall I eat, how many hours shall I sleep, whatshall I wear, " but "How can I manage to get into an environment amongliving and working conditions where the people I live with and want toplease, those who influence me and are influenced by me, make healthyliving easy and natural?"

7. _Because the problems of health have to do principally withenvironment, --home, street, school, business, --it is worth while tryingto relate hygiene instruction to industry and government, to preachhealth from the standpoint of industrial and national efficiency ratherthan of individual well-being. _ Since healthful living requires thecoöperation of all persons in a household, in a group, or in acommunity, we must find some working programme that will make it easyfor all the members of the group to observe health standards. A citygovernment that spends taxes inefficiently can produce more sickness, wretchedness, incapacity in one year than pamphlets on health canoffset in a generation. Failure to enforce health laws is a moreserious menace to health and morals than drunkenness or tobacco cancer. Unclean streets, unclean dairies, unclean, overcrowded tenements can domore harm than alcohol and tobacco because they can breed an appetitethat craves stimulants and drugs. Others have taught how the body acts, what we ought to eat, how we should live. We are concerned here notwith repeating the laws of health, but with a consideration of themechanism that will make it possible for us so to work together that wecan observe those laws. 

CHAPTER II

SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS

In making a health programme as in making a boat, a garden, or abaseball team, the first step is to look about and see what materialthere is to work with. A baseball team will fail miserably unless thecaptain places each man where he can play best. Gardening is profitlesswhen the gardener does not know the habits of plants and thepossibilities of different kinds of soil. So in planning a healthprogramme we must study our materials and use each where it will fitbest. The materials of first importance to a health programme incivilized countries are men; for men working together can control watersources, drainage, and ventilation, or else move away to surroundingsbetter suited to healthful living. Therefore the first concern of theleader in a health crusade is the human kind he has to work for andwork with. 

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

Seven catchwords make it easy to remember the characteristics and thesource of every motive, every kind of person, and every stage in theevolution 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 tosize up the situation, the needs, and the opportunity of theindividuals 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, andnoises, just as it causes us to seek that which is agreeable. Primitiveman in common with other animals learned by sad experience to avoidcertain herbs as poisons; to bury or to move away from the dead; toshun discolored drinking water. During the roaming period sun and airand water acted as scavengers. When tribes settled down in one spot forlong periods, habits that had hitherto been inoffensive and safe becamenoticeably injurious and unpleasant. Heads of tribes gave ordersprohibiting such habits and restricting disagreeable acts and objectsto certain portions of the camp. Instinct places outhouses on our farmsand then gradually removes them farther and farther from dwellings. Inmany school yards, more particularly in country districts and smalltowns, outhouses are a crying offense against animal instinct. Invisiting slum districts in Irish and Scotch cities, and in London, Paris, Berlin, and New York, I never found conditions so offensive tocrude animal instinct as those I knew when a boy in Minnesota schoolyards, or those I have since seen in a Boy Republic. But the evil isnot corrected because it is not made anybody's business to executeinstinct's mandates. In the Boy Republic the leaders were waiting forthe 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 thebody is still a matter of instinct, a bath not being taken until thebody is offensive, the hands not being washed until their conditioninterferes with the enjoyment of food or with one's treatment byothers. There is a point of neglect beyond which instinct will notpermit even a tramp to go. If cleanliness is next to godliness, theaverage child is most ungodly by nature, for it loathes the means ofcleanliness and otherwise observes instinct's health warnings onlyafter experience has punished or after other motives from the outsidehave prompted action. The chief form of legislation of the instinct ageis provision of penalties for those who poison food, water, orfellow-man. There are districts in America where hygiene is supposed tobe taught to children that are conscious of no other sanitarylegislation but that which punishes the poisoner. 

_Display_ has always been an active health crusader. Professor Pattensays the best thing that could happen to the slums of every city wouldbe for every girl and woman to be given white slippers, whitestockings, a white dress, and white hat. Why? Because they would atonce notice and resent the dirt on the street, in their hallways, andin their own homes. People that have nothing to "spoil" really do notsee dirt, for it interferes in no way with their comfort so far as theycan see. Their windows are crusted with dust, their babies' milkbottles are yellow with germs. Who cares? Similar conditions existamong well-to-do women who live on isolated farms with no one to noticetheir personal appearance except others of the family who prefer restto cleanliness. But let the tenement mother or the isolated farmer'swife entertain the minister or the school-teacher, the candidate forsheriff or the ward boss, let her go to Coney Island or to the countyfair, and at once an outside standard is set up that requires greaterregard for personal appearance and leads to "cleaning up. "

Elbow sleeves and light summer waists have led many a girl to dailybathing of at least those parts of the body that other people see. Entertainments and sociables, Saturday choir practice and church haveled many a young man to bathe for others' sake when quite satisfied toforego 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 becauseMadam Well-to-do cares so much for health, but because she associatescleanliness with social prestige. It is necessary for the display ofher carriages and dresses, just as paved streets and a plentiful supplyof water for public baths and private homes were essential to thedisplay of Rome's luxury. Generally speaking, residence streets arecleaned in small towns just as waterworks are introduced, to gratifythe display motive of those who have lawns to water and clothes toshow. 

Instinct strengthens the display motive. As every one can be interestedin instinct hygiene, so every one is capable of this display motive tothe extent that his position is affected by other people's opinion. Itwas love of display quite as much as love of beauty that gave Greecethe goddess Hygeia, the worship of whom expressed secondarily a desirefor universal health, and primarily a love of the beautiful among thosewho had leisure to enjoy it. 

_Commerce_ brooks no preventable interference with profits, whether bydisease, death, impassable streets, or disabled men. The age ofchivalry was also the age of indescribable filth, plague, Black Death, and spotted fever that cost the lives of millions. It would beimpossible in the civilized world to duplicate the combination ofluxury and filthy, disease-breeding conditions in the midst of whichQueen Bess and her courtiers held their revels. The first protest wasmade, not by the church, not by sanitarians, but by the great merchantswho were unable to insure against loss and ruin from the plagues thatthrived on filth and overcrowding. By an interesting coincidence thefirst systematic street cleaning and the first systematic shipcleaning--maritime quarantine--date from the same year, 1348 A. D. ; theformer in the foremost German trading town, Cologne, and the latter inVenice, the foremost trading town of Italy. The merchants ofPhiladelphia and New York started the first boards of health in theUnited States. For what purpose? To prevent business losses from yellowfever. Desire for passable streets, drains, waterworks, and strongboards of health has generally started with merchants. For commercialreasons many of our states vote more money for the protection of cattlethan for the protection of human life, and the United States votesmillions for the study of hog cholera, chicken pip, and animaltuberculosis, while neglecting communicable diseases of men. No classin a community will respond more quickly to an appeal for the rigidenforcement of health laws than the merchant class; none will oppose sobitterly as that which makes profits out of the violation of healthlaws. 

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 withdifferent incomes and different tastes try to live together. In a smalltown where everybody keeps a cow and a pig, piggeries and stablesoffend no one; but when the doctor, the preacher, the dressmaker, thelawyer, and the leading merchant stop keeping pigs and cows, they beginto find other people's stables and piggeries offensive. The early lawsagainst throwing garbage, fish heads, household refuse, offal, etc. , onthe main street were made by kings and princes offended by suchpractices. The word "nuisance" was coined in days when neighbors livedthe same kind of life and were not sensitive to things like houseslops, ash piles, etc. The first nuisances were things that neighborsstumbled over or ran into while using the public highway. Next, goatsand other animals interfering with safety were described as nuisances, and legal protection against them was worked out. It has never beennecessary to change the maxim which originally defined a nuisance: "Souse your own property that you will not injure another in the use ofhis property. " The thing that has changed and grown has been society'sknowledge of acts and objects that prevent a man from enjoying his ownproperty. To-day the number of things that the law calls nuisances isso great that it takes hundreds of pages to describe them. Stables andouthouses must be set back from the street. Every man must dispose ofgarbage and drainage on his own property. Stables and privies must beat least a hundred feet from water reservoirs. Factories may notpollute streams that furnish drinking water. Merchants may be punishedif they put banana skins in milk cans, or if they fail to scald andcleanse all milk receptacles before returning them to wholesalers. Automobile drivers may be punished for disturbing sleep. Anything thatinjures my health will be declared a nuisance and abolished, if I canprove that my health is being injured and that I am doing all I can toavoid that injury. No educational work will accomplish more for anycommunity than to make rich and poor alike conscious of nuisances thatare being committed against themselves and their neighbors. The richare able to run away from nuisances that they cannot have abated. Ifproper publicity is given to living conditions among those who do notresist nuisances, the presence of such conditions will itself becomeoffensive to the well-to-do, who will take steps to remove thenuisance. Jacob Riis in this way made the slums a nuisance to richresidents in New York City and stimulated tenement reform, building ofparks, etc. 

_Anti-slum_ motives originated in cities where there is a cleardividing line between the clean and the unclean, the infected and theuninfected, the orderly and the disorderly, high and low vitality. Assoon as one district becomes definitely known as a source of nuisance, infection, and disease, better situated districts begin to make laws toprotect themselves. A great part of our existing health codes and avery large part of the funds spent on health administration aredesigned to protect those of high income against disease incident tothose of low income, high vitality against low vitality, houses withrooms to spare against houses that are overcrowded. To the small townand the country the slum means generally the near-by city whose paperstalk of epidemic scarlet fever, diphtheria, or smallpox. Cities haveonly recently begun to experience anti-slum aversion to country dairieswhose uncleanliness brings infected milk to city babies, or to filthyfactories and farms that pollute water reservoirs and cause typhoid. The last serious smallpox epidemic in the East came from the South byway of rural districts that failed to notify the Pennsylvania stateboard of health of the outbreak until the disease was scatteredbroadcast. Every individual knows of some family or some district thatis immediately pictured when terms like "disease, " "epidemic, " "slum, "are pronounced. The steps worked out by the anti-slum motive toprotect "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 promptlyafter the dangers of the slum have been described. You and I worktogether to protect ourselves against neglect, nuisance, and disease. In a district by which we must pass and with which we must deal, one ofus or a neighbor or friend will turn our attention from our danger tothe suffering of those against whom we wish to protect ourselves. Charles Dickens so described Oliver Twist and David Copperfield thatGreat Britain organized societies and secured legislation to improvethe almshouse, school, and working and living conditions. When healthreports, newspapers, and charitable societies make us see that theslum menaces our health and our happiness, we become interested in theslum for its own sake. We then start children's aid societies, consumer's leagues, sanitary and prison associations, child-laborcommittees, and "efficient government" clubs. 

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

Most of the rights we call inalienable are political rights no longerquestioned by anybody and no longer thought of in connection with oureveryday acts, pleasures, and necessities. When our political rightswere formulated in maxims, living was relatively simple. There was nofactory problem, no transportation problem, no exploitation of womenand children in industry. Our ancestors firmly believed that if thestrong could be prevented from interfering with the political rights ofthe weak, all would have an equal chance. The reason that our politicalmaxims mean less to-day than two hundred years ago is that nobody ischallenging 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 truthabout men or governments. If, however, anybody should interfere withour freedom in this respect, it would be of tremendous help thateverybody we know would resent such interference and would point tomaxims handed down by our ancestors and incorporated in our nationaland state constitutions as formal expressions of unanimous publicopinion. 

The time is past when any one seriously believes that political freedomor personal liberty will be universal, just because everybody has aright to talk, to move from place to place, to print stories in thenewspapers. The relation of man to man to-day requires that weformulate rules of action that prevent one man's taking from anotherthose rights, economic and industrial, that are as essential totwentieth-century happiness as were political rights toeighteenth-century happiness. Political maxims showed how, throughcommon desire and common action, steps could be taken by the individualand by the whole of society for the protection of all. Health rights, likewise, are to be obtained through common action. A modern city mustknow who is accountable when an automobile runs over a pedestrian, whena train load of passengers lose their lives because of an engineer'scarelessness, when an employee is incapacitated for work by an accidentfor which he is not responsible, or when fever epidemics threaten lifeand liberty without check. How can a child who is prevented byremovable physical defects from breathing through his nose beenthusiastic over free speech? Of what use is freedom of the press tothose who find reading harder than factory toil? How futile the rightto trial by jury if removable physical defects make children unable todo what the law expects! Who would not exchange rights of petition forability to earn a living? Children permanently incapacitated to sharethe law's benefits cannot appreciate the privilege of pursuinghappiness. 

Succeeding chapters will enumerate a number of health rights and willshow through what means we can work together to guarantee that we shallnot injure the health of our neighbor and that our neighbor shall notinjure our health. The truest index to economic status and to standardsof living is health environment. The best criterion of opportunity forindustrial and political efficiency is the conditions affecting health. The seven catchwords that describe seven motives to health legislationand health administration, seven ways of approaching health needs, andseven reasons for meeting them, should be found helpful in analyzingthe problem confronting the individual leader. Generally speaking, wecannot watch political rights grow, but health rights are evolvedbefore our eyes all the time. If we wish, we can see in our own city ortownship the steps taken, one by one, that have slowly led to grantinga large number of health rights to every American. 

FOOTNOTES:

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

[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] Whathealth rights a community pretends to enforce will, as a rule, be foundin its health code. What health rights are actually enforced can belearned only by studying both the people who are to be protected andthe conditions in which these people live. A street, a cellar, a milkshop, a sick baby, or an adult consumptive tells more honestly thestory of health rights enforced and health rights unenforced thaneither sanitary code or sanitary squad. Not until we turn our attentionfrom definition and official to things done and dangers remaining canwe 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 ofevery other city. This is natural because those who write health codesgenerally copy other codes. Even small cities are given complicatedsanitary legislative powers by state legislatures. Therefore those whojudge a community's health rights by its health laws will get aserroneous an impression as those who judge hygiene instruction in ourpublic schools from printed statements about the frequency andcharacter of such instruction. Advocates of health codes have thoughtthe battle won when boards of health were given almost unlimited powerto 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. In1864 New York state prohibited the sale of adulterated milk. Law afterlaw has been made since that time, giving health officials power torevoke licenses of milk dealers and to send men to jail who violatedmilk laws. We now know that no law will ever stop the present frightfulwaste of infant lives, counted in thousands annually, unless dairiesare frequently inspected and forced to be clean; unless milk is kept ata temperature of about fifty degrees on the train, in the creamery, atthe receiving station, and in the milk shop; unless dealers scald andthoroughly cleanse cans in which milk is shipped; unless licenses aretaken from farmers, creameries, and retailers who violate the law;unless magistrates use their power to fine or imprison those who poisonhelpless babies by violating milk laws; and unless mothers are taughtto scald and thoroughly cleanse bottles, nipples, cups, and dishesfrom which milk is fed to the baby. We know that these things are notbeing done except where men or women make it their business to see thatthey are done. Experience tells us that inspectors will notconsistently do their duty unless those who direct them have regularrecords of their inspections, study those records, find out work notdone 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 inblack and white that show accurately the conditions of dairies and milkshops, the character of milk found and tested by inspectors, and thenumber of babies known to have been sick or known to have died fromintestinal diseases chiefly due to unsafe milk. Any teacher or parentcan learn for himself, or can teach children to learn, what steps aretaken to guarantee the right to pure milk by using a table such asTable III. Whether conditions at the dairy make pure milk impossiblecan be told by any one who can read the score card used by New YorkCity (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 | Allow33 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 thatlaws do not enforce themselves, that even good motives and goodintentions in the best of officials do not insure good deeds. Thousandsof lives are being lost every year, millions of days taken fromindustry and wasted by unnecessary sickness, millions of dollars spenton curing disease, the working life of the nation shortened, the hoursof enjoyment curtailed, because we have not seen the great gap betweenhealth laws and health-law enforcement. In our municipal, state, andnational politics we have made the same mistake of concentrating ourattention upon the morals and pretensions of candidates and officialsinstead of judging government by what government does. Gains of men andprogress of law are useful to mankind only when converted into deedsthat make men freer in the enjoyment of health and earning power. Inprotecting health, as in reforming government, an ounce of efficientachievement is worth infinitely more than a moral explosion. One monthof routine--unpicturesque, unexciting efficiency--will accomplish morethan a scandal or catastrophe. Such routine is possible only whenspecial machinery is constantly at work, comparing work done with workexpected, health practice with health ideals. Where such machinery doesnot yet exist, volunteers, civic leagues, boys' brigades, etc. , caneasily prove the need for it by filling out an improvised score cardfor 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 wasthe number of cases of preventable, communicable, contagious, infectious, transmissible diseases, such as smallpox, typhoid fever, yellow fever, scarlet fever, diphtheria, measles, whooping cough. Bynoticing streets and houses where these diseases occurred, studentslearned a century ago that the darker and more congested the street thegreater the prevalence of fevers and the greater the chance that oneattacked would die. The well-to-do remove from their houses and theirstreets the dirt, the decomposed garbage, and stagnant pools from whichfevers seem to spring. It was because fevers and congestion go togetherthat laws were made to protect the well-to-do, the comfortable, and theclean against the slum. It is true to-day that if you study your cityand stick a pin in the map, street for street, where infection is knownto exist, you will find the number steadily increase as you go fromuncongested to congested streets and houses, from districts of highrent to districts of low rent. Because it is easier to learn the numberof persons who have measles and diphtheria and smallpox than it is tolearn the incomes and living conditions prejudicial to health, andbecause our laws grant protection against communicable diseases to achild in whatever district he may be born, the record of cases ofcommunicable diseases has heretofore been the best test of healthrights unenforced. Even in country schools it would make a good lessonin hygiene and civics to have the children keep a record of absences onaccount of transmissible disease, and then follow up the record with asearch for conditions that gave the disease a good chance. 

But to wait for contagion before taking action has been found anexpensive way of learning where health protection is needed. Even wheninfected persons and physicians are prompt in reporting the presence ofdisease it is often found that conditions that produced the diseasehave been overlooked and neglected. 

For example, smallpox comes very rarely to our cities to-day. Whereverboards of health are not worried by "children's diseases, " as is oftenthe 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 schoolbuildings and churches are furnishing a soil to breed an epidemic in asurprisingly short time. Where, on the other hand, boards of healthregard every communicable disease as a menace to health rights, youwill find that health officials take certain steps in a certain orderto remove the soil in which preventable diseases grow. These steps, worked out by the sanitarians of Europe and America after a century ofexperiment, are seen to be very simple and are applicable by theaverage layman and average physician to the simplest village or ruralcommunity. How many of these steps are taken by your city? by yourcounty? 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 ofchildren and adults suffering from measles, typhoid fever, scarletfever, consumption, one can go within his own city or to a strange cityand in a surprisingly short time locate the nuisances, the dangerousbuildings, the open sewers, the cesspools, the houses without bathingfacilities, the dark rooms, the narrow streets, the houses without playspace and breathing space, the districts without parks, the pollutedwater sources, the unsanitary groceries and milk shops. In countrydistricts a comparison of town with town as to the prevalence ofinfection will enable one easily to learn where slop water is thrownfrom the back stoop, whether the well, the barn, and the privy are neartogether. 

 [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 healthkeeping track of and publishing every case of infection, but itrequires further that one community be compared with other communitiesof similar size, and that each community be compared with itself yearfor year. These comparisons have not been made and records do not existin many states. 

FOOTNOTES:

[3] A striking demonstration of law enforcement that followed lawmakingis 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 SCHOOLCHILDREN

Compulsory education laws, the gregarious instinct of children, theambition of parents, their self-interest, and the activities ofchild-labor committees combine to-day to insure that one or morerepresentatives of practically every family in the United States willbe in public, parochial, or private schools for some part of the year. The purpose of having these families represented in school is not onlyto give the children themselves the education which is regarded as afundamental right of the American child, but to protect the communityagainst the social and industrial evils and the dangers that resultfrom ignorance. Great sacrifices are made by state, individualtaxpayer, and individual parent in order that children and state may bebenefited by education. Almost no resistance is found to any demandmade upon parent or taxpayer, if it can be shown that compliance willremove obstructions to school progress. If, therefore, by any chance, we can find at school a test of home conditions affecting both thechild's health and his progress at school, it will be easy, in the nameof the school, to correct those conditions, just as it will be easy toread the index, because the child is under state control for six hoursa 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 thatwill register the fact as a thermometer tells us the temperature, or asa barometer shows moisture and air pressure? The house address alone isnot enough, for many children surrounded by wealth are denied healthrights, such as the right to play, to breathe pure air, to eatwholesome food, to live sanely. Scholarship will not help, because thefrailest child is often the most proficient. Manners mislead, for, likedress, they are but externals, the product of emulation, of otherpeople's influence upon us rather than of our living conditions. Nationality is an index to nothing significant in America, where allrace and nationality differences melt into Americanisms, all respondingin about the same way to American opportunity. No, our test must besomething that cannot be put on and off, cannot be left at home, cannotbe concealed or pretended, something inseparable from the child andbeyond his control. This test it has been conclusively proved inChicago, Boston, Brookline, Philadelphia, and particularly in New YorkCity, is the physical condition of the school child. To learn thiscondition the child must be examined and reëxamined for the physicalsigns called for by the card on page 34. Weight, height, andmeasurements are needed to tell the whole story. 

When this card is filled out for every child in a class or school orcity, the story told points directly to physical, mental, or healthrights 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, theprogress of the community as well as of the child will be clearlyshown. Such a history card (p. 314) is now in use in certain New Yorkschools, as well as in several private schools and colleges. 

Have you ever watched such an examination? By copying this card yourfamily physician can give you a demonstration in a very short time asto the method and advantage of examination at school. The schoolphysician goes at nine o'clock to the doctor's room in the publicschool, or, if there is no doctor's room, to that portion of the hallor principal's office where the doctor does his work. The teacher orthe nurse stands near to write the physician's decision. The doctorlooks the child over, glances at his eyes, his color, the fullness ofhis 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 topush down the tongue. There should be a stick for every child, so thatinfection cannot possibly be carried from one to the other. If this isimpossible, the stick should be dipped in an antiseptic such as boricacid or listerine. If, because of swollen tonsils, there is but alittle slit open in the throat, or if teeth are decayed, the mark is Yor B. The whole examination takes only a couple of minutes, but thephysician often finds out in this short time facts that will save a boyand his parents a great deal of trouble. Very often this examinationtells a story that overworked mothers have studiously concealed bybright ribbons and clean clothes. I remember one little girl offourteen who looked very prosperous, but the physician found her sothin that he was sure that for some time she had eaten too little, andcalled her anæmic. He later found that the mother had seven childrenwhom she was trying to clothe and shelter and feed with only tendollars a week. A way was found to increase her earnings and to giveall the children better living conditions, --all because of the shortstory told by the examination card. In another instance the card'sstory 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 thephysical condition of school children is that conducted by the board ofhealth 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 centhave been found to have defects, as shown in Table VI. 

TABLE VI

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

=============================================+==========+=========== | Total | Percentage---------------------------------------------+----------+-----------Number of children examined | 275, 641 | 100Number 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 defectsthan children elsewhere. If this assumption is wrong, if children inother parts of the United States are as apt to have eye defects, enlarged tonsils, and bad teeth as the children of the greatmetropolis, then the army of children needing attention would be sevenout of ten, or over 14, 000, 000. 

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

The seriousness of every trouble and its particular relation to schoolprogress and to the general public health will be explained insucceeding chapters. The point to be made here is that the examinationof the school child discloses in advance of epidemics and breakdownsthe children whose physical condition makes them most likely to "comedown" with "catching diseases, " least able to withstand an attack, lessfitted to profit fully from educational and industrial opportunity. 

The only index to community conditions prejudicial to health that willmake known the child of the well-to-do who needs attention is therecord of physical examination. No other means to-day exists by whichthe state can, in a recognized and acceptable way, discover the failureof these well-to-do parents to protect their children's health and takesteps to teach and, if necessary, to compel the parents to substituteliving conditions that benefit for conditions that injure the child. 

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

The New York Committee on the Physical Welfare of School Childrenvisited fourteen hundred homes of children found to have one or more ofthe physical defects shown on the above card. While they found that lowincomes have more than their proper share of defects and of unsanitaryliving conditions, yet they saw emphatically also that low incomes donot monopolize physical defects and unsanitary living conditions. Manyfamilies having $20, $30, $40 a week gave their children neithermedical nor dental care. The share each income had in unfavorableconditions is shown by the summary in the following table. 

TABLE VII

SHOWING PER CENT SHARE OF PHYSICAL DEFECTS OF CHILDREN, UNFAVORABLEHOUSING CONDITIONS, AND CHILD MORTALITY FOUND AMONG EACH FAMILY-INCOMEGROUP

========================+============================================= | 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 schooland college. 

Last winter the chairman of the Committee on the Physical Welfare ofSchool Children was invited to speak of physical examination before anassociation of high-school principals. He began by saying, "Thisquestion does not concern you as directly as it does the grammar-schoolprincipals, but you can help secure funds to help their pupils. " Oneafter another the high-school principals present told--one of his owndaughter, another of his honor girls, a third of his honor boys--thesame story of neglected headaches due to eye strain, breakdowns due toundiscovered underfeeding, underexercise, or overwork. Are we coming tothe time when the state will step in to prevent any boy or girl in highschool, college, or professional school from earning academic honors atthe expense of health? Harmful conditions within schoolrooms and onschool grounds will not be neglected where pupils, teachers, school andfamily physicians, and parents set about to find and to remove thecauses of physical defects. 

Disease centers outside of school buildings quickly register themselvesin the schoolroom and in the person of a child who is paying thepenalty for living in contact with a disease center. If a child sleepsin a dark, ill-ventilated, crowded room, the result will show in hiseyes and complexion; if he has too little to eat or the wrong thing toeat, he will be underweight and undersized; if his nutrition isinadequate 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, toolittle food. Existence of physical defects throws little light onincome at home, but conclusively shows lack of attention or ofunderstanding. Several days' absence of a child from school leads, inevery well-regulated school, to a visit to the child's home or to aletter or card asking that the absence be explained. Even newly arrivedimmigrants have learned the necessity and the advantage of writing theteacher an "excuse" when their children are absent. Furthermore, neighbors' children are apt to learn by friendly inquiry what theteacher may not have learned by official inquiry, why their playmate isno longer on the street or at the school desk. While physicians aresometimes willing to violate the law that compels notification ofinfection, rarely would a physician fail to caution an infected familyagainst an indiscriminate mingling with neighbors. Whether the familyphysician is careless or not, the explanation of the absence which isdemanded by the school would give also announcement of any danger thatmight exist in the home where the child is ill. 

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

Appreciation of health, as well as its neglect, is indexed by thephysical condition of school children. Habits of health are the otherside of the shield of health rights unprotected. Physical examinationwill discover what parents are trying to do as well as what they failto do because of their ignorance, indifference, or poverty. In so faras parents are alive to the importance of health, the schoolexamination furnishes the occasion of enlisting them in crusades toprotect the public health and to enforce health rights. The Committeeon the Physical Welfare of School Children found many parents unwillingto answer questions as to their own living conditions until told thatthe answers would make it easier to get better health environment notonly for their own children but for their neighbors' children. Generally speaking, fathers and mothers can easily be interested in anykind of campaign in the name of health and in behalf of children. Theadvantage of starting this health crusade from the most popularAmerican institution, the public school, --the advantage of institutingcorrective work through democratic machinery such as the publicschool, --is incalculable. To any teacher, pastor, civic leader, healthofficial, or taxpayer wanting to take the necessary steps for theremoval of conditions prejudicial to health and for the enforcement ofhealth rights of child and adult, the best possible advice is to learnthe facts disclosed by the physical examination of your schoolchildren. See that those facts are used first for the benefit of thechildren themselves, secondly for the benefit of the community as awhole. If your school has not yet introduced the thorough physicalexamination of school children, take steps at once to secure suchexamination. If necessary, volunteer to test the eyes and the breathingof one class, persuade one or two physicians to coöperate until youhave proved to parent, taxpayer, health official, and teacher that suchan examination is both a money-saving, energy-saving step and an act ofjustice. 

We shall have occasion to emphasize over and over again the fact thatit is the use of information and not the gathering of information thatimproves the health. The United States Weather Bureau saves millions ofdollars annually, not because flags are raised and bulletins issuedforetelling the weather, but because shipowners, sailors, farmers, andfruit growers obey the warnings. Mere examination of school childrendoes little good. The child does not breathe better or see betterbecause the school physician fills out a card stating that there issomething wrong with his eyes, nose, and tonsils. The examination tellswhere the need is, what children should have special attention, whatparents need to be warned as to the condition of the child, what homeconditions need to be corrected. If the facts are not used, that is anargument not against obtaining facts but against disregarding them. 

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

Apart from the advantage to the community of locating its healthproblems, physical examination is due every child. No matter where hisschooling or at whose expense, every child has the right to advance asfast as his own powers will permit without hindrance from his own orhis playmates' removable defects. He has the right to learn thatsimplified breathing is more necessary than simplified spelling, thatnose plus adenoids makes backwardness, that a decayed tooth multipliedby ten gives malnutrition, and that hypertrophied tonsils are even moremenacing than hypertrophied playfulness. He has the right to learn thathis own mother in his own home, with the aid of his own familyphysician, can remove his physical defects so that it will beunnecessary for outsiders to give him a palliative free lunch atschool, thus neglecting the cause of his defects and those offellow-pupils. 

FOOTNOTES:

[4] Sir John E. Gorst in _The Children of the Nation_ reads the index ofthe health of school children in the United Kingdom; John Spargo, in_The Bitter Cry of the Children_, and Simon N. Patten in _The New Basisof Civilization_, suggest the necessity for reading the index in theUnited 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 tocommunity health, who is to read the index? Unless the story is told ina language that does not require a secret code or cipher, unless someone besides the physician can read it, we shall be a very long timelearning the health needs of even our largest cities, and untildoomsday learning the health needs of small towns and rural districts. Fortunately the more important signs can be easily read by the averageparent or teacher. Fortunately, too, it is easy to persuade mothers andteachers that they can lighten their own labors, add to theirefficiency, and help their children by being on the watch for mouthbreathing, for strained, crossed, or inflamed eyes, for decaying teeth, for nervousness and sluggishness. Years ago, when I taught school in aMinnesota village, I had never heard of adenoids, hypertrophiedtonsils, myopia, hypermetropia, or the relation of these defects and ofneglected teeth to malnutrition, truancy, sickness, and dullness. I nowsee how I could have saved myself several failures, the taxpayers agreat deal of money, the parents a great deal of disappointment, andmany children a life of inefficiency, had I known what it is easy forall teachers and parents to learn to-day. 

 [Illustration: MOUTH BREATHERS BEFORE "ADENOID PARTY"]

The features in the following cut are familiar to teachers the worldover. 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 playfellowswhose scornful epithets are echoed by the looking-glass. No fashionplate ever portrays such faces. No athlete, thinker, or hero looks outfrom printed page with such clouded, listless eyes. The more wonder, therefore, that the meaning of these outward signs has not beenappreciated and their causes removed; conclusive reason, also, for notbeing misled by recent talk of mouth breathing, adenoids, and enlargedtonsils, 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 anddelinquency that would have saved millions of dollars and millions oflife failures had the civilized world listened. He was speaking ofdelinquent girls from seventeen to twenty years old in WappingWorkhouse: "I have never yet ascertained why a refractory habit shouldaffect the tonsils and the uvula; but I have always observed thatrefractories of both sexes and every grade, between a Ragged School andthe Old Bailey, have one voice, in which the tonsils and uvula gain adiseased ascendency. "

To-day we are just beginning to see over again the connection betweeninability to breathe through the nose and inability to see clearlyright from wrong and inability to want to do what teachers and parentswish. Physical examinations show now, and might just as well have shownfifty years ago, that the great majority of truants and juvenileoffenders have adenoids and enlarged tonsils. A recent examination madeby the New York board of health on 150 children in one school made upfrom the truant school, the juvenile court, and Randall's Island, showed that only three were without some physical defect and that 137had adenoids and large tonsils. Dickens wrote his observations in 1860;in 1854 the New York Juvenile Asylum was started, and up to 1908 caredfor 40, 000 children; in 1860 William Meyer pointed out, so that no oneneed misunderstand, the harmful effects of adenoids. What would havebeen the story of juvenile waywardness, of sickness, of educationaladvancement, had examinations for defective breathing been started in1853 or 1860 instead of 1905; if one per cent of the attention that hasbeen given to teaching mouth breathers the ten commandments had beenspent 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 andadenoids were removed was described by his father in this way: "Whenplaying with other boys on the street he seems dazed, and sluggish tograsp the various situations occurring in the course of the game. Whenhe decides to do something he runs in a heedless, senseless way, as ifrunning away, --will bump against something, pedestrian or building, before he comes to himself; seems dazed all the time. When toldsomething by his mother he giggles in the most exasperating way, forwhich he receives a whipping quite often. " The father said the whippingwas of no avail. The child was restless, talkative, and snored duringsleep. He had an insatiable appetite. He was removed or transferredfrom five different schools in New York City. To get redress the fathertook him to the board of education, whence he was referred to theassistant chief medical inspector of the department of health, whoseexamination revealed immensely large fungous-looking tonsils andexcessive pharyngeal granulations (adenoids). He was operated on at aclinic. The tonsils and adenoids removed are pictured on the oppositepage, reduced one third. After the operation the child was visited bythe assistant medical inspector. There was a marked improvement in hisfacial expression, --he looked intelligent, was alert and interested. When asked how he felt, he answered, "I feel fine now. " It requiredabout fifteen minutes to get his history, during all of which time hewas responsive and interested, constantly correcting statements of hisfather and volunteering other information. Eleven days after theoperation he was reported to have had no more epileptic seizures. "Doesn't talk in sleep. Doesn't snore. Doesn't toss about the bed. Hasmore self-control. Tries to read the paper. His immoderate appetite isnot 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 nottrue that the closed mouth, when awake and with other people, is proofthat there are no such defects. Children breathe through the mouth notbecause they like to, not because they have drifted into bad habits, not because their parents did, not because the human race isdeteriorating, but because their noses are stopped up, --because theymust. A mouth breather is not only always taking unfiltered dirt germsinto his system but is always in the condition of a person who hasslept in a stuffy room. What extra effort adenoids mean can beascertained by closing the nostrils for a forenoon. 

For many reasons it is perhaps unfortunate that we can breathe at allwhen the nose is stopped up. If we could see with our ears as well aswith our eyes, we should probably not take as good care of our eyes. Inthis respect the whole race has experienced the misfortune of the manof whom the coroner reported, "Killed by falling too short a distance. "Because we can breathe through the mouth we have neglected forcenturies the nasal passages. When a cold stops the nose we necessarilybreathe through the mouth. Unfortunately children make the necessaryeffort required to breathe through the nose long before other peoplenotice the lines along the nose and the slow mind. Mouth breathing willshow with the child asleep, before the child awake loses power toaccommodate his effort to the task. Therefore the importance of aphysical test at school to detect the beginnings of adenoids and largetonsils before these symptoms become obvious to others. 

No child should be exempted from this examination because of apocryphaltheories that only the poor, the slum child, the refractory, or theunclean have defects in breathing. This very afternoon a friend hastold me of her year abroad with a girl of nine, whose parents are verywealthy. 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 theyare too eminent to give attention to such simple troubles as adenoidsthat can be felt and seen. They are looking for complications of theliver or inflammation of muscles at the base of the brain. Onecelebrated French savant found the adenoids, assured the mother thatthe child would outgrow them, and advised merely that she be compelledto breathe through the nose. The mother and nursemaids nag the childall day. The poor unwise mother sits up nights to hold the child's jawstight in the hope that air coming through the nose will absorb theadenoids. The mother is made nervous. Of course this makes the childmore nervous and adds to the evil effects of adenoids. If the motherhad the good fortune to be very poor, she could not sit up nights, andwould long ago have decided either to let the child alone or else tohave the trouble removed. 

Adenoids are not a city specialty. Country earache is largely due toadenoids or to inflammation that quickly leads to adenoids. In 415villages of New York state twelve per cent were found to be mouthbreathers. For two summers I have known a lad named Fred. He lives atthe seashore. Throughout his twelve years he has lived in a veritableEl Dorado of health and nature beauty. Groves and dunes and flora viewith the blues of ocean and sky in resting the eye and in filling thesoul with that harmony which is said to make for sound living. Yet to achild, Fred's schoolmates are experts on patent medicines and on theheredity that is alleged to be responsible for bad temper, runningsores, tuberculosis, anæmia, and weak eyes. Freddie is particularlyfavored. His well-to-do parents have supplied him with ponies, games, and bicycles. Nothing prevents his breathing salt air fresh from thenorth pole but hermetically sealed windows. The father thinks it absurdto make a fuss over adenoids. Didn't he have them when a boy, anddoesn't he weigh two hundred pounds and "make good money"? The mothernever knew of operations for such trifles when she taught school; shesupposes her boy needs an operation, but "just can't bear to see thedear child hurt. " As for Fred, he breathes through his mouth, talksthrough his nose, grows indifferent to boy's fun, fails to earnpromotion at school, and fears that "I won't be strong in spite of allthe patent medicine I've taken. " Father, mother, and Fred feel profoundpity for the city child living so far from nature. 

Adenoids are not monopolized by children whose parents are ignorant ofthe importance of them and of physical examination. Last summer I wasasked by a small boy to buy some chocolate. A glance at his cigar boxwith its two or three uninviting things for sale showed that the boywas really begging. He had thick lips, open mouth, "misty" eyes, and anasal twang. I asked him if his teacher had not told him he had lumpsback of his nose and could not breathe right. He said, "No. " Iexplained then that he could make a great deal more money if he talkedlike other boys, stepped livelier, and breathed as other peoplebreathe. He said he had "been by a doctor onct but didn't want to beop'rated. " I turned to my companion and asked, "Have you never notedthose same lines on your boy's face?" Although he had been lecturing onmouth breathers, he had never noticed his own boy's trouble. Hehastened home and found the infallible signs. The mother declared itcould not be true of her boy. About five months before, their familyphysician had said of the child's earache, "The same inflammation ofthe nasal passages that causes earache causes adenoids; you must be onthe lookout. " Although in the country, the boy's appetite was not goodand his zest for play had flagged. They had looked for the trouble toback generations and in psychology books, --everywhere but at the boy'sface, in his mouth, and in his nose. After the operation, which tookless than two minutes, the appetite was ravenous, the eyes cleared, and the spirit rebounded to its old buoyancy that craved worlds toconquer. 

The new personal experience made a deep impression upon my friend'smind. He wanted everybody to know how easy it was to overlook a child'sdistress. One person after another had a story to tell him; even thejanitor said: "You'd ought to have seen our John at sixteen. He spent aweek by the hospital. " The only people who do not seem to know morethan the new convert are the mouth breathers whom he religiously stopson the street. 

The indexes to adenoids and large tonsils for the teacher to read atschool 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 ofconvincing the parents as to the advantages of the operation was merelya demand for the "right to knowledge, " which is never overlooked withimpunity. Reluctance to permit operation on a young child, and thenatural shrinking of a parent at seeing a child under the surgeon'sknife, require the teacher or school physician or nurse to answer fullythe 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 ofthe army reports that during the year 1905, out of 3004 operations onofficers and enlisted men in service, there were 225 operations on thenose, mouth, and pharynx, 103 of which were operations for adenoids andenlarged or hypertrophied tonsils. Allowing the child to "outgrow"adenoids may mean not only that he is being subjected to infectionchronically but that his body is allowed to be permanently deformed andhis health endangered. Beginning at the age of the second dentition, the bones of jaw, nose, throat, and chest are undergoing importantchanges--nasal occlusion. Adenoids left to atrophy--if large enough tocause mouth breathing--may mean atrophy of this developing process, permanent disfiguration of face, and permanent deformity of chest andlungs. 

2. Will the growth recur? In a few cases it does recur; frequentlyeither because it was not desirable to make a complete removal of theadenoid tissue or because the surgeon was careless. If the growths dorecur, 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? Thesequestions are best answered by the process and results of an "adenoidparty, " which was given especially for the benefit of this book, everystep and symptom of which were carefully studied. 

The seven children pictured here were discovered by their schoolphysician to have moderately large adenoid growths, --one boy havingenlarged tonsils also. 

 [Illustration: MOUTH BREATHERS IMMEDIATELY AFTER "ADENOID PARTY"]

The picture on page 46 was taken by flash light at 2. 30 P. M. , January15, 1908. At 3 P. M. The principal escorted these children into theoperating room at Vanderbilt Clinic. The doctor examined the throat andnose of each child, entered the name and age of each, together with hisdiagnosis, on a clinic card, sending each child into the next roomafter examination. He then called the first boy and explained that itwould hurt, but that it would be over in a minute. The principal stoodby and told him to be brave and remember the five cents he could havefor ice cream afterwards. The clinic nurse tied a large towel about himand put him in her lap; with one hand she held his clasped hands, whilethe other held his head back. The doctor then took the littleinstrument--the curette--and pushed it up back of the soft palate, andwith one twist brought out the offending spongy lump. The boy's headwas immediately held over a basin of running water. He was so occupiedwith spitting out the blood that rushed down to choke him that hehadn't time to cry before the acute pain had ceased. The rush of coolair through his nostrils was such a pleasurable sensation that hesmiled as the school nurse escorted him out into the hall to wait forhis 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 thesleepy, peaceful expression that comes with rest from the prolongedlabor of trying to get enough air. At 3. 45 P. M. They had been allreëxamined by the doctor, and a few tag ends were picked out of thenasopharynx of one child. At 4 P. M. The "party" had returned to theChildren's Aid Society's school and to the ice cream that follows eachadenoid party. 

It is worth while to tell mothers stories of the "marvelous improvementin school progress of those children whose brains have been poisonedand starved by the accursed adenoid growths, and how their bodiesfairly bloom when the mysterious and awful incubus is removed, " to usethe 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 beforethe mind of man devoted itself to preventing the diseases for which nosure cure had been found. Efforts to conquer these diseases were tardybecause men were taught that some unseen power was punishing men andgovernments for their sins. The difference between the old and the newway 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 andjewelry are torn from bodies not yet cold. In the foreground a musculargiant, paragon of conscious virtue, clad like John the Baptist andBible in hand, finds his way among his plague-stricken fellow-townsmen, urging them to turn from their sins. Modern efficiency learns of thefirst outbreak of the plague, isolates the patient, kills rats andtheir fleas which spread the disease, thoroughly cleanses or destroys, if necessary, all infected clothing, bedding, floors, and walls, andmakes it possible for us to go on living for each other with a betterchance of "bringing forth fruits worthy for repentance. "

Where boards of health make it compulsory to report cases of sicknessdue to contagion, health records are a reliable index to "catching"diseases. But now that the chief infection is the kind that afflictschildren, we can read the index before the outbreak that calls in aphysician to diagnose the case. School examination shows whichchildren have defects that welcome and encourage disease germs. Itpoints to homes that cultivate germs, and consequently menace otherhomes. To locate children who have enlarged tonsils may prevent adiphtheria epidemic. To detect in September those who areundernourished, who have bad teeth, and who breathe through the mouthwill help forecast winter's outbreaks of scarlet fever and measles. Onedollar spent at this season in examination for soil hospitable todisease germs may save fifty dollars otherwise necessary for inspectionand cure of contagious diseases. 

It is harder at first to interest a community in medical examinationthan in medical inspection, because we are all afraid of "catching"diseases, while few of us know how they originate and how they can beprevented by correcting the unfavorable conditions which physicalexamination of school children will bring to light. 

