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Title: Civics and Health

Author: William H. Allen

Contributor: William T. Sedgwick

Release Date: May 8, 2007 [EBook #21353]

Language: English

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LOUIS AGASSIZ
"A natural law is as sacred as a moral principle"

CIVICS AND HEALTH

BY

WILLIAM H. ALLEN

Secretary, Bureau of Municipal Research

Former Secretary of the New York Committee on Physical Welfare of
School Children, Author of "Efficient Democracy" and "Rural
Sanitary Administration in Pennsylvania," Joint Author
of "School Reports and School Efficiency"

WITH AN INTRODUCTION

BY

WILLIAM T. SEDGWICK

Professor of Biology in the Massachusetts Institute of Technology

GINN AND COMPANY
BOSTON ·  NEW YORK ·  CHICAGO ·  LONDON

Entered at Stationers' Hall

Copyright, 1909
By WILLIAM H. ALLEN

ALL RIGHTS RESERVED

910.4

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

INTRODUCTION

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

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

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

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

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

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

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

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

WILLIAM T. SEDGWICK

Massachusetts Institute of Technology

CONTENTS

CIVICS AND HEALTH

PART I. HEALTH RIGHTS

CHAPTER IToC

HEALTH A CIVIC OBLIGATION

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

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

Interviews with teachers and principals regarding the present apathy to formal hygiene instruction have brought [4]out the following points that merit the serious consideration of those who are struggling for higher health standards.

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

2. Teachers give as one reason for neglecting hygiene, that they are often compelled to struggle with a curriculum which [5]requires more than they are able to teach and more than pupils are able to learn in the time allowed. While an overcharged curriculum may explain, it surely does not justify, the violation of law and the dropping of hygiene from our school curriculum. If there is any class of citizen who should teach and practice respect for law as law, it is the teacher. Parents, school directors, county and state superintendents, university presidents, social workers, owe it not only to themselves, but to the American school-teacher, either to repeal the laws that enjoin instruction in hygiene or else so to adjust the curriculum that teachers can comply with those laws. The present situation that discredits both law and hygiene is most demoralizing to teacher, pupil, and community. Many of us might admire the man teacher who frankly says he never explains the evils of cigarettes because he himself is an inveterate smoker of cigarettes. But what must we think of the school system that shifts to such a man the right and the responsibility of deciding whether or not to explain to underfed and overstimulated children of the slums the truth regarding cigarettes? If practice and precept must be consistent, shall the man be removed, shall he change his habits, shall the law regarding instruction in hygiene be changed, or shall other provision be made for bringing child and essential facts together in a way that will not dull the child's receptivity?

3. Teachers are made to feel that while arithmetic and reading are essential, hygiene is not essential. Whatever may be the facts regarding the relative value of arithmetic and hygiene, whether or not our state legislators have made a mistake in declaring hygiene to be essential, are questions altogether too important for child and state to be left to the discretion of the individual teacher or superintendent. It is fair to the teachers who say they cannot afford to turn aside from the three R's to teach hygiene, to admit [6]that they have not hitherto identified the teaching of hygiene with the promotion of the physical welfare of children. Teachers awake to the opportunity will sacrifice not only hygiene but any other subject for the sake of promoting children's health. They do not really believe that arithmetic is more important than health. What they mean to say is that hygiene, as taught by them, has not heretofore had an appreciable effect upon their pupils' health; that other agencies exist, outside of the school, to teach the child how to avoid certain diseases and how to observe the fundamental laws of health, whereas no other agencies exist to give the child the essentials of arithmetic, reading, and geography. "We teach (or try to teach) what our classes are examined in. If you want a subject taught, you must test a class in it and hold a teacher responsible for results, and examinations are mercilessly unhygienic, you know."

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

If one illustration is better than ten lessons, if an open window is worth more than all that text-books have to say [7]about ventilation, if a seat adjusted to the child is better than an anatomical chart, this does not mean that instruction in hygiene should cease. On the contrary, it means that provision should be made for every teacher to open windows, to adjust desks, to use the experience of individual children for the education of the class. If the rank and file of teachers have not hitherto been sufficiently observant of physiological and hygienic facts, if they are unprepared from their own lives to detect or to furnish illustrations for the child, this again does not mean that the child should be denied the illustrations, but that the teacher should either have instruction and experience to incite interest and to stimulate powers of observation, or else be asked to give place to another teacher who is able to furnish such qualifications.

5. Children, like adults, can be interested in other people, in rules of conduct, in social conditions, in living and working relations more easily than in their own bodies. The normal, healthy child thinks very little of himself apart from the other boys and girls, the games, the studies, the animals, the nature wonders, the hardships that come to him from the outside. So true is this that one of the best means of mitigating or curing many ailments is to divert the child's attention from himself to things outside of himself that he can look at, hear, enjoy. The power to concentrate attention upon oneself is a sign either of a diseased body, a diseased mind, or a highly trained mind. To study others and to recognize the similarity between others and oneself is as natural as the body itself. Teachers are consulting this line of easiest access to children's attention when they honor children according to cleanliness of hands, of teeth, of shoes. Human interest attaches to what parks or excursions are doing for sickly children, how welfare work is improving factory employees, how smallpox is conquered by vaccination, how insurance companies [8]refuse to take risks upon the lives of men or women addicted to the excessive use of alcohol or tobacco.

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

6. Other people's habits of health influence our well-being quite as much, if not more, than our own. Because we are social beings, ability to get along with our families, our friends, our employers, is—at least so it seems to most of us—quite as important as individual health. For too [9]many of us, living hygienically is absolutely impossible without inconveniencing and bothering the majority of persons with whom we live. I remember a girl in college,—a fresh-air fiend,—who every morning, no matter how cold, threw the windows wide open. Then, with forty others, I thought this girl a nuisance as well as a menace to health, but now, twenty years afterwards, I find myself wanting to do the same thing. Professor Patten, the economist, whom I shall quote many times because he is particularly interested in the purpose of this book, was recently dining at my house and illustrated from his own health the importance of teaching hygiene so as to affect social as well as personal standards. "To be true to my own health needs, I ought to have declined nearly everything that has been offered me for dinner, but in the long run, if I am going to visit, my eating what is placed before me is better for society than making those who entertain me feel uncomfortable."

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

To live unhygienically where others live hygienically is quite as difficult. Witness the speedy improvement of dissipated men when boarding with country friends who eat [10]rationally and retire early. It must have been knowledge of this fact that prompted the tramways of Belfast to post conspicuous notices: "Spitting is a vile and filthy habit, and those who practice it subject themselves to the disgust and loathing of their fellow-passengers." It is almost impossible to have indigestion, blues, and headache when one is camping, particularly where action and enjoyment fill the day. Our practical question is, therefore, not "What shall I eat, how many hours shall I sleep, what shall I wear," but "How can I manage to get into an environment among living and working conditions where the people I live with and want to please, those who influence me and are influenced by me, make healthy living easy and natural?"

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

CHAPTER IIToC

SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS

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

Seven kinds of man are to be found in every community, seven different points of view with regard to health administration. Each individual, likewise, may have seven attitudes toward health laws, seven reasons for demanding health protection. These seven points of view, seven stages of development, are clearly marked in the evolution of sanitary administration throughout the civilized world. With few exceptions, it is possible, by examining ourselves, our friends, and our communities, to see where one motive begins and leaves off, giving way to or mixing with one or more other motives. A friend once asked me if I could keep this number seven from growing to eight or nine. Perhaps not. Perhaps there are more kinds of people, [12]more health motives, more stages in health progress; but I am sure of these seven, and certain that they have been of great help to me in planning health crusades for the state of New Jersey and for New York City. The number seven was not reached hit-or-miss fashion, nor was it chosen for its biblical prestige. On the contrary, it came as the result of studying health administration in twoscore British and American cities, and of reading scores of books on sanitary evolution.

Seven catchwords make it easy to remember the characteristics and the source of every motive, every kind of person, and every stage in the evolution of sanitary standards. These seven catchwords are: Instinct, Display, Commerce, Anti-nuisance, Anti-slum, Pro-slum, Rights. By the use of these catchwords any teacher, parent, public official, educator, or social worker should be able to size up the situation, the needs, and the opportunity of the individuals or the communities for whom a health crusade is planned.