Courses in germ sociology are therefore of prime necessity. How dogerms act? On what do they live? Why do they move from place to place?What causes them to become extinct? With few exceptions, germs migratefor the same reason as man, --search for food, love of conquest, andlove of adventure. When there is plenty of food they multiply rapidly. Full of life, overflowing with vitality, they move out for new worldsto conquer. Like human beings, they will do their best to get away froma country that provides a scanty food supply. Like men and women, theystarve if they cannot eat. Like boys and girls, they avoid enemies; theweak give way to the strong, the slow to the swift, the devitalized tothe vitalized. 

Human sociology imprisons, puts to death, deprives of opportunity to doevil, or reforms those who murder, steal, or slander. Germ sociologyteaches us to do the same with injurious germs. We imprison them, wetake away their food supply, we kill them outright, or we starve themslowly. They have a peculiar diet, being especially partial todecomposing vegetable and animal matter and to what human beings calldirt. By putting this diet out of their reach we make it impossible forthem to propagate their kind. By placing poison within their reach orby forcing it upon them we can successfully eliminate them as enemies. As the president of Mexico restored order "by setting a thief to catcha thief, " so modern science is setting germs to kill germs that harmcrops and human stock. Of utmost consequence is it that the body's germconsumer--its pretorian guard--be always armed with vitality ready tovanquish every intruding hostile germ. If we are false to our guard, itwill turn traitor and join invaders in attacking us. But here, as indealing with evils that originate with human beings, an ounce ofprevention is worth a ton of cure. The most effectual way to eliminategerm diseases is to remove the cause--the food supply of disease germs. The fact that many germs are plants, not animals, does not weaken theanalogy, for weeds do not get a chance in well-tilled soil. 

Perhaps the most notable recent example of government germextermination is the triumph over the yellow-fever and malaria mosquitoin Panama. When the French started to build a canal in Panama, thefirst thing they did was to build a hospital. The hospital was alwaysfull and the canal was given up. At the time the United States proposedto re-attempt the work, it was thought that it could not be donewithout great loss of life and without great labor difficulties. Instead of taking the sickness for granted and enlarging the Frenchhospital, the chief medical inspector, Gorgas, took for granted thatthere need be no unusual sickness if proper preventive measures weretaken. He knew what the French had not known, that the yellow-feverscourge depends for its terrors upon mosquitoes. Accordingly, with theaid of six thousand men and five million dollars he set about tostarve out the few infected and infectious kinds of mosquito, --theyellow-fever or house mosquito and the malaria or meadow mosquito. Heintroduced waterworks and hydrants, paved the streets, drained theswamps and pools in which they breed, and instituted a weeklyhouse-to-house inspection to prevent even so much as a pail of stagnantwater offering harbor to these enemies. The grass of the meadows wherethe malaria mosquito breeds was cut short and kept short within threehundred feet of dwellers, --as far as the mosquito can fly. All ditcheswere disinfected with paraffin, and the natives were forced to observesanitary laws. President Roosevelt, in his special message to Congresson the Panama Canal in 1906, stated that in the weekly house-to-housevisit of the inspectors at the time he was in Panama but two mosquitoeswere found. These were not of the dangerous type. As a consequence ofthis sanitary engineering there is very little sickness in Panama, thehospital is seldom one third full, and the canal is progressing verymuch faster than was expected. Panama, like Havana, is now safer thanmany American cities, because cleaner and less hospitable to diseasegerms. 

Any place where numbers of people are accustomed to assemble favors thepropagation of germs, --whether it be the meetinghouse, the townhall, the theater, or the school. Every teacher can be the sanitary engineerof her own schoolroom, school, or community by coöperating with theschool doctor, the town board of health, family physicians, andmothers. Every teacher can exterminate disease by applying the verysame principles to her schoolroom as Chief Medical Inspector Gorgasapplied to Panama. Knowledge, disinfection, absolute cleanliness, education, and inspection are the essential steps. First she must knowthat "children's diseases" are not necessary. She should discountenancethe old superstition that every child must run the gamut of children'sdiseases, that every child must sooner or later have whooping cough, measles, chicken pox, mumps, scarlet fever, just as they used to thinkyellow fever and cholera inevitable. The price of this terribleignorance has been not only expense, loss of time, acquisition ofpermanent physical defects, and loss of vitality, but, for the majorityof children, death before reaching five years of age. All these"catching" diseases are germ diseases, which disinfection caneliminate. The free use of strong yellow soap and disinfectants on theschool floor, windows, benches, desks, blackboards, pencils, in thecoat closets and toilets, plus the natural disinfectants, hot sun andoxygen, will prevent the schoolroom from being a source of danger. Oneor 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 ofthe means of preventing the spread of disease as the woman in a smallcountry town who used daily to astound the neighbors by the "shower ofsnow" she produced by shaking the bedding of her sick child out of thewindow. Their astonishment was soon changed to panic when that showerof snow resulted in a deadly epidemic of scarlet fever. Medicalinspection of New York City's schools was begun after an epidemic ofscarlet fever was traced to a popular boy who passed around among hisschoolmates long rolls of skin from his fingers. 

Much of the care exercised at school to prevent children's diseases iscounteracted because children are exposed at home and in public placesto contagion, where ignorance more often than carelessness is the causeof uncleanliness. By hygiene lessons, illustrating practically theproper methods of cleaning a room, much may be done to enlist schoolchildren in the battle against germs. Through the enthusiasm of thechildren as well as through visits to the homes parents may beinstructed as to the danger of letting well children sleep with sickchildren; the wisdom of vaccination to prevent smallpox, of antitoxinto prevent serious diphtheria, of tuberculin tests to settle thequestion whether tuberculosis is present; why anything that gathersdust is dangerous unless cleansed and aired properly; and why bedding, furniture, floor coverings, and curtains that can be cleansed and airedare more beautiful and more safe than carpets, feather beds, upholstery, and curtains that are spoiled by water and sunshine; how tocare for the tuberculous member of the family, etc. Anti-social actsmay be prevented, such as carrying an infected child to the doctor in apublic conveyance, thereby infecting numberless other people; sendinginfected linen to a common laundry; mailing a letter written by aninfected person without first disinfecting it; sending a child withdiphtheria to the store; returning to the dairy unscalded milk bottlesfrom a sick room. 

The daily inspection of school children for contagious diseases by theschool physician has, where tried, been found to reduce considerablythe amount of sickness in a town. Such inspection should be universallyadopted. Moreover, the teacher should be conversant with the earlysymptoms of these diseases so that on the slightest suspicion the childmay be sent home without waiting for the physician's call. Like thelittle girl who never stuttered except when she talked, school childrenand school-teachers are rarely frightened until too late to preventtrouble. The "easy" diseases such as measles, whooping cough, etc. , cost our communities more than the more terrible diseases like typhoidand smallpox. During one typical week ending May 18, 630 new cases ofmeasles were reported to one department of health. Obviously thenineteen deaths reported give no conception of the suffering, the cost, the anxiety caused by this preventable disease. The same may be saidof 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 sleepwith 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 finda culture medium--at the gateway of the human system. The mouth isnever out of service and is almost never in a state of truecleanliness. Solid particles from the breath, saliva, food between theteeth, and other débris form a deposit on the teeth and decompose in aconstant temperature of ninety-eight degrees Fahrenheit. In the normalmouth from eight to twenty years of age the teeth present from twentyto thirty square inches of dentate surface, constantly exposed toever-changing, often inimical, conditions. This bacterially infectedsurface makes a fairly large garden plot. Every cavity adds to thegerm-nourishing soil. Dental caries--tooth decay--is a disease hithertoalmost universal from birth to death. Thus the air taken in through themouth becomes a purveyor of its poisonous emanations and affects thelung tissues and the blood. Food and water carry hostile germs downinto 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 andreinfects himself but scatters germs in the air whenever he sneezes orcoughs. In a cold apartment where there is no appreciable current ofair a person can scatter germs for a distance of more than twenty-twofeet. Germs are also scattered through the air by means of salivary ormucous 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 childrenPox |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 effectsCough |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 bothFever or |with _headache, languor, | discharges |during attack andScarlatina |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 draughtsrather than to a cold germ, which finds a body unequipped withresisting power, with its germ police off guard, exhausted fromoverwork, or disaffected and ready to turn traitor if the enemy seemsstronger than our vitality. Sometimes it seems as if we contracted itfrom a sneezing fellow-passenger, sometimes from a draught from an opencar window. An uninformed opponent of the theory that colds are a germdisease 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 coldsthan we, had poorer health, and died twenty years younger, perhaps hewill listen to proof that his unclean warm air weakens the body andmakes it an easy prey to cold germs. 

Many physicians preach and practice this fallacy as to fresh air andcolds, but few physicians now deny that influenza is a germ disease orthat a nose so irritated and so neglected as to secrete largequantities of mucus is a better place for breeding disease germs than anose whose membranes are clean and not thus irritated. 

Until medical specialists are agreed, and until they have definitelylocated the cold germ, we laymen must choose for ourselves a workingtheory. The weight of opinion at the present time declares that coldsare due to germs. Strong membranes with good circulation and drainageprovide poor food for germs. Congested membranes furnish properconditions for propagation. The germ theory explains the spread ofgerms from the nose to the passages of the head, and from head toarteries and lungs. 

A cold can always be charged to some one else. How many can be laid toour account? There is one right that is universally not recognized, andthat is the right of protection from the germs showered in the air webreathe, over the food we eat, by the sneezes of our unfortunateneighbor at school, in the street car, at the restaurant. The chiefdanger of a cold is to our neighbor, not to ourselves. A cold which astrong person may throw off in a day or two may mean death to histuberculous neighbor. Though for our own health "lying up for a merecold" is an unnecessary bore, the failure to do so may deprive ourneighbor of a right greater than the right to protection againstscarlet fever or smallpox. Though formerly this statement would nothave been true, rights change with conditions, and the fact that to-daythe three most deadly diseases are pneumonia, tuberculosis, anddiphtheria, --all diseases of the respiratory organs, --justifies theassertion that we have a right to protection against colds. Theprevalence of colds, sore throats, irritated vocal cords, bad voices, catarrh, bronchitis, laryngitis, and asthma in America to-day demandssummary measures. One can learn to sneeze into a handkerchief, not intoa companion's face or into a room. School children can be taught toavoid handkerchiefs on which mucus has dried. In the far distant futurewe may be willing to use cheesecloth, and boil it or throw it away, or, like the Japanese, use soft paper handkerchiefs and burn them afterusing. 

TABLE IX

DEATH RATE PER 10, 000 POPULATION, PNEUMONIA AND BRONCHITIS FIVE-YEARPERIOD, 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, thusdepriving the class and family of the top of their vitality andefficiency without their consent. Because a person is thought aweakling who lies up for a "mere cold, " one is inclined to wish thatcolds were as prostrating as typhoid, in which case there would be somehope of their extermination. 

The exclusion of children with colds from school deserves trial as acheck to children's diseases. Many of these "catching" diseases startwith a cold in the head, as, for instance, measles, influenza, andwhooping cough. The first symptom of mumps, diphtheria, and scarletfever is a sore throat or swollen glands, which, because they commonlyaccompany a cold, are not at first distinguished from it. 

The first step for the teacher or mother in reading the index for coldsis to look into the coat closet for evidence of warm clothing andovershoes, then to note whether the children put them on when they goout for lunch or recess. Whether "cold" settles in the nasal passages, ear, or stomach depends upon which is the weak spot. Draughts, thinsoles, wet soles, exposure when perspiring, may be the immediate causeof the nutritional or respiratory disturbances that give cold germs afoothold. Adenoids, diseased teeth, inflamed ears, may furnish the foodsupply. "There is no use treating children and sending them onfresh-air trips as long as they have nutritional and digestivedisturbances due to bad teeth, or colds due to adenoids, " said aphysician when examining a party of children for a summer outing. Thegreat preventive measure to be taken for catching diseases, colds, diseased glands, --in fact all germ diseases, --is the repeated cleansingof those portions of the human body in which germs may findlodgment, --the mouth, the nose, the eyes, and the ears. 

In caring for young infants great pains is taken to cleanse all theorifices daily, but as soon as the child washes himself this practiceis usually abandoned. Washing these gateways is far more important thanwashing the surface of the body through which germs could not possiblygain entrance into the system except through wounds. Oftentimes thedouching of the nostrils with salt water will stop a cold at once. Themouth is the most important place of all, and the teacher should takecare of her pupils' mouths first and foremost. As bad teeth, enlargedtonsils, and adenoids harbor germs and putrescent matter that vitiateevery incoming and outgoing breath, these defects should be immediatelycorrected. Are we coming to a time when a thorough house-cleaning inthe mouth of every child will take place before he enters theschoolroom, preferably in the presence of the teacher?

Two other "catching" diseases cause city schools a great deal oftrouble, --trachoma and pediculosis (head lice). There are probably notwo diseases more quickly transmitted from one person to another. Almost before their presence is known, all children of a school or allpersons of a group have contracted them. When at college twenty men ofmy fraternity discovered almost at the same time that they had aninfectious eye trouble; yet we thought we were using different towelsand otherwise taking sanitary precautions. Last summer a Vassargraduate took a party of tenement children for a country picnic. Shereturned with head lice that required constant attention for weeks. What then may we expect of children who live in homes where there isneither water, time, nor privacy for bathing, where one towel mustserve a family of six, where mothers work for wages away from home andsee their children only before seven and after six?

Unfortunately for thousands of children, many parents still believethese troubles will be outgrown. Last summer a fresh-air agency in NewYork City arranged for several hundred school girls to go to a certaincamp for ten days each. The only condition was that the heads should befree from lice and nits (eggs). From the list furnished byschool-teachers--girls supposed to have been cured by schoolnurses--not one in five was accepted. A baby two weeks old, brought toCaroline Rest, had already begun to suffer from this easily preventablescourge. Of 1219 children examined in Edinburgh, Scotland, 909, or 69per cent, had some skin disease, and 60 per cent had sores due to headlice. Even when neglect has caused the loss of hair and ugly sores onthe head, mothers deceive themselves into believing that some othercause is responsible. 

Trachoma, if neglected, not only impairs the health of the eye, but maycause blindness. Tears carry the germs from the eye to the face, wherethey are taken up on handkerchiefs, towels, and fingers and infectother eyes. Of late, thanks to school nurses and physicians and hygieneinstruction, American cities have found relatively little trachomaexcept among recent immigrants. So dangerous is the germ and soinsidious its methods of propagation, that a physician should besummoned at once at the first sign of inflammation. Conjunctivitis isdue to a germ, and will spread unless checked. Since the board ofhealth of New York City has instituted the systematic examination ofthe eyes of the children in the public schools, it has found fully onethird affected with some form of conjunctivitis. Many of these casesare out-and-out trachoma, others acute conjunctivitis, and a largerproportion are "mild trachoma. " This last form of the disease is foundto a great extent among children who have adenoids. The adenoids shouldbe regarded as a predisposing factor rather than a direct cause. Therefore sore eyes are given as one of the indexes of adenoids. Whenwe consider that adenoids are made up of lymphoid material, and thattrachoma follicles are made up of the same sort of tissue, it is notsurprising that the two conditions are found in the same child. Thecatarrhal inflammation produced by adenoids in the nasal mucousmembrane travels up the lachrymal duct and thus infects the conjunctivaby contiguity. 

In preventing pediculosis and infection of the eye vigilance andcleanliness are indispensable. After the diseases are advanced, afterthe germ colonies have taken title, some antiseptic or germ killer moreviolent than water is needed, --kerosene for the hair or strong greenoil soap; for the eye, only what a physician prescribes. 

CHAPTER VII

EYE STRAIN

Wherever school children's eyes have been examined, from six to nineout of thirty are found to be nearsighted, farsighted, or otherwise inneed of attention. A child is dismissed from school for obstinatelydeclaring that the letter between _c_ and _t_ in "cat" is an _o_; "apupil in her fourth school year was recently brought to me by herteacher with the statement that she did unreasonably poor work inreading for an intelligent and willing child;" a boy is punished forbeing backward. These three cases are typical. Examinations showed thatthe first child was astigmatic and not obstinate; the boy had run a pininto one eye ten years before and destroyed its sight; while the secondgirl was found to be afflicted with diplopia, and in a friendly chattold the following story: "I very often see two words where there isonly one. When I was a very little girl I used to write every wordtwice. Then I was scolded for being careless. _So I learned that I mustnot 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 articlesand addresses freely illustrated from school experience, the art ofseeing is acquired, not congenital, and every human being who possessesit has learned it. 

The large proportion of children suffering more or less seriously fromeye trouble has led many persons to suggest physical deterioration asthe cause. Eye specialists, however, assure us that eye troubles areprobably as old as man. Our tardiness in learning the facts regardingthese troubles is due in part to the lack, until recently, ofinstruments for examining the eye and for manufacturing glasses tocorrect eye defects; in part, also, to the tendency of the medicalprofession, which I shall repeatedly mention, to explain disorders bycauses remote and hard to find rather than by those near at hand. 

About 1870 Dr. S. Weir Mitchell's attention was called "to the markedrelief of headache, insomnia, and other reflex symptoms following thecorrection of optical defects by glasses. " In 1874 and 1876 he wrotetwo articles that "impressed upon the general profession the gravesignificance of eye strain. " Since that time, "in Philadelphia atleast, no study of the rebellious cause of headache or of the obscurenervous diseases has ever been considered complete until a carefulexamination of the eyes has included them as a possible cause of thedisturbance. "

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 incipientpropaganda growing out of school tests that show the relation of eyestrain to headache, nervous diseases, stomach disorder, truancy, backwardness. 

Every school, private and parochial as well as public, should supplyitself with the Snellen card for testing eyes. Employers would do wellto have these cards in evidence also, for they may greatly increaseprofits by decreasing inefficiency and risks. If there is no expertoptician near, apply for cards to your health board or school board;failing there, write to your state health and school boards. In manystates rural teachers are already supplied with these cards by stateboards. In October, 1907, the New York state board of health sent outcards, with instructions for their use, to 446 incorporated towns. Thestate commissioner of education also sent a letter giving schoolreasons for using the cards. Results from 415 schools having shownthat nearly half the children had optical defects, it is proposed tosecure state legislation that will make eye tests obligatory in allschools. Such a test in Massachusetts recently discovered twenty-twoper cent of the school children with defective vision, and from fortyto fifty thousand in need of immediate care by specialists. 

 [Illustration: POSITIONS OFTEN SUGGEST EYE STRAIN]

Of course eye specialists, --oculists, --if skillful, know more abouteyes and eye troubles than general medical practitioners or teachers. Preliminary eye tests, however, may be made by any accurate person whocan read. The Massachusetts state board of health reports that testsmade by teachers were "not less efficient" than tests made byspecialists. In June, 1907, a group of eminent oculists recommended tothe school board of New York City that teachers make this first testafter being instructed by oculists. Persons interested in the schoolsnearest them can quickly interest teachers and pupils by starting testswith this card. In cities oculists can be found who will be glad toexplain to teachers, individually or in groups, how the cards should beused and what dangers to avoid. 

Nature intended the human eye to read the last line of this card at adistance of ten feet. This conclusion is not a guess, but is based uponthe examination of thousands of eyes. In making the test, the number offeet the eye ought to see is written as the denominator of thefraction; the distance the eye can see clearly is the numerator. If thechild's card reads, "Right eye 10/10, left eye 10/20, " it means thatthe right eye sees without conscious strain the distance it is intendedto see, while the left eye must be within ten feet to see what it oughtto 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) itdoes not register eye sickness due to dust, smoke, or disease germs;(2) it does not show unconscious eye strain due to successfulaccommodation. But it will discover a great part of the children whomost need care. Sooner or later, too, inflammation of the eyelids, dueto external causes, will affect the nerves of the eye and their powerto conceal by accommodation the eye's defects. Just as we unconsciouslyopen the mouth when a cold stops up the nose, the eye adapts itself toour needs without our realizing it. We expect it to see. It sees. Ifour eyes are not made alike, they do their best to work together. Likea good team of horses, the slow one hurries, the fast one holds back alittle. But if one eye is 10/15 and the other 10/10, they will both beunnatural and strained if both read the same type. The effects of thisstrain frequently upset the stomach before the eyes rebel. I learnedthat I needed eyeglasses after a case of protracted indigestion, firstdiagnosed as "nervous" and later traced to eyes. Thousands ofupper-grade children and college students are dieting for stomachtrouble that will last until the eyes are relieved of the undue andunrecognized strain. To prove the influence of eye strain onindigestion, persuade some obstinate parent to wear improperly focusedglasses for a day; she will then be willing to have her child's eyesattended to. 

It is unfortunate that the eyes will overwork without protesting. Foryears many persons suffer without learning that their eyes are unlike, or, as often happens, that one eye does all the close range work. Evenwhen being tested, eyes will seem to see easily what requires a greateffort of "accommodation. " To prevent this self-deception skilledoculists do not trust the eye card, but put a drug in the eye thatbenumbs the muscles of accommodation. They cannot contract or expand ifthey want to. The oculist then studies the length of the eye and themuscle of accommodation. With this absolute knowledge of how each eyeis made he knows what is wrong, exactly at what angle light enters theeye, whether objects are focused too soon or too late, exactly whatkind of eyeglasses or what operation upon the eye is needed to enableit to do its work without undue straining or accommodation. Sounconsciously do the eyes accommodate themselves to the work expectedof them that not infrequently a child with seemingly perfect sight maybe more in need of glasses than the child with imperfect sight. Practically, however, it is out of the question at the present time tohave the majority of children given a more thorough test than thatprovided by the Snellen card. Where eye strains escape this testteachers will find evidence in complaints of headache, nervousness, sick stomach, chorea, or even epilepsy. The constant strain may alsocause red or inflamed lids. Parents and teachers must be on theconstant lookout for these symptoms of good sight persisting in spiteof imperfect eyes. 

An epidemic of eyeglasses is usually the consequence of eye tests. Sonaturally do we associate eyeglasses with eye defects that some peopleassert that the eye tests at school originate with opticians moreintent upon selling spectacles than upon helping children. In fact, even among educators who proclaim the need for eye tests there has beenfar more talk of eyeglasses than of removable conditions that cause eyestrain. 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 ofabusing children's eyes. Putting glasses on children without changingcausal conditions is like giving alcohol to consumptives. The feelingof relief is deceptive. The trouble grows worse. 

For some time to come eye tests will find eye troubles by the wholesalein every industrial and social class, in country as well as cityschools. In 415 New York villages 48. 7 per cent of school children haddefects of vision, --this without testing children under seven, --while11. 3 per cent had sore eyes. 

There are three possible ways of remedying defects: (1) changing theeye by operation; (2) changing the light as it enters the eye byeyeglasses; (3) decreasing the demands made upon the eye. To changeeyes or light requires a technical skill which few physicians as yetpossess. It will be remembered that it is but thirty years since themedical profession in America first began to understand the relation ofeye defects to other defects. Until a generation of physicians has beentrained by medical colleges to learn the facts about the eye and toapply scientific remedies, it is especially necessary that teachers andparents reduce the demands made upon children's eyes; oral can besubstituted for written work, manual for optical work, relaxed andnatural movement for discipline, outdoor exercise for less home study. Other requirements are suitable light and proper position, andabolition of shiny paper, shiny blackboard, and fine print. Even afterit is easy to obtain the correction of eye defects it will still benecessary to adapt the demands upon children's eyes to the strength andshape of those eyes. Because we are born farsighted, nearsighted, andastigmatic, we must be watchful to eradicate conditions that aggravatethese troubles. Finally, there is no excuse whatever for permitting theparent of any school child in the United States to remain ignorant ofthe fact that it is just as absurd to go to the druggist or jeweler foreyeglasses as to the hardware store for false teeth. 

The education of physician, oculist, and optician can be expedited byeye tests in school and by the follow-up work of schools in removingthe prejudice of parents against glasses when needed. Because knowledgeof chemistry preceded knowledge of the human body, the teaching ofmedicine still shows the effect of predilection for the remote, theproblematical, the impossible. This predilection has influenced manyspecialists as well as many general practitioners, both overlooking toofrequently obvious causes that even intelligent laymen can be taught todetect. Very naturally the man who makes money out of attention tosimple troubles has stepped into the field not as yet occupied by thegeneral practitioner and the specialist. Thus we have the optician, thepainless tooth extractor, and quack cures for consumption. Opticiansare placing before hundreds of thousands simple truths about the eyenot otherwise taught as yet. Because they make their money by sellingeyeglasses and because their special knowledge pertains to glassesrather than to eyes they frequently fail to recognize theirlimitations. 

Physicians feel very strongly that it is as unethical for an opticianto fit eyeglasses without a physician's prescription as for apharmacist to give drugs without a physician's prescription. Thejustification for this feeling should be based not upon the commercialmotive of the optician but upon his ignorance. A physician uninformedas to eye troubles is just as unsafe as an optician determined to sellglasses. It must be made unethical and unprofessional for physician andoptician alike to prescribe in the dark. Laymen and physicians must betaught that it is just as unethical and unprofessional for oculists andphysicians to fail to bring their knowledge within the practical reachof the masses as for the optician to advertise his wares. School testswill not have been used to their utmost possibilities until opticianand physician alike take the ethical position that the firstconsideration is the patient's welfare, not their own profits. It mustsoon be recognized as unethical and unprofessional for an optician whois also a skilled physician to refer patients to a medical practitionerignorant as to optical science. 

Whether opticians and physicians are unprofessional or unethical may betold by reëxamination if the _examiner_ is himself competent andethical. There is no better judge of their efficiency than the patienthimself, who can tell whether the results promised have been effected. Whether the work of a country oculist is efficient and ethical can belearned: (1) by teaching country school children to recognize eyestrain; (2) by comparing his results with those of other physicians. Assoon as one or two states have tested eyes, we shall have an average bywhich to compare each class, school, and city with others of their sizeunder similar conditions. If a particular physician finds half as manymore or only half the average number, the presumption will be that hisresults are inaccurate and warrant an investigation. The interestedteacher or parent can render an inestimable service to her local schooland to the children of her state by taking steps to secure state lawscompelling eye tests in all schools. 

Finally, it must be remembered by teachers, employers, parents, and alleye users that eyes are constantly changing; that eyes may need glassessix months after they are examined and found sound; that glasses changeor develop the eye, so that they may be unnecessary and harmful sixmonths after they are prescribed, or the eye may require a strongerglass; that eyeglasses become bent and scratched, so that they worryand strain the eye; that a periodic examination is essential to thehealth of the eye. 

In caring for the health of the eye, we should also remember that oureyes are our chief interpreters of the world that gives us problems, profits, and pleasures. Out of gratitude, if not out of enlightenedself-interest, we owe our eyes protection, attention, and training, sothat without straining we shall always be able to see truth andbeauty. 

CHAPTER VIII

EAR TROUBLE, MALNUTRITION, DEFORMITIES

The presence of adenoids is a frequent cause of both slight andaggravated deafness. Of 156 deaf mutes examined 59 per cent hadadenoids, while only 6 per cent of the general run of the children inthe neighborhood had this trouble. In mouth breathing, the current ofair entering the mouth draws out some of the air from the Eustachiantube which ventilates the middle ear and unequalizes the atmosphericpressure on the eardrum, causing it to sink in and to blunt thehearing. An examination of the eardrums of school children in New Yorkwho are mouth breathers showed a high percentage of deafness, incipientor pronounced, accompanying adenoids. For example, of 9 mouth breathersselected from one class (average age 7-8 years), 6 were well-markedcases of deafness. Of 8 mouth breathers (average age 8-9 years), and of5 mouth breathers (average age 5-6 years), all had noticeable defectsof hearing. Many adults that suffer from deafness maintain that theynever had any trouble in childhood. Yet the evidences of nose andthroat trouble in childhood persist and disprove such statements. _Thefoundations of deafness in later life are, in most instances, laid inchildhood. _ Since the majority of cases of ear trouble occurring inschool children accompany diseased conditions of the nose and throat, the proper care of nose and throat will, in large measure, balance theshortcomings of the aural examinations. Since the examination of thedrum itself is not practicable, especial care should be given to theexamination of the nose and throat. 

The figures published by New York City's department of health show thatof 274, 641 children examined from March, 1905, to January, 1908, 3540, or 1. 2 per cent, gave evidence of defective hearing. Ear specialistssuggest that this small percentage results from employing the whispertest at twenty feet. The whisper test at sixty feet has been set byexperts as a test of normal hearing. But preciseness with this test iswell-nigh impossible when we consider that the acoustics, the qualityof the examiner's voice, the weather, the vowel or consonant sounds, all are variable quantities. The watch test is frequently used, butsince a young teacher in her enthusiasm used an alarm clock to make thetest, specialists have decided that the volume of sound differs inwatches to such a degree as to make the watch test unreliable. Theexamination of the eye has been reduced to mathematical precision, duealtogether to the anatomy of that organ. As yet there is no instrumentfor the ear comparable to the ophthalmoscope. The acoumeter is largelyused by aurists and can be obtained from the optician. This instrumenthas an advantage over the whisper or watch tests in that its tick isuniform. 

Each ear should be tested separately. Let the child place his fingeragainst the flap of one ear while the other is being tested. Thencompare the farthest distance from the ear at which the tick can beheard with the normal, standard distance. During the test all soundshould be eliminated as far as possible and the eyes should be closed. At a demonstration of ear testing at Teachers College, one studentstated that she could not hear the tick of the watch at a distancegreater than twenty inches. Then the tester walked noisily toward her, leaving the watch on the desk, five feet away from the patient. Sheheard it now. When the class burst out laughing she opened her eyes, and, seeing the watch so far away, exclaimed, "Why, I thought Iimagined it. " Be careful in testing a child to distinguish between whathe "thinks he imagines" and what he really hears. Because of thedifficulties of this test a doubt should be sufficient to warn theteacher to send the child to be tested by an expert. Detection ofslight deafness may lead to the discovery of serious defects of nose orthroat. Inflammation from cold or catarrh may cause deafness, which ifneglected may permanently injure the ear. Often deafness is due to anaccumulation of wax. A running ear should receive immediate attention, as it is an indication of inflammation which may imperil the integrityof the eardrum, and, if neglected, may eat its way through the thinpartition 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 ofhearing and should cause the teacher to examine the ears. No eartrouble is negligible. Children and parents should be taught that thenormal ear is intended to hear for us, not to divert our attention toitself. When the ear aches or "runs" or rumbles there is somethingwrong, 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 theform of nervous disease known as St. Vitus's Dance, or chorea. So proneare we to overlook moderate evils and moderate needs that the childwith aggravated St. Vitus's Dance is apt to be cured sooner than thechild who is just "nervous. " Teachers cannot know whether twitchingeyes, emotional storms, constant motion of the fingers or feet are dueto chorea, to malnutrition, to eye strain, or to habits acquired inbabyhood or early childhood and continued for the advantage thataccrues when discipline impends. Many a child treasures as his chiefasset in time of trouble the ability to lose his temper, to have a"fit, " to exhibit nervousness that frightens parent, teacher, orplaymate, incites their pity, and wards off punishment. The schoolexamination 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 ofschool children by exaggerated estimates of the number of children whoare underfed. As fast as figures were obtained for eye defects, breathing defects, bad teeth, some one was ready to declare that thesewere results of underfeeding. Hence the conclusion: give children atleast one meal a day at school. Scientific men began to set us straightand to give undernourishment a technical meaning, --soft bones, flabbytissue, under size, anæmia. While too little food might cause thiscondition, it was also explained that too much food of the wrong sort, or even food of the right sort eaten irregularly or hurriedly orpoisoned by bad teeth, might also cause undernourishment, including theextreme type known as malnutrition. In extreme instances the symptomsenable an observant teacher who has learned to distinguish between thepretty hair ribbon and clean collar and the sunken, pale, or hecticcheek and lusterless eyes to detect the cause. But as with eyes andnose, an unhealthy condition of nourishment may exist long beforeoutward symptoms are noticeable. Therefore the value of the periodicsearching 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, anklesores, spine and hip troubles, scrofula, running sores at joints, etc. , are not hereditary and inevitable, but are rather the direct result ofcarelessness on the part of adult consumptives. These conditions inschool are indices of homes and houses where tuberculosis is or hasbeen active, and of health boards that are or have been inactive inchecking the white plague. Early examination may disclose the smalllump 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 sisterswill 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 smallor big lumps under one or more jaws. Only physicians can find verysmall 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 ofthe lymphatic system, as adenoids prevent free breathing. Even when notactually infected with tubercle bacilli, they are fertile soil for theproduction of these germs. If detected early, they point to homeconditions and personal habits that can be easily corrected. In NewYork one child in four has these enlarged glands. If the sameproportion prevails in other parts of the United States, there are5, 400, 000 children whose strength is being needlessly drained, many ofwhom, 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 willdisappear. " This was an unexpected contribution to the debate upon freeeyeglasses for the school children of New York City. So little do mostof us realize the importance of sound, clean teeth, and theinterrelation of stomach and sense nerves, that even the schoolprincipals thought the eye specialist was exaggerating when he declaredthat 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 agreat many, probably the majority, do not appreciate that "bad" teethmean indigestion, lowered vitality, plague spots for contaminatingsound teeth and for breeding disease germs. Until recently the onlyrule about the teeth of new recruits in the United States army was:"There must be two opposing molars on each side of the mouth. Itdoesn't matter how rotten these molars may be. " The surgeon general waspersuaded to change to "four opposing molars on each side"; stillnothing as to the condition of the two additional molars! In the Germanarmy there is a regular morning inspection of teeth and toothbrushes. Several German insurance companies give free dental treatment to policyholders, not to bestow charity but to increase profits. 

Neglecting "baby teeth" and adenoids may mean crooked second teeth thatwill cause: (1) hundreds of dollars for straightening; (2) permanentbusiness handicap because crooked teeth are disagreeable to others, because mastication is less perfect, and because a disfigured mouthmeans dis-arranged nerves; or perhaps (3) large dental bills because itis difficult to clean between cramped, crooked teeth. 

Unfortunately the great majority of parents rarely think of theirchildren's teeth until too late to preserve them intact. Even amongfamilies where the rule of brushing the teeth twice daily prevails, regular dental examination is often not required. Doctors and dentiststhemselves have not been trained to realize that the teeth are a mostdangerous source of infection when unclean. Does your dentist insistupon removing tartar and food particles beyond your reach, uponpolishing and cleansing, or does he regard these as vanity touches, tobe omitted if you are in a hurry?

 [Illustration: INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL]

Physicians send tuberculosis patients to hospitals or camps withoutcorrecting the mouth conditions that make it impossible for the patientto eat or swallow without infecting himself. Tonics are given to womenwhose teeth are breeding and harboring disease germs that tear downvitality. Nurses watch their suffering patients and do the heaviertasks heroically, but are not trained to teach the simple truths aboutdental hygiene. The far-reaching results of neglect of teeth will notbe understood until greater emphasis is placed on the bacteriology, theeconomics, the sociology, and the æsthetics of clean, sound teeth. Whether or not there is at present a tendency to exaggerate theimportance of sound teeth, there is no difference of opinion as to thefact that the teeth harbor virulent germs, that the high temperature ofthe mouth favors germ propagation, that the twenty to thirty squareinches of surface constantly open to bacterial infection offer anextensive breeding ground, and that the formation of the teeth invitesthe lodgment of germs and of particles of food injurious both to teethand to other organs. 

By scraping the teeth with the finger nail and noticing the odor youcan convince yourself of the presence of decomposing organic matter nothealthful to be carried into the stomach. By applying a little iodineand then washing it off with water, your teeth may show stains. Thesestains are called gelatinous plaques, which are transparent andinvisible to the naked eye except when colored by iodine. These plaquesprotect the germs, which ferment and create the acid which destroystooth structure. Their formation can be prevented by vigorous brushingand by eating hard food. 

The individual with decayed teeth, even with unclean teeth, is open toinfection of the lungs, tonsils, stomach, glands, ears, nose, andadenoid tissues. Every time food is taken, and at every act ofswallowing, germs flow over the tonsils into the stomach. Mouthbreathers with teeth in this condition cannot get one breath ofuncontaminated air, for every breath becomes infected with poisonousemanations from the teeth. Bad teeth are frequently the sole cause ofbad breath and dyspepsia, and can convey to the system tuberculosis ofthe lungs, glands, stomach, or nose, and many other transmissiblediseases. They may also cause enlarged tonsils and ear trouble. 

Apart from decomposing food and stagnant septic matter from salivainjured by indigestion, and by sputum which collects in the healthymouth, there are in many infected mouths pus, exudations from theirritated and inflamed gum margins, gaseous emanations from decayingteeth, putrescent pulp tissue, tartar, and chemical poisons. Everyspray from such a mouth in coughing, sneezing, or even talking orreading, is laden with microbes which vitiate the air to be breathed byothers. Indigestion from imperfect mastication and imperfect salivation(themselves often due solely to bad teeth) is far less serious thanindigestion from germ infection. Germs taken into the stomach can sochange the composition of saliva (a natural disinfectant when healthy)as to render it no longer able to kill germs. Indigestion may result inexcess of uric acid and toxic material, so that the individual becomessubject to gout and rheumatism, which in turn frequently destroy thebony support of the teeth and bring about Riggs's Disease. The lastnamed is a prevalent and disfiguring disease, whose symptom is recedinggums. The irritating toxins deposited on the teeth cause inflammationof the tissues at the gum margins. The gums withdraw more and more fromsections of the teeth; the poisons get underneath and work back towardthe roots; the infection increases and hastens the loosening of theteeth. I know of a man who had all of his teeth extracted at twenty-oneyears of age, because he was told that this was the only treatment forthis disease, which was formerly thought to be incurable. Yet thoroughcleansing and removal of this matter from under the edges of the gums, disinfection, a few visits to the dentist, will stop the recession butcannot regain lost ground. 

Among those who regularly use the toothbrush, instinct, comfort, ordisplay is the ruling motive, while a small percentage have evolved tothe anti-nuisance stage, where the æsthetic standard of their groupforbids any member to neglect his teeth. The anti-slum and pro-slummotives for mouth cleanliness and dental sanitation have been awakenedin but one or two places. A significant pro-slum activity is the dentalclinic organized by forty volunteer dentists, acting for an industrialschool 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 teethfilled, 200 teeth treated for diseased pulp (and only 24 sets cleaned), 40 dentists taking turns in giving time to this work. The equipmentcost but $239; cards and stationery, $72; incidentals, $33. Theprincipal attends the clinic, because in her presence no child iswilling to confess fear or unwillingness. To supplement this work, thedentists have prepared for free distribution a leaflet which tells inshort, 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, dentaloffices, schools, and from many Sunday schools and missions. [5]

The time for the schools to begin is when the child is firstregistered. Examination and reëxamination must be accompanied byexplanation of the serious disadvantages of neglected teeth, and thephysical, social, and economic advantages of clean, sound teeth. Instruction at school must be followed by education of parents. Theschool or health authorities should examine the teeth of all childrenbefore issuing work certificates. Finally, the dental, medical, andnursing professions and the press must be enlisted in the school'scampaign for dental hygiene. The Dental Hygiene Council ofMassachusetts 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 detectedby a layman's naked eye. In fact, children can be interested in findingthe most obvious defects in their own or their brothers' teeth. Therecould be no better first lesson than to ask each pupil to look in ahand mirror and to count each tooth obviously needing a cleaning or afilling. The most urgent need can thus be ascertained without expertaid. But because parent, teacher, or child cannot discover defects doesnot prove that dental care is not imperative; hence the importance ofexamination by a dentist or by a physician competent to discover dentalneeds. If a private, public, or parochial school has no paid visitingdentist, a zealous school officer can, at least in large towns, persuade one or more dentists or physicians to make a few first teststo confirm the teacher's findings, and to persuade the community thatregular examination and reëxamination are necessary and a saving ofpain, beauty, and money. 

Reëxamination is necessary because decay _may_ start the day after adentist has pronounced a tooth sound. For most of us twice a year isoften enough. A reëxamination should be made upon the slightestsuspicion of decay, breaking, or loosening. 

Educational use should be made by the teacher of the results of schoolexamination. Children cannot be made self-conscious and cleanly bytelling 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 everynight if they once realize that cavities can be caused only by _mouthgarbage_. All decay of human teeth starts from the outside through theenamel that covers the soft bone of the tooth. This enamel can bedestroyed by accidentally cracking or breaking it, or by acids eatinginto it. These acids come from (1) particles of food allowed to remainin the teeth; (2) tartar, etc. , that adheres to the teeth and can beremoved only by a dentist; (3) saliva brought up from anill-conditioned stomach. Even where the enamel is destroyed, absolutecleanliness will prevent serious decay of the tooth. A perfectly cleantooth will not decay. Generally speaking, unless particles of food orremovable acids remain on or between the teeth long enough todecompose, teeth cannot decay. Decay always means, therefore, uncleanliness. To unclean teeth is due in large part the offensive odorof many schoolrooms. 

Uncleanliness becomes noticeable to our neighbors sooner or later. There is no offense we are so reluctant to commit as that of havinguncleanliness of our bodies disagreeable to those about us. Very youngchildren will make every effort in their power to live up to theschool's standard of cleanliness. The other side to this reason forhaving clean teeth is vanity. Because all cleanliness is beautiful tous, clean teeth are one attribute of beauty that all of us can possess. 

Habits of cleanliness are easily fixed. In the most crowded, mostoverworked section of large cities visitors from "uptown" are surprisedby the children's bright hair ribbons, clean aprons, clean faces, andsmoothly combed hair. It will be easy to add clean teeth to the list ofthings necessary to personal and family standing. Armenian childrenare taught to clean their teeth after eating, even if only an applebetween meals. They covet "beautiful teeth. " American standards willsoon prevent these Armenians from cleaning their teeth in public, butdesire for beautiful teeth will stay, and will remind them to care fortheir teeth in private. As coarse food gives way to sugars and softfoods, stiff toothbrushes must supplement tongue and toothpicks. 

 [Illustration: AN ARMENIAN SCHOOL GIRL]

Strong as are the instinct and display motives in cleaning teeth, bothparents and children need to be reached through the commerce motive. Instinct makes children afraid of the dentist, or content when thetooth stops aching. Display may be satisfied with cleaning the frontteeth, as many boys comb only the front hair or as girls hide dirtyscalps under pompadours and pretty ribbons. Desire to save money maygive stronger reasons for not going to the dentist than instinct andcomfort can urge for going. But parents can be made to see, as canchildren after they begin to picture themselves as wage earners, that adentist in time saves nine, and that no regular family investment willearn more money than the price of prompt and regular dental care. Aproblem in arithmetic would be convincing, if, by questions such asthose on page 98, we could compare the family cost of neglecting teethwith the cost of toothbrushes, bicarbonate of soda, pulverized chalk ortooth powder, early and repeated examination by a dentist, andtreatment 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 cleanand in repair the teeth of the entire family. How effective andeconomical is thorough cleaning is confessed by an eminent dentist, whotaught an assistant to clean his patients' teeth. "Do you know, " hesaid, "I had to stop it, so perceptibly did my work decrease. " Thetotal time required to examine school children for teeth needingattention is much less than the time now lost by absence from school orwasted at school on account of toothache. 

To remind school children regularly of dental hygiene is not moreimportant than for the school to remind parents repeatedly of the manyreasons 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 veryserviceable, but listening is a poor substitute for understanding. Schools should see that parents understand the æsthetics, theeconomics, the humanity of dental hygiene. The best test of whetherthe parent has understood is the child's tooth. 

Dental examination of children applying for work certificates gives thehealth and school authorities a means of enforcing their precepts. Whenno child is allowed to go to work whose teeth cause malnutrition ordisgust, the news will spread, and both child and parent will seeclearly the grave need for dental care. 

 [Illustration: WON BY THE ECONOMIC ARGUMENT]

Finally, local papers can be interested. They will print almostanything the teacher sends about the need for dental care. They likeparticularly facts about the number of cavities found, the number ofchildren needing care, efforts made to procure care, and new factsabout diseases that can be caused by bad teeth or about diseases thatcan injure teeth. Teachers can persuade dentists and physicians towrite stories. No newspaper will refuse to print such statements asthis: "A tuberculous patient in six weeks lost ground steadily. Ipersuaded him to go to a dentist to clean the vestibule to hisdigestive system, and to have a set of false teeth. He enjoys hismeals, and has gained twelve pounds in six weeks. " Popular magazinesand newspapers mention teeth seldom, because those who best know theinteresting vital things are making money, not writing articles orotherwise concerning themselves with dental education. It is said thatof forty thousand American dentists not over eleven thousand arereaders of dental journals, and probably not three hundred contributeto professional literature. One dentist who is working for thechildren's clinic described above, when asked by the board of educationto lecture to the people on the care of the teeth and to recommendsimple, 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 dentistserviceable for his knowledge rather than for his time and gold. 

Good dentists really "come too high" for both the poor and thecomfortably situated. Families in New York City that have four or fivethousand dollars a year hesitate to go to a dentist whom theythoroughly trust, because his time is worth more than they feel theycan afford to pay. 

The "free-extraction" dental parlors undoubtedly are doing a vastamount of harm. In every city are dental quacks that injurewage-earning adults as much as soothing-sirup quacks injure babies. Instead of teaching people to preserve their teeth, they extract, andthen, by dint of overpersuading by a pretty cashier hired for thepurpose, make a contract for a gold crown or a false set at anexorbitant price. A reputable dentist has said that a dental parlor cando more damage to the welfare of the race in a few months than awell-intentioned man in the profession can repair in a lifetime. Itsquestion is not, What can I do for this patient? but What is there inthis mouth for me? Many "parlors" never expect to see the same persontwice, 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 theexamination at first leads one to expect; refuse to correct mistakes;deny having ever seen the patient before. Yet true and severe as thisarraignment is, many of these parlors, with their liveried "runnersin, " are doing an educational service not otherwise provided; it isconceivable that in many cities they are doing less harm by theirmalpractice than well-intentioned men in the profession by neglect ofpublic needs or by failure to organize facilities for meeting thoseneeds. 

I realize that advertising is "unethical" among dentists as amongphysicians. Humbug and imposition are supposed to go inevitably withself-advertising by the methods used in selling shoes or automobiles. Therefore such advertising is prohibited. But what seems to beforgotten in this definition of ethics is that the need and theopportunity for dental care must be advertised in some way, if we areever to control diseases and evils due to bad teeth. The rich that onedentist can help are able to pay for his good taste, his neatattendants, his automobile, his club dues, his vacations at fashionableresorts, his hours without work, his standard of living. All of thesethings advertise him, just as hospital appointments and social positionmay and do advertise successful physicians. The patients of moderatemeans that one dentist can treat cannot afford to pay for rent, timedisengaged, and indirect advertising. Either they must have freetreatment, must go without treatment, or must go to a dental parlorwhere dental needs are organized so that a very large number willcontribute to rent and display. It is out of the question to have bothdentists and patients so distributed and prices so adjusted thatdentists can make a good living by charging what the patient canafford, and at the same time admit of every patient being properlytreated when necessary. Judging from every other branch of work, thesolution of the problem lies partly in free care for those who can paynothing or very little, and partly in coöperative treatment through theheretofore objectionable dental parlors. If instead of inveighingagainst advertisers, honorable and capable dentists worked throughdental and medical societies to secure adequate public supervision ofdental practice, more progress would be made against dentalmalpractice. 

Dental clinics will quickly follow the publication of facts thatschools should gather. In some places these should be separate; but atfirst the best thing is to make every hospital, every children's home, every settlement a clinic, and every school an examining center. Askilled dentist informs me: "The demand that will follow examination ofschool children's teeth will make it profitable for young dentists toadopt a coöperative scheme, where several young men hire a parlor in acheap district, and, under the supervision of some experienced dentist, give good advice at reasonable rates. This is the best antidote to thedental parlor which exploits the public so shamelessly. " BellevueHospital in New York is the first general hospital to establish regulardental examination; others will undoubtedly soon follow. 

Dental education for profit rather than for instruction and for healthhas been the rule. Even where universities have put in dental courses, they have demanded a net profit from tuition. Instead of protectingsociety against men incapable of caring for teeth, the schools havemarketed certificates to as large numbers as slowly enlightenedself-interest would permit. Much progress has been made toward uniformstandards of admission and graduation, but dental colleges sadly needthe light and the inspiration of school facts about teeth. 

Of fourteen dental journals in America, only one has the advancement ofdental science as its first reason for existence. Thirteen are tradejournals. Not one of these would print articles proving that thesupplies advertised by their backers were inimical to dental hygiene. Many dental colleges still retain on their faculties agents or editorsin the pay of supply houses, Harvard's new dental school being anotable exception. This trade motive tolerates and encourages thedisreputable practices of existing dental parlors. Largely because ofthis prostitution of the dental profession, patients generally neglectthe repairing and cleansing of the teeth and the sterilizing of themouth from which germs are carried to all parts of the body. Dentaljournalism for the sale of supplies cannot outlive the dentist'sreading of the school's index. 

Many dentists will say that they must learn dentistry before they learnthe economics and sociology of clean teeth. Being a young profession, it is natural that dentistry should first devote itself to learning itsown mechanics, --the tricks of the trade--how to fill teeth. But thefact that it took the medical profession centuries to begin to feelresponsibility for community health is no reason why the social senseof the dentist should be dormant for centuries or decades. We needtraining and exercise to determine what kind of filling will be mostcomfortable and most serviceable; whether the pulp of the teeth needstreating or removing before the filling is inserted; whether it isworth while to fill a deciduous or baby tooth. Sociology will nevertake the place of dental technic. The few dentists who have studied thesocial significance and social responsibility of their professiondeclare, however, that careless workmanship and indifferent educationof patients continue chiefly because dentists themselves do not see thecommunity's interest in dental hygiene. The school can socialize orhumanize the dental profession if teachers themselves possess thesocial sense and make known the facts about the need for dental careamong school children. 

FOOTNOTES:

[5] _The Teeth and Their Care_, by Thaddeus P. Hyatt, D. D. S. , is ashort, concise treatment of the principles of dental sanitation. 

CHAPTER X

ABNORMALLY BRIGHT CHILDREN

What is commonly considered abnormal brightness in a school child isoften a tendency to live an abnormal physical life. Being a childbookworm means that time is spent indoors that should be spent playinggames with one's fellows. Excellence in the activities of children, notability to imitate the activities of adults, should be the test ofchild brightness. To be able to hit a bull's-eye, to throw a ballaccurately, to calculate the swing of a curve or the bound of a"grounder, " these are tests of brightness quite as indicative of mentalpower as the ability to win highest marks in school, while lessinjurious to physical power. The child who is abnormally brightrequires special treatment just as much as the child who is abnormallydull. The former as well as the latter must have his abnormal conditioncorrected if he is to grow into a normally bright man. 

The college man who sacrifices health to "marks" is thus described bythe 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 suggestedto put a physical qualification upon the candidates of Phi Beta Kappaand their awards of scholarship. If scholarship men cannot be inducedto take time to improve their physique for fear of lowering theircollege standing, then give them credit for standing in physical work. 

The abnormally bright, at whatever age, is as much a subject forexamination and treatment as the child with adenoids and pulmonarytuberculosis. Such attention will increase the percentage of abnormallybright schoolmates who figure in active business in later life. Moreover, it will decrease the number of high school superintendentswho declare that their honor pupils are physical wrecks. 

There are children who develop very rapidly, both physically andmentally, and whose mental superiority is not at the expense of theirbodies. Protection of such children requires that their minds bepermitted to progress as rapidly as bodily health justifies. It is ascruel to keep back a physically and mentally superior child, as to pushthe physically or mentally defective beyond his powers. Worry andfatigue can be produced by lack of interest as well as by overwork. "Normal" should not be confused with "average. " To keep a bright childback with the average child--marking time till the dull ones catchup--is to make him abnormal. The tests that we have employed forgrading pupils are either the tests of age in years or of mentalcapacity. The first takes no account of slowness or rapidity ofphysiological development, --of physiological age. The second encouragesmental activity at the expense of physique. The entrance of a childinto school, the promotion from one class to another, the entrance intocollege, are thus determined either by the purely artificial test ofage or by the individual teacher's discretion. There is nothing toprevent the ambitious teacher or the ambitious parent from pushing achild into kindergarten at four, high school at twelve, college atfifteen. If this cannot be done at the public school, a private schoolis resorted to. A community of college professors once started a schoolfor faculty children. A tremendous pressure was put upon these scionsof intellectual aristocracy to enter the high school at twelve. Nothought was given to the ventilation of the school. The windows wereso arranged that they could not be opened without the air blowing onsome child's back. "You could cut the air with a knife" was adescription given by one sensible professor who had taken his sturdygirl of seven away from the school, because he feared that in thisenvironment 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 usualor the expected to the attention of this clinic. Every month a bulletinis published called the _Psychological Clinic_, which will be found ofgreat service in dealing with the abnormally bright as well as with theabnormally dull. Naturally the well-to-do and the rich are the first totake advantage of these special facilities for ascertaining just whatwork should be done by a precocious child or by the mentally andmorally retarded. 

Abnormal brightness means power to be happy and to be serviceable thatis above the average. Every school can be a miniature psychologicalclinic. While every teacher cannot be an expert, national and statesuperintendents can constantly remind teachers that the abnormallybright are also abnormally apt to neglect physical welfare and toendanger future mental power. 

CHAPTER XI

NERVOUSNESS OF TEACHER AND PUPIL

Nervousness of teacher and pupil deserves special mention. So universalis this physical defect that we take it for granted, especially forteachers. Teachers themselves feel that they need not even apologizefor nervousness, in fact they too frequently use it as an excuse forimpatience, ugly temper, discourtesy, and unfairness. Children, slates, papers, parents, blackboards "get on their nerves. " Nervousness ofteacher causes nervousness of pupils and adds to the evil results ofmouth breathing, bad teeth, eye strain, and malnutrition. Theseconditions, added to bad ventilation, bad light, and an overcrowdedschoolroom, render the atmosphere thoroughly charged withelectricity--nerves--toward the end of the day. Lack of oxygen tobreathe as well as inability to breathe it; lack of well-printed booksand 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 unwholesomephysical conditions. If the teacher attempts to treat these causes bycrushing the child, she makes confession of her own nervousness andinadequacy and visits her own suffering upon her pupils. A transfixingglance prolonged into an overbearing stare, a loud, sharp voice, arough manner, are successful only so far as they work on thenervousness of her pupil. She finds that it is temporarily effective, and so by her example and practice sets the child an example in losingcontrol of himself. The position often assumed by school children whenbefore authority, of hands held stiffly at the side, head drooped, androving eye, does not mean control: it means a crushed spirit, hypocrisy, or brooding anarchy. The mother or teacher who obtainsobedience by clapping her hands, pointing her finger, distorting herface, is copying in her own home the attitudes of caste in India, ofserfdom in Russia, the discipline of the prison the world over, amodern reminder of the power of life and death or of physical torture. 

A young college girl unfamiliar with the ways of the public school wassubstituting in the highest grammar grade. The time for civics arrived. Here, she thought, is a subject in which I can interest them. The boysshowed a vast amount of press information, as well as decided opinionson the politics of the day. The candidates which they elected for theposition of ideal American patriot were Rockefeller, Lincoln, andSharkey the prize fighter. During the ensuing debate, which gave backto Lincoln his proper rank, the boys in the back of the room had movedforward and were sharing seats with the boys in the front. Every boywas engrossed in the discussion. The room was in perfect order, --not, however, according to the ideas of the principal, who entered at thatmoment to see how the new substitute was managing the class, famed forits bad boys. With the stern look of a Simon Legree she demanded, "Howdare you leave your seats!" When one child started to explain sheshouted: "How dare you speak without permission! Don't you know yourteacher 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 hadbefore them the prospect of "work papers" and a grind less monotonousand more productive than the principal's discipline. She was a victimof a nerve-racking system, more sinned against than sinning. 

There is nothing in school life _per se_ to cause nervousness. Given awell-aired, sunny room, where every child has enough fresh air tobreathe, where he can see without strain, where he has a desk fitted tohis body and work fitted to his maximum abilities, a teacher who isphysically strong and mentally inspiring, and plenty of play space andplay time, there will be no nervousness. One who visits vacationschools is struck with the difference in the atmosphere from that ofthe winter day schools. Here are the same rooms, the same children, andin many cases the same teachers, but different work. Each child is busywith a bright, interested, happy expression and easy attitude. Some areat nature study, some are weaving baskets, making dresses, trimminghats, knitting bright worsted sacks and mittens for the winter. Boysare at carpentering, raffia, or wrought-iron work. In none of the roomsis the absolute unity or the methodical order of the winter schoolroom, but rather the hum of the workroom and the order that comes from aroomful of children interested in the progress of their work. Thiscondition only illustrates what a winter schoolroom might be werephysical defects corrected or segregated, windows open, light good, andwork adapted to the child. 

 [Illustration: VACATION SCHOOL INTEREST: AN ANTIDOTE TO NERVOUSNESS]

Nervousness is not a monopoly of city teachers and city pupils. Incountry schools that I have happened to know, nervous children were thechief problem. Nervousness led in scholarship, in disorder, inabsences, in truancy, and in backwardness. After reading MacDonald's_Annals of a Quiet Neighborhood_, I became interested in one or twoparticularly nervous children, just to see if I could overcome mystrong dislike for them. To one boy I gave permission to leave the roomor to go to the library whenever he began to lose his self-control. Mypredecessors had not been able to control him by the rod. A few weeksafter Willie's emancipation from rules, the county superintendent wasastonished 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, --therelation of eye strain, bad teeth, adenoids, "overattention, " andmalnutrition to nervousness and bad behavior, --I could have restoredmany "incorrigibles" to nerve control. Had I been led at college tostudy child psychology and child physiology, I should not have expecteda control that was possible only in a normal adult. [6] In its primaryaspect the question of nervousness in the schoolroom is purelyphysiological, and the majority of principals and teachers are nottrained by professional schools how to deal with it. Normal schoolsshould teach the physical laws which govern the child's development;should show that the pupil's mental, moral, and physical nature are oneand inseparable; that children cannot at one time be docile, sickly, and intelligent, --perfect mentally and imperfect physically. Untilteachers are so taught, the condition cannot be changed that makes ofour schools manufactories of nervous teachers and pupils. 

Country nervousness, like city nervousness, is of three kinds: (1) thatcaused by defective nervous systems; (2) that resulting from physicaldefects other than defects of the nervous system, but reacting upon it;(3) that due to habit or to lack of self-control. Children who sufferfrom a defective nervous system should, in city schools, be segregatedwhere they can have special care under constant medical supervision. Such children in schools too small for special classes should be givenspecial treatment. Their parents should know that they have chorea, which is the same trouble as St. Vitus's Dance, although often existingin a degree too mild to attract attention. Special treatment does notmean that such children should be permitted to interfere with theschool progress of other children. In many rural schools, where specialprivileges cannot be given children suffering with chorea withoutinjury to other children, it would be a kindness to the unfortunates, to their parents, and to all other children, were the parents requestedto keep such children at home. 

Nervousness that results from removable physical defects--eye strain, adenoids, indigestion, earache--will be easily detected by physicalexamination, and easily corrected by removing the physical defect. 

Preventable nervousness due to "habit" can be quite as serious in itseffects upon the mind and health as the other two forms of nervousness. Twitching the face, biting the nails, wetting the lips, blinking theeyelids, continually toying with something, being in perpetual motionand never relaxing, always changing from one thing to the next, beingforever on the rush, never accomplishing anything, are common faults ofboth teacher and pupil. We call them mannerisms or tricks ofpersonality. They are readily imitated by children. I once knew a younglawyer who had started life as an oyster dealer, whose power ofimitation helped to make him responsive to both helpful and harmfulinfluences. After being at the same table for two weeks with atalented man whom he admired, he acquired the latter's habit ofconstantly twitching his shoulder and making certain gestures. Thesehabits in turn quickly produced a nervousness that interfered with hispower to reason straight. 

Nervousness is often confused with aggressiveness, initiative, confidence. "Think twice before you jump, and perhaps you won't want tojump" is a very difficult rule to follow for any one whose bodilymovements are not under perfect control. 

It is said that the confusion of city life causes habits ofnervousness. Unfortunately no one knows whether the city children orthe country children have the highest percentage of nervousness. Thereis a general feeling that city life causes an unwholesome degree ofactivity, yet one finds that those people in the city who least noticethe elevated railway are those whose windows it passes. City noisesirritate those who come from the country, or the city man on returningto the city from the country, but a similar irritation is felt by thecity-bred man on coming to the country. Mr. Dooley's description of anight in the country with the crickets and the mosquitoes and the earlybirds shows that it is the unusual noise rather than the volume orvariety of noises that wreck nerves. At the time of the opening of theNew York schools in 1907 a newspaper published an editorial on "Wherecan the city child study?" showing that in New York the curriculum, theschoolhouse, and the tenements are so crowded and so noisy that studyis practically impossible. Lack of sleep, lack of a quiet place inwhich to study at school and at home, are causes for nervousness, whether these conditions are in the city or in the country. Whatevidence is there that the country curriculum is less crowded orcountry work better adjusted to the psychological and physiological ageof the country pupil? The index is there; it should be read. 

In breaking habits of nervousness the first step is to explain howeasily habits are formed, why their effects may be serious, and how alittle attention will correct them. When a habit loses its mystery itbecomes unattractive. Children will take an interest in coöperatingwith each other and with the teacher in curing habits acquired eitherat home or at school. My pupils greatly enjoyed overcoming the habit ofjumping or screaming after some sudden noise. I told them how, when aboy, my imagination had been very much impressed by one of Thackeray'scharacters, the last remnant of aristocratic traditions, almost apauper, but possessing one attribute of nobility, --absoluteself-control. When his house burned he stood with his ankles crossed, leaning on his cane, the only onlooker who was not excited. For monthsI imitated that pose, using sticks and rakes and fork handles. Theresult was that when I taught school, a scream, a broken desk, orunusual noise outside reminded me of my old aristocrat in time toprevent my muscles from jumping. In a very short time several fidgetyand nervous girls and boys had learned to think twice and to relaxbefore jumping. 

One test of thorough relaxation in a dentist's chair proves the follyof tightening one's muscles. When in school or out the remedy fornervousness is relaxation. The discipline that prohibits a pupil fromstretching or changing his posture or seat is as much to be condemnedas that which flourishes the rod. It has been said of our schools thatchildren are not worked to death but bored to death. Wherever a roommust be stripped of all beauty and interest to induce concentration, wherever the greater part of the teacher's time must be spent inkeeping order, there is confession either of inappropriateness of thepresent curriculum or of the failure of teacher and text-book topresent subjects attractive to the pupils. Nervous habits will beinevitable until the pupil's attention is obtained through interest. Sustained interest will be impossible until teacher and pupil alikepractice relaxation, not once a morning or twice a day, not duringrecess or lunch hour, but whenever relaxation is needed. 

In overcoming nervousness of teacher and pupil, both must be interestedin home causes as well as school causes of that nervousness. Time mustbe found to ask questions about those causes and to discuss means forremoving them. Naturally it will be embarrassing for a very nervousteacher to discuss nervousness with children, --until after she hasovercome her own lack of nerve stability. To help her or to compel herto learn the art of relaxation of bodily and of mental control is theduty and the privilege of the school physician, of her doctor, and ofsuperintendent and trustees. The outside point of view is necessary, because of the peculiar fact that almost every nervous person believesthat he has unusually good control over his nerves, just as a man inthe midst of his anger will declare that he is cool andself-controlled. Had Robert Burns been thinking of the habit ofnervousness he could not have thought of a better cure than when hewrote:

 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 andtheir School Training_ by Dr. Frances Warner, and _The Development ofthe Child_ by Nathan Oppenheimer show clearly the physical and mentallimitations 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 withoutphysical training means a father who drinks. When people havewholesome, well-disciplined bodies there will be less demand fornarcotics as well as for medicines. _ On these three propositionsenthusiasm has built arguments for city parks and playgrounds, forschool gymnastics, and for temperance instruction. We have tried theremedies and now realize that too much was expected of them. Neithermovement appreciated the mental and physical education of spontaneousgames and play. 

Like hygiene instruction, physical training was made compulsory by lawin many states, and, like hygiene instruction, physical training had toyield to the pressure of subjects in which children are examined. Atthe outset both were based upon distorted psychology and physiology. Oflate physical training has been revived "to correct defects of theschool desk and to relieve the strain of too prolonged study periods. "In New York grammar schools ten minutes a day for the lower grades, andthirty minutes a week for the higher grades, are set aside for physicaltraining. With the exception of eighteen schools where apparatus isused, the exercise has been in the class rooms. It consists of what areknown as "setting-up exercises, "--deep breathing and arm movements fortwo minutes between each study period, often forgotten until it is timeto go home, when the children are tired and need it least. Manyteachers 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 physicalexamination. Generally speaking, it has not yet, either in schools orin colleges, been related to physical needs of the individual pupil. Infact, there is no guarantee that it is not in many schools working apositive injury on defective children or imposing a defectiveenvironment on healthy children. Formal exercises in cramped space, inill-ventilated rooms, with tight belts and heavy shoes, are conceded tobe pernicious. Formal exercises should never be given to any childwithout examination and prescription by a physician. Children withheart weakness, enlarged tonsils, adenoid growths, spinal curvature, uneven shoulders, are frequently seen doing exercises for which theyare physically unfit, and which but serve to deplete further theiralready low vitality. Attention might be called to many a class engagedin breathing exercises when by actual count over half the boys wereholding their mouths open. Special exercises are needed by children whoshow some marked defect like flat foot, flat chest, weak abdominalmuscles, habitual constipation, uneven shoulders, spinal trouble, etc. 

That no physical training should be provided for normal children is thebelief of many leading trainers. This special training is useful todevelop athletes or to correct defects. Like massage, osteopathy, ormedicine, it should follow careful diagnosis. The time is coming whenformal indoor gymnasium exercises for normal pupils or normal studentswill be considered an anomaly. There is all the difference in the worldbetween physical development and what is called physical training. Thetest of physical development is not the hours spent upon a prescribedcourse of training, but the physical condition determined byexamination. To be refused permission to substitute an hour's walk foran 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 isreally health sustaining and health giving. 

Mere muscular development artificially obtained through the devices ofa gymnasium is inferior to the mental and moral development produced bygames and play in the open air. Eustace Miles, M. D. , amateur tennisplayer 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 gamesfoster rarely result from physical training as a business, at statedtimes, indoors, under class direction. It is too much like takingmedicine. A certain breakfast food is said to have lost much of itspopularity since advertised as a health food. When the NationalPlayground Association was organized President Roosevelt cautioned itsofficers against too frequent use of the word "supervision" on theground that supervision and direction were apt to defeat the verypurpose of games and to stultify the play spirit. Is the little girl onthe street who springs into a hornpipe or a jig to the tune of ahurdy-gurdy, or even the boy who runs before automobiles or trolleycars or under horses' noses, getting less physical education than thosewho play a round game in silence under the supervision of a teacher inthe school basement, or who stretch their arms up and down to the tuneof one, two, three, four, five, six? Who can doubt that the much-pitiedchild of the tenement playing with the contents of the ash can in theclothes yard or with baby brother on the fire escape is developing moreoriginality, more lung power, and better arteries than the child offortune 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 toleave space in cities, and time out of school, home work, and factorywork in which children may play. Again, the child--whether a city childor a country child--rarely needs to be taught how to play. Teaching himgames will not produce vitality. Games are the spontaneous product of ahealthy body, active mind, and a joy in living. Give the children parksand piers, roof gardens and playgrounds in which they may play, andleave the rest to them. Give them time away from school and housework, and leave the rest to them. Instead of lamenting the necessity forplaying in the streets, let us reserve more streets for children'splay. There are too many students of child welfare whose reasoningabout play and games is like that of a lady of Cincinnati, who, uponreading the notice of a child-labor meeting, said: "Well, I am glad tosee there is going to be a meeting here for child labor. It is hightime some measure was taken to keep the children off the streets. "Physical examinations would prove that streets are safer and betterthan indoor gymnasiums for growing children. Intelligent physicaltraining will train children to go out of doors during recess; willtrain pupils and teachers not to use recess for study, discipline, oreating lunch. 

 [Illustration: SPONTANEOUS PLAY ON ONE OF NEW YORK CITY'S SCHOOL ROOF PLAYGROUNDS]

"After-school" conditions are quite as important as physical trainingand gymnastics at school. Not long ago a nurse was visiting a sicktenement mother with a young baby. She found a little girl of twelvestanding on a stool over a washtub. This child did all the housework, took care of the mother and two younger children, got all the mealsexcept supper, which her father got on his return from work. As thenurse removed the infant's clothes to give it a bath, the little girlseized them and dashed them into the tub. "Yes, I am pretty tired whennight comes, " she confessed. This child has prototypes in the countryas well as the city, and she did not need physical training. She didnot lack initiative or originality. She did need playmates, open air, arun in the park, and "fun. "

The educational value of games and outdoor play should be weighedagainst the advantages of lowering the compulsory school age, and ofbridging over the period from four to seven with indoor kindergartentraining. Neither physical training nor education is synonymous withconfinement in school. The whole tendency of Nature's processes inchildren is nutritional; it is not until adolescence that she makesmuch effort to develop the brain. Overuse of the young mind results, therefore, in diverting natural energy from nutritive processes tohurried growth of the overstimulated brain. The result is a type ofchild with a puny body and an excitable brain, --the neurotic. The youngeye, for example, is too flat (hypermetropic)--made to focus only onobjects at a distance. Close application to print, or even to weavingmats or folding bits of paper accurately, causes an overstrain on theeye, which not only results in the chronic condition known asmyopia, --short-sightedness, --so common to school children, but whichacts unfavorably on the constitution and on the whole development ofthe child. At the recent International Congress of School Hygiene inLondon, Dr. Arthur Newsholme, medical officer of health of Brighton, made a plea for the exclusion of children under five years of age fromschools. "During the time the child is in the infant department it haschiefly to grow. Nutrition and sleep are its chief functions. Paints, pencils, paper, pins, and needles should not be handled in school bychildren below six. " Luther Burbank, in an article on "The Training ofthe 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 everychild can be protected from the stifling of the nature instinct of playby formal indoor "bossed" exercises, whether called games, physicaltraining, 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 constantconfinement in school has always been: "Where will the child be if outof school? Will its environment at home not work a worse injury to itshealth? Will not the street injure its morals?" Because we have not yetworked out a method of supervising the health of those children who arenot in school, it does not follow that such supervision is impossible. Perhaps the time will come when there will be state supervision overthe health of children from birth, parents being expected to presentthem once a year at school for examination by the school physician. Inthis way defects can be corrected and health measures devised to buildup a physique that should not break down under the strain of schoollife. For children whose mothers work during the day, and for thosewhose home environment is worse than school, it might be cheaper in thelong run to assign teachers to protect them from injury while they playin a park, roof garden, or out-of-door gymnasium. If parks andplaygrounds come too slowly, why not adopt the plan advocated by AlidaS. Williams, a New York principal, of reserving certain streets forchildren between the hours of three and five, and of diverting trafficto other streets less suitable for children's play? So great is thevalue--mentally, morally, and physically--of out-of-door play that ithas even been suggested that the substitution of such play for schoolfor all children up to the age of ten would insure better minds andsounder physiques at fifteen. It is generally admitted that the childwho enters school at eight rather than at six will be the gainer attwelve. What a travesty upon education to insist upon schooling forchildren because they are apt to be run over on the street, or to beneglected at home, to shoot craps, or belong to a gang and develop badmorals. 

Educators will some day be ashamed to have made the schools thecatch-all or the court-plaster for the evils of modern industry. Instead of pupils and mothers going to the school, enough hygieneteachers, and play teachers, and district physicians could be employedwith the money now spent on indoor instruction to do the house-to-housevisiting urged in many chapters of this book. Such a course of actionwould have an incalculable effect on the reduction of tuberculosis, notonly in making healthier physiques but by inculcating habits of outdoorlife and love of fresh air. The danger of those contagious diseaseswhich ravish childhood would be greatly reduced. An ambition forphysical integrity would make unnatural living unpopular. Competitionin games with children _of the same physical class_ develops accuracy, concentration, dispatch, resourcefulness, as much as does instructionin arithmetic. Smoking can easily be discredited among boys trying tohit the bull's-eye. A boy would sooner give up a glass of beer than thechampionship in rifle shooting or a "home run. "

The influence of the "spirit of the game" on practical life has beendescribed thus by New York's director of physical training, Dr. LutherH. 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 thesoundness or unsoundness of a nation's banking policy, namely, afinancial crisis or an expert audit. A searching audit that analyzeseach debit and each credit frequently shows that a bank is solvent onlybecause it is not asked to pay its debts. It continues to do businessso long as no obvious weaknesses appear, analogous to measles, adenoids, or paralysis. A frequent disorder of banking results fromdoing too big a business on too little capital, in making too manyloans 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 bediscovered if looked for in advance of a crisis. Many individuals andcommunities are likewise physically solvent only because their physicalresources are not put to the test. Weaknesses that lie near the surfacecan be discovered before a crisis by physical examination forindividuals and sanitary supervision for communities. Whetherindividuals or communities are trying to do too much business for theirhealth capital, whether the health reserves will pay debts that arisein a crisis, whether we are ill or well prepared to stand a run on ourvitality, can be learned only by carefully analyzing our healthreserves. Health debits are compared with health credits forindividuals by vitality tests, for communities by vital statistics. 

Of the many vitality tests none is practicable for use in the ordinaryclass room. Scientific training is just as necessary for such tests asfor discovering the quality of the blood, the presence or absence oftubercle bacilli in the sputum, diphtheria germs in throat mucus, ortyphoid germs in milk. But scientific truth, the results of scientifictests, can be made of everyday use in all class rooms. State andnational headquarters for educators, and all large cities, can affordto engage scientists to apply vitality tests to school children for thesake of discovering, in advance of physical breakdown and beforeoutward symptoms are obvious, what curriculum, what exercise, whatstudy, recreation, and play periods are best suited to childdevelopment. It will cost infinitely less to proceed this way than toneglect children or to fit school methods to the loudest, mostpersistent 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 themanner in which energy is exerted. Perhaps the time will come whenscience and commerce will supply every tintype photographer with anergograph and the knowledge to use it. Then we shall hear at summerresorts and fairs, "Your ergograph on a postal card, three for aquarter. " We can step inside, harness our middle finger to theergograph, lift it up and down forty-five times in ninety seconds, andlo! a photograph of our vitality! If we have strong muscles or goodcontrol, 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 physicianwas surprised to have four pupils show more strength late in the daythan in the morning. "Upon investigation it was found that the teacherof the four pupils had been called from school, and that they had noregular work, but had been sent to another room and employedthemselves, as they said, in having a good time. " The chart on page 127shows the effect of the noon recess and of the good time after threeo'clock. 

Chicago's child-study experts concluded after examining a large numberof 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 settledbeyond any possibility of modification, but as being fairly indicatedby 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, shouldbe considered in grading, not only for physical culture classes but forall high school or continuation classes. Dr. C. Ward Crampton, assistant physical director, while examining boys in the first grade ofthe High School of Commerce, noticed a greater variation in physicaladvancement than in years. He kept careful watch of the educationalprogress and discovered three clear divisions: (1) boys arrived atpuberty, --postpubescent; (2) boys approaching maturity, --pubescent; (3)boys not yet approaching maturity, --prepubescent. 

The work in lower grades they had all passed satisfactorily, but inhigh school only the most advanced class did well. Practically none ofthe not-yet-maturing boys survived and few of the almost mature. Inother words, the high school course was fitted to only one of the threeclasses of boys turned out of the grammar schools. The others succumbedlike hothouse azaleas at Christmas time, forced beyond their season. Physiological age, not calendar years or grammar school months, shoulddetermine the studies and the companions of children after the tenthyear. Physiological strength and vitality, not ability to spell or toremember dates, should be the basis of grading for play and study andcompanionship among younger children. Vitality, power to endurephysically, should be the test of work and recreation for adults. Physicians may be so trained to follow directions issued by expertsthat physical examinations will disclose the chief enemies of vitalityand the approximate limits of endurance. 

Teachers may train themselves to recognize signs of fatigue in schoolchildren and to adapt each day's, each hour's work to the endurance ofeach 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 tovitality tests, because few scientists are beseeching individuals to betested, because almost no one yearns to be tested, the promotion ofadult vitality and of community vitality can best be hastened bydemanding complete vital statistics. Industrial insurance companies andmutual benefit societies are doing much to educate laborers regardingthe 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 arenot gathering sufficiently complete information about causes ofsickness and death. American health and factory inspection is not evenprofiting, as it should, from British, German, and French statistics. Statistics are in ill repute because the truth is not generally knownthat our boasted sanitary improvements are due chiefly to the efficientuse of vital statistics by statesmen sanitarians. [7]

The vital statistics of greatest consequence are not the number ofdeaths or the number of births, not even the number of deaths frompreventable diseases, but rather the number of cases of sickness fromtransmissible diseases. The cost and danger to society from preventablediseases, such as typhoid, diphtheria, scarlet fever, measles, areimperfectly represented by the number of deaths. Medical skill couldgradually reduce death rates in the face of increasing prevalence ofinfectious disease. With few exceptions, only those patients who refuseto follow instructions will die of measles, diphtheria, or smallpox. The scarlet-fever patient who recovers and goes to church or schoolwhile "peeling" can cause vastly more sickness from scarlet fever thana patient who dies. Dr. W. Leslie Mackenzie, who has recently written_The Health of the School Child_, said ten years ago, while healthofficer 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, completerecord of cases of sickness. Statistics of sickness are confined tosickness from transmissible diseases, because we have not yet arrivedat the point where we recognize the state's right to requireinformation, except when the sick person is a menace to the health ofother persons. 

The annual report of a board of health should give as clear a pictureof a community's health during the past week or past quarter as theergograph gives of the pupils mentioned on page 126. As ragged, rapidlyshortening lines show nervousness and depleted vitality, so charts anddiagrams can be made to show the needless waste of infant life duringthe summer months, the price paid for bad ventilation in winter time, when closed windows cause the sickness-and-death line from diphtheriaand scarlet fever to shoot up from the summer level. In cities it isnow customary for health boards to report weekly the number of deathsfrom transmissible diseases. Health officers will gladly furnish factsas to cases of sickness, if citizens request them. Newspapers willgladly publish such information if any one will take the pains tosupply it. Wherever newspapers have published this information, itquickly takes its place with the weather reports among the newsnecessities. Marked changes are commented on editorially. Children caneasily be interested, as can adults, in filling out week by week atable that will show increases and decreases in preventable sicknessdue 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 | 422Diphtheria and | | | | | | | croup | 313 | 264 | 283 | 331 | 282 | 343 | 326Measles | 142 | 212 | 203 | 261 | 293 | 323 | 472Scarlet fever | 208 | 228 | 231 | 252 | 278 | 323 | 372Smallpox | -- | 1 | -- | 1 | -- | -- | 2Varicella | 40 | 83 | 91 | 162 | 136 | 115 | 167Typhoid fever | 106 | 105 | 107 | 123 | 86 | 77 | 71Whooping cough | 6 | 13 | 15 | 14 | 27 | 9 | 8Cerebro-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 | 402Diphtheria and | | | | | | croup | 369 | 338 | 347 | 308 | 370 | 406Measles | 471 | 517 | 346 | 581 | 691 | 803Scarlet fever | 397 | 417 | 426 | 478 | 562 | 585Smallpox | 4 | 3 | 2 | -- | 2 | --Varicella | 160 | 198 | 123 | 98 | 199 | 169Typhoid fever | 62 | 35 | 42 | 37 | 55 | 36Whooping cough | 12 | 19 | 3 | 25 | 24 | 14Cerebro-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 boardof danger centers, --that is, of patients sick from measles, smallpox, or diphtheria, --and in smaller communities where notices are sent onlyto state boards of health, parents will find it difficult to take akeen interest in vital statistics. But if teachers would start at thebeginning of the year to record in such a table the days of absencefrom school because of transmissible disease, both they and theirpupils would discover a new interest in efficient healthadministration. After a national board of health is organized we mayreasonably expect that either state boards of education or state boardsof health will regularly supply teachers with reports that will leadthem to compare the vitality photographs of their own schools andcommunities with the vitality photographs of other schools and othercommunities working under similar conditions. Then children old enoughto study physiology and hygiene will be made to see thehappiness-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 towhich statistics are now satisfactory, it would be better for us atthis point to make clear the significance of the movement for anational fact center for matters pertaining to personal, industrial, and community vitality. Five economic reasons are assigned forestablishing 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 thefollowing: infant hygiene; health education in schools; sanitation;pure food; registration of physicians and surgeons; registration ofdrugs, druggists, and drug manufacturers; registration of institutionsof 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 healthofficers, upon physicians, hospitals, schools, and industries to reportpromptly facts of birth, sickness, and death to national and statecenters able and eager to interpret the meaning of these facts in suchsimple language, and with such convincing illustrations, that thereading public will demand the prompt correction of preventable evils. 

Our tardiness in establishing a national board of health that shall dothis great educational work is due in part to the fact that Americansanitarians have frequently chosen to _do things_ when they should havechosen to _get things done_. Almost every state has its board ofhealth, with authority to require registration of births, deaths, andsickness due to transmissible disease; with few exceptions the heads ofthese state boards have spent their energies in abating nuisances. In ashort time they have degenerated into local scavengers, because theyhave shown the public neither the meaning of the vital statisticsgathered nor its duty to support efficient health administration. 

The state reports of vital statistics have not been accurate; thereforein many states we have the anomalous situation of an aggressiveveterinary board arousing the farmer and the consumer of milk to thenecessity of protecting the health of cattle, and an inactive, uninformed state board of health failing to protect the health of thefarmer and the consumer. 

Vital statistics presume efficient health administration. Aninefficient health officer will not take the initiative in gatheringhealth statistics. If some one else compels him to collect vitalstatistics, or furnishes him with statistics, they are as a lantern toa blind man. Unless some one also compels him to make use of them, unless we remove the causes of transmissible or infectious diseases andcheck an epidemic when we first hear of it, the collection ofinformation is of little social value. "Statistics" is of the samederivation as "states" and "statesmen. " Statistics have always beendistinguished from mere facts, in that statistics are instruments inthe hands of the statesman. Wherever the term "statistics" is appliedto social facts it suggests action, social control of futurecontingencies, mastery of the facts whose action they chronicle. Theobject of gathering social facts for analysis is not to furnishmaterial for future historians. They are to be used in shaping futurehistory. They are facts collected with a view to improving socialvitality, to raising the standard of life, and to eliminatingpermanently those forces known to be destructive to health. Unless theyare to be used this way, they are of interest only to the historicalgrub. No city or state can afford to erect a statistical office toserve as a curiosity shop. Unless something is to be done to preventthe recurrence of preventable diseases annually experienced by yourcommunity or your school, it is not reasonable to ask the publicprinter to make tables which indicate the great cost of thispreventable sickness. A tax collector cannot discharge his dutiesunless he knows the address of every debtor. The police bureau cannotprotect society unless it knows the character and haunts of offenders. A health officer cannot execute the law for the protection of society'shealth unless he knows the haunts and habits of diseases. For this hemust look to vital statistics. 

But the greatest service of vital statistics is the educationalinfluence. Health administration cannot rise far above the hygienicstandards of those who provide the means for administering sanitarylaw. The taxpaying public must believe in the economy, utility, andnecessity of efficient health administration. Power and funds comefrom town councils and state legislatures. To convince and move thesekeepers of the purse, trustworthy vital statistics are indispensable. Information will be used for the benefit of all as soon as it ispossessed by all. 

Fortunately the gathering of vital statistics is not beyond the powerof the kind of health officer that is found in small cities and inrural communities. If years of study of mathematics and of thestatistical method were required, we should despair of obtaining lightwithin 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 transmissiblediseases, conditions found upon examination of children applying forwork certificates, etc. Where expert skill is required, as at state andnational headquarters, it can be found. Every layman can train himselfto use skillfully the seven ingredients of the statistical method whichit is his duty to employ, and to know when to pay for expert analysisand advice. We can all learn to base judgment of health needs upon theseven pillars, --desire to know, unit of inquiry, count, comparison, percentages, classification, and summary. 

FOOTNOTES:

[7] Dr. Arthur Newsholme's _Vital Statistics_ should be in publiclibraries and on the shelves of health officers, public-spiritedphysicians, and school superintendents. 

CHAPTER XIV

IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?

Last year a conference on the physical welfare of school children wastold by a woman principal: "Of course we need physicians to examine ourchildren and to teach the parents, but many of us principals believethat our school curriculum and our school environment manufacture morephysical defects in a month than all your physicians and nurses willcorrect in a year. " At the same meeting the physical director ofschools of New York City appealed eloquently for "biological engineers"at school, who would test the child's strength as building engineersare employed to test the strength of beams and foundations. [8] Asexplanation for the need of the then recently organized National SchoolHygiene Association, he elaborated the proposition that schoolrequirements and school environment damage child health. "Oculardefects are in direct ratio to the length of time the pupil hasattended school. . . . A desk that is too high may easily be the indirectagent for causing scoliosis, producing myopia or astigmatism. . . . Physically examine school children by all means, but do not fail toexamine school desks. "

Fifty schools in different parts of New York City were examined lastyear with especial reference to the factors likely to cause or toaggravate physical defects. [9] The results, tabulated and analyzed, prove that the woman principal was right; many schools are so built orso conducted, many school courses are so devised or so executed, thatchildren are inevitably injured by the environment in which thecompulsory 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 nervouswhen she left school that we hesitated to employ her, was becoming rosyand spirited. The child herself explained the change: "I like itbetter. I have more money to spend. I get more outdoor exercise, andthen, oh, the room is so much sunnier and there is more air and thepeople are all so nice!" And these were just the necessities which werelacking in the school from which she came. Moreover, it is a faircommentary on the school work and the school hygiene in too many of ourtowns and cities to-day. "I like it better" means that school work isnot adapted to the dominant interests of the child, that the curriculumincludes subjects remote from the needs and ambitions of the modernschool child, and fails to include certain other subjects which itrecognizes as useful and necessary, and therefore finds interesting. "I have more money to spend" means that this little girl was able tohave certain things, like a warm, pretty dress, rubbers, or anoccasional trolley ride, which she longed for and needed. "I get moreoutdoor exercise" means that there was no open-air playground for herschool, that "setting up" exercises were forgotten, that recess wastaken up in rushing home, eating lunch, and rushing back again, andthat "after school" was filled up with "helping mother with thehousework. " "The office is so much sunnier and I get more air" accountsfor the increase in vitality; and "the people are all so nice, " for thehappy expression and initiative which the undiscriminating disciplineat 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 noapologies to make to rural districts. A wealthy suburb recently learnedthat there was overcrowding in every class room, and that one schoolbuilding 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 andsubjects that bore, are not peculiar to great cities. In a littlewestern town a competition between two self-governing brigades formerit points was determined by the amount of home study; looking backfifteen years, I can see that I was encouraging anæmic andoverambitious children to rob themselves of play, sleep, and vitality. Many a rural school violates with impunity more laws of health thancity factories are now permitted to transgress. 