Instinct was the first health officer and made the first health laws. Instinct warns us against unusual and offensive odors, sights, and noises, just as it causes us to seek that which is agreeable. Primitive man in common with other animals learned by sad experience to avoid certain herbs as poisons; to bury or to move away from the dead; to shun discolored drinking water. During the roaming period sun and air and water acted as scavengers. When tribes settled down in one spot for long periods, habits that had hitherto been inoffensive and safe became noticeably injurious and unpleasant. Heads of tribes gave orders prohibiting such habits and restricting disagreeable acts and objects to certain portions of the camp. Instinct places outhouses on our farms and then gradually removes them farther and farther from dwellings. In many school yards, more particularly in country districts and small towns, [13]outhouses are a crying offense against animal instinct. In visiting slum districts in Irish and Scotch cities, and in London, Paris, Berlin, and New York, I never found conditions so offensive to crude animal instinct as those I knew when a boy in Minnesota school yards, or those I have since seen in a Boy Republic. But the evil is not corrected because it is not made anybody's business to execute instinct's mandates. In the Boy Republic the leaders were waiting for the children themselves to revolt, as does primitive man.

Table I

Typhoid a Rural Disease[1]

Among large numbers of persons, in city as well as country, washing the body is still a matter of instinct, a bath not being taken until the body is offensive, the hands not being washed until their condition interferes with the enjoyment of food or with one's treatment by others. There is a point of neglect beyond which instinct will not [14]permit even a tramp to go. If cleanliness is next to godliness, the average child is most ungodly by nature, for it loathes the means of cleanliness and otherwise observes instinct's health warnings only after experience has punished or after other motives from the outside have prompted action. The chief form of legislation of the instinct age is provision of penalties for those who poison food, water, or fellow-man. There are districts in America where hygiene is supposed to be taught to children that are conscious of no other sanitary legislation but that which punishes the poisoner.

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

Elbow sleeves and light summer waists have led many a girl to daily bathing of at least those parts of the body that other people see. Entertainments and sociables, Saturday choir practice and church have led many a young man to bathe for others' sake when quite satisfied [15]to forego the ordeal so far as his own comfort and health were concerned. Streets on which the well-to-do live are kept clean. Why? Not because Madam Well-to-do cares so much for health, but because she associates cleanliness with social prestige. It is necessary for the display of her carriages and dresses, just as paved streets and a plentiful supply of water for public baths and private homes were essential to the display of Rome's luxury. Generally speaking, residence streets are cleaned in small towns just as waterworks are introduced, to gratify the display motive of those who have lawns to water and clothes to show.

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

Commerce brooks no preventable interference with profits, whether by disease, death, impassable streets, or disabled men. The age of chivalry was also the age of indescribable filth, plague, Black Death, and spotted fever that cost the lives of millions. It would be impossible in the civilized world to duplicate the combination of luxury and filthy, disease-breeding conditions in the midst of which Queen Bess and her courtiers held their revels. The first protest was made, not by the church, not by sanitarians, but by the great merchants who were unable to insure against loss and ruin from the plagues that thrived on filth and overcrowding. By an interesting coincidence the first systematic street cleaning and the first systematic ship cleaning—maritime quarantine—date from the same year, 1348 A.D.; the former in the foremost German [16]trading town, Cologne, and the latter in Venice, the foremost trading town of Italy. The merchants of Philadelphia and New York started the first boards of health in the United States. For what purpose? To prevent business losses from yellow fever. Desire for passable streets, drains, waterworks, and strong boards of health has generally started with merchants. For commercial reasons many of our states vote more money for the protection of cattle than for the protection of human life, and the United States votes millions for the study of hog cholera, chicken pip, and animal tuberculosis, while neglecting communicable diseases of men. No class in a community will respond more quickly to an appeal for the rigid enforcement of health laws than the merchant class; none will oppose so bitterly as that which makes profits out of the violation of health laws.

Table II

Cost in Life Capital of Preventable Diseases[2]

[17]Anti-nuisance motives do not affect health laws until people with different incomes and different tastes try to live together. In a small town where everybody keeps a cow and a pig, piggeries and stables offend no one; but when the doctor, the preacher, the dressmaker, the lawyer, and the leading merchant stop keeping pigs and cows, they begin to find other people's stables and piggeries offensive. The early laws against throwing garbage, fish heads, household refuse, offal, etc., on the main street were made by kings and princes offended by such practices. The word "nuisance" was coined in days when neighbors lived the same kind of life and were not sensitive to things like house slops, ash piles, etc. The first nuisances were things that neighbors stumbled over or ran into while using the public highway. Next, goats and other animals interfering with safety were described as nuisances, and legal protection against them was worked out. It has never been necessary to change the maxim which originally defined a nuisance: "So use your own property that you will not injure another in the use of his property." The thing that has changed and grown has been society's knowledge of acts and objects that prevent a man from enjoying his own property. To-day the number of things that the law calls nuisances is so great that it takes hundreds of pages to describe them. Stables and outhouses must be set back from the street. Every man must dispose of garbage and drainage on his own property. Stables and privies must be at least a hundred feet from water reservoirs. Factories may not pollute streams that furnish drinking water. Merchants may be punished if they put banana skins in milk cans, or if they fail to scald and cleanse all milk receptacles before returning them to wholesalers. Automobile drivers may be punished for disturbing sleep. Anything that injures my health will be declared a nuisance and abolished, if I can prove that my health is being injured and that I am doing all I can to [18]avoid that injury. No educational work will accomplish more for any community than to make rich and poor alike conscious of nuisances that are being committed against themselves and their neighbors. The rich are able to run away from nuisances that they cannot have abated. If proper publicity is given to living conditions among those who do not resist nuisances, the presence of such conditions will itself become offensive to the well-to-do, who will take steps to remove the nuisance. Jacob Riis in this way made the slums a nuisance to rich residents in New York City and stimulated tenement reform, building of parks, etc.

Anti-slum motives originated in cities where there is a clear dividing line between the clean and the unclean, the infected and the uninfected, the orderly and the disorderly, high and low vitality. As soon as one district becomes definitely known as a source of nuisance, infection, and disease, better situated districts begin to make laws to protect themselves. A great part of our existing health codes and a very large part of the funds spent on health administration are designed to protect those of high income against disease incident to those of low income, high vitality against low vitality, houses with rooms to spare against houses that are overcrowded. To the small town and the country the slum means generally the near-by city whose papers talk of epidemic scarlet fever, diphtheria, or smallpox. Cities have only recently begun to experience anti-slum aversion to country dairies whose uncleanliness brings infected milk to city babies, or to filthy factories and farms that pollute water reservoirs and cause typhoid. The last serious smallpox epidemic in the East came from the South by way of rural districts that failed to notify the Pennsylvania state board of health of the outbreak until the disease was scattered broadcast. Every individual knows of some family or some district that is immediately pictured when terms like "disease," "epidemic," "slum," are [19]pronounced. The steps worked out by the anti-slum motive to protect "those who have" from disease arising from "those who have not" are given on page 31.

A COUNTRY MENACE TO CITY HEALTH

Pro-slum motives are not exactly born of anti-slum motives, but, thanks to the instinctive kindness of the human heart, follow promptly after the dangers of the slum have been described. You and I work together to protect ourselves against neglect, nuisance, and disease. In a district by which we must pass and with which we must deal, one of us or a neighbor or friend will turn our attention from our danger to the suffering of those against whom we wish to protect ourselves. Charles Dickens so described Oliver Twist and David Copperfield that Great Britain organized societies and secured legislation to improve the almshouse, school, and working and living conditions. When health reports, newspapers, and charitable societies [20]make us see that the slum menaces our health and our happiness, we become interested in the slum for its own sake. We then start children's aid societies, consumer's leagues, sanitary and prison associations, child-labor committees, and "efficient government" clubs.

Rights motives are the last to be evolved in individuals or communities. The well-to-do protect their instinct, their comfort, their commerce, but run away from the slums and build in the secluded spots or on the well-policed and well-cleaned avenues and boulevards. Uptown is often satisfied with putting health officials to work to protect it against downtown. Pro-slum motives are shared by too few and are expressed too irregularly to help all of those who suffer from crowded tenements, impure milk, unclean streets, inadequate schooling. So long as those who suffer have no other protection than the self-interest or the benevolence of those better situated, disease and hardship inevitably persist. Health administration is incomplete until its blessings are given to men, women, and children as rights that can be enforced through courts, as can the right to free speech, the freedom of the press, and trial by jury. There is all the difference in the world between having one's street clean because it is a danger to some distant neighbor, or because that neighbor takes some philanthropic interest in its residents, and because one has a right to clean streets, regardless of the distant neighbor's welfare or interest. When the right to health is granted health laws are made, and all men within the jurisdiction of the lawmaking power own health machinery that provides for the administration of those laws. A system of public baths takes the place of a bathhouse supported by charity; a law restricting the construction and management of all tenements takes the place of a block of model tenements, financed by some wealthy man; medical examination of all school children takes the place of a private dispensary; [21]a probation law takes the place of the friendly visitor to the county jail.

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

The time is past when any one seriously believes that political freedom or personal liberty will be universal, just because everybody has a right to talk, to move from place to place, to print stories in the newspapers. The relation of man to man to-day requires that we formulate rules of action that prevent one man's taking from another those rights, economic and industrial, that are as essential to twentieth-century happiness as were political rights to eighteenth-century happiness. Political maxims showed how, through common desire and common action, steps could be taken by the individual and by the whole of society for the protection of all. Health rights, likewise, are to be obtained through common action. A modern city must [22]know who is accountable when an automobile runs over a pedestrian, when a train load of passengers lose their lives because of an engineer's carelessness, when an employee is incapacitated for work by an accident for which he is not responsible, or when fever epidemics threaten life and liberty without check. How can a child who is prevented by removable physical defects from breathing through his nose be enthusiastic over free speech? Of what use is freedom of the press to those who find reading harder than factory toil? How futile the right to trial by jury if removable physical defects make children unable to do what the law expects! Who would not exchange rights of petition for ability to earn a living? Children permanently incapacitated to share the law's benefits cannot appreciate the privilege of pursuing happiness.

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

FOOTNOTES:

CHAPTER IIIToC

WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?

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

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

[24]

A DAIRY INSPECTOR'S OUTFIT

The slip 'twixt law making and law enforcement is everywhere found. In 1864 New York state prohibited the sale of adulterated milk. Law after law has been made since that time, giving health officials power to revoke licenses of milk dealers and to send men to jail who violated milk laws. We now know that no law will ever stop the present frightful waste of infant lives, counted in thousands annually, unless dairies are frequently inspected and forced to be clean; unless milk is kept at a temperature of about fifty degrees on the train, in the creamery, at the receiving station, and in the milk shop; unless dealers scald and thoroughly cleanse cans in which milk is shipped; unless licenses are taken from farmers, creameries, and retailers who violate the law; unless magistrates use their power to fine or imprison those who poison helpless babies by violating milk laws; and unless mothers are taught to scald [25]and thoroughly cleanse bottles, nipples, cups, and dishes from which milk is fed to the baby. We know that these things are not being done except where men or women make it their business to see that they are done. Experience tells us that inspectors will not consistently do their duty unless those who direct them have regular records of their inspections, study those records, find out work not done properly or promptly, and insist upon thorough inspection.

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

Table III[26]

MILK INSPECTION WITHIN NEW YORK CITY, 1906

Table IV

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

Table V

Score Card for Citizen Use

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

But to wait for contagion before taking action has been found an expensive way of learning where health protection is needed. Even when infected persons and physicians are prompt in reporting the presence of disease it is often [31]found that conditions that produced the disease have been overlooked and neglected.

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

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

THE BABY, NOT THE LAW, IS THE TEST OF INFANT PROTECTION IN COUNTRY AND IN CITY

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

FOOTNOTES:

CHAPTER IVToC

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

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

[34]

What, then, is this test of home conditions prejudicial to health that will register the fact as a thermometer tells us the temperature, or as a barometer shows moisture and air pressure? The house address alone is not enough, for many children surrounded by wealth are denied health rights, such as the right to play, to breathe pure air, to eat wholesome food, to live sanely. Scholarship will not help, because the frailest child is often the most proficient. Manners mislead, for, like dress, they are but externals, the product of emulation, of other people's influence upon us rather than of our living conditions. Nationality is an index to nothing significant in America, where all race and nationality differences melt into Americanisms, all responding in about the same way to American opportunity. No, our test must be something that cannot be put on and off, cannot be left at home, cannot be concealed or pretended, something inseparable from the child and beyond his control. This test it has been conclusively proved in Chicago, Boston, Brookline, Philadelphia, and particularly in New York City, is the physical condition of the school child. To learn this condition the child must be examined and reëxamined for [35]the physical signs called for by the card on page 34. Weight, height, and measurements are needed to tell the whole story.

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

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

In looking at the teeth and throat a little wooden stick is used to push down the tongue. There should be a stick for every child, so that infection cannot possibly be carried from one to the other. If this is impossible, the stick should be dipped in an antiseptic such as boric acid or listerine. If, because of swollen tonsils, there is but a little slit open in the throat, or if teeth are decayed, the mark is Y or B. The whole examination takes only a couple of minutes, but the physician often finds out in this short time facts that will save a boy and his parents a great deal of trouble. Very often this examination tells a story that overworked [36]mothers have studiously concealed by bright ribbons and clean clothes. I remember one little girl of fourteen who looked very prosperous, but the physician found her so thin that he was sure that for some time she had eaten too little, and called her anæmic. He later found that the mother had seven children whom she was trying to clothe and shelter and feed with only ten dollars a week. A way was found to increase her earnings and to give all the children better living conditions,—all because of the short story told by the examination card. In another instance the card's story led to the discovery of recent immigrant parents earning enough, but, because unacquainted with American ways and with their new home, unable to give their children proper care.

LOOKING FOR ENLARGED TONSILS AND BAD TEETH
Note the mouth breather waiting

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

Table VI[37]

Physical Examination of School Children—performed by the
Department of Health in the Borough of Manhattan, 1905-1907

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

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

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

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

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

The New York Committee on the Physical Welfare of School Children visited fourteen hundred homes of children found to have one or more of the physical defects shown on the above card. While they found that low incomes have more than their proper share of defects and of unsanitary living conditions, yet they saw emphatically [39]also that low incomes do not monopolize physical defects and unsanitary living conditions. Many families having $20, $30, $40 a week gave their children neither medical nor dental care. The share each income had in unfavorable conditions is shown by the summary in the following table.

Table VII

Showing Per Cent Share of Physical Defects of Children,
Unfavorable Housing Conditions, and Child Mortality
found among each Family-income Group

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

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

Disease centers outside of school buildings quickly register themselves in the schoolroom and in the person of a child who is paying the penalty for living in contact with a disease center. If a child sleeps in a dark, ill-ventilated, crowded room, the result will show in his eyes and complexion; if he has too little to eat or the wrong thing to eat, he will be underweight and undersized; if his nutrition is inadequate and his food improper, he is apt to have eye trouble, adenoids, and enlarged tonsils. He may have defective lung capacity, due to improper breathing, too little exercise in the fresh air, too little food. Existence of physical defects throws little light on income at home, but conclusively shows lack of attention or of understanding. Several days' absence of a child from school leads, in every well-regulated school, to a visit to the child's home or to a letter or card asking that the absence be explained. Even newly arrived immigrants have learned the necessity and [41]the advantage of writing the teacher an "excuse" when their children are absent. Furthermore, neighbors' children are apt to learn by friendly inquiry what the teacher may not have learned by official inquiry, why their playmate is no longer on the street or at the school desk. While physicians are sometimes willing to violate the law that compels notification of infection, rarely would a physician fail to caution an infected family against an indiscriminate mingling with neighbors. Whether the family physician is careless or not, the explanation of the absence which is demanded by the school would give also announcement of any danger that might exist in the home where the child is ill.

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

Appreciation of health, as well as its neglect, is indexed by the physical condition of school children. Habits of health are the other side of the shield of health rights unprotected. Physical examination will discover what parents are trying to do as well as what they fail to do because of their ignorance, indifference, or poverty. In so far as parents are alive to the importance of health, the school examination furnishes the occasion of enlisting them in crusades to protect the public health and to enforce health rights. The Committee on the Physical Welfare of School Children found many parents unwilling to answer [42]questions as to their own living conditions until told that the answers would make it easier to get better health environment not only for their own children but for their neighbors' children. Generally speaking, fathers and mothers can easily be interested in any kind of campaign in the name of health and in behalf of children. The advantage of starting this health crusade from the most popular American institution, the public school,—the advantage of instituting corrective work through democratic machinery such as the public school,—is incalculable. To any teacher, pastor, civic leader, health official, or taxpayer wanting to take the necessary steps for the removal of conditions prejudicial to health and for the enforcement of health rights of child and adult, the best possible advice is to learn the facts disclosed by the physical examination of your school children. See that those facts are used first for the benefit of the children themselves, secondly for the benefit of the community as a whole. If your school has not yet introduced the thorough physical examination of school children, take steps at once to secure such examination. If necessary, volunteer to test the eyes and the breathing of one class, persuade one or two physicians to coöperate until you have proved to parent, taxpayer, health official, and teacher that such an examination is both a money-saving, energy-saving step and an act of justice.