After child labor is stopped, national and state child labor committeeswill learn that their real interest all the time has been childwelfare, not child age, and will be able to use much of the oldliterature, simply substituting for "factory" the word "school" whencondemning "hazardous occupations likely to sap [children's] nervousenergy, stunt their physical growth, blight their minds, destroy theirmoral fiber, and fit them for the moral scrap heap. "

Many of the evils of school environment the teacher can avert, othersthe school trustee should be expected to correct. So far as unsanitaryconditions are permitted, the school accentuates home evils, whereas itshould counteract them by instilling proper health habits that will betaken home and practiced. Questions such as were asked in Miss North'sstudy will prove serviceable to any one desiring to know the probableeffect of a particular school environment upon children subject to it. Especially should principals, superintendents, directors, and volunteercommitteemen apply such tests to the public, parochial, or privateschool, 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 ofcurriculum and discipline, teachers can do a great deal. Perhaps theycannot move the windows or the desks, but they can move the children. If they cannot insure sanitary conditions for home study, they can cutdown the home study. If the directors do not provide properblackboards, they can do less blackboard work. They can make childrenas conscious, as afraid, and as resentful of dirty air as of dirtyteeth. They can make janitors believe that "dry sweeping" or "featherdusting" may give them consumption, and leave most of the dirt in theroom to make work for the next day; that adjustable desks are made tofit the child's legs and back, not the monkey wrench; that thethermometer in the schoolroom is a safer guide to heat needed than aboiler gauge in the basement; that fresh air heated by coal is cheaperfor the school fund than stale air heated by bodies and by bad breath. Finally, they can make known to pupils, to parents, to principals andsuperintendents, to health officials and to the public, the extent towhich school environment violates the precepts of school hygiene. 

If the state requires the attendance of all children between the agesof five and fourteen at school for five hours a day, for five days inthe week, for ten months in the year, then it should undertake to seethat the machinery it provides for the education of those children forthe greater part of the time for nine years of their lives--theformative years of their lives--is neither injuring their health norretarding their full development. 

If the amount of "close-range" work is rapidly manufacturing myopiceyes; if bad ventilation, whether due to faulty construction or tofaulty management, is preparing soil for the tubercle bacillus; ifchildren with contagious diseases are not found and segregated; ifdesks are so ill adapted to children's sizes and physical needs thatthey are forming crooked spines; if too many children are crowded intoone room; if lack of air and light is producing strained eyes andmalnutrition; if neither open air, space, nor time is provided forexercise, games, and physical training; if school discipline is adaptedneither to the psychology nor the physiology of child or teacher, thenthe state is depriving the child of a greater right than the compulsoryeducation law forces it to endure. Not only is the right to healthsacrificed to the right to education, but education and health are bothsacrificed. 

In undertaking to enforce the compulsory education law, to put alltruants and child laborers in school, the state should be very sure forits own sake that it is not depriving the child of the health on whichdepends 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 manufacturingphysical defects. 

[9] By Professor Lila V. North, Baltimore College for Women, for the NewYork Committee on the Physical Welfare of School Children, 105 East 22dStreet, New York City. 

CHAPTER XV

THE TEACHER'S HEALTH

"Teachers, gentlemen, no less than pupils, have a heaven-ordained rightto work so adjusted that the highest possible physical condition shallbe maintained automatically. " This declaration thundered out by anindignant physician startled a well-meaning board of school directors. The teacher's right to health was, of course, obvious when oncementioned, 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 teachersin private or public schools and colleges. Without protest, and withoutnotice until too late, teachers often neglect their own health at homeand at school, --recklessly overwork, undersleep, and undernourish; ruintheir eyes, their digestion, and their nerves. School-teachers arefrequently "sweated" as mercilessly as factory operatives. The time hascome to admit that a school environment which destroys the health ofthe teacher is as unnecessary and reprehensible as an army camp thatspreads typhoid among a nation's defenders. A school curriculum or acollege tradition that breaks down teachers is as inexcusable as a gunthat kills the gunner when discharged. Experience everywhere elseproves that periodic physical examinations and health precautions, notessays about "happy teachers--happy pupils, " are indispensable ifteachers' health rights are to be protected. 

Physical tests are imposed upon applicants for teachers' licenses bymany boards of education. In New York City about three per cent ofthose examined are excluded for defects of vision, of hearing, ofprobable endurance. Once a teacher, however, there is no furtherphysical examination, --no way of discovering physical incapacity, nothing to prevent a teacher from exposing class after class topulmonary tuberculosis contracted because of overwork andunderventilation. The certainty of salary increase year by year and ofa pension after the twentieth year will bribe many a teacher to overtaxher own strength and to jeopardize her pupils' health. 

Seldom do training schools apply physical tests to students who intendto become teachers. One young girl says that before starting her normalcourse she is going to the physician of the board of education forexamination, so as to avoid the experience of one of her friends, who, after preparing to be a teacher, was rejected because of pulmonarytuberculosis. During her normal course no examination will benecessary. Overwork during the first year may cause pulmonarytuberculosis, and in spite of her foresight she, too, may be rejectedfour years hence. 

The advantages of physical examination upon beginning and during thecourses that prepare one for a teacher are so obvious that but littleopposition will be given by prospective teachers. The disadvantages toteacher and pupil alike of suffering from physical defects are soobvious that every school which prepares men and women for teachersshould make registration and certification dependent upon passing asatisfactory physical test. No school should engage a teacher who hasnot good proof that she can do the required work without injury to herown or her pupils' health. Long before physicians can discoverpulmonary tuberculosis they can find depleted vitality which invitesthis disease. Headaches due to eye trouble, undernourishment due tomouth breathing, preventable indigestion, are insidious enemies thatcannot escape the physical test. 

Three objections to physical tests for teachers will be urged, but eachloses its force when considered in the light of general experience. 

1. _A sickly teacher is often the most efficient teacher in a school ora county. _ It is true that some sickly teachers exert a powerfulinfluence over their pupils, but in most instances their influence andtheir efficiency are due to powers that exist in spite of devitalizingelements. Rarely does sickness itself bring power. It must be admittedthat many a man is teaching who would be practicing law had his healthpermitted it. Many a woman's soul is shorn of its self-consciousness bysuffering. But even in these exceptional instances it is probable thatchildren are paying too dearly for benefits directly or indirectlytraceable 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 thecontrary, it is probable that the teacher's opportunity will make evena stronger appeal to competent men and women after physical soundnessand vitality are made conditions of teaching, --after we all believewhat leading educators now believe, that the highest fulfillment ofhuman possibilities requires a normal, sound body, abounding invitality. 

3. _Examination by a physician, especially if a social acquaintance, isan unnecessary embarrassment. _ The false modesty that makes physicalexamination unwelcome to many adults, men as well as women, is easilyovercome when the advantages of such examination are understood. It islikewise easy to prove to a teacher that the loss of time required inhaving the examination is infinitesimal compared with the loss of timedue to ignoring physical needs. The programme for school hygieneoutlined in Chapter XXVII, Part IV, assumes that state and countysuperintendents will provide for the examination of teachers as well asof 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 preventivehygiene than our own health, it is probable that the generalexamination of teachers will come first as the result of a generalconviction that unhealthy teachers positively injure the health ofpupils and retard their mental development. Children at school age areso susceptible and imitative that their future habits of body and mind, their dispositions, their very voices and expressions, are influencedby those of their teachers. Experts in child study say that a child'svocal chords respond to the voices and noise about him before he isable to speak, so that the tones of his voice are determined before heis able to express them. This influence is also marked when the childbegins to talk. Babies and young children instinctively do what adultslearn not to do only by study, --follow the pitch of others' voices. Canwe then overestimate the effect upon pupils' character of teachers whoradiate vitality?

The character and fitness, aside from scholarship, of applicants forteachers' licenses are now subjected by the board of examiners of NewYork 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 andfor children's sake, should be rejected. The moral character, physicalfitness, quality of voice, personal bearing, self-command, executiveability, capacity for supervision, are qualities that are modified byconditions. The voice that is satisfactory in conference with anexaminer may be strident and irritating when the teacher is impatientor is trying to overcome street noises. On parade applicants areequally cleanly; this cannot be said of teachers in the service, comingfrom different home environments. Self-command is much easier in oneschool 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 todo the special task assigned to her, based upon physical evidence ofher own vitality and of her favorable influence upon her pupils' healthand enjoyment of school life. Shattered nerves due to overwork mayexplain a teacher's shouting: "You are a dirty boy. Your mother is adirty woman and keeps a dirty store where no decent people will go tobuy. " A physical examination of that unfortunate teacher would probablyshow that she ought to be on leave of absence, rather than, by heroverwork and loss of control, to cause the boys of her class to feelwhat one of them expressed: "Grandmother, if she spoke so of my motherI would strike her. "

Just as there should be a central bureau to count and correct the openmouths and closed minds that clog the little old red schoolhouse of thecountry, so a central bureau should discover in the city teacher aswell as in the country teacher the ailments more serious thantuberculosis that pass from teacher to pupil; slovenliness, uglytemper, frowning, crossness, lack of ambition, cynicism, --these shouldbe blackballed as well as consumption, contagious morphine habit, andcontagious skin disease. Crooked thinking by teacher leads to crookedthinking by pupil. Disregard of health laws by teacher encouragesunhygienic living by pupils. A man whose fingers are yellow, nervesshaky, eyes unsteady, and mind alternately sleepy and hilarious fromcigarettes, 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 physicalexamination of teachers that will give timely warning of attentionneeded. Until there is some system for giving this right to allteachers in private, parochial, charitable, and public schools, weshall produce many nervous, acrid, and physically threadbare teachers, where we should have only teachers who inspire their pupils with apassion 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 onmethods of fitting health remedies to local health needs. I told ofcertain dangers to be avoided, of results that had always followedcertain remedies, of motives to be sought and used, of community endsto seek. Not knowing the local situation, I could not tell them exactlywhat to do next, or how or with whom to do it; not seeing the patientor his symptoms, I did not diagnose the disease or prescribe medicine. Several members of the audience who were particularly anxious to starta new organization on a metropolitan model were disappointed becausethey were told, not just how to organize, but rather how to find outwhat sort of organization their town needed. They were right inbelieving that it was easier to copy on paper a plan tried somewhereelse, than to think out a plan for themselves. They had forgotten forthe time being their many previous disappointments due to copyingwithout question some plan of social work, just as they copy Paris orNew York fashions. They had not expected to leave this meeting with theconviction that while the _ends_ of sanitary administration may be thesame in ten communities, health _machinery_ should fit a particularcommunity like a tailor-made suit. 

American-like, they had a mania for organization. I once heard an agedkindergartner--the savant of an isolated German village--describe myfellow-Americans as follows: "Every American belongs to someorganization. The total abstainers are organized, the brewers areorganized, the teachers are organized, the parents are organized, theyoung people and even the juniors are organized. Finally, those whobelong to no organization go off by themselves and organize a societyof the unorganized. " Love of organization and love of copying havegiven us Americans a feverish desire for what we see or read about inEurope. When we talk about our European remedies we try to makeourselves believe that we are broad-minded and want to learn fromothers' experience. In a large number of cases our impatient demand forEuropean remedies is similar to the schoolboy's desire to show off themanners, the slang, or the clothes picked up on his first visit awayfrom home. With many travelers and readers European remedies orEuropean ways are souvenirs of a pleasant visit, to be described like acollection of postal cards, a curious umbrella, a cane associated withAlpine climbing, or a stolen hymnal from an historic cathedral. 

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

The souvenir value of European remedies is due to the assumption thatno better way was open to the European, and that the remedy actuallydoes what it is intended to do. Because free meals are given at schoolto cure and prevent undernourishment, it is taken for granted thatundernourishment stops when free meals are introduced; thereforeAmerica must have free meals. Because it is made compulsory in acharming Italian village for every child to eat the free school meal, it is taken for granted that the children of that village have nophysical defects; therefore let Kansas City, Seattle, and Bostonintroduce compulsory free meals. But when one goes to Europe to seeexactly how those much-advertised, eulogized remedies operate from dayto day, it is often necessary to write, as did a great Americansanitarian recently, of health administration in foreign citiescontinually held up as models to American cities: "In spite of therules and theories over here, the patient has better care in New YorkCity. "

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

Would it not be nice for country children to know that toward the endof the school year they would be given an excursion to the largest cityof their state, to its slums, its factories, parks, and art galleries?They would grow up more intelligent about geography. They would readhistory, politics, sociology, and civil government with greaterinterest. They would have less contracted sympathies. They might evendecide that they would rather live their life in the spacious countrythan in the crowded, rushing city. 

City children, on the other hand, would reap worlds of physical benefitand untold inspiration from periods of recreation and study in thecountry, with its quiet, its greens and bronzes and yellows, its birdsand animals, its sky that sits like a dome on the earth, itshopefulness. Winter sleigh rides and coasting would give new vigor andambition. Why spend so much on teaching physiology, geography, andnature study, if in the end we fail to send the child where alonenature and hygiene tell their story? Why tax ourselves to teach historyand sociology and commercial geography out of books when excursions tothe city and country will paint pictures on the mind that can never beerased? What more attractive or more reasonable than appetizing, warmmeals, or cool salads and drinks for the boys and girls who carrytheir little dinner pails and baskets down the long road whereeverything 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 schoolmeal. 

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

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

The economic defense of these remedies is many-sided. An Englishdrummer once instructed me during a railroad journey from southern tonorthern Ireland. As we entered the fertile fields of Lord Dunraven'sestate near Athlone, I expressed sympathy for other countriesimpoverished of soil, of wealth, and of thrift. My instructor replied:"It would pay the government to bring them all to this land free once ayear, just to show them what they are missing. " That his idea of aninvestment is sound has been proved by railroads and land companies andeven by states, who give away excursions to entice settlers and buyers. Ambition at almost any cost is cheaper than indifference toopportunity. It would be cheaper for our American taxpayer to sendschool children to city and country than to pay the penalty for havinga large number of citizens with narrow interests, unconscious of thestruggles and joys of their co-citizens. Free meals, free books, freerides, free eyeglasses, are cheaper than free instruction for thesecond, third, and sixth terms in studies not passed because ofphysical defects, --infinitely cheaper than jails and almshouses, truantofficers and courthouses. 

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

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

It costs $2. 50 to furnish a child with eyeglasses. It costs $25 to $50to give that child a year's schooling. If the child cannot see rightand fails in his studies, we have lost a good investment and, after oneyear 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 inschool, his mind turns to other things. He is made to think that it isuseless for him to try for first place. Perhaps he can play ball, andexcels. He chooses a career of ball playing. Valuable years are lost. 

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

Professor Patten says that it is easier to support in the almshousethan in competitive industry a man who cannot earn more than $1. 50 aday. The question, therefore, regarding European remedies is not, Towhat general theory do they belong? but, What will they accomplish? Howdo 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 thePhysical Welfare of School Children. The word "welfare" was used ratherthan "condition" because the committee proposed to use whatever factsit could gather for the improvement of home and school conditionsprejudicial 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 thefollowing proposition: _To insure a race physically able to receive ourvaunted free education, we must provide at school free meals, freeeyeglasses, free medical and dental care. _ Thanks to thesuperintendent of schools of New York City, to Robert Hunter's_Poverty_, to John Spargo's _Bitter Cry of the Children_, hundreds ofthousands of American citizens were made to realize for the first timethat a large proportion of our school children are in serious need ofmedical, dental, or ocular attention, or of better nourishment. 

Because physicians, dentists, oculists, hospitals, dispensaries, reliefagencies, had seemingly been unconscious of this serious state ofaffairs, they had no definite, constructive remedy to propose. Theirunpreparedness served to strengthen the arguments for the Europeanmethod of _doing things_. France, Germany, Italy, England, had found itnecessary to do things at school. Arguing from their experience, it wasonly a matter of time when American cities must follow their example. Why not, therefore, begin at once to deal radically with the situationand give school meals, school eyeglasses, etc. ? Those who organized theCommittee on the Physical Welfare of School Children realized thedanger of trying to settle so great a question with the little definiteinformation then available. If _doing things at school_ were to beadopted as a principle and logically carried out, vast sums must beadded to the present cost of the public school system. Complicationswould arise with private and parochial schools, whose children mighthave quite as serious physical defects, even though not educated bypublic funds. It would be difficult to obtain proper rooms for medicaland dental treatment and meals, and perhaps still more difficult toinsure proper food, skilled oculists, dentists, surgeons, andphysicians. No one was clear as to how the problem was to be solved bysmall cities and rural districts, whose needy children are no lessentitled to public aid simply because their numbers are smaller. Greatas were the difficulties, however, the committee saw that difficultiesare in themselves no reason for not doing the right thing. On theother hand, if doing things at school is wrong, if school meals fail tocorrect and remove physical defects, great social and educational wrongwould result from New York's setting an example that would not onlymisdirect funds and attention in that city, but would undoubtedly leadother cities to move in the wrong direction. Right could be hastened, wrong could be prevented more effectually by facts than by any amountof theory. School meals had been made a political issue in England. Thearguments supporting them were stronger than any possible argumentsagainst them, except proof that they would be less effective in helpingchildren than other means that might be proposed. If the Americanpeople must choose between sickly, unteachable, dull children withoutschool meals, on the one hand, and bright, teachable, healthy childrenplus school meals, on the other hand, they will not hesitate because ofexpense or eighteenth-century objections to "socialism. "

During one year of investigation and of _getting things done_ thecommittee has prepared three studies for publication: (1) a report onthe home conditions of fourteen hundred school children of differentnationalities, found by school physicians to have defects of vision, breathing, hearing, teeth, and nourishment; (2) an examination of fiftyschools--curriculum, buildings, home-study requirements, play space andplaytime, physical culture--in an attempt to answer the question, Howfar does school environment directly cause or aggravate physicaldefects of school children; (3) a comparative study of methods nowemployed in a hundred cities to record, classify, and make publicsignificant school facts. 

The results of the first year's work prove conclusively that physicaldefects are not caused solely by the inability of parents to pay forproper food. Among the twenty significant facts reported by thecommittee 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 _gettingthings done_ for one year, the committee drew fifteen practicalconclusions, 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 issomething about a request for coöperation, whether by schools or by anyother agency, that enlists the interest of those whose help is asked. The reason is not that people are flattered by requests to serve oncommittees, or that human nature finds it difficult to be unfriendly orunkind. On the contrary, men and women are by nature social; there ismore joy in giving than in withholding, in working with others than inworking alone. Men and women, official and volunteer agencies, willcoöperate with school-teachers when invited, for the same reason andwith the same readiness that ninety-nine farmers out of a hundred, onthe prairie or in the mountain, will welcome a request for food andlodging. 

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

Mothers will naturally take a greater interest in the welfare of theirchildren if held responsible for proper food and proper homesurroundings than if not reminded of their responsibility. In New YorkCity a woman district superintendent of schools, Miss Julia Richman, has organized a unique "social settlement. " She and severalschool-teachers occupy a house, known as "The Teachers' House. " This istheir residence. Here they are subject to neither intrusion norimportunity; no clubs or classes are held here; visitors are treated asguests, not as beneficiaries. The purpose these teachers have in livingtogether is to work out the methods of interesting private and officialleaders in community needs disclosed at school. 

Where clubs and social gatherings are held in school buildings, it isnot unusual for a thousand mothers, recent immigrants, to meet togetherin one hall to hear talks on the care of children. Thus, instead ofprincipals, teachers, and physicians taking the place of mothers (whichthey nowhere have succeeded in doing), they do succeed in harnessingmothers to the school programme. It may take two, three, or ten visitsto get a particular mother to do the necessary thing for her child, butwhen once convinced and once inspired to do that thing, she will go onday in and day out doing the right thing for that child and for allothers in her home. It may take a year to convert a police magistratewhose sympathy for delinquent parents and truant children is an activepromoter of disorder; but a magistrate convinced, efficient, andinterested is worth a hundred volunteer visitors. To get things done inthis way for a hundred thousand children costs less in time and moneythan 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 suppliedwith nerves. As one writer has said, the human brain is better "wired, "has better organized "centrals. " A poor system of centrals will spoil atelephone service, no matter how many wires it provides. An independentwire is of little use, because it will not reach the person desired atthe other end. The ideal system is that which almost instantly connectstwo persons, no matter how far away or how many other people aretalking at the same time on other wires. 

The school that tries to do everything for its pupils without usingother existing agencies for helping children[10] will be like the manwho refuses to connect his telephone with a central switch board, orlike a bank that will not use the central clearing house. As onetelephone center can enable scores of people to talk at once, and asone clearing house can make one check pay fifty debts, so hospital andrelief agencies enable a teacher who employs "central" to help severaltimes 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 indistress than to see that the cause of the misery is removed. In NewYork City there are over five hundred school principals, under them areover fifteen thousand teachers, and the average attendance of childrenis about six hundred thousand, representing one hundred and fiftythousand homes. If teachers give only to those children who ask forhelp, many will be neglected. In certain sections of the cityprincipals have combined to establish a relief fund to be given out tochildren who need food, clothes, shoes, etc. One principal had to stopreplacing stolen overcoats because, when it was known that he had afund, an astonishingly large number of overcoats disappeared. AtPoughkeepsie school children get up parties, amateur vaudeville, minstrel shows, basket picnics, to obtain food and clothing forchildren in distress. They are, of course, unable to help parents orchildren not in school. Of this method a district superintendent in NewYork said to his teachers and principals: "For thirty-two years I havebeen working in the schools of this district. I have given food andshoes to thousands of children. I know that however great our interestin a particular child when it comes to us with trouble at home, ourduty as teachers prevents us from following our gift into the home andlearning the cause of the child's trouble. This last winter we havemade an experiment in using a central society, which makes it abusiness to find out what the family needs, to supply necessaries, country board, medicine, etc. We now know that we can put a slip ofpaper with the name and address of the child into a general hopper andit will come out eyeglasses, food, rent, vacation parties, as the needmay be. "

Relief at home through existing agencies was brought about by thedistribution of cards like those on opposite page, which offer winterand 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 roomto room, asking children who needed help to raise the hand. In manycases parents were very angry that their children should have asked forhelp. But help given in instances like the following soon proved toteachers that they could afford the time necessary to notice childrenwho 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 equalresults for the individual children or for the families withoutneglecting school duties. By informing other agencies as to children'sneeds, teachers started movements that have since helped practicallyevery school child in New York City. Dispensaries are setting asideseparate hours for school children; fresh-air agencies are givingpreference to children found by teachers or school physicians to be inphysical need; relief agencies are making "rush orders" of every notefrom teachers; the health board is more active because volunteeragencies have added their voice to that of teacher and health officerin demanding adequate funds for physical examination of schoolchildren. 

 [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 keenlyalive to their responsibilities and are at least more apt to haveacquired the habit of coöperation when asked. Yet even here I have beentold repeatedly by teachers: "If we have to wait for that hospital orthat charitable society, our children will go barefoot. " In smallcommunities where hospital and relief agencies are for emergencies onlyand generally inactive, it seems that the first thing to do is to asksome friends to establish a small relief fund, just as it is easier togive a child a five-cent meal than to teach its mother how to prepareits food. But the school-teacher will find that it takes very much lessenergy to arouse the relief society than to maintain her own reliefwork. In fact, in many cities nothing could do more to strengthenhospitals and charitable societies than to put them in touch with theneeds of school children. For a principal to make known the fact thatschool children are neglected will help the charitable society andhospital to get the funds necessary to do their part better than theyare now doing it and better than the school could ever do it. Finally, one reason for a breakdown of charitable societies is not their owninadequacy, but rather the failure of the school and church to makeuse of an agency better equipped than themselves to give materialrelief. The teacher sees the child every day, while the relief societywill never see it and has no reason to see it until some one callsattention to it. The very first step, and an indispensable one inrelief policy, is for teachers to be on the lookout for children notadequately provided for, and then have the physical evidence discoveredat 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 willshow exactly what part of the community's work can be best done bytheir school. On the following page is charted the social work nowbeing conducted at the Massachusetts General Hospital, Boston. So faras agencies exist to deal with any individual or family problem cominginto the social-work square, the hospital aims to utilize that agency. Its own direct dealing with neurasthenics, with hygiene education, withsexual deviates, is primarily for the purpose of giving adequatetreatment to the needy, and secondarily to demonstrate how adequatetreatment should be organized for the community. Please to note thatgovernmental agencies are not mentioned in Dr. Cabot's chart. This doesnot mean that he would not emphasize the importance of those agencies, but that up to the present time, for the particular cases dealt with inhis clinics, governmental agencies can be reached most effectivelythrough the private charitable agencies in the reference square. So theteacher will frequently find that the relief bureau, children'ssociety, public education association, or church can get better resultsfor her pupils from public health and correctional agencies than canshe 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 adequaterelief. Fortunately, however, the distress is generally of such a kind, and the teacher so well acquainted with all the parents of herdistrict, that it will not be difficult to procure such attention as isnecessary. Country schools should be furnished by county and statesuperintendents with clear directions for getting the treatmentafforded in the immediate vicinity. Where teachers are alone in seeingthe 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 ofcurriculum, etc. _Getting things done_ is easy because it is human tolove the _doing_; getting things done is _doing_ of the highest order. 

FOOTNOTES:

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

CHAPTER XIX

SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE

The popular arguments for free meals, free relief, free medicaltreatment at school, are based upon the assumption that there are buttwo ways to travel, one leading to a physically sound, moral, teachablechild, the other to an undernourished, subnormal, backward child. Theytell us we must choose either school meals or malnutrition, schooleyeglasses or defective vision, free coal or freezing poor, free rentor people sleeping on the streets, free dental clinics at school orindigestion and undernourishment, free operation at school for adenoidsor backward, discouraged pupils. If there is no other alternative thanneglect of the child, if we must either waste fifty dollars in giving achild education that he is physically unable to take, or pay two, three, four, or even fifty dollars to fit him for that education, theAmerican people will not hesitate. Whether there are other roads tohealthy children, whether it is cheaper and better for the school tosee that outside agencies prepare the child for education rather thanitself to take the place of those outside agencies, is a question offact, not of theory. 

Facts prove, as we have seen, that there is more than one way toprevent malnutrition. Parents can be taught to attend to theirchildren; hospitals and dispensaries will furnish eyeglasses whereparents are unable to pay for them; charitable societies will go backof the need for eyeglasses to the conditions that produce that need andwill do vastly more for the child than can eyeglasses alone. Ifparents, hospitals, dispensaries, and charitable societies will attendto children's needs, then relief at school is unnecessary, even thoughit may seem desirable. 

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

Society is so organized that the treatment of serious physical defectsand social needs at school would upset the machinery a very great deal. For the school to do for its children whatever they may need duringtheir school years will require the setting up of a miniature societyin every school building or under every school board. Unless schoolsare to equip themselves to take the place of all existing facilitiesfor relief and surgery, children would not be so well taken care of asat present. It should not be forgotten that the physical welfare of theschool child is the most accurate index to the physical needs of thecommunity. After all, the child lives for six important years beforecoming to the school and leaves at the early age of fourteen orfifteen; even while attending school it sleeps at home and isinfluenced 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'sappeal to strengthen every agency having to do with community health, rather than to concentrate upon the child himself. If babies wereproperly cared for up to the sixth year, the protection of the schoolchild's health would be infinitely easier. To take our eyes from thechild not yet in school and from the child just out of school is tomake the mistake that so many advocates of the child labor movementhave made of going whither and only so far as our interest leads us andof 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'sinterest in the school child to put within the reach of every schoolbuilding adequate hospitals, dispensaries, relief centers, and parksfor school child and adult? Shall every little school have its library, or shall the child be taught at school how to use the same librarythat is available to his parents and older brothers and sisters? Ifthe library is to be under the school roof, if dispensary and reliefhospital are to be conducted on the same site as the school, shall theybe known as dispensary, library, relief bureau, each under separatemanagement, or shall they be known as school under the management ofschool principal and superintendent? So complicated and many-sided isthe problem of working together with one's neighbor for mutual benefitthat it is a safe rule for the schools to adopt: _We shall do nothingthat is unnecessary or extravagant. We shall have done our part if wedo well what no one else can do. Whatever any agency can do better thanwe, we shall leave to that agency. Work that another agency ought tohave done and has left undone, we shall try to have done by thatagency. _

 [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 afew blocks were three different relief agencies and twovisiting-nurse's associations, having among them over one hundredvisitors and nurses going to all sections of Manhattan. This nurse hadthe choice of telephoning to one of these agencies and asking it tocall at the needy home of one of her hospital patients, or of going tothe home herself. Had she chosen to use another agency, she could havebeen the means of furnishing the kind of help needed in every needyhome discovered in her hospital rounds, but she chose to do the runningabout herself and thus of helping ten families where she ought to havehelped five hundred. Much the same condition confronts the school thattries to do all extra work for its child instead of seeing that thework is done. Illustration is afforded by the New York tenementdepartment. Whereas European cities have built a few model tenements, New York City secured a law declaring that everybody who built atenement and everybody who owned a tenement should provide sanitarysurroundings. At the present time a philanthropist, by spending twomillion dollars, could give sanitary surroundings to thirty-fivefamilies; by spending each year the interest on one tenth that sum hecould insure the enforcement of the tenement laws affecting everytenement resident in New York City. 

If schools are to perform surgical operations, they are in danger ofbeing 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 ismade compulsory, the unpleasant and the controversial should be keptout of school. Because a democratic institution, the American schoolshould represent at all times a maximum of general agreement. 

To take _palliative measures to public schools_ not only _leaves undoneremedial_ work necessary for the health of public school children but_neglects entirely the still large numbers who go to parochial, privatepay, and private free schools_; no one has had the temerity to suggestthat the public shall force upon nonpublic schools a system of freeoperations, free eyeglasses, free meals. 

Civilization has painstakingly developed a large number of agencies forthe education and protection of mankind. Of these agencies the schoolis 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 asmall part of our resources. Instead of persuading each of the agenciesfor the promotion of health to do its part for school children, we setup the school in competition with them. Thus in trying to _do things_for school children we are in danger of crippling agencies equipped todo things for both school children and their parents, for babies beforethey 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 tosymptoms. _Getting things done_ will leave the school free toconcentrate its attention upon school problems; _doing things_ willlead it afield into the problem of medicine, surgery, restaurantkeeping, and practical charity. 

CHAPTER XX

PHYSICAL EXAMINATION FOR WORKING PAPERS

There is no sacred right to work when our work involves injury toourselves and to our neighbor. Work at the expense of health is anunjustifiable tax upon the state. It is the duty of society to protectitself against such depletion of national efficiency. 

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

It is undoubtedly true that just as the sick child may be found at thehead of his class, so unhealthy men and women are often good businessmanagers, good salesmen, good typewriters, successful capitalists. Theyexcel, however, not because of their ill health, but in spite of it, excepting of course those instances where men and women, because of illhealth, have devoted to business an attention that would have beengiven to recreation if bad health had not deprived recreation of itspleasure. As statistics in school have proved that the majority ofmentally superior children are also physically superior, so statisticswill probably prove that the number of the "sick superior" among theworking classes is very small, while the danger of inefficiency thatcomes from physical defect is very great. 

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

Every year from two to three million children leave the public schoolsof this country to join the army of workers. The percentage of thoserecruits who have physical defects needing attention is undoubtedlygreat; how great we shall never know until the benefits of physicalexamination are given to all of them. What steps is your state takingto ascertain the physical fitness of the children who presentthemselves each year for working papers? How does it insure itselfagainst the risk of their defective eyesight, chorea, deafness, orgeneral debility? Does it inform children of their defects, or tellthem how they may increase their earning power by correcting thesedefects? What effort does it make to induce children to avoid dangeroustrades, or trades that are particularly dangerous for their physiques?

At the close of school last spring I had my secretary look in upon theNew York board of health and see what demands that city makes upon itsboys and girls before allowing them to drive its machinery, to run itselevators, 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 roomwhere the children were being examined, greeted her as follows: "Youmust bring your child with you; bring his birth certificate or swearthat he is fourteen years old, and bring a signed statement from histeacher that he has been in school for one hundred and thirtyconsecutive days within twelve months. " "Is there no physicalexamination or test?" she asked. "No, no, " he answered impatiently. Yetthe board of health certifies that "said child has in our opinionreached the normal development of a child of its age, and is in soundhealth and is physically able to perform the work which it intends todo. " In addition the blank calls for place and date of birth, color ofhair and of eyes, height, weight, and facial marks. Volunteer societiesin practically every state in the Union have been working for years tohave it made a criminal offense to employ a child who has not been inschool a minimum of days after a stated age (12, 13, 14, 15). Even inNew York, however, the center of this agitation, no strong demand wasmade upon the board of health to apply a physical-fitness test as wellas an age test until 1908 when examination for working papers was addedto the programme for child hygiene. Yet who does not know girls andboys of sixteen less fit for factory or shop work than other boys andgirls of twelve? It is the fetich of age which has made possible the"democracy" that permits a child of fourteen to work all day oncondition 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 railroadthousands 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 founddetrimental to business. The Interborough Rapid Transit Company of NewYork 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 standardare rejected, but in each case the physical condition is explained tothe applicant. Where defects are removable or correctable, theapplicant is told what to do and invited to take another test aftertreatment. Moreover, accepted employees are periodically reëxamined. While designed to increase company profits and to reduce companylosses, this examination obviously decreases the employees' lossesalso, and increases the certainty of work and prospect of promotion. 

Our states, and many of our industries, still have the attitude of acertain manufacturer who employs several hundred boys and girls. Iasked him what tests he employed. "I look over a long line of theapplicants and say, " pointing his finger, "I want you, and you, andyou; the rest may go. " I asked him if he made a point of picking outthose who looked strong. "No. The work is easy, sitting down all daylong 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 inthe workroom had an epileptic fit and it frightened everybody and upsetthe work so that the foreman always asks, 'Do you have fits? Because ifyou do, you can't work here. '" He makes no attempt to determine thephysical fitness and endurance of the children employed, because whenthe strength of one is spent there is always another to step into herplace. 

Because the apprentice's future is of no value to the manufacturer, thestate must restrict the manufacturer's freedom to spend like watersociety's capital, --the health of the coming generation. Could there bea grosser mis-management of society's business than to permit trade towaste children on whose education society spends so many millionsyearly? The most effective and most timely remedy is physicalexamination as a condition of the work certificate. A simple, easilyapplied, inexpensive measure that imposes only a legitimate restrictionupon individual freedom, it is absolutely necessary in order to get tothe bottom of the child labor problem. If thoroughly applied, childrenof the nation will no longer be exploited by unscrupulous orindifferent employers, nor will their health be hazarded by lack ofdiscriminating examination that rejects the obviously sick and favorsthe apparently robust. Furthermore, knowledge that this test will beapplied when work certificates are required, will be an incentive tothe school boy and girl to keep well. Tell a boy that adenoids or weaklungs will keep him from getting a job, and you will make him a strongadvocate of operation and of fresh air. Show him that his employerswill not wish his services when his week is out if he is physicallybelow par, and he will gladly submit to a board of health examinationand 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 economicinstinct. This objection does not remove the instinct. The normal childis greedy for a job. His greed, as well as that of the manufacturer andparent, is responsible for much of the child labor; his greed foractivity, for association, for money, and so for work. A little boycame into my office and wanted to hire as an office boy. I looked athim and said: "My little fellow, you ought to be in school. What do youwant to hire out here for?" He said, "I am tired of school; nothingdoing. " He doesn't care about work for its own sake; he doesn't careabout wealth for its own sake; he wants to get into life; to be wherethere is "something doing. " In this lies one potent argument forvocational training. To tell a boy of his physical needs just before hehas taken his first business step is to put him everlastingly in ourdebt. Then he is responsive, and, fortunately for the extreme cases, necessarily dependent, for he knows that his refusal would standbetween himself and his ambition. 

When boys and girls go for work certificates to Dr. Goler, medicalofficer of health at Rochester, he requires not merely evidence of ageand of schooling, but examines their eyes for defective vision and fordisease, their teeth for cavities and unhealthy gums, and their nosesand throats for adenoids and enlarged tonsils. If a boy has sixteendecayed teeth, Dr. Goler explains to him that teeth are meant to be notonly ornaments and conveniences, but money getters as well. The boylearns that decayed teeth breed disease, contaminate food, interferewith digestion, make him a disagreeable companion and a less efficientworker. If he will go and have them put into proper condition he willenjoy life better and earn good wages sooner. After the teeth areattended to the boy secures his work certificate. If the boy's motherprotests in tears or in anger that her boy does not work with histeeth, she learns what she never learned at school, that sound teethhelp 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 tomeet, how the lower jaw drops, how much better she looks with her jawsand lips together. She is told that other people breathe through thenose, and that perhaps the reason she dislikes school and does not feelas she used to about play is that she cannot breathe through her noseas she used to. She is shown that her nose is stopped up by a spongysubstance, as big as the end of her little finger, which obstructioncan be easily removed. She is shown adenoids and enlarged tonsils thathave been removed from some other girl, and is so impressed with thebefore-operation and after-operation contrast and by the story of theother girl's rapid increase in wages, that she and her mother bothdecide not to wait for the adenoids to disappear by absorption. Afterthe operation they come back with proof that the trouble is gone, andget the "papers. " Similar instruction is given when defects of visionseriously interfere with a child's prospects of getting ahead in hiswork, or when evidence of incipient tuberculosis makes it criminal toput 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 workcertificates to children physically unfit to become wage earners. Ahigher law than that which any legislature can pass or revoke, hasgiven Dr. Goler power over children and parents, namely, interest inchildren and knowledge of the industrial handicap that results fromphysical defects. This higher law authorizes every health officer inthe United States to examine the school child before issuing a workcertificate, to tell the child and his parents what defects need to beremoved, for what trades he is physically unfitted, what trades willnot increase his physical weakness, and to what trade he is physicallyadapted. 

We should not forget that a large proportion of our children neverapply 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 andstates where prohibition of child labor is not enforced. Because thereis no reason for this large proportion of children to visit a board ofhealth, some substitute must be found. This substitute has been alreadysuggested by principals and district superintendents in New York City, who claim that the natural place for the examination of children is theschool and not health headquarters. Developing the idea that the schoolshould pronounce the child's fitness to leave school and to engage inwork, we are led to the suggestion that the state, which compelsevidence that every child, rich or poor, is being taught during thecompulsory school age, shall also at the age of fourteen or sixteenrequire evidence that the child is physically fit to use his education, and that it shall not, because of preventable ill health, prove alosing investment. 

Parochial and private schools, the ultra-religious and ultra-rich, mayresent for a time public supervision of the physical condition ofchildren who do not ask for work certificates. This position will beshort-lived, because however much we may disagree about society's rightto control a child's act after his physical defects are discovered, fewof us will question the state's duty to tell that child and hisparents the truth about his physical needs before it accepts his laboror permits him to go to college, to "come out, " to "enter society, " orto live on an income provided by others. Thus an invaluablecommencement present can be given by the state to children in countryschools and to those compelled to drop out of fourth or fifth grades ofcity 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 beingmade by several boards of health at the instance of the National Bureauof Labor, will prove conclusively that parents are grateful for thetimely discovery of these defects which handicap because of theirexistence, not because of their discovery. Of the cadets preparing forwar at West Point, it has recently been decided that those "who in thephysical examinations are found to have deteriorated below theprescribed physical standard will be dropped from the rolls of theacademy. " Shall not cadets preparing for an industrial life andcitizenship be given at least a knowledge of an adequate physicalstandard? To allow the school child to deteriorate whether before orafter going to work is only to waste potential citizenship. Citizenswho use themselves up in the mere getting of a living have no surplusstrength or interest for overcoming incompetence in civic business, orfor achieving the highest aim of citizenship, --the art ofself-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 ofachievement. How many men and women can you count who are squanderingtheir health bank account? How many do you know who are now physicallybankrupt? The man who is prodigal of his health may work along allright for years, never realizing until the test comes that he isrunning behind in his vitality. The test may be hard times, promotion, exposure to cold, heat, fever, or a sudden call for all his control inavoiding accident. If his vitality fails to stand the test, his careermay be ruined, "all for the want of a horseshoe nail": because of nohealth bank account to draw upon in time of need, --failure; because ofvitality depleted by alcohol, tobacco, overeating, underexercise, ortoo little sleep, --no power to resist contagious diseases; because ofignorance of existing lung trouble, --a year or more of idleness, perhaps poverty for his family; or there is neglected ear or eyetrouble, --and thousands of lives may be lost because the engineerfailed to read the signals. 

Adults are now examined when applying for insurance or accidentpolicies, for work on railroads, for service in the army and on thepolice and fire forces of cities that provide pensions. It is somewhatsurprising that the hundreds of thousands who carry life insurancepolicies have not realized that a test which is rigorously imposed forbusiness reasons by insurance companies can be applied by individualsfor business reasons. Generations hence the state will probablyrequire of every person periodic physical examination after school age. Decades hence business enterprises will undoubtedly require evidence ofhealth and vitality from employees before and during employment, justas schools will require such evidence from teachers. It is, after all, but a step from the police passport to the health passport. Why shouldwe not protect ourselves against enemies to health and efficiency aswell as against enemies to order? But for the present we must rely uponthe intelligence of individuals to recognize the advantage tothemselves, their families, and their employers, of knowing that theirbodies do not harbor hidden enemies of vitality and efficiency. From asemi-annual examination of teeth to a semi-annual physical examinationis but a short step when once its effectiveness is seen by a few ineach 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. Nosociety is rich enough to afford members ignorant of physicalweaknesses prejudicial to others' health and efficiency. Every one ofus, even though to all appearances physically normal, needs thebiological engineer. New conditions come upon us with terrificrapidity. The rush of work, noise, dust, heat, and overcrowding ofmodern industry make it important to have positive evidence that wehave successfully adapted ourselves to these new conditions. Only bymeasuring the effects of these environmental forces upon our bodies canwe prevent some trifling physical flaw from developing into a chronicor acute condition. As labor becomes more and more highly specialized, the body of the laborer is forced to readapt itself. The kind of work aman does determines which organs shall claim more than their share ofblood and energy. The man who sets type develops keenness of vision andmanual dexterity. The stoker develops the muscles of his arms and back, the engineer alertness of eye and ear. All sorts of devices have beeninvented to aid this specialization of particular organs, as well as tocorrect their imperfections: the magnifying glass, the telescope, themicroscope, extend the powers of the eye; the spectacle or an operationon the eye muscles enables the defective eye to do normal work. A manwith astigmatism might be a policeman all his life, win promotion, anddie ignorant of his defect; whereas if the same man had become achauffeur, he might have killed himself and his employer the firstyear, or, if an accountant, he might have been a chronic dyspeptic fromlong-continued eye strain. It is a soul tragedy for a man to attempt acareer for which he is physically unadapted. [11] It is a social tragedywhen men and women squander their health. A great deal of the successattributed to luck and opportunity, or unusual mental endowment, is inreality due to a chance compatibility of work with physique. To securesuch compatibility is the purpose of physical examination after schoolage. 