We shall have occasion to emphasize over and over again the fact that it is the use of information and not the gathering of information that improves the health. The United States Weather Bureau saves millions of dollars annually, not because flags are raised and bulletins issued foretelling the weather, but because shipowners, sailors, farmers, and fruit growers obey the warnings. Mere examination of school children does little good. The child does not breathe better or see better because the school physician fills out a card stating that there is [43]something wrong with his eyes, nose, and tonsils. The examination tells where the need is, what children should have special attention, what parents need to be warned as to the condition of the child, what home conditions need to be corrected. If the facts are not used, that is an argument not against obtaining facts but against disregarding them.

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

Apart from the advantage to the community of locating its health problems, physical examination is due every child. No matter where his schooling or at whose expense, every child has the right to advance as fast as his own powers [44]will permit without hindrance from his own or his playmates' removable defects. He has the right to learn that simplified breathing is more necessary than simplified spelling, that nose plus adenoids makes backwardness, that a decayed tooth multiplied by ten gives malnutrition, and that hypertrophied tonsils are even more menacing than hypertrophied playfulness. He has the right to learn that his own mother in his own home, with the aid of his own family physician, can remove his physical defects so that it will be unnecessary for outsiders to give him a palliative free lunch at school, thus neglecting the cause of his defects and those of fellow-pupils.

FOOTNOTES:

PART II. READING THE INDEX TO HEALTH RIGHTS

CHAPTER VToC

MOUTH BREATHING

If the physical condition of school children is our best index to community health, who is to read the index? Unless the story is told in a language that does not require a secret code or cipher, unless some one besides the physician can read it, we shall be a very long time learning the health needs of even our largest cities, and until doomsday learning the health needs of small towns and rural districts. Fortunately the more important signs can be easily read by the average parent or teacher. Fortunately, too, it is easy to persuade mothers and teachers that they can lighten their own labors, add to their efficiency, and help their children by being on the watch for mouth breathing, for strained, crossed, or inflamed eyes, for decaying teeth, for nervousness and sluggishness. Years ago, when I taught school in a Minnesota village, I had never heard of adenoids, hypertrophied tonsils, myopia, hypermetropia, or the relation of these defects and of neglected teeth to malnutrition, truancy, sickness, and dullness. I now see how I could have saved myself several failures, the taxpayers a great deal of money, the parents a great deal of disappointment, and many children a life of inefficiency, had I known what it is easy for all teachers and parents to learn to-day.

[46]

MOUTH BREATHERS BEFORE "ADENOID PARTY"

The features in the following cut are familiar to teachers the world over. Parents may reconcile themselves to such lips, eyes, and mouths, but seldom do even neglectful parents fail to notice "mouth breathing." Children afflicted by such features suffer torment from playfellows whose scornful epithets are echoed by the looking-glass. No fashion plate ever portrays such faces. No athlete, thinker, or hero looks out from printed page with such clouded, listless eyes. The more wonder, therefore, that the meaning of these outward signs has not been appreciated and their causes removed; conclusive reason, also, for not being misled by recent talk of mouth breathing, adenoids, and enlarged tonsils, into the belief that the race is physically deteriorating. Three generations ago Charles Dickens in his Uncommercial Traveller pointed out a relation between open mouths and backwardness and delinquency that would have saved millions of dollars and millions of life failures had the civilized world listened. He was speaking of delinquent girls from seventeen to twenty years old in Wapping Workhouse: "I have never [47]yet ascertained why a refractory habit should affect the tonsils and the uvula; but I have always observed that refractories of both sexes and every grade, between a Ragged School and the Old Bailey, have one voice, in which the tonsils and uvula gain a diseased ascendency."

To-day we are just beginning to see over again the connection between inability to breathe through the nose and inability to see clearly right from wrong and inability to want to do what teachers and parents wish. Physical examinations show now, and might just as well have shown fifty years ago, that the great majority of truants and juvenile offenders have adenoids and enlarged tonsils. A recent examination made by the New York board of health on 150 children in one school made up from the truant school, the juvenile court, and Randall's Island, showed that only three were without some physical defect and that 137 had adenoids and large tonsils. Dickens wrote his observations in 1860; in 1854 the New York Juvenile Asylum was started, and up to 1908 cared for 40,000 children; in 1860 William Meyer pointed out, so that no one need misunderstand, the harmful effects of adenoids. What would have been the story of juvenile waywardness, of sickness, of educational advancement, had examinations for defective breathing been started in 1853 or 1860 instead of 1905; if one per cent of the attention that has been given to teaching mouth breathers the ten commandments had been spent on removing the nasal obstructions to intelligence?

A "DEGENERATE" MADE NORMAL BY REMOVAL OF ADENOIDS

William Hegel, who is pictured on page 48, before his tonsils and adenoids were removed was described by his father in this way: "When playing with other boys on the street he seems dazed, and sluggish to grasp the various situations occurring in the course of the game. When he decides to do something he runs in a heedless, senseless way, as if running away,—will bump against something, [48]pedestrian or building, before he comes to himself; seems dazed all the time. When told something by his mother he giggles in the most exasperating way, for which he receives a whipping quite often." The father said the whipping was of no avail. The child was restless, talkative, and snored during sleep. He had an insatiable appetite. He was removed or transferred from five different schools in New York City. To get redress the father took him to the board of education, whence he was referred to the assistant chief medical inspector of the department of health, whose examination revealed immensely large fungous-looking tonsils and excessive pharyngeal granulations (adenoids). He was operated on at a clinic. The tonsils and adenoids removed are pictured on the opposite page, reduced one third. After the operation the child was visited by the assistant medical inspector. There was a marked improvement in his facial expression,—he looked intelligent, was alert and interested. When [49]asked how he felt, he answered, "I feel fine now." It required about fifteen minutes to get his history, during all of which time he was responsive and interested, constantly correcting statements of his father and volunteering other information. Eleven days after the operation he was reported to have had no more epileptic seizures. "Doesn't talk in sleep. Doesn't snore. Doesn't toss about the bed. Has more self-control. Tries to read the paper. His immoderate appetite is not present."

REASON ENOUGH FOR MOUTH BREATHING
Adenoid and tonsils reduced one third

While the open mouth is a sure sign of defects of breathing, it is not true that the closed mouth, when awake and with other people, is proof that there are no such defects. Children breathe through the mouth not because they like to, not because they have drifted into bad habits, not [50]because their parents did, not because the human race is deteriorating, but because their noses are stopped up,—because they must. A mouth breather is not only always taking unfiltered dirt germs into his system but is always in the condition of a person who has slept in a stuffy room. What extra effort adenoids mean can be ascertained by closing the nostrils for a forenoon.

For many reasons it is perhaps unfortunate that we can breathe at all when the nose is stopped up. If we could see with our ears as well as with our eyes, we should probably not take as good care of our eyes. In this respect the whole race has experienced the misfortune of the man of whom the coroner reported, "Killed by falling too short a distance." Because we can breathe through the mouth we have neglected for centuries the nasal passages. When a cold stops the nose we necessarily breathe through the mouth. Unfortunately children make the necessary effort required to breathe through the nose long before other people notice the lines along the nose and the slow mind. Mouth breathing will show with the child asleep, before the child awake loses power to accommodate his effort to the task. Therefore the importance of a physical test at school to detect the beginnings of adenoids and large tonsils before these symptoms become obvious to others.

No child should be exempted from this examination because of apocryphal theories that only the poor, the slum child, the refractory, or the unclean have defects in breathing. This very afternoon a friend has told me of her year abroad with a girl of nine, whose parents are very wealthy. The girl is anæmic. Her backwardness humiliates her parents, especially because she gave great promise until two years ago. High-priced physicians have prescribed for her. It happens that they are too eminent to give attention to such simple troubles as adenoids that [51]can be felt and seen. They are looking for complications of the liver or inflammation of muscles at the base of the brain. One celebrated French savant found the adenoids, assured the mother that the child would outgrow them, and advised merely that she be compelled to breathe through the nose. The mother and nursemaids nag the child all day. The poor unwise mother sits up nights to hold the child's jaws tight in the hope that air coming through the nose will absorb the adenoids. The mother is made nervous. Of course this makes the child more nervous and adds to the evil effects of adenoids. If the mother had the good fortune to be very poor, she could not sit up nights, and would long ago have decided either to let the child alone or else to have the trouble removed.

Adenoids are not a city specialty. Country earache is largely due to adenoids or to inflammation that quickly leads to adenoids. In 415 villages of New York state twelve per cent were found to be mouth breathers. For two summers I have known a lad named Fred. He lives at the seashore. Throughout his twelve years he has lived in a veritable El Dorado of health and nature beauty. Groves and dunes and flora vie with the blues of ocean and sky in resting the eye and in filling the soul with that harmony which is said to make for sound living. Yet to a child, Fred's schoolmates are experts on patent medicines and on the heredity that is alleged to be responsible for bad temper, running sores, tuberculosis, anæmia, and weak eyes. Freddie is particularly favored. His well-to-do parents have supplied him with ponies, games, and bicycles. Nothing prevents his breathing salt air fresh from the north pole but hermetically sealed windows. The father thinks it absurd to make a fuss over adenoids. Didn't he have them when a boy, and doesn't he weigh two hundred pounds and "make good money"? The mother never knew of operations for such trifles when [52]she taught school; she supposes her boy needs an operation, but "just can't bear to see the dear child hurt." As for Fred, he breathes through his mouth, talks through his nose, grows indifferent to boy's fun, fails to earn promotion at school, and fears that "I won't be strong in spite of all the patent medicine I've taken." Father, mother, and Fred feel profound pity for the city child living so far from nature.

Adenoids are not monopolized by children whose parents are ignorant of the importance of them and of physical examination. Last summer I was asked by a small boy to buy some chocolate. A glance at his cigar box with its two or three uninviting things for sale showed that the boy was really begging. He had thick lips, open mouth, "misty" eyes, and a nasal twang. I asked him if his teacher had not told him he had lumps back of his nose and could not breathe right. He said, "No." I explained then that he could make a great deal more money if he talked like other boys, stepped livelier, and breathed as other people breathe. He said he had "been by a doctor onct but didn't want to be op'rated." I turned to my companion and asked, "Have you never noted those same lines on your boy's face?" Although he had been lecturing on mouth breathers, he had never noticed his own boy's trouble. He hastened home and found the infallible signs. The mother declared it could not be true of her boy. About five months before, their family physician had said of the child's earache, "The same inflammation of the nasal passages that causes earache causes adenoids; you must be on the lookout." Although in the country, the boy's appetite was not good and his zest for play had flagged. They had looked for the trouble to back generations and in psychology books,—everywhere but at the boy's face, in his mouth, and in his nose. After the operation, which took less than two minutes, the appetite was [53]ravenous, the eyes cleared, and the spirit rebounded to its old buoyancy that craved worlds to conquer.

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

The indexes to adenoids and large tonsils for the teacher to read at school are:

The adenoids and large tonsils discovered at school are an index:

The riot that occurred when the adenoids of children in a school on the "East Side" in New York City were [54]removed without the preliminary of convincing the parents as to the advantages of the operation was merely a demand for the "right to knowledge," which is never overlooked with impunity. Reluctance to permit operation on a young child, and the natural shrinking of a parent at seeing a child under the surgeon's knife, require the teacher or school physician or nurse to answer fully the usual questions of the hesitant mother and father.

1. Is the operation necessary? Will the child not outgrow its adenoids? Usually the adenoid growths atrophy or dry up after the age of puberty. Adenoids are not uncommon in adults, however. The surgeon general of the army reports that during the year 1905, out of 3004 operations on officers and enlisted men in service, there were 225 operations on the nose, mouth, and pharynx, 103 of which were operations for adenoids and enlarged or hypertrophied tonsils. Allowing the child to "outgrow" adenoids may mean not only that he is being subjected to infection chronically but that his body is allowed to be permanently deformed and his health endangered. Beginning at the age of the second dentition, the bones of jaw, nose, throat, and chest are undergoing important changes—nasal occlusion. Adenoids left to atrophy—if large enough to cause mouth breathing—may mean atrophy of this developing process, permanent disfiguration of face, and permanent deformity of chest and lungs.

2. Will the growth recur? In a few cases it does recur; frequently either because it was not desirable to make a complete removal of the adenoid tissue or because the surgeon was careless. If the growths do recur, then they must be removed again.

3. Is the operation a dangerous one?

4. Is an anæsthetic necessary?

5. Will the operation cure the child of all its troubles? These questions are best answered by the process and [55]results of an "adenoid party," which was given especially for the benefit of this book, every step and symptom of which were carefully studied.

The seven children pictured here were discovered by their school physician to have moderately large adenoid growths,—one boy having enlarged tonsils also.

MOUTH BREATHERS IMMEDIATELY AFTER "ADENOID PARTY"

The picture on page 46 was taken by flash light at 2.30 P.M., January 15, 1908. At 3 P.M. the principal escorted these children into the operating room at Vanderbilt Clinic. The doctor examined the throat and nose of each child, entered the name and age of each, together with his diagnosis, on a clinic card, sending each child into the next room after examination. He then called the first boy and explained that it would hurt, but that it would be over in a minute. The principal stood by and told him to be brave and remember the five cents he could have for ice cream afterwards. The clinic nurse tied a large towel about him and put him in her lap; with one hand she held his clasped hands, while the other held his head back. The doctor then took the little instrument—the curette—and pushed it up back of the soft palate, and with one twist [56]brought out the offending spongy lump. The boy's head was immediately held over a basin of running water. He was so occupied with spitting out the blood that rushed down to choke him that he hadn't time to cry before the acute pain had ceased. The rush of cool air through his nostrils was such a pleasurable sensation that he smiled as the school nurse escorted him out into the hall to wait for his companions. At 3.30 P.M. all seven children were out in the hall, all seven mouths were closed, and all seven faces were clothed with the sleepy, peaceful expression that comes with rest from the prolonged labor of trying to get enough air. At 3.45 P.M. they had been all reëxamined by the doctor, and a few tag ends were picked out of the nasopharynx of one child. At 4 P.M. the "party" had returned to the Children's Aid Society's school and to the ice cream that follows each adenoid party.

It is worth while to tell mothers stories of the "marvelous improvement in school progress of those children whose brains have been poisoned and starved by the accursed adenoid growths, and how their bodies fairly bloom when the mysterious and awful incubus is removed," to use the words of one school principal. It is worth while to show them "before" and "after" pictures, and "before" and "after" children, and "before" and "after" school marks.

CHAPTER VIToC

CATCHING DISEASES, COLDS, DISEASED GLANDS

Deadly fevers, the plague, black death, cholera, malaria, smallpox, taught mankind invaluable lessons. Millions of human beings died before the mind of man devoted itself to preventing the diseases for which no sure cure had been found. Efforts to conquer these diseases were tardy because men were taught that some unseen power was punishing men and governments for their sins. The difference between the old and the new way is shown powerfully by a painting in the Liverpool Gallery entitled "The Plague." A mediæval village is strewn with the dead and dying. Bloated, spotted faces look into the eyes of ghouls as laces and jewelry are torn from bodies not yet cold. In the foreground a muscular giant, paragon of conscious virtue, clad like John the Baptist and Bible in hand, finds his way among his plague-stricken fellow-townsmen, urging them to turn from their sins. Modern efficiency learns of the first outbreak of the plague, isolates the patient, kills rats and their fleas which spread the disease, thoroughly cleanses or destroys, if necessary, all infected clothing, bedding, floors, and walls, and makes it possible for us to go on living for each other with a better chance of "bringing forth fruits worthy for repentance."

Where boards of health make it compulsory to report cases of sickness due to contagion, health records are a reliable index to "catching" diseases. But now that the chief infection is the kind that afflicts children, we can read the index before the outbreak that calls in a physician to diagnose the case. School examination shows which [58]children have defects that welcome and encourage disease germs. It points to homes that cultivate germs, and consequently menace other homes. To locate children who have enlarged tonsils may prevent a diphtheria epidemic. To detect in September those who are undernourished, who have bad teeth, and who breathe through the mouth will help forecast winter's outbreaks of scarlet fever and measles. One dollar spent at this season in examination for soil hospitable to disease germs may save fifty dollars otherwise necessary for inspection and cure of contagious diseases.