If the periodic visit to the doctor is the first law of adult health, still more imperative is the law that competent physicians should beseen at the first indication of ill health. Even when competentphysicians are at hand, parents and teachers should be taught whatwarning signs may mean and what steps should be taken. In Germanyinsurance companies find that it saves money to provide free medicaland dental care for the insured. Department stores, many factories andrailroads, have learned from experience that they save money byinducing their employees to consult skilled physicians at the firstsign of physical disorder. Many colleges, schools, and "homes" have aresident physician. Wherever any large number of people are assembledtogether, --in a hotel, factory, store, ship, college, or school, --thereshould be an efficient consulting physician at hand. If people areneedlessly alarmed, it is of the utmost importance to show them thatthere is nothing seriously wrong. Therefore visits to the consultingphysician should be encouraged. 

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

A celebrated economist was forced to give up academic work, andconsecrated his life to painful and chronic dyspepsia because of eyetrouble detected upon the first physical examination. A woman secretarysuffered from alleged heart trouble; paralysis threatened, continuousheadache and blurred vision forced her to give up work and income; aphysical examination found the cause in nasal growths, whose removalrestored normal conditions. A woman lecturer on children's health hearddescribed last summer a friend's experience with receding gums: "'Why, I never heard of that disease. ' she said. 'Don't you know you have ityourself'? I asked. She had never noticed that her gums were growingaway in little points on her front teeth. I touched the uncoveredportion and she winced. That ignorance has meant intense pain and uglyfillings. If it had gone longer, it might have meant the loss of herfront teeth. " A teacher lost a month from nervous prostration; physicalexamination would have discovered the eye trouble that deranged thestomach and produced the nerve-racking shingles which forced him totake a month's vacation. A journalist lost weeks each year because ofstrained ankles; since being told that he had flat foot, and that thearch of his foot could be strengthened by braces and specially madeshoes, he has not lost a minute. A relief visitor, ardent advocate ofthe fresh-air, pure-milk treatment for tuberculosis, had a "littlecough" and an occasional "cold sweat"; medical friends knew this, buthumored her aversion to examination; when too late, she submitted to anexamination and to the treatment which, if taken earlier, would mostcertainly have cured her. A mother's sickness cost a wage-earningdaughter nearly $3000; softening of the brain was feared; after sixyears of suffering and unnecessary expense, physical examinationdisclosed an easily removable cause, and for two years she hascontributed to the family income instead of exhausting it. Untoldsuffering is saved many a mother by knowledge of her special physicalneed in advance of her baby's birth. Untold suffering might be savedmany a woman in business if she could be told in what respects she wastransgressing 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 morbidthinking of disease. One reason for our tardiness in recognizing theneed for thorough physical examination is the doctor's tradition oftreating symptoms. After men and women are intelligent enough to demandan inventory of their physical resources, --a balance sheet of theirphysical assets and liabilities, --physicians will study the whole manand not the fraction of a man in which they happen to be specializingor about which the patient worries. By removing the mystery of bodilyailments and by familiarizing ourselves with the essentials to healthyliving, we find protection against charlatans, quacks, faddists, andexperimenters. By taking a periodic inventory of our physical resourceswe discharge a sacred obligation of citizenship. 

FOOTNOTES:

[11] See _Dangerous Trades_, compiled by Thomas Oliver; also list ofreports 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 theright moment without having to think. The technic of musician, stenographer, artist, electrician, surgeon, orator, is gained only frompatient training of the body's reflex muscles to do brain work. [12] Thelower nerve centers are storehouses for the brain energy, just ascentral power houses are used for storing electric energy to be spentupon 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 toladies or to elderly persons, use acceptable table manners. No personseems "to the manner born" who has to think out each act necessary to"company manners. " How numerous are the mental and physical processesessential to good manners no one ever recognizes but the very bashfulor the uncouth person trying to cultivate habits of unconsciousness inpolite society. The habit of living ethically enables us to go throughlife without being tempted to steal or lie or do physical violence. Noperson's morals can be relied upon who is tempted constantly to doimmoral acts; ethical training seeks to incapacitate us for committingunethical deeds and to habituate us to ethical acts alone. 

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

That industrial inefficiency results from chronic habits of unhealthyliving is generally recognized. The alcoholic furnishes the most vividillustration. The penalties suffered by him and his family are graveenough, but because he has not full possession of his faculties he isunpunctual, wastes material, disobeys instructions, endangers others'lives, decreases the product of his trade and of his employer, lessensthe profits of both, depresses wages, increases insurance and businessrisks. Because no one can foresee when the "drop too much" will betaken, industry finds it important to know that the habit of drinkingalcoholics moderately has not been acquired by train dispatcher, engineer, switchman, chauffeur. Because the habit of drinkingmoderately is apt, among lower incomes, to go hand in hand with otherhabits injurious to business and fatal to integrity, positions of trustin industry seek men and women who have the habit of declining drink. 

In the aggregate, milder forms of unhealthy living interfere withindustrial efficiency even more than alcoholism. Many capable men andwomen, even those who have had thorough technical training, fail to winpromotion because their persons are not clean, their breath offensive, their clothes suggestive of disorderly, uncleanly habits. Persons ofextraordinary capacity not infrequently achieve only mediocre resultsbecause they fail to cultivate habits of cleanliness and health. Anemployer can easily protect his business from loss due to alcoholismamong his own employees; but loss through employees' constipation, headache, bad ventilation at home, irregular meals, improper diet, toomany night parties, nicotinism, personal uncleanliness, is loss muchharder to anticipate and avoid. Because evil results are less vivid, itis also hard to convince a clerk that intemperance in eating, sleeping, and playing will interfere with his earning capacity and his enjoymentcapacity quite as surely as intemperance in the use of alcohol andnicotine. Where employees are paid by the piece, instead of by thehour, day, or week, the employer partially protects himself againstuneven, sluggish, slipshod workmen; but, other things being equal, heawards promotion to those who are most regular and who are most oftenat their best, for he finds that the man who does not "slump" earnsbest 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 andindustrial efficiency are won by people who violate laws ofhealth, --but at what cost to their efficiency? Your efficiency shouldbe measured not by some other person's advancement, but by what youyourself ought to accomplish; while the effect of abusing your physicalstrength is shown not only in the shortening of your industrial lifeand in the diminishing returns from your labor, but by the decrease ofnational and trade efficiency. "Sweating" injures those who buy andthose in the same trade who are not "sweated" just as truly as itinjures the "sweated. "

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

What are the health habits that should become instinctive andeffortless for every worker? What acts can we make our lower nervecenters--our subconscious selves--do for us or remind us to do? Thefollowing constitutes a daily routine that should be as involuntary asthe 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 reducinghis industrial efficiency. No man chronically neglects all of themwithout becoming, sooner or later, a health bankrupt. 

In addition to this daily routine, there are certain other acts thatshould 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, consciouseffort is made to accustom the body to them. When this is once done, however, the body not only attends to its primary health needsautomatically, but it rebels at their omission, as surely as does thestomach at the omission of dinner. Witness the discomfort of theconsumptive, trained to fresh air at a sanatorium, when he returns tohis overheated and underventilated home, or the actual pain experiencedin readjusting our own healthy bodies to the stuffy workroom orschoolroom after a summer vacation out of doors. I heard a consumptivesay that he left a sanatorium for a day class after trying for threenights to sleep in an unventilated ward. For many people the regularmorning 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 dietor the same amount of food or time for eating is not of equal value forall. The temperature of bath water, the kind and quality of food, areinfluenced by one's work and one's cook. Set rules about these thingsdo more harm than good. Such questions must be decided for eachindividual, --by his experience or by the advice of a physician, --butthey must be decided and the decisions converted into health habits ifhe would attain the highest efficiency of which he is capable. Hereagain our old contrast between "doing things" and "getting things done"applies. Get your body to attend to the essential needs for you, andget 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 foryou 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 ofcorrecting those habits of factory, family, trade, city, or nation thatmake health habits impracticable. We must change others' prejudicesbefore 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 thefamily coöperates in making definite plans for the use of toilet andbath for each member, constipation and bad circulation are sure toresult. Indigestion is inevitable if employees are not given lunchperiods and closing hours that permit of regular, unhurried meals. Cleanliness of person costs more than it seems to be worth where citiesfail either to compel bath tubs in rented apartments or to erect publicbaths. A temperate subsistence on adulterated, poisonous, or druggedfoods might be better for one's health than gormandizing on pure foods. No recipe has ever been found for bringing up a healthy baby onunclean, infected milk; for avoiding tuberculosis among people who arecompelled to work with careless consumptives in unclean air; or formaking a five-story leap as safe as a fire escape. Perfect habits ofhealth on the part of an individual will not protect him againstenervation or infection resulting from inefficient enforcement ofsanitary 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 isindispensable to protecting industrial efficiency. Public lavatories, above or below ground, have done much to reduce inefficiency due toalcoholism, constipation of the bowels, and congestion of the kidneys. Theaters, churches, and assembly rooms could be built so as to drillaudiences in habits of health instead of fixing habits of uncleanlybreathing. Street flushing, drinking fountains, parks and breathingspaces, playgrounds and outdoor gymnasiums, milk, food, and druginspection, tenement, factory, and shop supervision, enforcement ofanti-spitting penalties, restriction of hours of labor, prohibition ofchild labor, --these inculcate community habits of health that promotecommunity efficiency. It is the duty of health boards to compel allcitizens under their jurisdiction to cultivate habits of health and topunish all who persistently refuse to acquire these habits, so far asthe evils of neglect become apparent to health authorities. Theunlimited educational opportunity of health boards consists in theirprivilege to point out repeatedly and cumulatively the industrial andcommunity benefits that result from habits of health, and theindustrial and community losses that result from habits of unhealthyliving. 

FOOTNOTES:

[12] Serviceable guides to personal habits of health are _Aristocracy ofHealth_ 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 ofindustry" implies that modern industry not influenced by that movementis brutalized. The brutalizing of industry was due chiefly to a generalignorance of health laws, --an ignorance that registers itself clearlyand promptly in factory and mine. It is not that a man is expected todo too much, but that too little is expected of the human body. Thepresent recognition of the body's right to vitality is not because theemployer's heart is growing warmer, or because competition is lessvicious, but because the precepts of hygiene are found to be practical. Where better ventilation used to mean more windows and repair bills, itnow means greater output. Where formerly a comfortable place in whichto eat lunch meant giving up a workroom and its profits, it now means25 per cent more work done in all workrooms during the afternoon. Thegeneral enlightenment as to industrial hygiene has been accelerated bythe awakening that always follows industrial catastrophes, by thesplendid crusade against tuberculosis, and by compulsory notificationand treatment of communicable diseases. 

Catastrophes, however, have dominated the vocabulary that describesfactory "welfare work. " Because accidents such as gas in mines, fire infactories, fever in towns, and epidemics of diseases incident tocertain trades were beyond the power of the workers themselves tocontrol or prevent, wage earners have come to be looked upon ashelpless victims of the cupidity and inhumanity of their employers. This attitude has weakened the usefulness of many bodies organized topromote industrial hygiene. Although the term "industrial hygiene" isbroad enough to include all sanitary and hygienic conditions thatsurround the worker while at work, it is restricted by some to theefforts made by altruistic or farsighted employers in the interest ofemployees; others think of prohibitions and mandates, in the name ofthe state, that either prevent certain evils or compel certainbenefits; for too few it refers to what the wage earner does forhimself. 

Pity for the employee has caused the motive power of the employee to bewastefully allowed to atrophy. Yet when a man becomes an employee, hedoes not forfeit any right of citizenship, nor does being an employeerelieve him from the duties of citizenship. In too many cases it hasbeen overlooked that a worker's carelessness about habits of health, aswell as about his machinery, causes accidents and increases industrialdiseases. Too often the worker himself is responsible for uncleanlinessand lack of ventilation and his own consequent lack of vitality. Astudy into the conditions of ventilation and cleanliness of workers'homes will prove this. 

Knowing that a light, well-aired, clean, safe factory would not ofitself insure healthy men, many employers have built and suppliedhouses for their workmen at low rents. Just as these employers failedto see that they could reach more people and secure more permanentresults if they demanded that tenement laws and the sanitary code beenforced as well as the laws for the instruction of children inhygiene, so the employee has failed to see that he is a part of thepublic that passes laws and determines the efficiency of factoryinspection. The enforcement of state legislation for working hours, proper water and milk supply, proper teaching of children, propertenement conditions, efficient health administration, is dependent uponthe interest and activity of the public, of which the working class isno 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 forworkingmen is to make sure that they know the rights that the lawalready gives them. Men still throw out their chests when talking oftheir rights. The posting of the game laws in a club last summer, andthe instruction of all the natives of the countryside in regard totheir rights as against those of outsiders, meant that for the firsttime in their history the game laws were enforced. All the natives, instead of poaching as has been their wont, joined together inprotecting club property from intruding outside sportsmen. Poacherswere caught and served with the full penalties of the law. Over winterfires these people's heroism will grow, but their respect for law willgrow also, and it is doubtful if the game laws can be violated in thatsection so long as the tradition of this summer's work lives. And soit would be in a factory, if employees once realized that by unitingthey could, as citizens, enforce health rights in the factory. 

The hygiene of the workshop is not the same problem as the hygiene ofthe home and schoolhouse, because there are by-products of factory workthat contaminate the air, overheat the room, and complicate theordinary problems of ventilation. Certain trades are recognized as"dangerous trades. " The problem of adequate government control offactories is one for a sanitary engineer. It has to do withdisease-bearing raw material that comes to a factory, disease-producingprocesses of manufacture. There is need for revision of thedangerous-trade list. Many of the industries not so classed should be;many of the so-called dangerous trades can be made comparativelyharmless by devices for exhausting harmful by-products. Industrialdiseases should be made "notifiable, " so that they can be controlled bythe factory or health department. It is those trades that are dangerousbecause of remediable unsanitary and unhygienic conditions which demandthe employer's attention. Complaints should be made by individuals whencarelessness or danger becomes commonplace. 

The manner in which many organizations have tried to better workingconditions is similar to the manner in which Europeans are trying tohelp defective school children. Here, as there, is the differencebetween _doing things_ and _getting things done_. Here more than thereis the tendency to exaggerate legislation and to neglect enforcement oflaw. Instead of harnessing the whole army of workingmen to the crusadeand strengthening civic agencies such as factory, health, and tenementdepartments, houses are built and given to men, clubs are formed toamuse factory girls, amateur theatricals are organized. All this iscalled "welfare work. " "What is welfare work?" reads the pamphlet of alarge national association. "It is especial consideration on the partof the employer for the welfare of his employees. " In the words of thispamphlet, the aim of this association "is to organize the best brainsof the nation in an educational movement toward the solution of some ofthe great problems related to social and industrial progress. " Themembership is drawn from "practical men of affairs, whose acknowledgedleadership in thought and business makes them typical representativesof business elements that voluntarily work together for the generalgood. " As defined by this organization, welfare work is something givento the employee by the employer for the welfare of both. It is notsomething the employee himself does to improve his own workingconditions. 

 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 anecessary step in the development of industrial hygiene. Undoubtedly ithas succeeded, in many cases, in bringing to an employer'sconsciousness the needs of his workmen, in accustoming employees tohigher sanitary standards, and in teaching them to demand health rightsfrom their employers. In many cases, however, "welfare work" hasmiseducated both employer and employee. The fact that "the so-calleddemocratic idea, purely a fad, has never been successfully operated, "is due to the interpretation given to "democratic idea. " The twoalternatives in the paragraph above quoted are lunch rooms, wash rooms, as gifts from employers to employees, or lunch rooms and wash rooms tobe furnished by employees at their own expense. The true democraticidea, however, is that factory conditions detrimental to health shallbe prohibited by factory legislation, and this legislation enforced byefficient factory inspectors, regardless of what may be given toemployees above the requirement of hygiene. 

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

Welfare work at its best is a method of dividing business profits amongall who participate in making these profits. Too often welfaresecretaries teach employees how to be happy in the director's way, rather than in their own way. This adventitious position increasessuspicion on both sides, disturbs the discipline of the foreman, weakens rather than strengthens the worker's efficiency, because itdepends upon other things than work well done and the relation ofhealth to efficiency. In a small factory town the owner of a largecotton mill has recognized the financial benefit of physically strongworkers, and is trying the experiment of a welfare director. The manhimself works "with his sleeves up. " The social worker has an office inthe factory. A clubhouse is fitted up for the mill hands to make merryin. 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 bythe employer to the employees, which he himself attends. He has thrownhimself into whatever schemes his director has suggested. The directorcomplained that the reason the new lunch room was not more popular wasbecause a piano was needed. A second-hand one would not do, for thatwould cultivate bad taste in music. This showed the employer that sooneverything would be expected from the "big house on the hill. " An eventwhich happened at the time when the pressure was greatest on him forthe piano, convinced him that his employees could supply their realneeds without any trouble or delay. The assistant manager was about toleave, and in less than a week five hundred dollars was raised amongthe workers for his farewell gift. Walking home that night late fromhis office the owner was attracted by the sound of jollity, and saw alittle room jammed full of mill people enjoying the improvised music ofa mouth organ played to the accompaniment of heels. He resolvedhenceforth to train his employees to do his work well and to earn morepay, --and to let them amuse themselves. From that time on he refused tobe looked upon as the _deus ex machina_ of the town. He decided thatthe best way to give English lessons to foreigners was to improve theschool. His beneficence in supplying them with pure water at the milldid not prevent a ravaging typhoid epidemic because the town water wasnot watched. He saw that the best way to improve health was tostrengthen the health board and to make his co-workers realize thatthey were citizens responsible for their own privileges and rights. 

Emergency hospitals and Y. M. C. A. Buildings are sad substitutes forsafety devices and automatic couplers. Christmas shopping in Novemberis less kind than prevention of overwork in December. Night school andgymnastic classes are a poor penance for child labor and for workunsuited to the body. The left hand cannot dole favors enough to offsetthe evils of underpay, of unsanitary conditions, of inefficientenforcement of health laws tolerated by the right hand. 

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

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

Would it help to punish employees for working in unhealthy places? Thehighest service that can be rendered industrial hygiene is to educatethe industrial classes to recognize hygienic evils and to coöperatewith 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 ofthe nineteenth century were its sanitary achievements, the Lecky of thetwenty-first century will probably honor our generation not for itselectricity, its trusts, and its scientific research, but for itscrusade against the white plague and for its recognition of healthrights. Thanks to committees for the prevention of tuberculosis, --local, state, national, international, --we are fast approaching the time whenevery parent, teacher, employer, landlord, worker, will see intuberculosis a personal enemy, --a menace to his fireside, his income, and his freedom. Just as this nation could not exist half slave, halffree, we of one mind now affirm that equal opportunity cannot existwhere one death in ten is from a single preventable disease. [13]

Of no obstacle to efficient living is it more true than oftuberculosis, that the remedy depends upon enforcing rather than uponmaking law, upon practice rather than upon precept, upon health habitsrather than upon medical remedies, upon coöperation of lay citizensrather than upon medical science or isolated individual effort. Withoutlearning another fact about tuberculosis, we can stamp it out if wewill but apply, and see that officers of health apply, lessons ofcleanliness 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 combatingtuberculosis are those of the Massachusetts General Hospital in Boston. To visit its tuberculosis classes reminds one more of the sociable thanthe clinic. In fact, one wonders whether the milk diet and the restcure or the effervescing optimism and good cheer of the physicians andnurses should be credited with the marvelous cures. The first part ofthe hour is given to writing on the blackboard the number of hours thatthe class members spent out of doors the preceding week. So great wasthe rivalry for first place that the nurse protested that a certain boyin the front row gave himself indigestion by trying to eat his meals inten or fifteen minutes. It was then suggested that twenty hours a daywould be enough for any one to stay out of doors, and that plenty oftime should be taken for meals with the family and for cold baths, keeping clean, etc. Interesting facts gathered by personal interviewsof two physicians with individual patients are explained to the wholeclass. Next to the number of hours out of doors, the most interestingfact is the number of hours of exercise permitted. A man of forty, thehead of a family, beamed like a school child when told that, afternearly a year of absolute rest, he might during the next week exerciseten minutes a day. A graduate drops in, the very picture of health, weighing two hundred pounds. An apparently hopeless case would brightenup and have confidence when told that this strong, handsome man hasgained fifty pounds by rest, good cheer, fresh air, all on his ownporch. One young man, just back from a California sanatorium where heprogressively lost strength in spite of change of climate, is nowreturning 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 followinginstructions:

 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, evenwhere 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 simplelaws that must be followed, once having placed oneself in a positionto secure the rest, the fresh air, and the health diet, no better nextsteps can be taken than to observe the closing injunction in the rulesfor 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 campswithin and near cities, milk and egg clinics, home visiting, change ofair and rest for those who are known to be tuberculous, theirimportance is infinitesimal compared with the protection that comesfrom clean, healthy environment and natural living for those not knownto be tuberculous. This great fact has been recognized by the variousbodies now engaged in popularizing the truth about tuberculosis bymeans of stationary and traveling exhibits, illustrated lectures, street-car transfers, advertisements, farmers' institutes, anti-spitting signs in public vehicles and public buildings, board ofhealth instructions in many languages, magazine stories, and pressreports of conferences. This brilliant campaign of education shows whatcan 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 primarilyto the organizing capacity of laymen in the New York CharityOrganization Society rather than to schools or hospitals? Most of thelocal secretaries are men whose inspiration came from contact with thenon-medical relief of the poor in city tenements. The secretary of thenational association is a university professor of anthropology, who hasalso a medical degree. The child victim's plea--Little Jo's Smile--wasnationalized by an association of laymen, aided by the advertisingmanagers of forty magazines. The smaller cities of New York state arebeing aroused by a state voluntary association that for years hasvisited almshouses, insane asylums, and hospitals. These facts Iemphasize, for they illustrate the opportunity and the duty of the layeducator, whether parent, teacher, labor leader, or trustee ofhospital, orphanage, or relief society. 

Three fundamental rules of action should be established as firmly asreligious 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 theenforcement of these three principles must be modified or abolished. Ifthe teachers of America will list for educational use in their owncommunities the local obstacles to these rules of action, they will seeexactly where their local problem lies. The illustrations that aregiven in this book show in how many ways these rules of action are nowbeing universalized. Three or four important steps deserve especialcomment:

 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 byHermann M. Biggs, M. D. , chief medical officer: 1893, partiallyvoluntary, partially compulsory; 1897, compulsory for all. Physicianswho now hail Dr. Biggs as a statesman called him persecutor, autocrat, and violator of personal freedom fifteen years ago. Foreign sanitariansvied with American colleagues in upbraiding him for his exaggeration ofthe transmissibility of consumption and for his injustice to itsvictims. As late as 1899 one British expert particularly resented therejection of tuberculous immigrants at Ellis Island, and said to me, "Perhaps if you should open a man's mouth and pour in tubercle bacillihe might get phthisis, but compulsory notification is preposterous. " In1906 the International Congress on Tuberculosis met in Paris andcongratulated New York upon its leadership in securing at healthheadquarters a list of the known disease centers within its borders; in1906 more than twenty thousand individual cases were reported, tenthousand of these being reported more than once. To know the nature andlocation of twenty thousand germ factories is a long step towardjudging their strength and their probable product. To compulsorynotification in New York City is largely due the educational movementsof the last decade against the white plague, more particularly thegrowing ability among physicians to recognize and to treat conditionspredisposing to the disease. As in New York City, the public shouldprovide free of cost bacteriological analysis of sputum to learnpositively whether tuberculosis is present. Simpler still is thetuberculin test of the eyes, with which experiments are now being madeon a large scale in New York City, and which bids fair to become cheapenough to be generally used wherever physical examinations are made. This test is known as Calmette's Eye Test. Inside the eyelid is placeda drop of a solution--95 per cent alcohol and tuberculin. Ifconjunctivitis develops in twenty-four hours, the patient is proved tohave tuberculosis. Some physicians still fear to use this test. Othersquestion its proof. The "skin test" is also being thoroughly tried inseveral American cities and, if finally found trustworthy, willgreatly simplify examination for tuberculosis. Dr. John W. Brannan, president of Bellevue and Allied Hospitals, New York City, is to reporton skin and eye tuberculin tests for children at the InternationalCongress 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 obstacleis the lack of hospitals. In New York ten thousand die annually fromtuberculosis and fifty thousand are known to have it, yet there areonly about two thousand beds available. So long as the patients anxiousfor hospital care exceed the number of beds, it does not seem fair togive a bed to some one who does not want it. On the other hand, itshould not be forgotten that patients are taken forcibly to smallpoxand scarlet-fever hospitals, not for their own good, but for theprotection of others. The last person who should be permitted to stayat home is the tuberculous person who is unable, unwilling, or tooignorant to take the necessary precautions for others' protection. Arigid educational test should be applied as a condition of remaining athome without supervision. 

The objections to compulsory removal are two: (1) it is desired to makesanatorium care so attractive that patients will go at the earlieststage of the disease; (2) an unwilling patient can defeat thesanitarian's effort to help him and others. The alternative forcompulsory removal is gratuitous, and, if need be, compulsory, supervision of home care, such as is now given in New York City. InBrighton, England, Dr. Newsholme treats his municipal sanatorium as avacation school, giving each patient one month only. Thus one bed helpstwelve patients each year. Almost any worker can spare one month and inthat 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 ofbone tuberculosis. Many of the crippled children at Sea Breeze werefound to have consumptive fathers or mothers. In one instance thefather had died before Charlie had "hip trouble. " Long after we hadknown Charlie his mother began to fail. She too had consumption. Familyparties were planned for 290 families. Weights were taken and carefulexamination made, the physician explaining that predisposition meansdefective lung capacity or deficient vitality. Of 379 members, supposedly free from tuberculosis, sixteen were found to havewell-marked cases. (Of twenty Boston children whose parents were in atuberculosis class, four had tuberculosis. ) In one instance the fatherwas astonished to learn not only that he was tuberculous, but that hehad probably given the disease to the mother, for whom he was tenderlyconcerned. Of special benefit were the talks about teeth andnourishment, and about fresh air and water as germ killers. Oneexamination of this kind will organize a family crusade againstcarelessness. 

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

Tuberculous teachers ought to be excluded from schoolrooms not merelybecause they may spread tuberculosis, but because they cannot dojustice to school work without sacrifices that society ought not toaccept. A tuberculous teacher ought to be generous enough to permitpublic hospitals to restore her strength or enterprising enough tojoin tuberculosis classes. It is selfish to demand independence at theprice 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 childbefore he is accepted as an industrial soldier. Many trades nowdangerous would be made safe if workers knew the risk they run, and ifsociety forbade such trades needlessly to exhaust their employees. Aperfectly sound man is predisposed to tuberculosis if he elects to workin stale, dust-laden air. Ill-ventilated rooms, cramped positions, lackof exercise in the open air, prepare lungs to give a cordial receptionto tubercle bacilli. Rooms as well as persons become infected. Fortunately, opportunities to work are so varied in most localitiesthat workers predisposed to tuberculosis may be sure of a livelihood inan occupation suited to their vitality. Destruction of germs in theair, in carpets, on walls, on streets, is quite as important asdestruction of germs in lungs. Why should not tenants and workersrequire health certificates stating that neither house nor workingplace is infected with tubercle bacilli? Some cities now compel thedisinfection of premises occupied by tuberculous persons _after_ theirremoval. Landlords, employers, tenants, and employees can easily betaught to see the advantage of disinfecting premises occupied bytuberculous 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 fromschoolrooms within twenty-four hours after school-teachers declare thatthey shall disappear. We have no right to expect street cleaners, tenement and shop janitors, or overworked mothers to be more carefulthan school-teachers. Last year I said to a janitress, "Don't yourealize that you may get consumption if you use that feather duster?"Her reply caused us to realize our carelessness: "I don't want any morethan I've got now. " Shall we some day have compulsory examination andinstruction of all cleaners, starting with school cleaners?

 [Illustration: FIGHTING TUBERCULOSIS IN OPEN TENTS]

Taxing is swift to follow teaching in matters of health. Teachers caneasily compute what their community loses from tuberculosis. The totalswill 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 isestimated at $23, 000, 000 and to the United States at $330, 000, 000. Thecost of exterminating it will be but a drop in the bucket ifschool-teachers do their part this next generation with the twentymillion children whose day environment they control for three fourthsof the year, and whose habits they can determine. 

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

How many aspects there are to this problem, and how many kinds ofpeople may be enlisted, may be seen from the seven section names: I. Pathology and Bacteriology; II. Sanatoriums, Hospitals, andDispensaries; III. Surgery and Orthopedics; IV. Tuberculosis inChildren--Etiology, Prevention, and Treatment; V. Hygienic, Social, Industrial, and Economic Aspects; VI. State and Municipal Control ofTuberculosis; 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 outtuberculosis is shown by the preliminary programme of the eightsessions of Section V. These topics suggest an interesting andinstructive year's study for clubs of women, mothers, or teachers, orfor 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 bestevidence of effective work in the prevention or relief of tuberculosisby any voluntary association since 1905; (2) for the best exhibit of asanatorium for working classes; (3) for the best exhibit of a furnishedhome for the poor, designed primarily to prevent, but also to permitthe 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, andphotographs will prove an interesting aid to self-education or toinstruction of children, working girls' clubs, or mothers' meetings. Everybody ought to enlist in this war, for the fight againsttuberculosis is a fight for cleanliness and for vitality, for a fairchance against environmental conditions prejudicial to efficientcitizenship. 

So sure is the result and so immediate the duty of every citizen thatDr. Biggs wrote in 1907: _In no other direction can such large resultsbe achieved so certainly and at such relatively small cost. The time isnot far distant when those states and municipalities which have notadopted a comprehensive plan for dealing with tuberculosis will beregarded as almost criminally negligent in their administration ofsanitary affairs and inexcusably blind to their own best economicinterests. _

FOOTNOTES:

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

[14] Those desiring copies this year or hereafter will do well to writeto The National Association for the Study and Prevention ofTuberculosis, 105 East 22d St. , New York City. The congress is under thecontrol of the National Association and is managed by a specialcommittee appointed by it. Even after a national board of health isestablished, the National Association for the Study and Prevention ofTuberculosis will continue to be a center for private interest in publicprotection against tuberculosis. One of its chief functions is thepreparation 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 theDepartment of Agriculture, [15] the [national quarantine] service hasundertaken to prepare a complete report upon the milk industry fromfarm to the consumer in its relation to the public health. " Thispromise of the United States Treasury insures national attention to theevils of unclean milk and to the sanitary standards of farmer andconsumer. Nothing less than a national campaign can make the vividimpression necessary to wean dairymen of uncleanly habits and mothersof the ignorant superstition that babies die in summer just becausethey are babies. When two national bureaus study, learn, and report, newspapers will print their stories on the first page, magazines willherald the conclusions, physicians will open their minds to new truths, state health secretaries will carry on the propaganda, demagogues andquacks 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 milkfollows the seven stages and illustrates the seven health motivespresented in Chapter II. I give the story of Robert M. Hartley becausehe began and prosecuted his pure-milk crusade in a way that can beduplicated 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 thatcharacterized lower New York in 1825. Meeting drunken men and women oneafter another, he first wondered whether they were helped by tracts, and then decided that the mind befogged with alcohol was unfit toreceive the gospel message. Then for fifteen years he threw himselfinto a total-abstinence crusade, distributing thousands of pamphlets, calling in one year at over four thousand homes to teach the industrialand moral reasons for total abstinence. Finally, he began to wonderwhether back of alcoholism there was not still a dark closet that mustbe explored before men could receive the message of religion andself-control. So in 1843 he organized the New York Association forImproving the Condition of the Poor, which ever since has rememberedhow Hartley found alcoholism back of irreligion, and how back ofalcoholism and poverty and ignorant indifference he found indecenthousing, unsanitary streets, unwholesome working conditions, and impurefood. 

 [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 thiscountry. While visiting a distillery for the purpose of trying topersuade the owner to invest his money in another business, he noticedthat "slops smoking hot from the stills" were being carried to cowstables. He followed and was nauseated by the sights and odors. Severalhundred uncleaned cows in low, suffocating, filthy stables were beingfed on "this disgusting, unnatural food. " Similar disgust has in manyother American cities caused the first effort to better dairyconditions. Hartley could never again enjoy milk from distillery cows. Furthermore, his story of 1841 made it impossible for any readers ofnewspapers in New York to enjoy milk until assured that it was notproduced by distillery slops. The instinctive loathing and thediscomfort of buyers awakened the commerce motives of milk dealers, whocovered their wagons with signs declaring that they "no longer" or"never" fed cows on distillery refuse. But Hartley could not stop whenthe anti-nuisance stage was reached. He did not let up on his fightagainst impure or adulterated milk until the state legislature declaredin 1864 that _every baby, city born or country born, no matter howhumble 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 diseasegerms that are carried by unclean milk into the human stomach. Sciencehad not yet proved that many forms of barnyard filth could do quite asmuch harm as distillery refuse. Commerce had not invented milk bottlesof glass or paper. The law of 1864 failed in two particulars: (1) itdid not demand cleanliness from cow to consumer; (2) it did not providemeans for its own enforcement, for learning whether everything andeverybody that had to do with milk was clean. Not knowing of germs andtheir love for a warm climate and warm food, they naturally did notprohibit a temperature above fifty degrees from the time of milking tothe time of sale. How much has been left for our generation to do tosecure pure milk is illustrated by the opening sentence of thischapter, and more specifically by the programme of a milk conferenceheld in New York in November, 1906, the board of health joining in thecall. The four-page folder is reproduced in facsimile (excepting thenames on the fourth page), because it states the universal problem, andalso because it suggests an effective way to stimulate relevantdiscussion and to discourage the long speeches that spoil manyconferences. 

This conference led to the formation of a milk committee under theauspices of the association founded by Hartley. Business men, children's specialists, journalists, clergymen, consented to servebecause they realized the need for a continuing public interest and apersisting watchfulness. Such committees are needed in other cities andin states, either as independent committees or as subcommittees ofgeneral organizations, such as women's clubs, sanitary leagues, countyand state medical societies. Teachers' associations might well beadded, especially for rural and suburban districts where they are moreapt than any other organized body to see the evils that result fromunclean milk. The New York Milk Committee set a good example in payinga secretary to give his entire time to its educational programme, --apaid secretary can keep more volunteers and consultants busy than coulda dozen volunteers giving "what time they can spare. " Thanks chiefly tothe conference and the Milk Committee's work, several important resultshave been effected. The general public has realized as never beforethat 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 atnight; score cards have been introduced, thanks to the convincingexplanations of their effectiveness by the representatives of theBureau 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 percent reacted to the tuberculin test); state societies and statedepartments have been aroused to demand an efficient live-stocksanitary board; magistrates have fined and imprisoned offenders againstthe milk laws, where formerly they "warned"; popular illustrated milklectures were added to the public school courses; illustrated cardswere 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 homehow to prepare baby's milk. In 1908 a Conference on Summer Care ofBabies was organized representing the departments of health andeducation, and fifty private agencies for the care of sick babies andthe instruction of mothers. The superintendent of schools instructedteachers to begin the campaign by talks to children and by giving outillustrated cards. Similar instructions were sent to parochial schoolsby 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) thosewho want cities to _do things_, to pasteurize all milk, start milkfarms, milk shops, or pure-milk dispensaries; and (2) those who wantcities and states to _get things done_. So far the New York MilkCommittee has led the second school and has opposed efforts tomunicipalize the milk business. The leader of the other school is thenoted philanthropist, Nathan Strauss, who has establishedpasteurization plants in several American and European cities. Thediscussion of the two schools, similar in aim but different in method, is made more difficult, because to question philanthropy's methodalways seems to philanthropy itself and to most bystanders anungracious, ungrateful act. As the issue, however, is clean milk, notpersonal motive, it is important that educators and parents in allcommunities 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 researchover 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, municipalinfant-milk depots, are the four chief remedies of the _doing things_school. European experience is cited in support of each. We are toldthat cow's milk, intended by nature for an infant cow with fourstomachs, is not suited, even when absolutely pure, to the humaninfant's single stomach. Cow's milk should be modified, weakened, diluted, to fit the digestive powers of the individual infant; hencethe municipal depot or milk dispensary that provides exactly the rightmilk for each baby, prescribed by municipal physicians and nurses whoknow. That the well-to-do and the just-past-infancy may have milk assafe as babies receive at the depot, municipalization of farm and milkshop is advocated. Some want the city to run only enough farms and milkshops to set a standard for private farmers, as has been done inRochester. This is city ownership and operation for educationalpurposes only. Finally, because raw milk even from clean dairies maycontain germs of typhoid, scarlet fever, or tuberculosis, pasteurization is demanded to kill every germ. There are advocates ofpasteurization that deprecate the practice and deny that raw milk isnecessarily dangerous; they favor it for the time being until farms andshops have acquired habits of cleanliness. Likewise many would preferprivate pasteurization or laws compelling pasteurization of all milkoffered for sale; but they despair of obtaining safe milk unless cityofficials are held responsible for safety. Why wait to discusspolitical theories about the proper sphere for government, when, byacting, hundreds of thousands of lives can be saved annually? Thesemethods of _doing things_ will not add to the price of milk; it is, infact, probable that the reduction in the cost of caring for the sickand 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 ofcleanliness is two, four, or ten cents a quart. Whether ideally cleanmilk is safe or not, raw milk that is not clean is unfit for humanconsumption. All cities should compel evidence of pasteurization as acondition of sale. Large cities should have their own pasteurizingplants, just as many cities now have their own vaccine farms andantitoxin laboratories. Parents in small towns and in the countryshould be taught to pasteurize all milk. 

The _getting things done_ school admits the need for modified milk ofstrength suited to the infant's stomach; affirms the danger of milkthat contains harmful germs; demands educational work by city, state, and nation; confesses that talk about cleanliness will not make milksafe. On the other hand, it denies that raw milk is necessarilydangerous; that properly modified, clean, raw milk is any safer whenpasteurized; that talking about germ-proof milk insures germextinction. It maintains that pasteurization kills benign germsessential to the life of milk, and that after benign germs are killed, pasteurized milk, if exposed to infection, is more dangerous than rawmilk, for the rapid growth of harmful germs is no longer contested bybenign germs fighting for supremacy. While it is admitted that raw milkproduced under ideal conditions may become infected by some personignorant of his condition, and before detection may cause typhoid, scarlet fever, or consumption, it has not been proved that suchinstances are frequent or that the aggregate of harm done equals thatwhich pasteurized milk may do. Pasteurization does not remove chemicalimpurities; boiling dirt does not render it harmless. The remedy forgerm-infected milk is to keep germs out of milk. The remedy for uncleanmilk is cleanliness of cow, cow barn, cowyard, milker, milk can, creamery, milk shop, bottle, nipple. If the sale of unclean milk isprevented, farmers will, as a matter of course, supply clean milk. Byteaching farmers and milk retailers the economic advantages ofcleanliness they will cultivate habits that guarantee a clean milksupply. By punishing railroads and milk companies that transport milkat a temperature which encourages germ growth, and by dumping in thegutter milk that is offered for sale above 50 degrees, therefrigerating of milk will be made the rule. Purging magistrates'courts of their leniency toward dealers in impure, dangerous milk isbetter than purging milk of germs. Boiling milk receptacles will savemore babies than boiling milk. Teaching mothers about the care ofbabies will bring better results than giving them a false sense ofsafety, because only one of many dangers has been removed bypasteurization. Educating consumers to demand clean milk and tosupport aggressive work by health departments leaves fewer evilsunchecked 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 anintelligent interest in the inquiries that are now being made by city, state, and national governments. Because everybody believes that cleanmilk is safer than unclean milk, that milk at 50 degrees will not breedharmful germs, we can demand milk inspection that will tell our healthofficers and ourselves which dealers sell only clean milk at 50 degreesand never more than 60 degrees, that never shows over 100, 000 coloniesto the cubic centimeter. We can get our health departments to publishthe 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 thebest 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 whendirty or careless, but explaining how to make more money by beingclean. Finally, mothers can be taught at home how to cleanse thebottles, the nipples, all milk receptacles, and all things in roomswhere milk is kept. Absolutely clean milk of proper temperature _at theshop_ may not safely be given to a baby in a dirty bottle. Infant milkdepots, pasteurization, the best medical and hospital care, breastfeeding itself, cannot prevent high baby mortality if mothers are notclean. The most effective volunteer effort for pure milk is that whichfirst 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 JuniorSea Breeze, --a school for mothers right in the heart of New York'supper East Side. In the summer of 1907 twenty nurses went from house tohouse telling 102, 000 mothers how to keep the baby well. This was theonly district that had fewer baby deaths than for 1906. Had other partsof the city shown the same gain, there would have been a saving of 1100babies. The following winter a similar work was conducted by nursesfrom the recently founded Caroline Rest, which has an educational fundfor instruction of mothers in the care of babies, especially babies notyet born and just born. Heretofore the baby has been expected to cryand to have summer complaint before anybody worried about the treatmentit received. If the baby lived through its second summer, it wasconsidered great good fortune. Junior Sea Breeze and Caroline Reststart their educational work before the baby is sick, in fact, beforeit is born. Their results have been so notable that several well-to-domothers declare that they wish they too might have a school. Dispensaries and diet kitchens and more particularly maternity wards ofhospitals, family physicians, nurses, and midwives, should be requiredto know how to teach mothers to feed babies regularly, the rightquantities, under conditions that insure cleanliness whether the breastor the bottle is used. Perhaps some day no girl will be given agraduating 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 AnimalIndustry, Washington, D. C. 

CHAPTER XXVI

PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER

No profession, excepting possibly the ministry, is regarded withgreater deference than the medical profession. Our ancestors listenedwith awe and obedience to the warnings and behests of the medicine man, bloodletter, bonesetter, family doctor. In modern times doctors havedisagreed with each other often enough to warrant laymen in questioningthe infallibility of any individual healer or any sect, whetherhomeopath, allopath, eclectic, osteopath, or scientist. Yet to this daymost of us surround the medical profession or the healing art with anatmosphere of necromancy. Even after we have given up faith in drugs orafter belief is denied in the reality of disease and pain, we reverethe calling that concerns itself, whether gratuitously or for pay, withconquering bodily ills. 

Self-laudation continues this hold of the medical profession upon thelay imagination. One physician may challenge another's faults, ridiculehis remedies, call his antitoxin dangerous poison, but their commonprofession he proudly styles "the most exalted form of altruism. " Youngmen and women beginning the study or the practice of medicine areexhorted to continue its traditions of self-denial, and in their verysouls to place human welfare before personal or pecuniary advancement. Newspapers repeat exhortation and laudation. We laymen pass on thestory 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, notbetter, than for a layman to make the same mistake. Neither the moralcode nor the law of self-preservation enjoins a tuberculous mother totake alcohol or to sleep in an unventilated room, even if an uninformedphysician prescribes it. Instruction in physiology and hygiene would befutile if those who are educated as to the elementary facts of hygieneand physiology must blindly follow blind physicians. A family doctorwho gives cod-liver oil for anæmia due to adenoids may do a child asmuch harm as a nurse who drugs the baby to make it sleep. The physicianwho refuses to tell the board of health when smallpox or typhoid feverfirst breaks out takes human life just as truly as if he tore up thetracks in front of an express train. This is another way of saying thatparents and teachers must fit themselves to know whether the familyphysician and their community's physicians are efficient practitionersand teachers. Every one can learn enough about the preventable causesof sickness and depleted vitality to insist upon the ounce of educationand prevention that is better than a pound of cure. 