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

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

Human sociology imprisons, puts to death, deprives of opportunity to do evil, or reforms those who murder, steal, or slander. Germ sociology teaches us to do the same with injurious germs. We imprison them, we take away their food supply, we kill them outright, or we starve them slowly. They have a peculiar diet, being especially [59]partial to decomposing vegetable and animal matter and to what human beings call dirt. By putting this diet out of their reach we make it impossible for them to propagate their kind. By placing poison within their reach or by forcing it upon them we can successfully eliminate them as enemies. As the president of Mexico restored order "by setting a thief to catch a thief," so modern science is setting germs to kill germs that harm crops and human stock. Of utmost consequence is it that the body's germ consumer—its pretorian guard—be always armed with vitality ready to vanquish every intruding hostile germ. If we are false to our guard, it will turn traitor and join invaders in attacking us. But here, as in dealing with evils that originate with human beings, an ounce of prevention is worth a ton of cure. The most effectual way to eliminate germ diseases is to remove the cause—the food supply of disease germs. The fact that many germs are plants, not animals, does not weaken the analogy, for weeds do not get a chance in well-tilled soil.

Perhaps the most notable recent example of government germ extermination is the triumph over the yellow-fever and malaria mosquito in Panama. When the French started to build a canal in Panama, the first thing they did was to build a hospital. The hospital was always full and the canal was given up. At the time the United States proposed to re-attempt the work, it was thought that it could not be done without great loss of life and without great labor difficulties. Instead of taking the sickness for granted and enlarging the French hospital, the chief medical inspector, Gorgas, took for granted that there need be no unusual sickness if proper preventive measures were taken. He knew what the French had not known, that the yellow-fever scourge depends for its terrors upon mosquitoes. Accordingly, with the aid of six thousand men and five million dollars he set about to starve [60]out the few infected and infectious kinds of mosquito,—the yellow-fever or house mosquito and the malaria or meadow mosquito. He introduced waterworks and hydrants, paved the streets, drained the swamps and pools in which they breed, and instituted a weekly house-to-house inspection to prevent even so much as a pail of stagnant water offering harbor to these enemies. The grass of the meadows where the malaria mosquito breeds was cut short and kept short within three hundred feet of dwellers,—as far as the mosquito can fly. All ditches were disinfected with paraffin, and the natives were forced to observe sanitary laws. President Roosevelt, in his special message to Congress on the Panama Canal in 1906, stated that in the weekly house-to-house visit of the inspectors at the time he was in Panama but two mosquitoes were found. These were not of the dangerous type. As a consequence of this sanitary engineering there is very little sickness in Panama, the hospital is seldom one third full, and the canal is progressing very much faster than was expected. Panama, like Havana, is now safer than many American cities, because cleaner and less hospitable to disease germs.

Any place where numbers of people are accustomed to assemble favors the propagation of germs,—whether it be the meetinghouse, the townhall, the theater, or the school. Every teacher can be the sanitary engineer of her own schoolroom, school, or community by coöperating with the school doctor, the town board of health, family physicians, and mothers. Every teacher can exterminate disease by applying the very same principles to her schoolroom as Chief Medical Inspector Gorgas applied to Panama. Knowledge, disinfection, absolute cleanliness, education, and inspection are the essential steps. First she must know that "children's diseases" are not necessary. She should discountenance the old superstition that every child [61]must run the gamut of children's diseases, that every child must sooner or later have whooping cough, measles, chicken pox, mumps, scarlet fever, just as they used to think yellow fever and cholera inevitable. The price of this terrible ignorance has been not only expense, loss of time, acquisition of permanent physical defects, and loss of vitality, but, for the majority of children, death before reaching five years of age. All these "catching" diseases are germ diseases, which disinfection can eliminate. The free use of strong yellow soap and disinfectants on the school floor, windows, benches, desks, blackboards, pencils, in the coat closets and toilets, plus the natural disinfectants, hot sun and oxygen, will prevent the schoolroom from being a source of danger. One or more of these germ-killing remedies must be constantly applied; cleansing deserves a larger part in every school budget.

Often country towns are as ignorant of the existence of germs and of the means of preventing the spread of disease as the woman in a small country town who used daily to astound the neighbors by the "shower of snow" she produced by shaking the bedding of her sick child out of the window. Their astonishment was soon changed to panic when that shower of snow resulted in a deadly epidemic of scarlet fever. Medical inspection of New York City's schools was begun after an epidemic of scarlet fever was traced to a popular boy who passed around among his schoolmates long rolls of skin from his fingers.

Much of the care exercised at school to prevent children's diseases is counteracted because children are exposed at home and in public places to contagion, where ignorance more often than carelessness is the cause of uncleanliness. By hygiene lessons, illustrating practically the proper methods of cleaning a room, much may be done to enlist school children in the battle against germs. Through the enthusiasm of the children as well as through [62]visits to the homes parents may be instructed as to the danger of letting well children sleep with sick children; the wisdom of vaccination to prevent smallpox, of antitoxin to prevent serious diphtheria, of tuberculin tests to settle the question whether tuberculosis is present; why anything that gathers dust is dangerous unless cleansed and aired properly; and why bedding, furniture, floor coverings, and curtains that can be cleansed and aired are more beautiful and more safe than carpets, feather beds, upholstery, and curtains that are spoiled by water and sunshine; how to care for the tuberculous member of the family, etc. Anti-social acts may be prevented, such as carrying an infected child to the doctor in a public conveyance, thereby infecting numberless other people; sending infected linen to a common laundry; mailing a letter written by an infected person without first disinfecting it; sending a child with diphtheria to the store; returning to the dairy unscalded milk bottles from a sick room.

The daily inspection of school children for contagious diseases by the school physician has, where tried, been found to reduce considerably the amount of sickness in a town. Such inspection should be universally adopted. Moreover, the teacher should be conversant with the early symptoms of these diseases so that on the slightest suspicion the child may be sent home without waiting for the physician's call. Like the little girl who never stuttered except when she talked, school children and school-teachers are rarely frightened until too late to prevent trouble. The "easy" diseases such as measles, whooping cough, etc., cost our communities more than the more terrible diseases like typhoid and smallpox. During one typical week ending May 18, 630 new cases of measles were reported to one department of health. Obviously the nineteen deaths reported give no conception of the suffering, the cost, the anxiety caused by this preventable disease. The same [63]may be said of diphtheria and croup, of which only thirty-two deaths are reported, but 306 cases of sickness. Yet no one to-day will send a child to sleep with a playmate so as to catch diphtheria and "be done with it."

The most strategic point of attack is almost universally unrecognized. That is the child's mouth. Here the germs find lodgment, here they find a culture medium—at the gateway of the human system. The mouth is never out of service and is almost never in a state of true cleanliness. Solid particles from the breath, saliva, food between the teeth, and other débris form a deposit on the teeth and decompose in a constant temperature of ninety-eight degrees Fahrenheit. In the normal mouth from eight to twenty years of age the teeth present from twenty to thirty square inches of dentate surface, constantly exposed to ever-changing, often inimical, conditions. This bacterially infected surface makes a fairly large garden plot. Every cavity adds to the germ-nourishing soil. Dental caries—tooth decay—is a disease hitherto almost universal from birth to death. Thus the air taken in through the mouth becomes a purveyor of its poisonous emanations and affects the lung tissues and the blood. Food and water carry hostile germs down into the stomach. Thence they may be carried into any organ or tissue, just as nourishment or poison is carried.

Moreover, the child with an unclean mouth not only infects and reinfects himself but scatters germs in the air whenever he sneezes or coughs. In a cold apartment where there is no appreciable current of air a person can scatter germs for a distance of more than twenty-two feet. Germs are also scattered through the air by means of salivary or mucous droplets. It is this fact that makes colds so dangerous.

Table VIII

City of Manchester Education Committee

INFECTIOUS OR CONTAGIOUS DISEASES IN SCHOOLS INFORMATION FOR TEACHERS

In the following diseases only the affected child is excluded

[66]Most people still think that colds are due to cold air or draughts rather than to a cold germ, which finds a body unequipped with resisting power, with its germ police off guard, exhausted from overwork, or disaffected and ready to turn traitor if the enemy seems stronger than our vitality. Sometimes it seems as if we contracted it from a sneezing fellow-passenger, sometimes from a draught from an open car window. An uninformed opponent of the theory that colds are a germ disease wrote the following letter last winter to a New York newspaper:

After the correspondent has learned that our ancestors had more colds than we, had poorer health, and died twenty years younger, perhaps he will listen to proof that his unclean warm air weakens the body and makes it an easy prey to cold germs.

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

[67]Until medical specialists are agreed, and until they have definitely located the cold germ, we laymen must choose for ourselves a working theory. The weight of opinion at the present time declares that colds are due to germs. Strong membranes with good circulation and drainage provide poor food for germs. Congested membranes furnish proper conditions for propagation. The germ theory explains the spread of germs from the nose to the passages of the head, and from head to arteries and lungs.

A cold can always be charged to some one else. How many can be laid to our account? There is one right that is universally not recognized, and that is the right of protection from the germs showered in the air we breathe, over the food we eat, by the sneezes of our unfortunate neighbor at school, in the street car, at the restaurant. The chief danger of a cold is to our neighbor, not to ourselves. A cold which a strong person may throw off in a day or two may mean death to his tuberculous neighbor. Though for our own health "lying up for a mere cold" is an unnecessary bore, the failure to do so may deprive our neighbor of a right greater than the right to protection against scarlet fever or smallpox. Though formerly this statement would [68]not have been true, rights change with conditions, and the fact that to-day the three most deadly diseases are pneumonia, tuberculosis, and diphtheria,—all diseases of the respiratory organs,—justifies the assertion that we have a right to protection against colds. The prevalence of colds, sore throats, irritated vocal cords, bad voices, catarrh, bronchitis, laryngitis, and asthma in America to-day demands summary measures. One can learn to sneeze into a handkerchief, not into a companion's face or into a room. School children can be taught to avoid handkerchiefs on which mucus has dried. In the far distant future we may be willing to use cheesecloth, and boil it or throw it away, or, like the Japanese, use soft paper handkerchiefs and burn them after using.

Table IX

Death Rate per 10,000 Population, Pneumonia and Bronchitis
Five-Year Period, 1896-1900

One child with a cold can infect a whole class or family, thus depriving the class and family of the top of their vitality and efficiency without their consent. Because a person is thought a weakling who lies up for a "mere cold," one is inclined to wish that colds were as prostrating as typhoid, in which case there would be some hope of their extermination.

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

The first step for the teacher or mother in reading the index for colds is to look into the coat closet for evidence of warm clothing and overshoes, then to note whether the children put them on when they go out for lunch or recess. Whether "cold" settles in the nasal passages, ear, or stomach depends upon which is the weak spot. Draughts, [69]thin soles, wet soles, exposure when perspiring, may be the immediate cause of the nutritional or respiratory disturbances that give cold germs a foothold. Adenoids, diseased teeth, inflamed ears, may furnish the food supply. "There is no use treating children and sending them on fresh-air trips as long as they have nutritional and digestive disturbances due to bad teeth, or colds due to adenoids," said a physician when examining a party of children for a summer outing. The great preventive measure to be taken for catching diseases, colds, diseased glands,—in fact all germ diseases,—is the repeated cleansing of those portions of the human body in which germs may find lodgment,—the mouth, the nose, the eyes, and the ears.

In caring for young infants great pains is taken to cleanse all the orifices daily, but as soon as the child washes himself this practice is usually abandoned. Washing these gateways is far more important than washing the surface of the body through which germs could not possibly gain entrance into the system except through wounds. Oftentimes the douching of the nostrils with salt water will stop a cold at once. The mouth is the most important place of all, and the teacher should take care of her pupils' mouths first and foremost. As bad teeth, enlarged tonsils, and adenoids harbor germs and putrescent matter that vitiate every incoming and outgoing breath, these defects should be immediately corrected. Are we coming to a time when a thorough house-cleaning in the mouth of every child will take place before he enters the schoolroom, preferably in the presence of the teacher?

Two other "catching" diseases cause city schools a great deal of trouble,—trachoma and pediculosis (head lice). There are probably no two diseases more quickly transmitted from one person to another. Almost before their presence is known, all children of a school or all [70]persons of a group have contracted them. When at college twenty men of my fraternity discovered almost at the same time that they had an infectious eye trouble; yet we thought we were using different towels and otherwise taking sanitary precautions. Last summer a Vassar graduate took a party of tenement children for a country picnic. She returned with head lice that required constant attention for weeks. What then may we expect of children who live in homes where there is neither water, time, nor privacy for bathing, where one towel must serve a family of six, where mothers work for wages away from home and see their children only before seven and after six?

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

Trachoma, if neglected, not only impairs the health of the eye, but may cause blindness. Tears carry the germs from the eye to the face, where they are taken up on handkerchiefs, towels, and fingers and infect other eyes. Of late, thanks to school nurses and physicians and hygiene instruction, American cities have found relatively little trachoma except among recent immigrants. So dangerous is the germ and so insidious its methods of propagation, [71]that a physician should be summoned at once at the first sign of inflammation. Conjunctivitis is due to a germ, and will spread unless checked. Since the board of health of New York City has instituted the systematic examination of the eyes of the children in the public schools, it has found fully one third affected with some form of conjunctivitis. Many of these cases are out-and-out trachoma, others acute conjunctivitis, and a larger proportion are "mild trachoma." This last form of the disease is found to a great extent among children who have adenoids. The adenoids should be regarded as a predisposing factor rather than a direct cause. Therefore sore eyes are given as one of the indexes of adenoids. When we consider that adenoids are made up of lymphoid material, and that trachoma follicles are made up of the same sort of tissue, it is not surprising that the two conditions are found in the same child. The catarrhal inflammation produced by adenoids in the nasal mucous membrane travels up the lachrymal duct and thus infects the conjunctiva by contiguity.

In preventing pediculosis and infection of the eye vigilance and cleanliness are indispensable. After the diseases are advanced, after the germ colonies have taken title, some antiseptic or germ killer more violent than water is needed,—kerosene for the hair or strong green oil soap; for the eye, only what a physician prescribes.

CHAPTER VIIToC

EYE STRAIN

Wherever school children's eyes have been examined, from six to nine out of thirty are found to be nearsighted, farsighted, or otherwise in need of attention. A child is dismissed from school for obstinately declaring that the letter between c and t in "cat" is an o; "a pupil in her fourth school year was recently brought to me by her teacher with the statement that she did unreasonably poor work in reading for an intelligent and willing child;" a boy is punished for being backward. These three cases are typical. Examinations showed that the first child was astigmatic and not obstinate; the boy had run a pin into one eye ten years before and destroyed its sight; while the second girl was found to be afflicted with diplopia, and in a friendly chat told the following story: "I very often see two words where there is only one. When I was a very little girl I used to write every word twice. Then I was scolded for being careless. So I learned that I must not say two words even when I saw them." As Miss Alida S. Williams, principal of Public School 33 in New York City, has in many articles and addresses freely illustrated from school experience, the art of seeing is acquired, not congenital, and every human being who possesses it has learned it.

The large proportion of children suffering more or less seriously from eye trouble has led many persons to suggest physical deterioration as the cause. Eye specialists, however, assure us that eye troubles are probably as old as man. Our tardiness in learning the facts regarding these [73]troubles is due in part to the lack, until recently, of instruments for examining the eye and for manufacturing glasses to correct eye defects; in part, also, to the tendency of the medical profession, which I shall repeatedly mention, to explain disorders by causes remote and hard to find rather than by those near at hand.

About 1870 Dr. S. Weir Mitchell's attention was called "to the marked relief of headache, insomnia, and other reflex symptoms following the correction of optical defects by glasses." In 1874 and 1876 he wrote two articles that "impressed upon the general profession the grave significance of eye strain." Since that time, "in Philadelphia at least, no study of the rebellious cause of headache or of the obscure nervous diseases has ever been considered complete until a careful examination of the eyes has included them as a possible cause of the disturbance."

The new fact, therefore, is not weak eyes or strained eyes, but rather (1) an increase in the regular misuse of eyes by school children, seamstresses, stenographers, lawyers, etc.; and (2) the incipient propaganda growing out of school tests that show the relation of eye strain to headache, nervous diseases, stomach disorder, truancy, backwardness.