For its sins of omission, as for its sins of commission, the medicalprofession shares responsibility with laymen. For years leadingeducators, business men, hospital directors, public officials, haveknown that communicable diseases could be stamped out. The methods havebeen demonstrated. There is absolutely no excuse to-day for epidemicsof typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarletfever in the small towns of Minnesota, for uninterrupted epidemics oftuberculosis everywhere. Had either laymen, physicians, orschool-teachers made proper use of the knowledge that has been intext-books for a generation, this country would be saving thousands oflives and millions of dollars every year. Our _doing_ and _gettingdone_ have lagged behind our _knowing_. 

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

Preventive hygiene is not an essential part of the training of Americanphysicians or nurses to-day. Not only are there no colleges ofpreventive hygiene, but medical schools have not provided individualcourses. It is possible for a man to graduate with honors from ourleading medical colleges without knowing what "vital statistics" means. Even boards of health, their duties and their educationalopportunities, are not understood by graduates; it is an accident ifthe "social and economic aspects of medical practice, " "statisticalfallacies, " "hospital administration, " "infant mortality, " are familiarterms. It is for this reason, rather than because physicians areselfish, that indispensable and beneficent legislation is so generallyopposed by them when the prerogatives of their profession seem indanger. Practically every important sanitary advance of the pastcentury has been fought at the outset by those whose life work shouldhave made them see the need. Physicians bitterly attacked compulsoryvaccination, medical inspection of schools, compulsory notification ofcommunicable diseases. What is perhaps more significant of thephysician's indifference to preventive hygiene is the fact that most ofthe sanitary movements that have revolutionized hygienic conditions inAmerica 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, movementfor a national board of health, prison, almshouse, and insane-asylumreform, schools for mothers, and milk committees. The first hospitalfor infectious diseases, the first board of health, the firstout-of-door sea-air treatment of bone tuberculosis in the UnitedStates, were the result of lay initiative. 

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

For a few months in 1907 New York City had a highly efficientcommissioner of street cleaning, who, in spite of the unanimousprotests and appeals of the press, refused to give up the practice ofmedicine. Hitherto the board of health of that city has been unable toobtain the full time of its physicians because professional standardsgive greater credit to the retail application of remedies than to thewholesale application of preventives. 

Statesmanship as well as professional ability is expected of physiciansin the leading European cities, more particularly of those connectedwith health departments. There it is not felt that a medical degree isof itself a qualification for sanitary or health work. After theprofessional course, physicians must take courses in preventive hygieneand in health administration. Medical courses include such subjects asvital statistics, duties of medical officers of health, sanitarylegislation, state medicine. 

The needless cost for one year of "catching" diseases in New York Citywould endow in perpetuity all the schools and lectureships and journalsnecessary to teach preventive hygiene in every section of this greatcountry. That city alone sacrifices twenty-eight thousand livesannually to diseases that are officially called preventable. The yearlyburial cost of these victims of professional and community neglect ismore than a million dollars. When to the doctor bills, wages lost, burial cost of those who die are added the total doctor bills, wageslost, and other expenses of the sick who do not die, we find that onecity loses in dollars and cents more every year from communicablediseases than is spent by the whole United States for hospitals andboards of health. 

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

In the absence of special attention to preventive medicine new truth isforced to fight its way, sometimes for generations, before it isaccepted by the medical profession. So strong are the traditions ofthat profession and so difficult is it for the unconventional orheterodox individual to retain the confidence of conservative patients, that the forces of honorable medical practice tend to discourageresearch and invention. The man who discovers a surgical appliance isforced by the ethics of his profession either to commercialize it andlose his professional standing, or to abide the convenience of hiscolleagues and their learned organizations in testing it. Rather thanbe branded a quack, charlatan, or crank, the physician keeps silent asto convictions which do not conform to the text-books. Many alife-saving, health-promoting discovery which ought to be taken up andincorporated into general practice from one end of the country to theother, and which should be made a part of the minimum standard ofmedical practice and medical agreement, must wait twenty-five or fiftyyears 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 universallyevery new truth, the medical colleges are permitted to remaintwenty-five or fifty years behind absolutely demonstrated facts as tomedical truth and medical practice. In 1761 a German physician, Avenbruger, after discovering that different sounds revealed diseasedtissue, used "chest tapping" in the diagnosis of lung trouble. In 1815Lëannec discovered that sound from the chest was more distinct througha paper horn. On that principle the modern stethoscope is built. Hemade an accurate diagnosis of tuberculosis, and while suffering fromthat disease treated himself as a living clinical study. In 1857Pasteur proved the presence of germs "without which no putrefaction, nofermentation, no decay of tissue takes place. " In 1884 Trudeau startedthe first out-of-door care of pulmonary tuberculosis in America. In1892 Biggs secured the compulsory notification of pulmonarytuberculosis. In 1904 began our first out-of-door sea-air treatment forbone tuberculosis. Yet there are thousands of physicians to-day whosincerely believe that they are earning their fees, who, from housesshut up like ovens, give advice to patients for treatment oftuberculosis, who prescribe alcohol and drugs, who diagnose the diseaseas malaria for fear patients will be scared, who oppose compulsoryregistration, and who never look for the tuberculous origin of crippledchildren. Just think of its being possible, in 1908, for a tuberculousyoung man of thirty to pay five dollars a day to a sanatorium whosechief reliance is six doses of drugs a day!

In 1766 America's first dentist came to the United States. By 1785itinerant dentists had built up a lucrative practice. In 1825 a courseof lectures on dentistry was delivered before the medical class at theUniversity of Maryland. As early as 1742 treatises were written "UponDentition and the Breeding of Teeth in Children. " In 1803 thepossibility of correcting irregularities was pointed out, as was thepernicious effect of tartar on the teeth in 1827. In 1838 attempts weremade to abolish, "in all common cases, the pernicious habit of toothdrawing. " In 1841 treatises were written on the importance ofregulating the teeth of children before the fourteenth year and on theimportance of preserving the first teeth. Yet in 1908 it is necessaryto write the chapter on Dental Sanitation. Few physicians, whether inprivate practice or hospitals or just out of medical college, considerit necessary to know the conditions of the mouth before prescribingdrugs for physical illness. 

Osteopathy furnishes an up-to-date illustration. Discredited by themedical profession, by medical journals and medical schools, it has infifteen years built up a practice of eight thousand men, having fromone to three years' training, including over one hundred physicianswith full medical training plus a course in osteopathy. There weremeans of learning fifteen years ago what was truth and what wasquackery about the practice of osteopathy. By refusing to look for itstruth and by concentrating attention upon its quackery the medicalprofession has lost fifteen years. Whereas the truth of osteopathyshould have been adopted by the medical colleges and a knowledge of itspossibilities and limitations required of every practicing physician, aposition has been reached where alleged quackery seems in severalimportant points to be discrediting the sincerity, the intelligence, and the efficiency of orthodox medicine. No appeal to the natural canbe stronger, no justification of schools of preventive medicine morecomplete, than the following paragraph from an osteopathic physicianwho is among the small number who, having both the medical andosteopathic degrees, see both the possibilities and limitations ofmanual surgery and demand the inclusion of this new science in themedical 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 bymedical schools and medical experts, just as its spiritual truth hasbeen disdained by religious leaders, until it has grown to suchstrength that laymen are almost forced to question the sincerity andthe efficacy of the conventional in religion as well as medicine. InMay, 1907, the Emmanuel Church in Boston organized a clinic for thepurpose of utilizing for neurasthenics particularly both the spiritualand the physical truths underlying religion and the various branches ofmedical science. Daily papers and magazines are giving a great deal ofspace to this experiment in "psychotherapy, " which is discussed in thechapter on Mental Hygiene. Schools and chairs in preventive hygienewould soon give to the medical profession a point of view that wouldwelcome every new truth, such as the alliance of religion and medicine, and estimate its full worth promptly. Truth seeking would be not onlyencouraged but made a condition of professional standing. 

Just what attitude any particular physician takes can be learned by theteacher or parents whose children he treats. If he pooh-poohs orresents board of health regulations as to isolation of scarlet-feverpatients, he is a dangerous man, no matter how noble his personalcharacter. If he says cross-eyes will straighten, weak eyes willstrengthen, or nose-stopping adenoids "absorb, " he is bound to do harm. If he says tuberculosis is incurable, noncommunicable, hereditary, orcurable by drugs, or if he tries to cure cancer by osteopathy, he cando more injury than an insane criminal. If he fails to teach a motherhow to bathe, feed, and clothe the baby, how to ventilate a room forthe sick or the well, he is an expensive luxury for family or forschool, and belongs to an age that knew neither school nor preventivehygiene. If he takes no interest in health administration; if heoverlooks unclean milk or unclean streets, open sewers, and unsanitaryschool buildings, street cars, churches, and theaters; if he does nothelp the health board, the public hospitals, the schools, the factory, and tenement departments enforce sanitary laws, he is derelict as acitizen and as a member of an "exalted profession. " If he sees onlythe patients he himself treats or one particular malady, he is derelictas a teacher, no matter how charming his personality or how skilled inhis specialty. If a school physician is slovenly in his work, if hespends fifteen minutes when he is paid for an hour, should theefficient school-teacher conceal the fact from her superiors because heis a physician? If private hospitals misrepresent facts or compromisewith political evils for the sake of a gift of public money, theiroffense is more heinous because of their exalted purpose. The test of aphysician's worth to his patients and to his community is not what heis or what he has learned, and not what his profession might be, butwhat happens to patient and to community. Human welfare demands thatthe medical profession be judged by what it does, not by what it mightdo if it made the best possible use of its knowledge or itsopportunity. 

 [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 isno better than a street-car company that chronically provides too fewseats and too many straps. Unless physicians test themselves and theirprofession by results, we shall be compelled to "municipalize themedical man. " Preventable sickness costs too much, causes too muchwretchedness, and hampers too many modern educational and industrialactivities to be neglected. If the medical profession does not fititself to serve general interests, then cities, counties, and stateswill take to themselves the cure as well as the prevention ofcommunicable and other preventable sickness. Human life and publichealth are more precious than the medical profession, more importanteven than theories and traditions against public interference inprivate matters. The unreasoning opposition of medical men togovernment protection of health, their concentration on cure, and theirtardy emphasis on prevention have forced many communities to stumbleinto the evil practices mentioned in Chapter XVI. Incidentally, thebest physicians have learned that the prosperity of their professionincreases with every increase in the general standard of living. It isthe man in the ten-room house not the man in one room who supportsphysicians in luxury. It is the healthy man and the healthy communitythat value efficient medical service. 

Many American cities maintain dispensaries and hospitals for the poor. Whether they will go to the logical conclusion of engaging physiciansto give free treatment to all regardless of income depends largely uponwhat the next generation of private physicians do. The state alreadysays when a physician's training fits him to practice. It will soonexpect him to pass rigid examinations in the social and economicaspects of his profession, --its educational opportunity, vitalstatistics, sick and death rates. Will it need to municipalize him inorder to protect itself?

Obviously the teacher or parent should not begin cooperation withphysicians by lecturing them or by assuming that they are selfish andunwilling to teach. The best first step is to ask questions that theyshould 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 learnand will ask the right questions, all physicians can be converted intohygiene missionaries, heralds of a statesmanship that guarantees healthrights to all. 

LICENSING THE PRACTITIONER

Three parties are interested in setting a high standard for physicians, dentists, druggists, nurses, and veterinary surgeons--the professionitself, the schools that educate, and the general public on whom thearts are practiced. The schools and the practitioners are, for the mostpart, primarily interested in protecting a monopoly of skill. Theirinterest in restrictive legislation is analogous to that of the laborunion which limits the number of apprentices. This trade unionism amongprofessional colleges and professional graduates of these colleges hasgradually developed a higher and higher standard that results ingreater protection to the public. The first step is generally to demandthat all persons entering a profession after a given date shall proveto the state their ability to "practice" without injury to clients. Itis almost impossible to get such laws through unless the original lawexempts all persons by whatever name, who are practicing the art inquestion at the time the law is passed. Whether we are speaking ofmedicine, law, dentistry, accountancy, osteopathy, or barbering, thishas been the history of compulsory restriction and of stateexaminations. 

As with regard to most other legislation, the enforcement of the lawlags behind its definition. Moreover nothing is done after a man haspassed a certain examination to see that he remains fit and safe totreat the public. Because no supervision is provided except on the dayof examination, it is possible for men and women to fill their brainsfor a week or two weeks with the information necessary to pass whatcoaches and tutors have learned will, in all probability, be asked. Forever after, the public is left to protect itself. Out of thiscondition have arisen the evil, unethical, and unprofessional practicesrepresented particularly by painless dentists, by ignorant or dishonestphysicians, 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 forexamination in advance of certification that will show whether or notthose who make a livelihood by caring for others' health are equippedto mitigate rather than aggravate evils, and for further tests by whichthe public can learn from time to time which, among those professionalmen who are protected by the public against competition, continue to besafe. Finally, if, as will be clearly seen, it is desirable that whatwe call professional ethics persist and that self-advertisement bediscouraged, society must, for its own protection, adopt some othermeans than epithets to correct the evils of self-advertisement andquackery. Even though we admit the responsibility of each citizen whenhe goes to the house of a private practitioner who has made no othereffort to lure him thither than to place a card in the window, it mustbe seen that we cannot hold responsible for their choice men and womenwho receive through newspapers, magazines, or circulars convincingnotices that Dr. So-and-So or the Integrity Company or the PeerlessDental Parlor will place at their disposal, at prices within theirreach, skill and devotion absolutely beyond their reach at the officeof an efficient private practitioner. Some way must be found by whichdepartments of health will currently impose tests of methods andresults upon physicians, opticians, pharmacists, manufacturers ofmedicine, and dentists. 

As laymen become more intelligent regarding their own bodies andhealthy living, it grows harder and harder for quacks and incompetentsto mislead and exploit them. Better than any possible outside safeguardis hygienic living. Fortunately, we can all learn the simple tests ofenvironment and of living necessary to the selection of physicians, dentists, and opticians, or other "architects of health" whoseefficiency 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 thepublic school. State laws say nothing about compulsory hygiene inmilitary academies, ladies' seminaries, or other preparatory andfinishing schools. Yet when one thinks of it, one must conclude thatthe right to health and to healthful school environment cannotequitably be confined to the children whose tuition is given at publicexpense. There is a better way to check "swollen" fortunes than byruining the health of "fortune's children. " The waste and danger ofslow-minded, noticeably inefficient children are no less when parentsare rich than when parents are poor. There is no justification forneglecting the health of children in parochial schools, in privateschools for the well-to-do or rich, or in commercial schools for theambitious youth of lower income strata. Nor has the commercial, parochial, private school, or college, any clearer right than thepublic school to injure or to fail to promote pupils' health. So far asschool hygiene is advisable, so far as it is right to make hygienecompulsory, its personal and social benefits should be shared bychildren of school age without regard to income, and its laws should beenforced by all teachers, principals, and officers that have to dowith school. In presenting a programme for school hygiene this chapterrefers to the hygiene taught, the hygiene practiced, the hygiene nottaught, and the hygiene not practiced in buildings and on grounds wherechildren and youth are at school, whether these children are inkindergarten or high school, in reformatory or military academy, incharitable school, or in finishing and preparing center for society'sjuniors. 

The question of the local, state, and national machinery by whichproper standards of school hygiene shall be made effective will betaken up after we have considered individual steps in a comprehensiveprogramme 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 needsand the relations of their vitality to the vitality of their pupils. Are your teachers examined? Do they know the laws of health and thesigns of child health? Are they permitted to continue in schoolroomsafter tuberculosis is discovered? Are normal graduates given physicaltests before being permitted to teach and before being permitted togive four years to preparation for teaching?

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

We believe a vast number of things that "ain't so" about the health ofcountry children as compared with city children, of private-schoolchildren as compared with public-school children. Where do we find moredegenerate men, physically and morally, than in so-called "Americansettlements, " where, for generations, children have had all outdoors toplay in, except when in homes and schoolhouses that are seldom cleansedand seldom ventilated? Open mouths and closed minds clog the "littlered schoolhouse"; there headaches do not suggest eye strain; theredeafness and running ears are frankly attributed to scarlet fever whicheverybody must have with all the other "catching" diseases, the earlierthe better; there colds begin in December and run until March, to theserious injury of attendance and promotion records; there bonetuberculosis is called "knee trouble" or "spine trouble in the family";there boys like my little friend Fred count the bottles of cod-liveroil they take to cure adenoids that could be removed in two minutes. 

The index to community life and community living conditions should beread in the country, not only for the country's sake, but also for thesake of the city whose milk and water, poisoned in the country, causethousands of deaths annually, besides annual sick bills exceeding manytimes over the Russell Sage and Carnegie Foundations, which we rightlycall munificent. Reading the index of private schools and colleges isimportant for their children and youth, but still more important forthe community upon which unbridled passion, inability to work or tospend 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 entranceto date of leaving school, showing condition at successiveexaminations, absence because of illness, etc. 

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

To give working papers to children seriously handicapped by physicaldefects is to buy future industrial trouble, hospital and poorhousebills. A boy with adenoids, a girl with eye trouble, should not bepermitted to begin the fight for self-support without at least beingclearly shown that the correction of these defects will increase theirearning power. At present a schoolgirl with incipient tuberculosis, orpredisposed to that disease, can get working papers, go to a hammock ortobacco factory, work long hours, breathe bushels of dust, deplete hervitality, spread tuberculosis among her co-workers and home associates, infect a tenement, --and all this without any help or advice or anyprotection from society until she is too sick to work and her physiciannotifies the health department that she is a danger center. We maydisagree about society's right to control a child's act after thedefects are discovered, but who will question society's duty to tellthat child and her parents the truth about her physical needs before itaccepts her labor or permits her to "enter society"?

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

Superintendent Maxwell, of New York City, and other educational leadersurge teachers to do their utmost to learn the physical conditions andhome environment of the individual child, and to fit school treatmentto the individual possibilities and handicaps. But experience provesconclusively that try as they will, teachers and principals haveneither the special knowledge nor the time to acquire the specialknowledge requisite to use the facts disclosed by the physicalexamination of school children. Physicians and nurses are needed, notso much for treating children, as for teaching children, parents, teachers, family and dispensary physicians. 

Private schools have visiting physicians who may be consulted; theyneed physicians to supervise, with power to examine or to requirecertificates of examination. The Committee on the Physical Welfare ofSchool Children found that when a visitor was detailed for that purposeit was easy to secure the coöperation of parents, teachers, familyphysicians, dispensaries, school boards, and charitable societies. TheHawthorne Club's school secretary has been similarly successful inBoston, as have those of Hartley House, Greenwich House, and the PublicEducation Association in New York. 

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

Whether the hours of study at school and at home are excessive cannotbe learned from treatises on pedagogics or physiology. Because childrendiffer in vitality as in ability to learn, the maximum limit for studyhours should be determined by the individual child's physicalcondition. When the Japanese went to war with Russia the highestauthority in the field was the army surgeon. To this fact was largelydue the astonishingly small amount of sickness and the high fightingcapacity and endurance of the Japanese, working under unfavorableconditions. No board of school superintendents or board of directors, no state superintendent of schools or college professor, has the rightto compel or to allow study hours beyond the maximum compatible withthe individual student's physical condition and endurance. Thephysician responsible for school hygiene should have an absolute vetoupon any educational policy, method, or environment demonstrablydetrimental to children's vitality. 

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

The advantages of _getting things done_ over _doing things_ have beenrepeatedly emphasized. In smaller cities and in rural districts it isparticularly important for schools to get things done better byexisting local agencies, such as churches, health and street-cleaningdepartments, hospitals, clinics, medical and sanitary societies, tradeunions, young people's societies, and women's clubs. Where parents whohave been followed up and taught, obstinately or ignorantly refuse toattend to their children's needs, the segregation of the physicallydefective or needy will encourage the coöperation of childrenthemselves in persuading parents to act intelligently for the child'ssake. No child wants to remain "queer" or "dopey" or behind his peers. The city superintendent of schools for New York City has asked for lawscompelling parents to permit operations and punishing them forneglecting to take steps, within their power, to remove physicaldefects 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 schoolcurriculum. _ On this subject the studies of Dr. C. Ward Crampton, referred to in the chapter on Vitality Tests, are invaluable and asconvincing as they are revolutionary. Scientists accept his proof thatour present high school curriculum is ill adapted to a large proportionof children; the "physiologically too young" drop out; only thephysiologically mature succeed. The two physiological ages should begiven different work. Children whose bodies yearn for pictures, muscular and sense expression, should be given a chance in school fornormal development. Analysis should wait for action. Organized play andphysical training antedated physical examination in our schools. Likethe curriculum they often disregard physiological age, doing harminstead of good. Facts as to physical condition and physiologicaldevelopment would enable us to utilize the momentum of these two tobroaden school hygiene and to insure proper physical supervision. Onlygood would result from adopting Leipsic's plan of having schoolchildren examined without clothing, in the presence of parents ifparents desire. Expensive? Not so expensive as high school "mortality"due to maladjusted curriculums that force the great majority of boysand girls to drop out before graduation and ruin the health of a largefraction of those who remain. 

8. _Construction of school building and of curriculum so that, whenproperly conducted, they shall neither produce nor aggravate physicaldefects. _

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. Thousandsof children are now being subjected to conditions in school far moreinjurious than the factory and shop conditions against which thenational and state child labor committees have aroused universalindignation. Two illuminating studies of school buildings in New YorkCity were made last year by the Committee on the Physical Welfare ofSchool Children, and later by the Board of Education. Similar studiesshould be made of every schoolroom. Whereas our discussions ofbuildings and curriculum have hitherto proceeded largely from abstractprinciples of light, ventilation, heating, and pedagogics, these tworeports deal with rooms, equipment, courses of study, and school habitsas they are, with obvious detrimental effects on child victims. Numerous questions that it is practicable to answer are given inChapter XIV. 

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

In passing it is worth while to note that in large cities teachers arefrequently forced to choose between bad ventilation and street noises. From Boston comes the suggestion that we avoid noises and evils ofcongestion by building schoolhouses for city children on the outskirtsin the midst of fields, transporting, and, if necessary, feedingchildren at public expense. While it is true that the public funds nowspent in attempting to cure physical and moral ills would purchaseample country reservations, the practical next step seems to be toprovide ample play space and breathing space within the city for everyschool building already erected, and without fail for all buildings tobe erected hereafter. 

9. _Hygiene should be so taught that children will cultivate habits ofhealth and see clearly the relation of health and vitality to presenthappiness and future efficiency. _ Social rather than personal, publicrather than private, health needs emphasis. Children can be shown howtheir health affects their neighbor; why money spent for health boardsis a better investment than money given to corrupt politicians; thatthe cost of accepting Thanksgiving turkey or a park picnic from apolitical leader who encourages inefficient government is sickness, misery, deficient schooling, lifelong handicap; that children andadults have health rights in school and factory, on street andplayground, which the law will protect if only they know when theserights 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 schoolchildren--should be read and interpreted. Headquarters should learnwhether or not physical examinations are made and whether harmfulconditions are corrected. So far as public schools are concerned, "headquarters" means for cities the fact center that informs citysuperintendent or school board; for rural schools, it means the countysuperintendent's office. Whether city or county headquarters have thefacts and act accordingly should be known by state superintendents. Whether state superintendents are demanding the facts and educating thecounty and city headquarters of their states should be known to thenational commissioner of education and by him published for all theworld. Some people think the state health board should be responsible, others the state educational authority. The important thing is to makesome one officer responsible. Methods can be easily worked out if theneed is conceded. Legislatures will gladly confer the powers necessaryto reading the index of all public schools. 

As for parochial and private schools, they may resent for a time publicsupervision of their hygiene teaching and practice. However, the casecould be so presented that they would ask for it, because it would helpnot only their pupils and society but the schools themselves. Noreligious belief or private investment can afford to admit that itdisregards child health; state supervision would require nothing morethan evidence of adequate school hygiene. 

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

Machinery that must some day exist for the execution of this programmewill 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 theboard of education or the board of health is a question that it isimpossible to decide without knowledge of local conditions. So far asstate and county organizations are concerned, it is clear that whateverthe boards of health may do, it will be necessary for state and countysuperintendents of education to equip themselves with the machineryabove recommended. In cities it is quite clear that a board ofeducation should be responsible for all of the machinery suggested, excepting the three divisions that have to do with work hithertoconsidered as protection against transmissible diseases, namely, inspection, examination, district visiting. In Cleveland these areschool duties. In New York they are duties of the health department. Boston has school nurses and health department physicians. The statelaw of Massachusetts provides that where health boards do not examineschool children, school boards may spend money for the purpose. 

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

Dr. Biggs feels that responsibility for the physical welfare of schoolchildren will strengthen health work in all cities, and, given properinterest on the part of school officials, should make possibleuniversal coöperation in a constructive programme. On the other hand, he believes that division of responsibility between school and healthboards will weaken both in their appeals for funds and for support of aconstructive programme. I have heard principals and superintendentsmaintain also that the moral effect of a visit to the school by arepresentative of the health board vested with powers of that board wasmuch greater than a visit by a representative of the school board. Theyfurther allege that a physician coming from the outside is more apt tosee things that need correction and less apt to accept excuses than aninspector who feels that he belongs to the same working group as theschool-teacher. Because the follow-up work in the homes incident tosuccessful use of knowledge gained at school involves so many sanitaryremedies, it is theoretically better organization to hold the healthauthority responsible. 

CHAPTER XXVIII

PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY

Many of the elements of the machinery outlined in the preceding chapteralready exist in New York City. All of them brought together, either byamalgamation or by proper coördination, would present a very strongfront. Unfortunately, however, there is not only unsatisfactory teamwork, but the efficiency of individual parts is seriously questioned bythe heads of the health and school departments. 

The inspection for contagious diseases, the examination for physicaldefects, the follow-up work by nurses and physicians, are in charge ofthe department of health. Physical training and athletics forelementary and high schools, winter recreation centers, and vacationplaygrounds are under directors and assistants employed by the board ofeducation. Heretofore inadequate powers and inadequate assistance fortraining 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 248schools--less than half the total number--were any examinations forpossible diseases made. In these 248 schools not more than one third ofthe pupils were examined. It is only a few months since anyexaminations for physical defects were made outside of the boroughs ofManhattan and The Bronx, and then only on account of the New YorkCommittee on the Physical Welfare of School Children. "

As is so often the case, it is difficult to decide the merits of amethod that has not been efficiently executed. The department of healthhas not hitherto done its best in its school relations. Thecommissioner of health, in a public interview, expresses resentment atthe strictures by the school authorities. Yet in 1907 he permitted toaccumulate an unexpended balance of $33, 000 specifically voted forschool inspectors, and repeatedly tried to have this amount transferredto other purposes. The interest of the Bureau of Municipal Research inmunicipal budgets that tell for what purposes money is voted and thenprevent transfers without full publicity, preserved this particularfund. Moreover, the discussion that prevented its diversion fromphysical examinations strengthened the health department's interest inthis important responsibility. Neither physicians nor nurses have beenadequately supervised. Instead of seeing that defects were removed, thedepartment 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, ofwhich only one in twenty stated that attention had actually been giventhe needy child. The department had been satisfied with evidence thatfamily physicians had advised parents properly, as in the case of thechild 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 toJune, 1908, consult the report of the Bureau of Municipal Research, presented to the Washington Congress of Public Education Associationsin October, 1908, by Commissioner of Health, Dr. Darlington. Thebureau's study is entitled _A Bureau of Child Hygiene_, and, inaddition to the story of medical examination in New York City schools, gives the blank forms adopted for use in September, 1908. Important asare the facts given in this study, its greatest value, its authorsdeclare, is in its account of "the method of intelligent self-criticismand experiment which alone enables a public department to keep itsservice abreast of public needs. "

The Bureau of Municipal Research made its study for the purpose oflearning whether the disappointing results emphasized by the schoolauthorities were due to "dual responsibility in the school--that of theboard of education and that of the department of health"--and to "lackof power or inclination to compel parents to remedy defects, " or to_deficient administration_ of power and inclination by healthofficials. Coöperating with school physicians and nurses in threeschools, 1442 children were examined, of whom 1345, or 93. 2 per cent, had 3458 defects that needed treatment. The postal-card notice wasfollowed 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 percent secured or permitted treatment for one or more defects, while 15per cent promised to take the proper steps at the earliest possibledate. Three fourths of the parents acted after one personal interview. "The net average result of a day's work by a nurse was the actualtreatment of over five children, three of them completely, and two ofthem 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 doall in their power to remove defects that handicapped their children, it was obviously the duty of the health department so to organize itswork that it could insure the education of parents. The new Bureau ofChild Hygiene gives foremost place to instruction of parents in care ofbabies, in needs of school children, and in the importance of physicalexamination when enlisting in the industrial army. Whether this work iswell done is learned by result tests applied at headquarters, wherework done and results are reported daily and summarized weekly. Nolonger will it be possible, without detection, for one physician tofind only eye trouble and to neglect all other defects; for twoinspectors examining different children in the same school to reportresults differing by 100 per cent; for physicians in different schoolsto find one 18 per cent, another 100 per cent with defects; for twoinspectors examining identical children to agree on 51 out of 101 casesof vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases ofskin disease. 

So conclusive were the results of follow-up work efficiently supervisedby the department of health, that school officials are, for thepresent, inclined to waive the demand for the transfer of physiciansand nurses to the board of education, and to substitute education forcompulsion with parents who obstinately refuse to take proper remedialmeasures for their children when reported defective. 

This present plan requires the entire working time of inspectors andnurses for school work. Thus New York has for the present definitelyabandoned the plan of having the district inspection for contagiousdiseases done by school physicians. The purpose of the change is not toreduce danger of infection, which was negligible, but to increase theprobability of scientific attention to school children. 

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

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

CHAPTER XXIX

OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS

The argument for _getting things done_ presumes adequate activemachinery, official and private, for _doing things_ that schools arebeing urged to do. The chapter on Departments of School Hygienesuggests local, county, state, and national machinery necessary (1) toprotect the child from injuries due to school environment, schoolmethods, and school curriculum; (2) to getting those things done forthe child at home and on the street, need for which is disclosed byphysical and vitality tests at school. It is unreasonable to confinethe school to the activities above outlined unless health machinery, adequate to the demands placed upon it by school and other communityneeds, is devised and kept in order. 

Generally speaking, adequate health machinery is already provided forby city charters and by the state laws under which villages, townships, and counties are organized. Quite as generally, however, machinery andmethods of adequate administration are undeveloped. How much machineryhas already been set to work by New York City is shown by theaccompanying chart. A useful exercise for individuals or school classeswishing to study health administration would be to chart in this waythe machinery actually at work in their locality, county, and state. Even for New York it should be remembered that this chart does notinclude national quarantine, the state protection of the port, thestate dairy and health commissions, or the state and national foodinspection. To get an idea of the vast amount of attention givento health in New York City there should be added to this chart the workof many departments other than the department of health. The buildingbureau, tenement-house department, board of water supply, sewagecommission, street cleaning, public baths and comfort stations, thedepartment of water, gas, and electricity, and finally the departmentof 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 towardpublic health. The chairman of a committee on public health of a statelegislature was heard to remark, "I asked for that committee becausethere isn't a blooming thing to do. " If voters, nonvoters, and healthofficials will follow the suggestion of this book to secure school andhealth reports that will disclose community and health needs, it willbe increasingly difficult for legislators to refuse funds necessary toefficient health administration. 

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

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

In order to have health machinery work properly, the appointing officershould not be allowed to shift responsibility for failure to hissubordinates. For example, it was recently found in New York City thatwhile the tenement-house commissioner was being condemned for failingto enforce the law, he had turned over to the corporation counsel, alsoappointed by the mayor, for prosecution ten thousand "violations" towhich no attention whatever had been paid!

The voter, nonvoter, appointing officer, legislative officer, andjudicial officer determine the character and purpose of machinery andare analogous to the surveyors, stock-holders, directors, andconstructors who provide railroads with tracks and with running stock. The actual running force of health department or railroad is what ismeant by its official machinery. What this machinery should be depends, of course, upon the amount of business to be done, and differs withthe 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 evilsmentioned in preceding chapters. In general, one man is better thanthree to execute, although three may be better than one to legislate. Where small communities do not wish to have the entire state sanitarycode rigidly administered, they can adopt New York's method of alegislative board of three members, headed by an executive, whosebusiness it is to act, not talk; to watch subordinates, and to enforcerigidly and continuously ordinances passed by the board. The NationalBureau of Census places under the general heading Health and Sanitationthe following activities: health administration, street cleaning andrefuse disposal, sewers and sewage disposal. Sanitarians generallyemphasize also the health significance of efficient water service. 

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

To find out whether local machinery is adequate, the reader mustenumerate the things that need to be done in his community, rememberingthat in all parts of the United States to-day there are sanitary lawsoffering protection against dangers to health, excepting some dangersnot understood until recently, such as child labor, dangerous trades, lack of safety devices. Adequate local protection, however, will notbecome permanent until adequate state machinery is secured. 

State health machinery should be of two kinds, --fact-gathering andexecutive supervision through inspection. The greatest service of stateboards of health is to educate localities as to their own needs, usingthe experience of all communities to teach each community in how farits health administration menaces itself and its neighbors. In additionto registration of contagious diseases, facts as to deaths and birthsshould be registered. State health boards should "score" communities asdairies and milk shops are now being scored by the National Bureau ofAnimal Industries and several boards of health. When communitiespersist in maintaining a public nuisance and in failing to enforcehealth laws, state health machinery should be made to accomplish byforce 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 sourcesand to food. The economic motive of farmers has developed strongveterinary boards for the protection of cattle. Similar executiveprecaution must soon be taken by cities for the protection of babiesand adults of the human species. It is far more economical to insureclean dairies, clean water sources, and wholesome manufactured foods bystate inspectors than by local inspectors. At present the task ofobtaining clean milk and clean water falls upon the few citiesenlightened enough and rich enough to finance the inspection ofcommunity foods. Once tested, it would be very easy to prove thatproperly supported state health authorities will save many times thecost of their health work in addition to thousands of lives. 

County or district machinery is little known in America. For thatreason rural sanitary administration is neglected and rural hospitalsare lacking. In the British Isles rural districts are given almost ascareful inspection as are cities. Houses may not be built below acertain standard of lighting, ventilation, and conveniences. Outbuildings must be a safe distance from wells. Dairies must be keptclean. Patients suffering from transmissible diseases may be removed byforce to hospitals. What is more to the point, rural hospitals haveproved that patients cared for by them are far more apt to recover thanpatients cared for much more expensively and less satisfactorily athome, while less likely to pollute water and milk sources or otherwiseto endanger health. 

With national machinery the chapter on Vital Statistics has alreadydealt. We shall undoubtedly soon have a national board of health. Likethe state boards, its first function should be educative. In addition, however, there are certain administrative functions where inefficiencymay result in serious losses to nation, state, and locality. Nationalquarantine, national inspection of meats, foods, and drugs areadministrative functions of vital consequence to every citizen. Authorities are acquainted at the present time with the fact that thesanitary administration of the army and navy is unnecessarily andwithout excuse wasteful of human energy and human life. In the SpanishAmerican War 14 soldiers died of disease for 1 killed in battle; in theCivil War 2 died of disease to 1 killed in battle; during the wars ofthe last 200 years 4 have died of disease for 1 killed in battle. YetJapan in her war with Russia, by using means known to the United StatesArmy in 1860, gave health precedence over everything else and lost but1 man to disease for 4 killed in battle. Diseases are still permittedto make havoc with American commerce because the national governmentdoes not apply to its own limits the standards which it hassuccessfully 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 thingis not what they did, but that they were allowed to do it. It is aterrible thing that Congress should choose to make one of its raredisplays of economy in a matter where a few thousand dollars savedmeans, in case our army should have anything to do, not only theutterly needless and useless loss of thousands of lives, but anenormous decrease of military efficiency, and might, conceivably, makeall the difference between victory and defeat. "

FOOTNOTES:

[16] The technic and principles of municipal engineering have beentreated in detail in _Principles of Sanitary Science and the PublicHealth_, by William T. Sedgwick, and in _Municipal Sanitation in theUnited States_, by Charles N. Chapin, M. D. 

CHAPTER XXX

SCHOOL AND HEALTH REPORTS

For every school-teacher or school physician responsible for thewelfare of children at school, there are fifty or more parentsresponsible for the physical welfare of children at home. Therefore itis all important for parents to know how to read the index for theirown children, for their children's associates, and for their community. School reports and health reports should tell clearly and completelythe 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 menand women to be interested in the reports published by school andhealth boards, for, with few exceptions, little effort is made to writethese reports so that they will interest the parent. Fortunately, asmall number of persons wishing to be intelligent can compel publicofficials to ascertain the necessary facts and to give them to thepublic. So backward is the reporting of public business that at thepresent time there is probably no service that a citizen can render hiscommunity which would prove of greater importance than to secure properpublicity from health and school boards. 

Generally speaking, these published reports fail to interest thecitizen, not because officials wish to conceal, but because officialsdo not believe that the public is interested. A mayor of Philadelphiaonce furnished a notable exception. He called at the department ofhealth and complained against publishing the number of cases of typhoidand smallpox lest stories in the newspapers "frighten the city andinjure business. " A sanitary inspector who was in the room asked ifPhiladelphia's business was more important than the health ofPhiladelphia's citizens. As a result of her "impertinence" theinspector was removed. That same year an epidemic of smallpox spreadthrough all the rural districts and cities of Pennsylvania, becausephysicians thought it would be kinder to the patients not to make knownto their neighbors the presence of so disagreeable a disease. Almostall health and school authorities, however, can be made to see theadvantage of taking the public into their confidence, because publicconfidence means both public recognition and greater success inobtaining funds. With more funds comes the power to do more work. 

Other details with regard to health reports will be found in thechapter on Vital Statistics. As to school reports, little thought hasbeen given in the past to their educational possibilities. A book wasrecently published--_School Reports and School Efficiency_--by theCommittee on the Physical Welfare of School Children, which tells theorigins of school reports; contains samples of reports from one hundredcities; gives lists of questions frequently answered, occasionallyanswered, and never answered; and shows how to study a particularreport so as to learn whether or not important questions are answered. The United States commissioner of education has organized among stateand city superintendents special committees on uniform and adequatereporting. His aggressive leadership is welcomed by school mengenerally, and promises vast benefits. 

Just because the physical welfare of the school child is an index tohealth needs, the school report can put into one statement for a cityor a state the story told by the index. The accompanying card tellsfacts that the individual teacher and individual parent want to knowabout a child, what a superintendent wants to know about all children, and what a community wants to know about all children. A modificationof this card will soon be adopted in New York City. It is both a cardindex and a card biography of the individual boy or girl. It isexpected to follow the child from class to class, each teacher tellingthe story of his physical welfare and his progress. When the boy goesto a new school or new grade, his new teacher can see at a glance notonly what subjects have given him trouble, but what diseases orphysical defects have kept him out of school or otherwise retarded hisprogress. With this card it is easy to take a hundred children of thesame age and the same grade, to put down in one column those who haveeye defects, and in another those who have no eye defects, for everyschool, every district, and for the schools as a whole. Schools thatuse these record cards are enabled, by thus classifying the total, tolearn 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, andparents 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 particularschools 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 toone 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 reallycorrects the defects, saves the pupil's time and teacher's time, discovers many defects; and we want to find out whether the one hundredand 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, peoplewill wonder whether among the thousand not examined there is the sameproportion--three out of five, or six hundred--who have some troublethat needs attention. Having begun to wonder, they will ask questions, and will expect the board of health or the school physicians to seethat the questions are answered. As has been proved in New York, taxpayers and the press will go farther and will demand that the annualbudget provide for making general next year the benefits found toresult last year from a test of health policies. 

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

TABLE XII

PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN

(Case rate schools)

KEY:A: In SchoolB: 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: OtherB: Scarlet fever K: RingwormC: Measles L: ImpetigoD: Smallpox M: ScabiesE: Chicken pox N: FavusF: Whooping cough O: PediculosisG: Mumps P: MiscellaneousH: Total Q: TotalI: 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 setforth in the following table:

TABLE XIV

MEDICAL EXAMINATION OF SCHOOL CHILDREN: NONCONTAGIOUS PHYSICAL DEFECTSFOUND 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, properventilation, adequate medical inspection, safe drinking water, ampleplay space, and what schools are without these necessities is to causethe 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 isneglected. " County and state superintendents in many states haveacquired the habit of ranking schools according to the number ofchildren who pass in arithmetic, algebra, etc. It would greatly furtherthe cause of public health and, at the same time, advance the interestof education if state superintendents would rank individual schools, and if county superintendents would rank individual schools, _accordingto the number of children found to have physical defects, the numberafflicted with contagious diseases, and the number properly treated_. 

It is difficult to compare one school with another, because it isnecessary to make subtractions and divisions and to reduce topercentages. It would not be so serious for a school of a thousandpupils as for a school of two hundred, to report 100 for adenoids. Tomake it possible to compare school with school without judging eitherunfairly, the state superintendent of schools for Connecticut has madetables 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 abattalion, "according to height. " A general table is then shown, whichgives 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 isreminded that rank 18 in children not treated is as good a record for aschool that ranks 30 in register as is rank 6 for a school that ranks10 in register. 

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

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

TABLE XVI

TABLE OF RANKING-SCHOOLS ARRANGED ACCORDING TO REGISTER, NOTALPHABETICALLY

============================================================= | | RANK INSCHOOL +----------+----------+----------+----------+--------- | 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 unlikelythat people will read the table of ranking because of the difficulty offinding their own school, an alphabetical table might be given thatwould show where to look in the general ranking table for the school orschools in which the reader is interested. 

Experience will demonstrate to public school superintendents thestrategic advantage of putting together all the things they need and oftelling the community over and over again just what needs there are, what penalties are paid for want of them, and what benefits wouldresult from obtaining them. If health needs of school children wereplaced side by side with mental results, the relation would come out soclearly that parents, school boards, and taxpayers would realize howinextricably they are bound together and would see that health needsare satisfied. To this end superintendents should require teachers tokeep 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, takenthree times a day, tells the parent exactly what is the efficiency ofthe ventilating and heating apparatus in the particular school in whichhe is interested; whereas the report of the department of buildingsgives only the number of schools which have an approved system ofventilation and steam heat. School authorities may or may not know thatthis system of ventilation is out of order, that the thermometer in theindoor playground of School A stood at forty degrees for many days inwinter. But they must know it when the principal of School A sends in adaily record; the school board, the parents, or the press will thensee that the condition is remedied. If the condition is due to lack offunds, funds will never be forthcoming so long as the condition isconcealed. 

Similar results will follow publicity of overcrowding, too little playspace, dry cleaning of school buildings, etc. The intent of suchreporting is not to "keep tabs" on the school-teacher, the schoolchild, the janitor, the principal, superintendent, or board, but toinsure favorable conditions and to correct bad conditions. This is donebest by giving everybody the facts. The objective test of theefficiency of a method throws emphasis on the method, not on the motiveof those operating it. The blackboard method of publishing factsconcentrates attention upon the importance of those facts and enlistsaid in the attainment of the end sought. 

CHAPTER XXXI

THE PRESS

The president of Princeton University declares that for several decadeswe have given education that does not instruct and instruction thatdoes not educate. Others tell us that because we read daily papers andmagazines our minds become superficial, that our power to concentrateor memorize is weakened, --that we read so much of everything that welearn little of anything. As the habit of reading magazines andnewspapers is constantly increasing, I think we must assume that it hascome to stay. If we cannot check it, we can at least turn it to goodadvantage, 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 ofhygiene. No greater service can be rendered the community than forthose who are conducting discussions of health to teach people how toread correctly this mass of information regarding health, to separatemisinformation from information, and to apply the lessons learned topersonal and public hygiene. There is no better way of doing this thanto teach a class or a child to clip out of magazines and newspapers allimportant references to health, and then to classify these under thesubject-matter treated. A teacher, parent, or club leader mightpractice by using the classification of subjects outlined in theContents of this book. It is surprising how rapidly one builds up avaluable collection serviceable for talks or papers, but moreparticularly for giving one a vital and intelligent interest inpractical health topics. 

Interested in comparing the emphasis placed on health topics in athree-cent paper having a small circulation with a penny paper havingtwenty times the circulation, I made during one week thirty-eightclippings from the three-cent paper and ninety-five from the pennypaper. The high-priced paper had no editorial comment within the fieldof health, whereas the penny paper had three columns, in which werediscussed among other things: _The Economics of Bad Teeth_; _Need forIndividual Efficiency_; _"Good Fellows" Lower Standard of Living byNeglecting their Families_. The penny paper advertised fifty-two foods, garments, whiskies, patent medicines, or beautifiers urged upon healthgrounds. In the three-cent paper twenty-six out of thirty-eight itemsadvertised food, clothing, patent medicine, or whisky. One issue of amonthly magazine devoted to woman's interests contained twenty-eightarticles and editorials and fifty-five advertisements that concernhealth, --thirty-seven per cent of total reading matter and thirty-sevenper cent of total advertisement. 

Excellent discipline is afforded by this clipping work. It isastonishing how few men and women, even from our better colleges, knowhow to organize notes, clippings, or other data, so that they can beused a few weeks later. There is a satisfaction in seeing one's materialgrow, as is remembered by all of us, in making picture scrapbooks orcollections of picture postal cards and stamps. "Collections" havegenerally failed for want of classification, --putting things of a kindtogether. Chronological arrangement is uninteresting becauseunprofitable. One never knows where to find a picture, or a stamp, or ahealth clipping. Clippings, like libraries, will be little used if notproperly catalogued so that use is easy. If a health-clipping collectionis 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 theenvelope most useful because most easily carried and filed, --mostlikely to be used. But clippings should be bound together in orderlyappearance, or else it will be disagreeable working with them. Children, however, will like the pasting on sheets, which show clearlythe growth of each topic. Envelopes or cards should not have clippingsthat deal with only one health topic. Unless a test is made to see howmany health references there are in a given period, it should be made arule not to clip any item that does not contain something new, --someaddition to the knowledge already collected. 

Advertisements will prove interesting and educative. When newspapersand magazines announce some new truth, the commercial motive ofmanufacturer or dealer sees profit in telling over and over again howcertain goods will meet the new need. Children will soon notice thatthe worst advertisements appear in the papers that talk most of"popular rights, " "justice, " and "morality. " They will be shocked tosee that the popular papers accept money to tell falsehoods about fakecures. They will be pleased that the best monthly magazines contain nosuch advertisements. They will challenge paper or magazine, and thuswill be enlisted while young in the fight against health advertisementsthat injure health. 

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

The art of cross-referencing is invaluable to the organized mind. Thepurpose of classifying one's information is not to show how much thereis, 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 mightanswer three. If magazines may not be cut, it will be easy to recordthe fact of a useful article by writing the title, page, and date onthe appropriate index card, or inclosing a slip so marked in the properenvelope. 

While it is true that the most important bibliography one can have inhis private library is a classification of the material of which hehimself has become a part while reading it, there are a number ofhealth journals that one can profitably subscribe for. In fact, it isoften true that the significant discoveries in scientific fields, orthe latest public improvements, such as parks, bridges, modeltenements, will not be appreciated until one has read in healthjournals how these improvements affect the sickness rate and theenjoyment rate of those least able to control their living conditions. The physician and nurse in their educational work for hospitals aredistributors 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 thisjournal up to a high standard by quoting, thanking, criticising it. InNew Jersey, for example, is a monthly called the _New Jersey Review ofCharities and Corrections_ that deals with every manner of subjecthaving to do with public health as well as with private and publicmorality and education. 

A similar journal, intended for national instruction, is _The Survey_, whose topical index for last year enumerates two hundred and thirty-twoarticles 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 intendedfor nurses and physicians, but full of suggestive material forunprofessional readers. National magazines concerned with health, butseeking 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_, andother technical journals published in this country. For many persons, to make the best use of any one copy of these magazines, clipping is ofcourse impossible, but noting on a card or envelope is practicable. 

Of late many of the national popular magazines have several columnsdevoted to health. We have not appreciated the educationalpossibilities of these columns. In most large cities there are monthlybook reviews which may be profitably consulted in learning the newthought in the health field. If teachers would either write theirexperience or ask questions, if children knew that in a certainmagazine or newspaper questions as to ventilation, bathing, exercise, would be answered, they would take a keen interest in the progress ofdiscussions. The large daily papers make a great feature of theirhealth hints. It is not their fault if questioners care more aboutcosmetics and hair bleaches than about the fresh-air cure of headaches. They will coöperate with teachers and parents in securing more generaldiscussion of other problems than beauty doctoring. 

Finally, persons wanting not only to have intelligence as to matterspromoting health, but actually to exert a helpful influence in theircommunity, ought to want the published reports of the mayor, healthdepartment, the public schools, and other institutions, notingcarefully all that is said about conditions relating to health andabout efforts made to correct all unfavorable conditions. The bestliterature of our day, with regard to social needs, appears in thereports of our public and private institutions and societies. Ofincreasing value are the publications of the national governmentprinting office. Because it is no one's business to find out whatvaluable material is contained in such reports, and because noeducational museum is comparing report with report, those who livenearest to our health problems and who see most clearly the healthremedies, are not stimulated to give to the public their specialknowledge in an interesting, convincing way. 

Teaching children how to find health lessons in public documents willadvance the cause of public ethics as well as of public health. At theNew York State Conference of Charities, of 1907, one officialcomplained that the physicians made no educational use of theirvaluable experience for public education. He stated that a study ofmedical journals and health articles in popular magazines revealed thefact that the number of papers prepared by physicians in statehospitals averaged one to a doctor for every five or six years ofservice. This state of affairs is even more exaggerated in strictlyeducational institutions. Columbia University has recently instituted aseries of lectures to be given by its professors to its professors, sothat they may have a general knowledge of the work being done in otherfields besides their own at their own university. This is equallyimportant for teachers and heads of departments in elementary schools. It is now admitted by most educators that elementary schools and youngchildren present more pedagogical difficulties and pressing biologicalproblems than higher schools. If teachers and parents would realizethat their method of solving the health problems that arise daily inthe schoolroom and in the home would interest other mothers andteachers, their spirit of coöperation would soon be reflected in schooljournals, 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 notfor love"--_nor for work_. Work of itself never killed anybody nor madeanybody sick. Work has caused worry, mental strain, and physicalbreakdown, only when men while working have been deprived of air, sun, light, exercise, sleep, proper food at the proper time, opportunity tolive and work hygienically. Fortunately for human progress, doingnothing brings ailments of its own and has none of the compensations ofwork. As the stomach deprived of substantial food craves unnaturalfood, --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 thelack of bodily exercise that generally accompanies it, reactsunfavorably on physical health. An editor has aptly termed thedo-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 whereyoung men and women are inclined to associate health and happiness withdoing nothing recently gave two columns to "Dandy Jim, " the richest dogin the world. Dandy Jim's mistress left him a ten-thousand-dollarlegacy. During his lifetime he wore diamonds. Every day he ate candythat cost eighty cents a pound. The coachman took him driving in thepark sunny afternoons. He had no cares and nothing to work for. Hisfood came without effort. He had fatty degeneration of the vitalorgans. He was pampered, coddled, and killed thereby. Thousands of menand women drag out lives of unhappiness for themselves and othersbecause, like Dandy Jim, they have nothing to work for, are pampered, coddled victims of fatty degeneration. When President Butler ofColumbia University finds it necessary to censure "the folly andindifference of the fathers, vanity and thoughtless pride of themothers" who encourage do-nothing ailments; and when the editor of the_Psychological Clinic_ protests that the fashionable private schoolsand the private tutor share with rich fathers and mothersresponsibility for life failures, --it is time that educators teachchildren themselves the physical and moral ailments and disillusionsthat come from doing nothing. 

Ten years ago a stenographer inherited two hundred and fifty thousanddollars. Her dream of nothing to do was realized. She gave up herstrenuous business life. Possessions formerly coveted soon clogged herpowers of enjoyment. She imagined herself suffering from variousdiseases, shut herself up in her house, and refused to see any one. Shegrew morbid and was sure that every person who approached her had somesneaking, personal, hostile motive. Though always busy, sheaccomplished little. Desultory work, procrastination, andself-indulgence destroyed her power of concentration. She could notthink long enough on one subject to think it out straight, thereforeshe was constantly deceived in her friends and interests. She firsttrusted everybody, then mistrusted everybody. Infatuation with everynew acquaintance was quickly followed by suspicion. For years she was avery sick woman, a victim of do-nothing ailments. 

Doing nothing has of late been seriously recommended to Americanbusiness men. They are advised to retire from active work as soon astheir savings produce reasonable income. It is true, this suggestionhas been made as an antidote to greed rather than for the happiness ofthe business man. What retiring from business is apt to mean, isindicated by a gentleman who at the age of sixty decided to sell hisseat on the New York Stock Exchange and to enjoy life. He becamerestless and very miserable. He threw himself violently into one thingafter 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 tothink 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 thebody and mind than having too little to eat. Social reformers emphasizethe bad effect on society of vagrancy. Evils of indiscriminate reliefto the poor are vividly described year after year. The philanthropistis condemned, who, by his gifts, encourages an employee's family tospend what they do not earn, and to shun work. Yet the idleness of thetramp, street loafer, and professional mendicant is a negligible evilcompared with the hindrance to human progress caused by the idleness ofthe 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 ofdo-nothingism, as to refuse to have their teeth attended to or to haveglasses fitted to weak eyes. 

From the point of view of community welfare it is far more serious forthe rich child to be brought up in idleness or without a purpose thanfor the poor child to become a public charge. Not only has society aright to expect more from rich children in return for the greaterbenefits they enjoy, but so long as rich children control theexpenditure of money, they control also the health and happiness ofother human beings. Unless taught the value and joy of wholesome workthey cannot themselves think straight, nor are they likely to want tounderstand how they can use their wealth for the benefit of mankind. Toquote 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 shouldnot be overlooked. The energy spent in forcing oneself to do adistasteful task can be turned to productive channels when work is madepleasurable. The fact is frequently deplored that whereas formerly aman became a full-fledged craftsman, able to perform any branch of histrade, he is now confined to doing special acts because neither hisinterest nor his mind is called into play. Work seems to reactunfavorably on his health. He has not the pride of the artisan in thefinished product, for he seldom sees it. He does a task. His employeris a taskmaster. He decides that work is not good for him as easily aswhen a school-boy he grasped the meaning of escape from his lessons. Byfailing to fit studies to a student's interest, or by failing to insurea student's interest in his studies, schools and colleges miseducateyoung men and young women to look upon all work as tasks, asdiscipline, necessary but irksome, and to be avoided if possible. Justas there is a way of turning all the energy of the play instinct intoschool work, so there is a way of interesting the factory and officeworker in his job. However mechanical work may be, there is always theinterest in becoming the most efficient worker in a room or a trade. Routine--accurate and detailed work--does not mean the stultificationof the imagination. It takes more imagination to see the interestingthings in statistical or record work than to write a novel. Thereforeemployers should make it a point to help their employees to realize thesignificance of the perfection of each detail and the importance ofeach man's part. The other day a father said to me, "I want my boys tobe as ashamed to do work in which they are not interested as to acceptgraft. " When interest in work and efficiency in work are regarded as ofmore importance than the immediate returns for work, when it is asnatural for boys and girls to demand enjoyment and complete living inwork 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 canmake the sick well and keep the well from getting sick. It is the chiefreliance 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 thatI could not have inherited tuberculosis from two uncles who died ofconsumption. For years I had known that I was a marked victim. SilentlyI carried my tragedy, suspecting each cold and headache to be thetelltale messenger that should let others into my secret. He was averitable emancipator who informed me that heredity did not work fromuncle to nephew; that not more than a predisposition to consumptioncould pass even from parent to child; that a predisposition toconsumption would come to nothing without the germ of the disease andthe environmental conditions which favor its development; and that ifthose so predisposed avoid gross infection, lead a healthy life, andbreathe fresh air they are as safe as though no tuberculous lungs hadever existed in the world. Some years later I learned to understand theother side of the case; I realized how I had been in real danger ofcontracting consumption in the darkened, ill-ventilated sick room ofthe uncle who taught me my letters and gave me my ideal of God'spurpose in sending uncles to small boys. 

There are two distinct things which make each individual life: theliving stuff, the physical basis of life, handed down from parent tochild; and the environmental conditions which surround it and play uponit and rouse its reactions and its latent possibilities. It is like theseed and the cultivation. You cannot grow corn from wheat, but you cangrow the best wheat, or you may let your crop fail through carelesshandling. 

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

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

In the second place, if science has shown anything more clearly thanthe importance of heredity, it is the importance of environment. Thisinfluence upon human lives is within our control, and it is a graveerror to neglect what lies clearly within our power and to bemoan whatdoes not. Science has wrought no benefits greater than those whichresult from drawing a clear line between heredity bugaboos and hereditytruths. An overemphasis on the hereditary factor in development at theexpense of the environmental factor, I call a heredity bugaboo; and itis a tendency which cannot be too strongly condemned. To fight againstthe sins and penalties of one's grandfather is a forlorn task thatquickly discourages. To overcome diseases of environment, of shop andstreet, 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 newscience which biologists and sociologists hope will some day remake thevery living stuff of the human race. But meanwhile let us take up withhope and courage and enthusiasm the great hemisphere of human fatewhich lies within our grasp. Good food and fresh air, well-builtcities, enlightened schools and well-ordered industries, stable andfree and expert government, --given these things, we can transform theworld with the means now at our disposal. We can reap, if we will, splendid possibilities now going to waste, and by intelligentbiological and sociological engineering we can hand on to the nextgeneration an environmental inheritance which will make their task fareasier than ours. 

"Physical deterioration" is a bugaboo that is discovered by some inheredity and by others in modern industrial evils. The British directorgeneral called attention a few years ago to the fact that from forty tosixty per cent of the men who were being examined for military servicewere physically unfit. A Commission on Physical Deterioration wasappointed to investigate the cause, and to learn whether the lowphysical standard of the would-be Tommy Atkins was due to inheriteddefects. The results of this study were published in a large volumecalled _Report on Physical Deterioration, 1904_, in which is set fortha positive programme for obtaining periodically facts as to thephysique of the nation. In the course of the commission's exhaustiveinvestigation there was found no evidence that any progressivedeterioration was going on in any function of the body except theteeth. "There are happily no grounds for associating dental degeneracywith progressive physical deterioration. " The increase in opticaldefects is attributed not to the deterioration of the eye, but togreater knowledge, more treatment, and better understanding of theconnection 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 collectedwill have some effect in allaying the apprehensions of those who, as itappears, on insufficient grounds, have made up their minds thatprogressive deterioration is to be found among people generally. " Inregard to the facts which started the fear, the report says: (1) theevidence adduced in the director general's memorandum was inadequate toprove that physical deterioration had affected the classes referred to;(2) no sufficient material (statistical or other) is at presentavailable to warrant any definite conclusions on the question of thephysique 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 ofconditions that need to be carefully studied before we can know whatenvironment 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 toheredity truths and heredity bugaboos unless records are kept now, showing the physical condition of school children and of applicants forwork certificates and for civil service and army positions. The Britishinvestigators declared that "anthropometric records are the onlyaccredited 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 underthe administration of the Factory Acts offer ready material for theimmediate application of such tests. " In addition to the physical testsproposed in other chapters, there is great educational opportunity inthe records of private and public hospitals. Every nation, every state, and every city should enlist all its educational and scientific forcesto ascertain in what respects social efficiency is endangered byphysical deficiencies that can be avoided only by restrictingparenthood, and the environmental deficiencies that can be avoided byefficient health machinery. 

The greatest of all heredity truths are these: (1) the deficiencies ofinfants are infinitesimal compared with the deficiencies of the worldwith which we surround them; (2) each of us can have a part inbegetting 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 madecompulsory to teach the evils of alcoholism. For nearly a generationthe great majority of school children of the United States have beentaught that alcohol, in however small quantities, is a poison and amenace to personal and national health and prosperity. Yet during thisvery period the per capita consumption of every kind of alcoholicbeverage has increased. Whereas 16. 49 gallons of spirituous liquorswere consumed per capita of population in 1896, 22. 27 gallons were usedin 1906. Obviously the results of methods hitherto in vogue forcombating alcoholism are disappointing. 

Why this paradoxical relation of precept to practice? Why is this, themost hygiene-instructed country in the world, the Elysium of thepatent-medicine and cocaine traffic? If we have only the expecteddivergence of achievement from ideal, then there is nothing for us todo but to congratulate ourselves and posterity upon the part played bycompulsory legislation in committing all states and territories tohygiene instruction in all public schools. If, on the other hand, ourdisappointment is due to ineffective method, then the next step is tochange our method. 

The chief purpose of school hygiene has hitherto been not to promotepersonal and community health, but to lessen the use of alcohol andtobacco. Arguments were required against whisky, beer, cigars, andcigarettes. As the strongest arguments would probably make the mostlasting impression upon the school child and the best profits forauthor and bookseller, writers vied with one another in the rhetoricand hyperbole of platform agitation. What effect would it have upon youif you were exhorted frequently during the next eight years to avoidtobacco because a mother once killed a child by washing its head intobacco water? What is the effect on the mind of a boy or a girl whosees that the family doctor, the minister, the teacher, the judge, thegovernor, the President, and the philanthropist use tobacco andalcoholic beverages, when taught that "boys who use tobacco andalcoholic beverages will find closed in their faces the doors tostrength, good health, skill in athletics, good scholarship, long life, best companions, many business positions, highest success"? It isprobably true that "a boy once drank some whisky from a flask and diedwithin a few hours. " But that story is about as typical of boys and ofwhisky as that a boy once drank whisky from a flask and did not die forninety years afterwards, or that George Washington drank whisky andbecame the Father of his Country. 

How special pleading has dominated the teaching of school hygiene isillustrated by a recent book which, for the most part, successfullybreaks away from the narrow point of view and the crude methodshitherto prevailing. It presents the following facts concerning NewYork 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 manywords that the shutting up of the saloons would obviate all the arrestsand all the hospital, jail, and charity bills. Instead of _wipe out_she says _shrivel_. No truth would have been lost by avoiding allmisrepresentation. 

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

The reaction has already begun against exaggeration in hygienetext-books, against drawing lessons from accidental or exceptionalcases of excessive use of alcohol, against classing moderate drinkingand smoking with drunkenness as sins of equal magnitude, and againstoverlooking grave social and industrial evils that threaten childrenfar earlier and more frequently than do tobacco and alcohol. Instead ofadding an ell to the truth, text-book writers are now adding only aninch or two at a time. No longer do we favor highly colored charts thatpicture in purple, green, and black the effect of stimulants andnarcotics upon the heart and brain, the stomach, the liver, the knee, and the eardrum, _assuming that all resultant evils are concentrated inone organ_. Menacing habits, such as overeating and indulgence inself-pity, are beginning to receive attention. It is also true thatphysiology and anatomy are progressively made more interesting. Publishers are looking for the utmost originality compatible with thepurpose of the present laws and with the only effective publicsentiment that has hitherto been interested in the interpretation ofthose laws. 

A score of improvements in the method of carrying out a small idealwill not take the place of enlarging that ideal. If existing laws standin the way of broadening the purpose of school hygiene, let the laws bechanged. If text-book publishers stand in the way, let us induce orcompel them to get out of the way. If we fear rumsellers, their money, and the insidious political methods that they might employ to bring inundertruth if overtruth is once sacrificed, let us go to ourcommunities and locate the rumseller's guns, draw their fire, tell thetruth 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 ourrespective communities that there is a better way of inculcating habitsof temperance and self-restraint than by telling untruths, overtruths, or half truths about alcohol and tobacco. Let us prove, as we can, thata subject vital to every individual, to every industry, and to everygovernment is now prevented from fulfilling its mission not by itsenemies but by its friends. We can learn the character of hygieneinstruction in our schools and the interest taken in it by teachers, principals, and superintendents. We can learn how teachers practicehygiene at school, and how the children of our communities are affectedby the hygiene instruction now given. Finally, we can compel a publicdiscussion of the facts, and action in accordance with facts. Withoutquestioning anybody's avowed motive, we can learn how big that motiveis and how adequate or inadequate is the method of executing it. 

Alcohol and tobacco really occupy but a very small share of theinterest and attention of even those men and women by whom they arehabitually used. Hygiene, on the other hand, is of constant, uninterrupted concern. Why, therefore, should it be planned to havealcohol and tobacco displace the broader subject of personal and publichygiene in the attention and interest of children throughout the schoollife? Beyond the text-book and schoolroom a thousand influences are atwork to teach the social evils, the waste of energy, and theunhappiness that always accompany the excessive use--and frequentlyresult from a moderate use--of stimulants and narcotics. Of the manyreasons for not drinking and smoking, physiology gives those thatleast interest and impress the child. The secondary effects, ratherthan the immediate effects, are those that determine a child's action. Most of the direct physiological effects are, in the majority ofinstances, less serious in themselves than the effects of overeating, of combining milk with acids, of eating irregularly, of neglectingconstipation. Were it not for the social and industrial consequences ofdrunkenness and nicotinism, it is doubtful if the most lurid picture offatty degeneration, alcoholic consumption, hardened liver, inactivestomach lining, would outweigh the pleasing--and deceiving--sensationsof alcoholic beverages and cigarettes. 

The strong appeal to the child or man is the effect these habits haveupon his mother, his employer, his wife, his children. The vastmajority of us will avoid or stop using anything that makes usoffensive to those with whom we are most intimately associated, and tothose upon whom our professional and industrial promotion depends. Children will profit from drill in and out of school in the science ofavoiding offense and of giving happiness, but unless thecategories--_acts that give offense_ and _acts that givehappiness_--are wide enough to include the main acts committed in thenormal relations of son, companion, employer, husband, father, andcitizen, those who set out to avoid alcohol and tobacco find themselvesill equipped to carry the obligations of a temperate, law-abidingcitizen. 

Things do not happen as described in the early text-book. Other thingsnot mentioned hinder progress and happiness. The child at work resentsthe mis-education received at school and suspects that he has beenfollowing false gods. The enemies that cause him trouble come fromunexpected sources. He finds it infinitely easier to eschew alcohol andtobacco than to avoid living conditions that insidiously undermine hisaversion to stimulants and narcotics. The reasons for avoidingstimulants in the interest of others are more numerous and more cogentthan the reasons for avoiding stimulants and narcotics for one's ownsake. The altruistic reasons for shunning stimulants and narcoticscannot be implanted in the child unless he sees the evil of excess _perse_ in anything and everything, and unless he becomes thoroughlygrounded in the life relations and health relations to which he mustadapt himself. 

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

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

If Sunday closing of saloons, local option, high license, andprohibition have failed, there is no evidence that the failure is dueto the principles underlying any one of these methods. Until moreearnest effort is made to study the effects of these methods, theresults of their enforcement and the causes of their nonenforcement, noone is justified in declaring that either policy is successful orunsuccessful. It is very easy to select from the meager facts nowavailable convincing proofs both that prohibition does not prohibit andthat high license leads to increased drunkenness. The consequence isthat the movements to control, restrict, or prohibit the use of alcoholare emotional, not rational. 

It is impossible to keep emotion, sensation, sentiment, at white heat. Most extremists worship legislation and do not try to keep interestalive by telling every week or every month new facts about the week orthe month before. No new fuel is added to the anti-saloon fire, whichgradually cools and dies down. Not so, however, with those who makemoney by the sale of intoxicants. The greater the opposition, the morebrains, the more effort, the more money they put into overcoming orcircumventing that opposition. Fuel is piled on and the bonfire is fedfreely. Every day the anti-restriction bonfire becomes larger andlarger, and the anti-saloon bonfire becomes smaller and smaller. Bycarefully selecting their facts, by counting the number of arrests fordrunkenness and the number of saloons open on Sunday, by reiteration oftheir story the pro-saloonists gradually win recruits from theopposition, and, when the next election comes, their friends outnumbertheir enemies and the "dry" policy of a city, county, or state isreversed. 

The failures attributed to prohibitive or restrictive measures areprobably no more numerous than the failures of government in otherrespects. The present ambassador from England, James Bryce, writing his_American Commonwealth_, declared that municipal government wasAmerica's "most conspicuous failure. " The mayor of Toledo, writing in1907, says, "There has been a pessimism, almost enthusiastic, about thecity. " These failures are due not to any lack of desire for goodgovernment, not to any fundamental evils of cities, but to the factthat municipal reform, like the crusade against alcohol, has been basedupon emotionalism, not upon definite proof. Reformers have been unableto lead in the right direction, because they have looked at theirlantern instead of their road. Not having cumulative information as togovernment acts, they have been unable to keep their fires burning. Toillustrate: in November, 1907, the governor of New York state, themayor of New York City, and reformers of national reputation eulogizedthe tenement-house department; yet this department, whose founding wasregarded as a national benefaction, was the only department of the citygovernment that did not receive an increase for 1908. It is in theposition of temperance legislation, the facts of whose enforcement ornonenforcement 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 toalcoholism, are the three chief motives that have swept alcohol trafficout of the greater part of the South. Knowledge of physiological evilshas had little influence, except as it may have rendered moreacceptable the claim that alcoholism is a disease against which thereis no insurance except abolition of alcohol as a beverage. Religiousrevivals, street parades by day and by night, illustrated banners, personal intercession, lines of women and children at the polls, madeit necessary for voters to make known their intention, and made itextremely difficult for respectable men, engaged in respectablebusiness, to vote for saloons. Some states have gone so far as toprohibit the manufacture of alcoholic stimulants, even though notoffered for sale within state limits. In Georgia wine cannot be used atthe communion service, nor can druggists sell any form of liquor exceptpure alcohol. In Louisiana it is illegal for representatives of "wetdistricts" to solicit orders for liquor in any of the "dry districts. "In Texas the sale of liquor in dining cars is forbidden, and thetraveler may not even drink from his own flask. Congress is being urgedby senators and congressmen, as well as by anti-saloon advocates, topass laws prohibiting common carriers from delivering alcoholics to any"dry" community. The more optimistic anti-saloon workers believe it isbut a matter of a short time when Congress will pass laws prohibitingthe manufacture or sale of alcoholic beverages within any limitsprotected by the United States Constitution. 

Southern states have been warned that they could not afford thedepreciation of real estate values, of rents, and of business thatwould surely follow the "confiscation of capital" and "interferencewith personal liberty. " This warning has been met by plausiblearguments that the buyers of legitimate and nonpoisonous commoditiescould pay better rents, better profits on business and on real estate, if freed from the uneven fight against temptation to drink. Theargument that schools and streets and health must suffer if the licensemoney was withdrawn, has been met by the plausible argument that theultimate taxpayer--the family that wants clothing, food, andshelter--will save enough money to be able to spend still larger sumsthan heretofore upon education, health, and public safety. 

For the first time dealers in alcohol recognize the possibility of agreat national movement and of national prohibition. Both the defectsin methods hitherto used to oppose saloon legislation and the reasonsfor meeting the present situation by new methods are presented in theMay issue (1907) of the _Transactions of the American BrewingInstitute_. Under the title, "Social Order and the Saloon--the Measureof the Brewer's Responsibility, " Mr. Hugh F. Fox, known throughout theUnion as a defender of child rights, advocate of probation andchildren's courts, promoter of health and education, outlined a planfor research that is indispensable to the proper settling of this greatquestion. Whether brewer or anti-saloon leaguist, total abstainer ormoderate drinker, employer or trade unionist, it is necessary to theintelligent control of alcohol that each of us approach this momentousquestion of control or abolition of the saloon in the spirit expressedin this paper, whose thoroughness and whose social point of view woulddo credit to a church conference. The address is quoted and itsquestions copied because both show how much depends upon knowingwhether laws are enforced and how much greater is the difficulty ofcoping with a conciliatory antagonist who professes willingness tosubmit 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 legalizedsaloon, as ocean waves have from time to time engulfed peninsulas, islands, and whole continents, depends upon the power of Americaneducators and American officials to answer right such questions as theforegoing. The great danger is that we shall, as usual, over-emphasizelawmaking, underemphasize lawbreaking, and go to sleep during the nexttwo or three years when we should be wide-awake and constantly activein seeing that the law is enforced. Unless exactly the same principlesof law enforcement are applied in "dry districts" as we have urged foreradication of smallpox, typhoid, scarlet fever, and adenoids, localand 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 doneconsistently unless funds are provided to pay one or more persons ineach populous locality to give their entire time to the enforcement oflaws, just as the improvement of other ills of municipal governmentrequire the constant attention of trained investigators. Cogentarguments for such funds have recently appeared in the _New YorkEvening Post's_ symposium on "How to Give Wisely, " by Mrs. Emma GarrettBoyd, of Atlanta, and Miss Salmon, of Vassar College. 

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

CHAPTER XXXV

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

If children are taught that the most effective way of combatingalcoholism is to insure the enforcement of existing laws and to profitfrom lessons taught by such enforcement; if children are taught thatthe strongest reasons for total abstinence are social, economic, andindustrial rather than individual and physiological, --there is much tobe gained and little to lose from telling them the truth, the wholetruth, and nothing but the truth about alcohol. To stimulate a child'simagination by untruths about alcohol is as vicious as to stimulate hisbody 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 betraced to alcohol. On the contrary, it is unquestionably true that themajority of the nation's heroes have used alcoholics moderately orexcessively for the greater part of their lives. It is probably truethat among the hundred most eminent officials, pastors, merchants, professors, and scientists of to-day, the great majority of each classare moderate users of one or more forms of alcoholics. Overeating ofpotatoes or cake or meat, sleeping or working in ill-ventilated rooms, neglect of constipation, may occasion physiological and industrialinjuries that are not only as grave in themselves as the evils ofmoderate drinking, but, in addition, actually tempt to moderatedrinking. 

All of this can be safely admitted, because whether parents andteachers admit it or deny it, children by observation and by readingwill become convinced that up to the year 1908 the noblest and the mostsuccessful men of America, as well as the most depraved and leastsuccessful, have used alcoholics. To be candid enough to admit thisenables us to gain a hold upon the confidence and the intelligence ofchildren and youth that will strengthen our arguments, based uponsocial and industrial as well as physiological grounds, against runningthe risks that are inevitably incurred by even the moderate use ofalcohol. 

Other things being equal, the same man will do better work withoutalcohol than with alcohol; the same athlete will be stronger and morealert without alcohol than with alcohol; the clerk or lawyer or teacherwill win promotion earlier without alcohol than with alcohol; man orwoman will grow old quicker with than without alcohol. Other thingsbeing equal, a man of fifty will have greater confidence in a totalabstainer than in a man of identical capacity who uses alcoholmoderately; a mother will give better vitality and better care to herchildren without than with alcohol; a policeman or fireman orstenographer is more apt to win promotion without than with alcohol. Whatever the physical ailment, there is in every instance a betterremedy for an acute trouble, and infinitely better remedies fordeep-seated troubles, than alcoholics. 

The percentage of failure to use alcoholics moderately is so high, theuncertainty as to a particular individual's ability to drink moderatelyis so great, as to lead certain insurance companies, first, to givepreference to men who never use alcoholics, and later, to refuse toinsure moderate drinkers. Life insurance companies have the generalrule that habitual drinkers are bad risks, as the alcohol habit isprejudicial to health and longevity; but they have no means of studyingthe risk of moderate drinkers, because, except where alcohol hasalready left a permanent impression upon the system, the indicationsare by no means such as to enable the medical examiner to trace itsexistence with certainty. For this reason the life insurance companieshave little effect in _preventing_ alcoholism. Though they are agreedthat habitual drinkers ought to be declined altogether, only a fewcompanies have taken the decided stand of declining them. "Habitualdrinkers, if not too excessive, are admitted into the general classwhere the expected mortality, according to the experience of thePennsylvania Mutual Life Insurance Company, is 80 per cent, as against56 per cent for the temperate class. Though it is only necessary tolook over the death losses presented each day to see that intemperancein the use of liquors, as shown by cirrhosis of the liver, Bright'sdisease, diseases of the heart, brain, and nervous system, is the causeof a large proportion of the deaths, these companies prefer to gradethe premiums accordingly rather than to decline habitual drinkersaltogether. While this is partly due to the difficulty and expense ofdiagnosis, it is more probably due to an objection to take a definitestand on the temperance question. "

Thus the insurance companies' rules touch only the confirmed drinker, whose physique is often irreparably injured. One company writes: "Menwho have been intemperate and taken the Keeley or other cures are neveraccepted until five years have elapsed from the date of taking thecure, and only when it can be conclusively shown that during the wholeperiod they have refrained entirely from the use of alcoholic liquor, and that their former excesses have not in any way impaired thephysical risk. "

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

Naturally the moderate drinker is first rejected for positions where anoccasional overindulgence would be most noticeable and most serious. The manager of a large factory tells his men: "You cannot work hereunless you are sober. If you must drink at parties, stay at home ifnecessary until 12 o'clock the next day and sleep it off, but don'tcome here till you are straight. We cannot afford it. " Occasionally hismen stay at home and not a word is said, but the minute they are foundat work in an unsteady condition they are summarily discharged. Fromthis position it is but a step to that of an upholsterer in New YorkCity, who prints on his order blanks, "No drinking man employed. " Hiscompany recently discharged a man after twenty years of service becausea customer for whom this man was working detected a whisky breath. Menreported to trade unions for frequent intoxication are blacklisted. Acertain financial corporation permits no liquor on its grounds or inits lunch rooms. The head of one of its large branches was heard to sayrecently that he would discharge on the spot a man who showed evidencesof drinking, even though he had previously worked faithfully for years. 

Rejection of moderate drinkers by business houses is not done on moralgrounds alone, but because experience has proved the danger ofemploying men who have not their faculties fully under control _all_the time they are at work. The rules are especially strict for menworking for a railroad or street railway company. The PennsylvaniaRailroad Company replied to my inquiry as to their custom ofdiscriminating against drinking men in these words: "We have no printedrules in regard to this except in a general way, --that no employee isallowed to go into a saloon during his hours of work or wearing thecompany's uniform. Of course the men are promptly discharged ordisciplined if they show the effects of liquor while on duty, and thewhole tendency of the administration of the rules is to get rid of anymen who are habitual drinkers, but the administration of the rules anddiscipline is left to the superintendent of each division. " TheInterborough Rapid Transit Company of New York has these printed rulesfor 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 growingtendency on the part of large corporations, factories, and businesshouses to take a decided stand against drinking, are having a markedeffect in reducing drunkenness where it does most harm. This practicehas been declared by John Bach McMasters, the noted American historian, to have exerted a stronger influence in promoting temperance and totalabstinence than all the temperance crusades from Hartley's time to theprohibition wave of 1907. The school, by instructing children how thealcohol habit will affect their chances of business success, futureusefulness as citizens, and enjoyment of life, will inevitably reducethe evils of alcohol. By teaching based on facts that intimatelyconcern the life of the child, as well as by caring for his health andhis environment, the schools can help supplant the desire for alcoholwith other more healthy desires. 

No truth about alcohol is more important than that the craving foralcohol or something just as bad will exist side by side with imperfectsanitation, too long hours of work, food that fails to nourish, lack ofexercise, rest, and fresh air. Conditions that produce boundingvitality and offer freedom for its expression at work and at play willsupplant the craving for stimulants. Finally, the great truth containedin the last chapter must be taught, that success in coping withalcoholism is a community task requiring efficient government above allelse. 

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 tojustify, the tobacco habit. To soothe excited nerves by lying to themabout their condition and by weakening where we promise to nourish, isvicious and harmful just as other lying and robbery are vicious andharmful. Yet two essential facts in dealing with tobacco evils must beconsidered: tobacco does soothe excited nerves, and the harm done tothe majority of smokers seems to them to be negligible. For these tworeasons the tobacco user, unless frightened by effects already visible, refuses to listen to physiological arguments against his amiableself-indulgence. Cheerfully he admits the theoretical possibility thatby its method of soothing nerves tobacco kills nerve energy. But in allsincerity he points to men who have found the right stopping point upto which tobacco hurts less perhaps than coffee or tea, candy orlobster, overeating or undersleeping. Therefore the physician, thebishop, the school superintendent, candidly run the necessary risk forthe sake of nerve soothing and sociability. 

Less harm would be done by tobacco if it were more harmful. Like somany other food poisons, its use in small quantities does not producethe prompt, vivid, unequivocal results that remove all doubt as to theuser's injuries and intemperance. As inability to see the physiologicaleffect upon himself encourages the tobacco user to continue smoking orchewing, so failure to identify evil physiological effects upon thesmoker encourages the nonuser to begin smoking or chewing. A very fewsmokers give up the habit because they fear its results, but too oftenthe man who can see the evil results would rather give up almostanything else. The one motive that most frequently stops inveteratesmoking--fear--is the least effective motive in dissuading those whohave not yet acquired the habit; every young man, unless alreadysuffering from known heart trouble, thinks he will smoke moderately andwithout harm. Unfortunately, every boy who begins to smoke succeeds inpicturing to himself the adult who shows no surface sign of injury fromtobacco, 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 otherweapons against tobacco evils in addition to fear of physiologicalinjuries. Among these weapons are:

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

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

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 whatin adults would be called moderate smoking, the proper physicalexamination of school children will reveal injuries which in turn willshow where and to what extent the cigarette evil exists among thechildren of a community. Even the scientists who claim that "in somecases tobacco aids digestion, " or that "tobacco may be used without badeffects when used moderately by people who are in condition to use it, "declare emphatically that tobacco "must not be used in any form bygrowing children or youths. " Prohibitive laws can be rigidly enforcedif a small amount of attention is given to organizing the strongpublic sentiment that exists against demoralizing children by tobacco. Thus children and youths will not need to make a decision regardingtheir own use of tobacco until after other arguments than physiologicalfear have been used for many years by parent, teacher, and society. 

One effective weapon is the sign on a ferryboat or street car: "Nosmoking allowed on this side, " or "Smoking allowed on three rear seatsonly. " Public halls and vehicles in increasing numbers either prohibitsmoking altogether or put smokers to some considerable inconvenience. The trouble involved in going to places where smoking is permittedtends gradually to irritate the nerves beyond the power of tobacco tosoothe. Again, many men would rather not soothe their excited nervesafter five, than have their nerves excited all day waiting for freedomto smoke. Restrictions as to time or place make possible and expeditestill further restrictions. Thus gradually the army of occasionalsmokers or nonsmokers is being recruited from the army of regularsmokers. 

The anti-nuisance motive follows closely upon the drawing of sharplines of time and place for the use of tobacco. Like treason, smokingin the presence of nonsmokers can be considered respectable only whenthe numbers who profess and practice it are numerous. If the twofirst-mentioned weapons are effectively used, there will be anincreasing proportion of nonsmokers and not-yet-smokers who will giveattentive ear to proof that nicotinism is a nuisance. The physicalevidences of the cigarette habit can easily be made distasteful to allnonsmokers if frankly pointed out, --the yellow fingers, the yellowteeth, the nasty breath, the offensive excretions from the pores thatsaturate the garments of all who cannot afford a daily change ofunderwear. The anti-nuisance argument is always insidious and abiding. In the presence of nonsmokers accustomed to regard tobacco using as anuisance, smokers become self-conscious and sensitive. Men and womenalike would prefer a reputation for cleanliness to the pleasures oftobacco. The educational possibility of fighting tobacco with the name"nuisance" was recognized the other day by an editorial that protestedagainst a law to prevent women from using cigarettes in restaurants. "The way for any man who has the desire to reform some woman addictedto the cigarette habit is insidiously and gently to point out theinjurious effects on her appearance. Cigarette smoking stains a woman'sfingers and discolors her teeth. It also tends to make her complexionsallow and to detract from the rubiness of her lips. It bedims thesparkle of her eyes. It makes her less attractive mornings. " Chewinghas practically disappeared, not because it ceased to soothe excitednerves but because it was seen to be a nasty nuisance. 

Finally, the selfishness of the smoker is a nuisance that continuesonly because it has not been called by its right name. "Do you mind ifI smoke?" was a polite question two hundred years ago when tobacco wasrare enough to make smoking a distinction, or fifty years ago wheneverybody smoked at home and in public. But it is effrontery to-daywhen people do mind, when smoking pollutes the air of drawing room andoffice, and while soothing the excited nerves of the smoker lowers thevitality of nonsmokers compelled to breathe smoke-laden air. It isselfish to intrude upon others a personal weakness or a personalappetite. It is selfish to divert from family purposes to "soothingexcited nerves" even the small amounts necessary to maintain the cigaror cigarette habit. It is selfish to run the risk of shortening one'slife, of reducing one's earning capacity. Because the tobacco habit isselfish it is anti-social and a nuisance, and should be fought bysocial 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 gainingin strength. The soothing qualities of all drugs are found to beexpensive to physical and business energy if enjoyed during businesshours. Strangely enough, employers who smoke are quite as apt as arenonsmokers, to forbid the use of tobacco by employees at work. Some ofthis seeming inconsistency is due to a dislike for cheaper tobacco orfor mixed brands in one atmosphere; some of it is due to the smoker'sknowledge that "soothing nerves" and sustained attention do not go handin hand, while "pipe dreams" and unproductive meditation are fastcompanions; finally no little of the opposition to tobacco in businessis due to fear of fire. These various motives, combining with theanti-nuisance motive among nonsmokers, have led many businessenterprises to prohibit the use of tobacco in any form on theirpremises or during business hours, even when on the premises of others. Notable examples are railroads that permit no passenger trainman to usetobacco while on duty. (Freight trainmen are restricted more tardilybecause the risk of damages is less and the anti-nuisance objection iswanting. )

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

Armed with these weapons against tobacco, parents and teachers caneffectively introduce physiological arguments against excessive use, against use by those who suffer from nervous or heart trouble, andagainst any use whatever by those who have not reached physicalmaturity. By avoiding physiological arguments that children willnot--cannot--believe contrary to their own eyes, parents and teachersare able to speak dogmatically of that which children willbelieve, --injuries to children, evils of excess, restrictions as totime and place, and offensiveness to nonsmokers. But even here it iswrong, as it is inexpedient, to leave the physical strength of the nextgeneration to the persuasive power of parents and teachers or to thefaith and knowledge of minors. Society should protect all minorsagainst their own ignorance, their own desires, the ignorance ofparents and associates, and against the economic motive of tobaccosellers 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 Americanpeople why they spend over two hundred million dollars annually onpatent medicines. Americans consume more drugs and use more patentmedicines than the people of any other country on the civilized globe. Self-medication has grown to tremendous proportions. Everywhere--incars, on transfers, on billboards, in magazines, in newspapers, in themails--are advertised medicines to cure disease and devices to promotehealth. When we consider that electric cars contain from thirty-two tofifty-two advertisements each, three fourths of which are directly orindirectly concerned with health; when we multiply these by the numberof cars actually in use in American cities; when we consider the numberof advertisements in magazines and daily papers, and the enormouscirculation of these papers and magazines; when we consider that anincreasingly large proportion of advertising space is devoted tohealth, --we begin to realize the cumulative power for good or for evilthat health advertisements must have. 

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

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

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

Besides the classic patent medicines, such as Lydia Pinkham's VegetableCompound, Castoria, Cod Liver Oil, etc. , there are "Colds Cured in OneDay, " "Appendixine, " health foods, massage vibrators, violet rays, Porosknit underwear, sanitary tooth washes, soaps, vitopathic, naturopathic, and faith cures. New ones appear every day, --enough tomake a really sick person dizzy, let alone a person suffering fromimaginary ailments. All seem to outline my particular symptoms. Afterthey have flamed at me in red letters in the surface cars, pursued mein the elevated and underground, accompanied me out into the countryand back again to the city, greeted me each morning in the daily paperand in my daily mail, each week or each month in the periodical, thecoincidence of a familiar package on a drug-store counter seems to beprovidential and therefore irresistible. I know that I ought to beexamined by a physician, but I am busy and not unwilling to gamble formy health; it cannot kill me and there is a chance that it will cureme. If there is nothing the matter with us, we may be cured by ourfaith. If we are taking a cure for consumption, the morphine in it maylull us into thinking we feel better. If we are taking a tonic forspring fever, the cheap alcohol may excite us into thinking ourvitality has been heightened. Soothing sirup soothes the baby, oftendoping its spirit for life, or soothing it into a sleep from which itnever wakes. 

In spite of the fact that the "Great American Fraud" has been exposedrepeatedly in newspapers and magazines of wide circulation, the appealof the quack still catches men and women of intelligence. The othernight a friend went out to a dinner and conference with a lawyer in theemploy of the national government. Annoyed by a nagging headache, hemade for the nearest drug store and ordered a "headache powder. " Headmitted 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 ascorn for friends of his whom he knew to be bromo-seltzer fiends, buthe had the headache and the work to do--a sure cure and a quick oneseemed imperative. The headache was due to overwork, indigestion, constipation. Plain food and quiet sleep was what he needed most. Butthe dinner conference plus the headache was the unanswerable argumentfor a dose with an immediate result. 

Last winter an Irish maid slowly lost her rosy cheeks and grewhollow-eyed and thin. She was taken to a specialist who discovered arapidly advancing case of consumption. He said that owing to the girl'signorance, stupidity, and homesickness, her only chance of recovery wasto return to the "auld countrie" at once. The girl agreed to go, butinsisted 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 NewYork tenement. She had found a doctor who had given her a little bottleof medicine for two dollars, which would cure her in the city. It wasfutile 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. Itseemed to "set her up"; but it so undermined her strength, through itsartificial nerve spur, that chronic catarrh was followed byconsumption. It later transpired that the cure's chief ingredient waswhisky, and cheap whisky. A good grandmother, herself a vigoroustemperance agitator and teetotaler, offered to pay for it as long as myfriend would take it faithfully. The irony of it makes one wonder howmany earnest advocates of total abstinence are in reality addicted tothe liquor habit. 

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

Is it not pitiful, this grasping for a poison in an extremity; thisseizing 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 byoverexposure. Nor can it be cured by legislation, legislation, legislation, unless laws are rigidly enforced. 

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

Overexposure is ineffective. It is the evils of patent medicines thatdo harm, not their name and not their patents. The medical professionhas in vain protested against proprietary medicines. Ethical barrierscannot be erected by resolution. Calling things unethical does not makethem unethical. The mere patenting of medicines for profit does notmake the medicine injurious any more than the mere mixing of unpatenteddrugs makes a physician safe. Physicians who would not themselvespatent a drug will use certain patented drugs whose ingredients areknown to be safe and uniform. True exposure of patent-medicine evilswill enable the average physician and the average layman to distinguishthe dangerous from the safe, the fraud from the genuine, lies fromtruths. 

Legislation is needed to crystallize modern knowledge and to establishin courts the right to protection against the evils of patentmedicines. The national Pure Food Law, passed January 1, 1907, and nowin force throughout the country, requires on the "labels of allproprietary medicines entering into interstate commerce, a statement ofthe quantity or proportion of any alcohol, morphine, opium, heroin, chloroform, cannabis indica, chloral hydrate, or acetanilid, or anyderivative or preparation of any such substance contained therein; thisinformation must be in type not smaller than eight-point capitalletters; also _the label shall embody no statement which shall be falseor misleading in any particular_. " This law does not forbid patentmedicines nor the use of alcohol and narcotics in patent medicines; itmerely says, "Let the label tell, that all who _buy_ may read. " It doesnot require that all who _run_ may read, for _it does not say thatadvertisements of a patent medicine shall tell the truth about itsingredients or its action on the human body_; only that the label onthe bottle shall tell. The object of this law is to explain to theconsumer the exact nature of the medicine. But to the majority ofpeople the word "acetphenitidin" on the label of a headache medicinedoes not explain. The new order that requires manufacturers tosubstitute acetanilid for acetphenitidin does no more than replace fogwith mist. Protection requires legislation that cannot be evaded bytechnical terms. The present law requires that packages must beproperly labeled _on entering the state_. To carry out the nationallaw, state laws should make it an offense for dealers to have in theirpossession proprietary medicines without explanatory labels thatexplain. Where state laws to this effect do not exist, the packagesonce in the state may be deprived of their labels and sold as secretremedies, thus nullifying the whole effect of the national law. 

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

Legislation and enforcement should reach the newspaper, magazine, billboard, street car, that advertises a falsehood or less than theessential truth regarding drugs, foods, and patent medicines. Publicsentiment condemns the advertising of many opportunities to commitcrime or to be disorderly or indecent or to injure one's neighbor. Thefacts about hundreds of nostrums can be absolutely determined. Theadvertising agency, whether secular or religious, that carriesmisrepresentation of drugs and foods should be forbidden circulationthrough the mails. The existence of such advertisements should be madeevidence 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 tosell patent foods and medicines, should print circulars exposingfrauds, and punish so far as the law permits. 

While trying to secure adequate legislation and efficientadministration of the above-mentioned standards, there is much that canbe done by individuals and clubs. We can give preference to thosejournals that refuse drug and food advertisements unless evidence isproduced that the truth is told and that the goods are not harmful. Wecan refuse to have in the house a paper or journal which prints noticesthat lie or that conceal the truth. If this drastic measure would cutus off entirely from daily papers, we could choose the least offensiveand petition it to exclude specific lying methods. When it preacheshealth, honesty, and philanthropy, we can cut out of one issue thenoble editorial and the exploiting advertisements and send them to theeditor with our protest. Knowledge of the ingredients and dangers ofpatent medicines should be a prerequisite for the practice of medicineor pharmacy. We can help bring about such conditions, and we canpatronize physicians who send patients to drug stores that cater tointelligence rather than to ignorance. 

Fighting patent-medicine evils is a civic duty to be accomplished bycivic coöperation, not private effort. It is impossible to organizeunofficial educational agencies that can offset the cumulative, lyingadvertisement. Personal opposition is but the beginning. Officialmachinery must be set running and kept running so as to protect thepublic health against the commercial motive that preys upon ignoranceand easily inspired faith. 

CHAPTER XXXVIII

HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH

It is usually considered futile to attempt to defeat the devil with hisown methods, because he knows so much better how to use them. But abusedoes not do away with use, and the success of quacks in reaching thepeople demands our respect. There is no reason why their methods, basedon a knowledge of human nature and human psychology, should not beemployed to appeal to needs rather than to weaknesses. A good thing maylie unused because of lack of advertisement. Vitality is coming to bethe passion of the American people. It is on this sincere passion thatfakirs have so long traded. 

There can be no doubt that advertisements of health-promoting goods arequite as profitable as health advertisements that injure health, whenequally effective methods are used to make them reach the public. Thetradition has been repeatedly mentioned in this book that the betterthe doctor, the less he advertises himself, except in medical andscientific journals that notoriously fail to reach the people. The sameis too often true of reputable remedies and goods. The theory thatthese things stand or fall on their merits is not borne out bypractical 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 itsusefulness, and is therefore unjustifiable, whether we speak ofmedicine, legal aid, or dental clinics. 

An intensive study of the methods used to advertise patent medicineswill suggest means of extending the usefulness of health-promotinggoods. Aside from clever methods of suggestion that lead many people totake medicine for imaginary ailments, especially seasonal ailments, patent-remedy advertisers have employed (as an argument for theefficiency of their cures) scientific theory, bacterial origin ofdiseases, recent medical or physiological discoveries, and state andnational movements for promoting health. In fact, they have turned totheir own uses the very law that seeks to control them and theexposures that seek to exterminate them. Whatever may be the merits ofCastoria, the "Don't Poison Baby" advertisement on the following page, printed just after the accompanying "Babies Killed by PatentMedicines, " which appeared in a home journal, was surely a clever bitof advertising. Upon an editorial in a daily paper on the relation ofeyeglasses to headache and indigestion, an optician based a promise ofimmediate relief for these ailments if he himself were patronized. Therecent investigations of the Department of Agriculture, and ofProfessors Chittenden and Fisher, in regard to foodstuffs, are provinghelpful to food quacks and advertisers of pills for constipation andindigestion. Since the passage of the Pure Food Law one health food isadvertised in a column headed "Pure Food. "

When the season for pneumonia comes around numerous medicines are "surecures" for grippe and pneumonia. "Rosy teachers look better in theschoolroom than the sallow sort, " is surely a good introduction to anew food. Woman's vanity sells many a remedy advertised to counteractthe "vandal hand of disease, which robs her of her beauty, yellows andmuddies her complexion, lines her face, pales cheek and lip, dulls thebrilliancy of her eye, which it disfigures with dark circles, aging herbefore her time. " Who in your town is as good a friend to "owners ofbad breath" as the advertiser who tells them that they "whiff out odorwhich makes those standing near them turn their heads away indisgust"? The climax of effective educational advertising as well as ofconsummate presumption and villainy is reached in the notice of analcoholic concoction that uses the headline, "Medical SupervisionNeeded to Prevent the Spread of Consumption in the Schools. " Thusgrafting itself on the successful results of the medical examination inthe Massachusetts schools, it enlists the aid of teachers, trades onthe fear of tuberculosis, even indorses the fresh-air treatment. Soconvincing was this appeal that it was reprinted in the news columnsof 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 theyin reaching great numbers of people, that if reputable physicians wouldtake lessons of them, they might conduct a health crusade that wouldexterminate tuberculosis, diminish the use of alcohol and tobacco, andsave thousands of babies that die unnecessarily. The theory ofpatent-medicine advertising is sound. It emphasizes the joys of health, the beauty of health, the earning power of health. It adapts itsmessage to season, event, and need. It offers testimonials of realpersons cured. It is all-appealing, promising, convincing, --a fearfulmenace to health when the remedies offered are dishonest, a universalopportunity for promoting health if the cure is genuine. 

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

Recent press discussions about furnishing free eyeglasses to thechildren in the public schools have so enlightened people as to theneed for expert examination of their eyes that opticians will be forcedto employ competent oculists to make the preliminary examination and tosee that the glasses are properly adjusted. In spite of the longmis-education by makers of corsets, the persistent advertising of "goodhealth" and "common-sense" waists has gained an increasing number ofrecruits from the ranks of the self-persecuting. It is only a matter oftime when the term "stylish" will be transferred to the advocates ofhealth, because advertisers who tell the truth will, if persistent, gain a larger patronage than advertisers of falsehoods; there isprofit in retaining old customers. The advertisement of a window devicefor "Fresh air while you sleep" will make prevention of tuberculosismore 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 thisadvertisement, not a man who sells toothwash that, when pure, is littlebetter than water, that is seldom pure, and that always hurts theteeth. Many children and adults are being cured of flat foot by men whomake money by selling shoes designed to strengthen the arch of thefoot. Millions would never know how to discover the evil effects uponthemselves of coffee and alcohol except for money-makingadvertisements. Little Jo's Smile taught a nation that the majority ofcrippled children are victims of neglect on the part of adultconsumptives. 

Certain it is that advertising is an art promoted by the severestcompetition of the cleverest brains. It is a force which we cannotafford to ignore. If we can harness it to the promotion of aids tohealth, it will do more good than all the hygiene books ever written. To this end we must educate ourselves to distinguish between goodswhich do what they profess to do and those which do not. A good eyeopener would be to keep for a week clippings from a high-priced dailypaper, a penny daily paper, and one or two representative magazines, including a religious paper. Teachers and parents can very easilyinterest children in such clippings. Moreover, they can use thebulletin method, the stereopticon exhibit, the _cumulativeillustration_ of a fact, which is the essence of successfuladvertising. Boards of health can use all the typographical aids toclear understanding, --cuts, diagrams, interesting anecdotes. In NewYork both the health board and the school board have issued circularsand given illustrated lectures, some of them being in school and someon public squares. Medical and sanitary societies and other educatorscan be induced to follow what a successful business man has called thethree 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, thefollowing was urged at a national conference for the betterment ofsocial conditions: "We have been too prudish. Because we have beenunwilling to teach school children the evils of violating sex hygiene, we have been unsuccessful in combating evils justly attributable toignorance on the part of girls as to the duties and dangers ofmotherhood. " This point of view is shared by so many men and women thata national body was organized in 1905 to promote the teaching of sexhygiene, --the Society for Sanitary and Moral Prophylaxis. This societyhas its headquarters in New York, and distributes at cost lectures andessays. The second of its educational pamphlets is addressed toteachers, and is entitled "Instruction in the Physiology and Hygiene ofSex. " The introduction asks eleven questions of the teachers asfollows:

 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, evenin the upper grades of public and private schools, is hinted at in thepamphlet. The purpose of the publishing society as given in itsconstitution is "to eliminate the spread of diseases which have theirorigin in the social evil. " Although sex hygiene does not begin withsex immorality, almost every text-book on sex hygiene, and almost everypamphlet urging class instruction in sex hygiene, begins with seximmorality. Yet only the exceptional school child is in danger ofviolating sex morals, while every school child needs instruction in sexhygiene. 

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

To expect fear to prompt sex hygiene is to make a mistake that hasretarded the development of sound measures in the treatment ofoffenders against criminal law. For centuries man failed in attempts tofit the punishment to the crime. To deter men from committing crime byholding up a threat of prolonged and dreadful punishment has been foundfutile. Individuals take the risk because they think they will escapedetection. It is an axiom of criminal procedure that a would-beoffender is deterred by the certainty, not by the severity, ofpunishment. The modern theory of probation is, that children and adultsmay be best led away from evil practices by crowding out old influenceswith newer and stronger interests. Occupations that are wholesome aremade 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 alwaysbe traced to general physical ill health or to an unhealthy moralenvironment. Cure and prevention require two kinds of treatment withinreach of parents and teachers: (1) build up the child's physicalcondition; and (2) give him other interests. Proper physical care, andwork adjusted to body and mind, may be relied upon to do infinitelymore to promote sex hygiene than instruction, either at home or atschool, in immoral sex diseases. That sex morality is weak anduntrustworthy which is based upon fear of sex diseases. Like alcoholismand nicotinism, the saddest results of sex diseases are social andeconomic. The strongest reasons against such diseases are economic andsocial, 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 sexhygiene upon sex health rather than upon sex immorality, upon sexfunctions rather than upon sex diseases, the chief objection to schoolinstruction and to instruction in class will disappear. Our schooltext-books in history, literature, and biology abound in references tosex distinctions, sex functions, and sex health. In enumerating thedaily routine of health habits I mentioned daily bathing of the armpitsand crotch. There is nothing in this injunction to offend or injure aboy or girl. If studies and physical training are to be adapted tophysiological age, and if children are to know why they are gradedaccording to physiological age as well as mental brightness, we shallsoon be talking of mature, maturing and not-yet-maturing girls andboys, so that everybody will be instructed in sex hygiene withoutoffense. Any teacher who can explain the family troubles of King HenryVIII without becoming self-conscious can easily learn to look a classof girls and boys in the face and explain how a mother's health willinjure her baby before its birth, why breast-fed babies are more apt tolive than bottle-fed babies, why it is as important for the mother tokeep a nursing breast absolutely clean as to clean the nipple of anursing bottle. Words whispered by children, or marked in dictionaries, to be stealthily and repeatedly looked upon and talked over with otherchildren, lose all their glamour when pronounced by a teacher. 

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

Class instruction in hygiene is practicable for all matters pertainingto normal sex health. Girls of thirteen should be taught in classes thefact and meaning of menstruation, and its grave importance to thehealth, in order that they may care for themselves not only before, during, and immediately after the menstrual period, but throughout themonth, in order that menstruation itself shall not be unnecessarilypainful, enervating, and harmful to efficiency. It is not yet advisableto discuss dangers peculiar to girls or dangers peculiar to boys inmixed classes. Generally speaking, it is undesirable that men teachersdiscuss girls' troubles with girl pupils. But why should it not becomepossible for women teachers to explain health dangers peculiar to girlsto classes of boys?

Individual instruction in sex matters should be reserved for thediseased mind, for the boy or girl who has already been morbidlyinstructed. Discussion of immoral sex diseases should be confined toindividual talk. This field teachers have already entered. Repeatedphysical examination of children will detect symptoms of sexabnormality. When detected, the fact and the meaning should beexplained to the individual by school physician, school nurse, orschool-teacher. While much can be done through mothers' meetings andthrough individual instruction of parents, the most effective means ofimproving the general attitude towards sex health is to give the simpletruth to the millions of children who have not yet left school. Armedwith the A B C's of sex hygiene at school, boys and girls will beprepared to select employment, associates, and newspapers that willpermit normal, healthy sex development. Men and women who are leadingnormal lives, who have plenty of work, sleep, fresh air, nourishingfood, amusement, and exercise are unlikely to be sexually abnormal. 

After all, the question of instruction in sex hygiene will quicklysettle itself when it is made a condition of a teacher's certificatethat the applicant shall himself or herself know the personal andsocial reasons for sex health. The woman who does not know how to takecare of her own sex health, the man who is ignorant of a woman'sspecial 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 thelaw of sex health will be disclosed as soon as trustees andsuperintendent dare to ask the necessary questions. Whether aninstructor's personality will enable him to fill the minds of childrenwith interests more wholesome, more absorbing than obscene stories ormorbid sex curiosity can also be learned. When school-teachers areprepared to teach the social and economic aspects of general healththey will quickly solve the problem of instruction in sex health. 

Just one word about country morality. It is customary to deplore theinfluence of large cities on the young. Of late, however, there hasbeen a tendency to question whether, after all, sex morality is apt tobe higher in the country than in the city. Parents and teachers insmall towns and in rural districts will do well to take an inventory ofthe influences surrounding their children. It will always be impossibleto give country children city diversions. One great disadvantage ofcountry children frequently counter-acts the beneficial influence ofout-of-door living; namely, isolation. The city child is practicallyalways 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 bestrangers, mean restraint and pervading social conscience. Citychildren find it difficult to have good times in pairs. No amount ofinstruction of rural pupils in sex hygiene will take the place ofamusements and entertainments for groups of children, forming thus aspecial antidote for "two's company, three's a crowd. " Liberating andstandardizing normal intersex relations and discouraging cramped socialintersex relations are more urgent needs than instruction in sexdiseases. A working environment that permits pure-mindedness will domore to inculcate a reverence for sex cleanliness and for parenthoodthan 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 suchenormous dividends unless there was some truth in their claims; unlesstheir victim found some beneficial return for his money. They winconfidence because they raise hopes and combat fear. They do curethousands of people of fear and of "ingrowing thoughts. " In so doingthey remove the sole cause of much disability. [17] In so doing they aremerely applying by wholesale principles of mental hygiene that arelegitimately used by physicians, tradesmen, teachers, and parents whodeal successfully with nervousness. 

Quackery makes cures and makes money because of the undoubted influenceof mind in causing and in removing those ailments that originate infear, imagination, or morbid introspection. A few years ago a littleout-of-the-way town in southern Minnesota was visited by train loads ofthe sick and crippled from miles around. Miraculous cures were heraldedbroadcast. Life-long cripples left wagon loads of crutches and bracesto decorate the little church with the enchanted transom. People whohad not walked for years returned to their homes cured. The marvels offamous shrines were fast being duplicated when the church authoritiesat St. Paul issued an explanation of the alleged miraculous appearanceof biblical figures in the transom of the new church. The outlines of amother carrying a baby had been vaguely impressed in the transom glasswhen molten. When the mystery was explained the excursions and thecures stopped. 

Nearly every physician and practically every medical charlatan cancount scores of cures of ailments that had previously defied the skillof eminent physicians. A child's bumps actually stop aching after themother or nurse kisses the abused spot. Invalids forget theirlimitations under stress of some great excitement or some intensedesire for pleasures incompatible with invalidism. Many a physician ofreputation owes his success in great part to the discriminating use ofthe _placebo_, --a bread pill designed to supplant the patient's fearwith confidence. Hypnotism and "suggestion" have been successfully usedto cure alcoholism and to fill patients' minds with conviction strongerthan the fear that produced the sickness. A well-known writer andpreacher cures insomnia by auto-suggestion, telling himself he issleepy, is very sleepy, is going to sleep, is almost asleep, is fastasleep. Treatment by osteopathy has been followed by disappearance ofdiseases that cannot possibly be cured by osteopathy. Christian Sciencehas restored to health and happy usefulness hundreds of thousands ofchronic invalids. Verily is hygiene of the mind an important factor inthe civics of health. 

Fear can originate with mind. Fear produces fear. Fear disarrangescirculation of the blood and the nourishment of muscle and nerve. Fearcan produce many bodily disorders which in turn feed fear. Fear cannotlast unless bodily symptoms exist or arise to justify and feed it. Fearcan be cured and removed in two ways: (1) by driving away fear andreleasing bodily disorders from its thraldom; (2) by removing thedisorders and making fear impossible to the logical mind. An enforcedsea voyage begins with the disorder; a clever, buoyant physician beginswith the fear. Patent-medicine proprietors, quacks, and fakes of everykind begin by displacing the fear with hope or cheer; the physicaldisorders frequently vanish by the same window as fear. For _fear_write _self-pity_, _morbid self-consciousness_, _hypertrophiedsubmission_; to _hope_ and _cheer_ add _smile_, _relaxation_, and_zest_; and we have the chief elements of mental hygiene and the reasonwhy intelligent as well as unintelligent men like to be swindled bymedical or other quacks. 

The social aspects of mental hygiene are particularly important. Onceadmitting the power of the mind to decrease vitality, we recognize theduty of seeming happy, buoyant, cheerful, vital, at least when withothers, for the sake of others' minds and bodies. Secondly, we find theduty to refrain from commenting on others' appearance in a way thatwill start "ingrowing thoughts. " A "grouchy" foreman can give blues andindigestion to a roomful of factory girls. A self-pitying teacher cancheck the heart beats of her class, cause arteries and lungs tocontract, and deprive the brain of fresh blood. An oversympatheticneighbor can put a strong man to bed by discovering signs of nervousdisintegration. Shall we gradually work out a code of mental hygienerights and nuisances that will require compulsory notification of the"blues" and compulsory segregation of every person unable to "smiledull care away"? Is the time coming when boards of health willaccompany infection leaflets with messages such as this from JamesWhitcomb 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 beencondemned to generally evil associations, because the rank and filehave been ignorant of hygiene of every kind. Medical science has solong enveloped itself in mystery that it is in danger now of becomingdiscredited and of falling heir to the mantle of quackery. 

Quacks often get social and economic results more agreeable to thepatient and more helpful to society than orthodox medicine. "Whentraitors become numerous enough treason becomes respectable. " So whenmental hygiene succeeds, it becomes science for the case in question, and for that case orthodox medicine loses its respectability. For thelayman there is no safety except in having intelligence enough to knowwhether his trouble has defied the sincere application of mentaltreatment, auto-suggestion, and loyalty to the health ideal. 

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

The most recent practical application of mental hygiene for moral andphysical uplifting is the "moral clinic" or "psychotherapeutic" clinicestablished by Emmanuel Church in Boston. This clinic represents theunion of three forces, --religion, medical diagnosis, mental hygiene. Asa result of this alliance it is anticipated that both religion andmedicine will be humanized, socialized, vitalized, made to express moreaccurately and more consistently that community consciousness and thatyearning for equal opportunity and equal happiness which constitute theprofoundest religious impulse. No person is treated at this moralclinic whose trouble is organic or structural. In determining whetherthe case belongs to this clinic, expert medical diagnosis is reliedupon rather than the credulity of the patient or the zeal of theclergyman. Medical scientists of highest repute can consistentlycoöperate, because they recognize two scientific facts: first, thatmany troubles are due primarily to mental disorder; and, second, thegreatest 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, whateverthat synthetic philosophy, that explanation of being, which guides mylife, it can be of inestimable aid if enlisted in an effort to securenormal vitality of mind and body. 

The controlling motive of the moral clinic has proved infectious. Thereis reason to believe that the alliance of medicine and religion hascome to stay, and that the present excitement over psychotherapeuticswill settle down into a scientific utilization of religious motive andmedical 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 areused to their utmost possibilities. The success of the Boston moralclinic is due to establishing in the mind of the neurasthenic, thealcoholic, the world-weary, and the purposeless a truer conception ofthe pleasures that result from vitality and from altruistic effort. 

It is too early to classify by kind of functional disorder the patientstreated. Results from one patient have been described in newspapers asfollows:

 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 alikethroughout the country. After individual treatments are given, afterreligious motive is appealed to, and the soul stirred to heed thelessons of religion, medicine, and sociology, patients are given thework cure. Thus a branch of social service is established, whereafter-treatment is given to the patient whose thoughts have been turnedfrom himself to others. All of a sudden the church finds itself in needof definite knowledge as to opportunities for altruistic work, as todefinite community needs not met, as to people in distress who can berelieved by volunteers, as to agencies which can be called upon tocoöperate both in treating the individual and in utilizing his energiesfor others' benefits. 

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

Mental hygiene cannot survive conscious violation of the fundamentallaws of medicine and religion. The alliance of medicine and religionwill prove utterly futile unless habits of living and of thinking areinculcated that conform to nature's law of self-preservation and toGod's law of brotherly love. Self-centered religion, like self-centeredmedicine, destroys both body and soul. 

FOOTNOTES:

[17] The alliance of mental hygiene, medicine, and religion is discussedin the Emmanuel Church book, _Religion and Medicine; the Moral Controlof 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" thatLouis Agassiz, scientist, had written the sentence with which Iintroduce a final appeal for living that will permit physical and civicefficiency. Agassiz has been called "America's greatest educator, " andagain "the finest specimen yet discovered of the genus _homo_, of thespecies _intelligens_. " The story of his long life as teacher ofteachers reads like a romance. But among his gifts to education andcitizenship none can be made to mean more than the simple propositionthat natural law is as sacred as a moral principle. All who rememberthis "beatitude" will be helped to solve many perplexing problems ofdress, 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 anuisance when not immoral. On the other hand, compromise with theunnatural, like compromise with vice, quickly leads first to tolerationand thence to interest and practice. Therefore the importance of givingchildren Agassiz's conception of the sacredness of the laws that governthe human body. A passion for the natural is a strong foundation forhabits of health and a priceless possession for one who wishes to knowmorality in its highest sense. 

"Natural" is less attractive to us than it would be had Agassiz firstinterpreted it for us rather than Rousseau or present-day exponents of"the simple life, " "back to nature, " and "back to the land. " It is toooften forgotten that no one sins against natural law more grievouslythan the primitive man or the isolated man in daily contact withnon-human nature. Communing with nature seems not only to requirecommuning with man but to give joys in proportion as the nature loveris concerned for the human society of which he is a part. Natural lawdoes not become a moral principle until man is benefited or injured byman's use of nature's resources within and about him. Natural livingaccording to natural law must be something sounder, more beautiful, andmore 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 aNature Up and Beyond as well as a Nature Down and Behind. The Naturethat was yesterday will not do for to-morrow, any more than a man iswilling to give up his nature aspirations for the careless, animal waysof romping childhood. Civilization is constantly urged at each step torepeat the prayer of Holmes's old man who dreams for the Autocrat ofthe 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, andcivilization flatly refuses to relinquish these gifts. Sound maturityis 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 toNature Back, when only the few could be healthy, when one baby in threedied in infancy, when old age was toothless and childish, wheninfection ravished nations, when the average life was twenty yearsshorter 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 thebenefits and to conquer all the dangers of civilization. It is notlooking back, but looking in and forward that reveals what natural lawpromises to those who obey it. 

By using numerous tests which have been suggested in preceding chapterswe can learn how far we and our communities obey natural law whenworking and playing. Health for health's sake has nowhere been urged. On the contrary, healthful living has been frankly valued for its aidto efficient living by individual and by community; wherefore theemphasis upon others' health and upon the civic aspects of our ownhealth. Tests furnish us with the technic necessary to efficientliving; civics, with the larger reason; natural law, with the "pillarof fire by night" to help us choose our path among habits and pleasureswhose immediate results upon efficient living cannot easily bedetermined. 

Fashions, tastes, mannerisms, personal indulgences, have been left forAgassiz to deal with. Generally speaking, we all know of numerous actscommitted and numerous acts omitted in our daily routine that convictus of not living up to our knowledge of physiology and hygiene, --wearingtight shoes or tight corsets, drinking strong coffee, smoking, readingwhile reclining, failing to insure clean air and clean bodies. Thenthere are other acts whose omission or commission violate no physicallaw so far as we can see, but whose unnaturalness we concede, --puttingchalk on the eyebrows, wearing false hair or curious puffs, puttingperfumery in the bath or on handkerchiefs, assuming artificial poses ofbody or mouth. These violations of natural law are forced upon us by"style" or "custom" or family convenience. When we come to choosebetween following fashions and disobeying them, we generally decide thatit is better to do a foolish or slightly harmful thing than to occasioncriticism, mirth, or even special notice by our dress or ourabstemiousness. 

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

Nature Back says I should not have gone to this dinner. But I wascompelled to go. I know I am going to others. I cannot do my workunless I overdraw my current health account. Nature Fore tells me thateffective coöperation with others will frequently require me to eat atthe dinner hour of others, to retire at others' sleeping time, to wearwhat others will approve, to violate natural law. But Nature Fore alsotells me how to build up a health reserve so that I can meet theseemergencies without endangering my health credit. 

Nature Back demands "dress reform. " Nature Fore tells me that I canmarch in step with my contemporaries without either attractingattention or discrediting and affronting natural law. Passion for thenatural has effected numerous reforms in dress, diet, and socialhabits, until commerce provides a natural adaptation of practicallyevery fashion. With regard to few things is it necessary to-day for anyone who reads magazines to do violence to bodily health for fashion'ssake. We may wear what we will, eat what we prefer, decline what isunnatural for us, without inviting censure. The debauches of thoseunfortunate people who live an unnatural, purposeless existence, affectsuch a small number that their laws need not be considered here. Natural law makes obedience to itself attractive; hence commerce israpidly learning to cater to distaste for the unnatural. With fewexceptions, only temporary concessions to unnatural living are requiredin order to dress and act conventionally. 

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

INDEX

Adenoids. See _Mouth breathing_

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

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

Agassiz, Louis, 398, 400

Air, night, 216. See _Fresh air_

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

Animal sanitation, 252, 260, 307

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

Babies. See _Milk_

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

Beauty, reason for health, 15

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

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

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

Boston Society for the Relief and Study of Tuberculosis, 155

Boyd, Emma Garrett, 355

Brannan, John Winters, M. D. , 240

Breath, bad, 360, 379

Brightness, abnormal, 104-106

Bronchitis, 67

Brookline, 34

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

Burbank, Luther, 120

Bureau of Municipal Research, 298, 306

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

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

Calmette's Eye Test, 238

Carnegie Foundation, 285

Caroline Rest, 70, 267

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

Charity Organization Society, New York, 236, 239

Chicago, 34

Chicken-pox, 64

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

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

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

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

Chorea. See _Nervousness_

Christian Science, 276, 392

Christmas shopping, 227

Cigarettes. See _Tobacco_

Cincinnati, 118

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

Cleveland, Ohio, 294

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

Coffee, strong, 401

Colds, 63-69

College, physical tests, 39

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

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

Conference on Summer Care of Babies, New York, 260

Congestion: evils avoided, 290; and alcoholism, 348

Conjunctivitis, 71. See _Eyes_

Connecticut's school reports, 318

Constipation, 210, 216, 347, 357

Consumption. See _Tuberculosis_

Corsets, 381, 401

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

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

Dangerous trades, 191

Darlington, Thomas, M. D. , 297

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

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

Delinquency, and mouth breathing, 47

Dental Hygiene Council, 95

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

Devine, Professor Edward T. , 174

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

Diet kitchens, 267

Diphtheria, 18, 65

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

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

Do-nothing ailments, 329-334

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

Edinburgh, 70

Ellis Island, 238

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

Epidemics, 18, 38

Epilepsy, 47, 49

Ergograph, 125-127

Erysipelas, 65

Ethics, professional, 81, 101, 281

Eugenics, and heredity, 336

European remedies, 159-165

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

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

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

Fear and bodily disorders, 392

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

Follow-up work, 295-301

Fox, Hugh F. , 351

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

Georgia, 350

Germany, 160, 204

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

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

Glands, 88

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

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

Government. See _Administration_

Greenwich House, 287

Grenfell Association, 197

Grippe, 379

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

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

Hartley House, 287

Hartley, Robert M. , 252

Havana, 60

Hawthorne Club, 287

Headache, 210

Heredity, 335-342

High schools need physical tests, 39

Hip trouble. See _Tuberculosis_

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

Hughes, Governor Charles E. , 201

Hunter, Robert, 167

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

Impetigo, 65

Income, 34, 38, 39

India, 108

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

Individual record card, 35, 312-314

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

Influenza, 65-68

Ingram, Helene, 177

Insomnia, 392

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

Instinct, motive to health, 12, 14, 94

International Congress on tuberculosis, 238, 245

Itch, 65

Japan, 23, 287, 309

Junior Sea Breeze, 267

Kansas City, 161

Kidney trouble, 217

Labrador, 197

Lavatories, public, 217

Laws: nonenforcement demoralizing, 4; define rights, 23; when not enforced, 25; should not injure health, 151; enforcement better than character, 219; regarding milk, 258; licensing practitioners, 280; need machinery, 303, 348; to control liquor, 343, 355; test of prohibition, 353; on patent medicine, 373; on pure foods, 379

Leipsic, 289

Louisiana, 350, 376

Lung trouble. See _Tuberculosis_

Machinery, health: unsatisfactory coordination, 296; necessary, 302-309; five elements, 303

Mackenzie, W. Leslie, M. D. , 132

Magistrates: promote disorder, 173; enforce health laws, 303

Malnutrition, 35; income distribution, 39; signs and tests, 86; prevention of, 184; education of family, 241

Massachusetts, 74

Maxwell, Superintendent William H. , 286, 288

Measles, 64

Mental hygiene, 391-397; blues, anti-social, 10; hospital welfare work, 182; moral clinics, 276, 291, 295; and insomnia, 392

Meyer, William, M. D. , 47

Milk: unclean dairies, 10; scalding receptacles of, 17; carries typhoid, 18; inspector's outfit, 24; tests of protection, 25; score cards, 26, 259, 337; public should know, 219; fight for pure, 252-267; New York conferences, 255, 260; breast feeding, 266

Milk committee, New York, 258, 260

Minnesota, 45, 269

Misgovernment causes sickness, 10

Mitchell, S. Weir, M. D. , 73

Montclair, 265

Mosquitoes, 59, 307

Motives, seven health, 11-22, 377

Mouth breathing, 45-56; and delinquency, 47; adenoid parties, 55; causes deafness, 83; injures baby teeth, 89; industrial disadvantage of, 195; in Labrador, 197; preventable defect, 272; inefficient inspection of, 300

National Association for the Study and Prevention of Tuberculosis, 236, 246

National Board of Health, 133, 292, 308

National Bureau of Labor, 199

National Bureau of Census, 305

National Bureau of Animal Industry, 306

National Bureau of Education, 171, 292

National Playground Association, 118

National School Hygiene Association, 139

Nature Fore and Nature Back, 398-403

Negroes and alcoholism, 350

Nervousness, 85; and school life, 108; physical defects, 110; preventable, 111; causes of, 112; habit, 111, 113; from tobacco, 363

Neurasthenia. See _Mental Hygiene_

New Jersey, 12

Newsholme, Arthur, M. D. , 120, 131, 229, 241

New York City, 16, 25, 34

New York Juvenile Asylum, 47

New York state, 12, 24

New York State Charities Aid Association, 236, 242

Nicotinism. See _Tobacco_

Normal schools, 110

North, Professor Lila V. , 142

Notification of diseases, 31, 41

Nuisances, 17, 18, 23, 366

Nurses at school, 230, 286, 293, 300. See _Milk_

Oliver, Thomas, 203

Orthopedics. See _Tuberculosis_

Ophthalmia, 65

Oppenheimer, Nathan, M. D. , 110

Osteopathy, 275

Panama, 59

Parents: and school hygiene, 3; interested by examinations, 41; should coöperate with physician, 279; interested in school examinations, 297; need health reports, 310; heredity, 335-342; nicotinism, 368

Parks and playgrounds, 7, 32, 118, 122, 142, 186, 290, 294

Parochial schools, 189, 198

Patent medicines: evils of, 369-377; advertisements, 380

Patten, Professor Simon N. , 9, 14, 33, 165

Pediculosis, 69-71

Pennsylvania, 311

Philadelphia, 34

Phthisis. See _Tuberculosis_

Physical training, 115-117; in New York City, 296; and sex hygiene, 387

Physician: preventive medicine, 268-282; and eyes, 81; semi-annual visit to, 204; self-advertisement, 378; school, 173, 286, 293, 315

Physiological age, 105, 289, 387

Pittsburgh, 269

Plague, 15, 57

Pneumonia, 67, 379

Preventable diseases: those not communicable, 272. See _Catching Diseases_

Private schools, 189, 198, 283, 291, 330

Prohibition laws, 348, 350, 355

Pro-slum motive, 19-20

Public Education Association, New York, 287, 298

Publicity, 45, 81, 99, 292, 310-321, 382

Quarantine, first, 15; national, 308

Records: of disease centers, 31; defective, 32; individual, 35, 312-314

Reform's failure, 349

Registration: of diseases, 31

Relief, material: sound principles of, 174; at school, 175, 179, 184; indiscriminate, harmful, 332

Richman, Julia, 172

Riggs disease, 92

Rights: political, 21; not enforced, 23-32; of workmen at work, 190; machinery for enforcing, 283-322

Riis, Jacob, 18

Ringworm, 65

Rochester, N. Y. , 262, 266

Rome, 15

Roosevelt, Theodore, 60, 118

Rural districts: encourage disease, 13; compared, 32; physical defects, 74; schools unsanitary, 141; hygiene in Great Britain, 308

Russia, 108

Sage Foundation, 285

St. Vitus's dance, 111

Salmon, Professor Lucy M. , 355

Scabies, 65. See _Itch_

Scarlatina, 65

Scarlet fever: thrives in slums, 18; signs and method of infection, 65; "peeling, " 132; compulsory removal of cases, 240; germ carried in milk, 264

School hygiene: and employers, 3; instruction compulsory, 3-10; practice of, 5, 18; biological engineering, 139, 203, 339; departments of, 283-293; in New York City, 294, 296-301

Score cards, 27, 29, 259, 337

Scranton, 269

Sea Breeze fresh-air home, 176

Sea Breeze seaside hospital, 9, 240

Seaman, L. L. , M. D. , 23

Seattle, 161

Sedgwick, Professor William T. , 304

Sex hygiene, 384-389

Sexual deviates, 182

Shoes, tight, 401

Sickness, preventable, cost of, 278

Sleep and vitality, 201, 272

Slum, a menace, 13, 20

Smallpox: epidemics great teachers, 6; conquered by vaccination, 7; neglected in rural Pennsylvania, 18; comes rarely to cities, 31; compulsory removal of cases, 240

Snedden, Professor David S. , 33, 165, 311

Snellen eye test, 73, 77

Society for Sanitary and Moral Prophylaxis, 384

Southern states, 351

Spargo, John, 33, 167

Spitting, 223, 235

State activity, 4, 73, 121, 236, 292, 306

Statistics, object of, 131, 134, 333

Strauss, Nathan, 260

Streets, 15, 122, 217, 254, 348

Study hours, too long, 287

Sweating, 152, 211

Taxes, taxpayers. See _Budget_

Teacher's health: tests of, 152-158

Teachers: social work, 172; health passport, 202; for tuberculous pupils, 237; excluded when tuberculous, 242; and physicians, 279; physical examination of, 284; use of alcohol, 358; cigarettes, 368; use clippings, 382

Teeth. See _Dental Sanitation_

Temperance. See _Alcoholism_

Tenement reforms, 20, 186, 209, 304, 403

Thompson, J. Arthur, 336

Tobacco: instruction at school, 3; economic injuries of, 201; forbidden to employees, 210; evils of nicotinism, 363-368, 386

Tonsils, hypertrophied, 44

Trachoma, 69-71

Trudeau, E. L. , M. D. , 274

Tuberculosis: pupils excluded from school because of, 65; aggravated by colds, 68; bone tuberculosis, 87, 88, 236; and bad teeth, 90, 99; in teachers, 153; examination for working papers, 191; periodical examination for, 201; last days of, 229-251; eye and skin tests for, 240; tests of cows, 260; carried in milk, 264; out-of-door treatment, 274; only predisposition to, inherited, 335

Typhoid: a rural disease, 13; carried in milk, 264

University Extension Society, 178

Vacation schools, playgrounds, 109, 296

Veiller, Lawrence, 9

Vitality tests and statistics, 124-138

Water, drinking: reason for works, 15; factories pollute, 17; fountains, 217; public responsibility for, 226; protecting sources, 307

Welfare work, 7, 221-225

West Point, 199

Wheeler, Herbert L. , D. D. S. , 93

Whipple, George C. , Ph. D. , 13, 16

White plague. See _Tuberculosis_

Whooping cough, 64

Williams, Alida S. , 72, 122

Williams, Linsly R. , M. D. , 241

Work: physical examination for working papers, 190-200, 285; healthful habits, 208-217; unpatented medicine, 334. See _Industrial Hygiene_

Young Men's Christian Association, 227

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