Every school, private and parochial as well as public, should supply itself with the Snellen card for testing eyes. Employers would do well to have these cards in evidence also, for they may greatly increase profits by decreasing inefficiency and risks. If there is no expert optician near, apply for cards to your health board or school board; failing there, write to your state health and school boards. In many states rural teachers are already supplied with these cards by state boards. In October, 1907, the New York state board of health sent out cards, with instructions for their use, to 446 incorporated towns. The state commissioner of education also sent a letter giving school reasons for using the cards. Results from 415 schools having [74]shown that nearly half the children had optical defects, it is proposed to secure state legislation that will make eye tests obligatory in all schools. Such a test in Massachusetts recently discovered twenty-two per cent of the school children with defective vision, and from forty to fifty thousand in need of immediate care by specialists.

POSITIONS OFTEN SUGGEST EYE STRAIN

Of course eye specialists,—oculists,—if skillful, know more about eyes and eye troubles than general medical practitioners or teachers. Preliminary eye tests, however, may be made by any accurate person who can read. The Massachusetts state board of health reports that tests made by teachers were "not less efficient" than tests made by specialists. In June, 1907, a group of eminent oculists recommended to the school board of New York [75]City that teachers make this first test after being instructed by oculists. Persons interested in the schools nearest them can quickly interest teachers and pupils by starting tests with this card. In cities oculists can be found who will be glad to explain to teachers, individually or in groups, how the cards should be used and what dangers to avoid.

Nature intended the human eye to read the last line of this card at a distance of ten feet. This conclusion is not a guess, but is based upon the examination of thousands of eyes. In making the test, the number of feet the eye ought to see is written as the denominator of the fraction; the distance the eye can see clearly is the numerator. If the child's card reads, "Right eye 10/10, left eye 10/20," it means that the right eye sees without conscious strain the distance it is intended to see, while the left eye must be within ten feet to see what it ought to see twenty feet away.

The practical steps for a teacher to take in making eye tests are:

The limits of the card test must be constantly kept in mind: (1) it does not register eye sickness due to dust, smoke, or disease germs; (2) it does not show unconscious eye strain due to successful accommodation. But it will discover a great part of the children who most need care. Sooner or later, too, inflammation of the eyelids, due to external causes, will affect the nerves of the eye and their power to conceal by accommodation the eye's defects. Just as we unconsciously open the mouth when a cold stops up the nose, the eye adapts itself to our needs without our realizing it. We expect it to see. It sees. If our eyes are not made alike, they do their best to work together. Like a good team of horses, the slow one hurries, the fast one holds back a little. But if one eye is 10/15 and the other 10/10, they will both be unnatural and strained if both read the same type. The effects of this strain frequently upset the stomach before the eyes rebel. I learned that I needed eyeglasses after a case of protracted indigestion, first diagnosed as "nervous" and later traced to eyes. Thousands of upper-grade children and college students are dieting for stomach trouble that will last until the eyes are relieved of the undue and unrecognized strain. [78]To prove the influence of eye strain on indigestion, persuade some obstinate parent to wear improperly focused glasses for a day; she will then be willing to have her child's eyes attended to.

It is unfortunate that the eyes will overwork without protesting. For years many persons suffer without learning that their eyes are unlike, or, as often happens, that one eye does all the close range work. Even when being tested, eyes will seem to see easily what requires a great effort of "accommodation." To prevent this self-deception skilled oculists do not trust the eye card, but put a drug in the eye that benumbs the muscles of accommodation. They cannot contract or expand if they want to. The oculist then studies the length of the eye and the muscle of accommodation. With this absolute knowledge of how each eye is made he knows what is wrong, exactly at what angle light enters the eye, whether objects are focused too soon or too late, exactly what kind of eyeglasses or what operation upon the eye is needed to enable it to do its work without undue straining or accommodation. So unconsciously do the eyes accommodate themselves to the work expected of them that not infrequently a child with seemingly perfect sight may be more in need of glasses than the child with imperfect sight. Practically, however, it is out of the question at the present time to have the majority of children given a more thorough test than that provided by the Snellen card. Where eye strains escape this test teachers will find evidence in complaints of headache, nervousness, sick stomach, chorea, or even epilepsy. The constant strain may also cause red or inflamed lids. Parents and teachers must be on the constant lookout for these symptoms of good sight persisting in spite of imperfect eyes.

An epidemic of eyeglasses is usually the consequence of eye tests. So naturally do we associate eyeglasses with [79]eye defects that some people assert that the eye tests at school originate with opticians more intent upon selling spectacles than upon helping children. In fact, even among educators who proclaim the need for eye tests there has been far more talk of eyeglasses than of removable conditions that cause eye strain. The women principals of New York City have sounded an alarm, and urge more attention to light and to reading position, more rest, more play, more hand work, less home study and less eye work at school, rather than more eyeglasses to conceal temporarily the effect of abusing children's eyes. Putting glasses on children without changing causal conditions is like giving alcohol to consumptives. The feeling of relief is deceptive. The trouble grows worse.

For some time to come eye tests will find eye troubles by the wholesale in every industrial and social class, in country as well as city schools. In 415 New York villages 48.7 per cent of school children had defects of vision,—this without testing children under seven,—while 11.3 per cent had sore eyes.

There are three possible ways of remedying defects: (1) changing the eye by operation; (2) changing the light as it enters the eye by eyeglasses; (3) decreasing the demands made upon the eye. To change eyes or light requires a technical skill which few physicians as yet possess. It will be remembered that it is but thirty years since the medical profession in America first began to understand the relation of eye defects to other defects. Until a generation of physicians has been trained by medical colleges to learn the facts about the eye and to apply scientific remedies, it is especially necessary that teachers and parents reduce the demands made upon children's eyes; oral can be substituted for written work, manual for optical work, relaxed and natural movement for discipline, outdoor exercise for less home study. Other requirements are [80]suitable light and proper position, and abolition of shiny paper, shiny blackboard, and fine print. Even after it is easy to obtain the correction of eye defects it will still be necessary to adapt the demands upon children's eyes to the strength and shape of those eyes. Because we are born farsighted, nearsighted, and astigmatic, we must be watchful to eradicate conditions that aggravate these troubles. Finally, there is no excuse whatever for permitting the parent of any school child in the United States to remain ignorant of the fact that it is just as absurd to go to the druggist or jeweler for eyeglasses as to the hardware store for false teeth.

The education of physician, oculist, and optician can be expedited by eye tests in school and by the follow-up work of schools in removing the prejudice of parents against glasses when needed. Because knowledge of chemistry preceded knowledge of the human body, the teaching of medicine still shows the effect of predilection for the remote, the problematical, the impossible. This predilection has influenced many specialists as well as many general practitioners, both overlooking too frequently obvious causes that even intelligent laymen can be taught to detect. Very naturally the man who makes money out of attention to simple troubles has stepped into the field not as yet occupied by the general practitioner and the specialist. Thus we have the optician, the painless tooth extractor, and quack cures for consumption. Opticians are placing before hundreds of thousands simple truths about the eye not otherwise taught as yet. Because they make their money by selling eyeglasses and because their special knowledge pertains to glasses rather than to eyes they frequently fail to recognize their limitations.

Physicians feel very strongly that it is as unethical for an optician to fit eyeglasses without a physician's prescription as for a pharmacist to give drugs without a physician's [81]prescription. The justification for this feeling should be based not upon the commercial motive of the optician but upon his ignorance. A physician uninformed as to eye troubles is just as unsafe as an optician determined to sell glasses. It must be made unethical and unprofessional for physician and optician alike to prescribe in the dark. Laymen and physicians must be taught that it is just as unethical and unprofessional for oculists and physicians to fail to bring their knowledge within the practical reach of the masses as for the optician to advertise his wares. School tests will not have been used to their utmost possibilities until optician and physician alike take the ethical position that the first consideration is the patient's welfare, not their own profits. It must soon be recognized as unethical and unprofessional for an optician who is also a skilled physician to refer patients to a medical practitioner ignorant as to optical science.

Whether opticians and physicians are unprofessional or unethical may be told by reëxamination if the examiner is himself competent and ethical. There is no better judge of their efficiency than the patient himself, who can tell whether the results promised have been effected. Whether the work of a country oculist is efficient and ethical can be learned: (1) by teaching country school children to recognize eye strain; (2) by comparing his results with those of other physicians. As soon as one or two states have tested eyes, we shall have an average by which to compare each class, school, and city with others of their size under similar conditions. If a particular physician finds half as many more or only half the average number, the presumption will be that his results are inaccurate and warrant an investigation. The interested teacher or parent can render an inestimable service to her local school and to the children of her state by taking steps to secure state laws compelling eye tests in all schools.

[82]Finally, it must be remembered by teachers, employers, parents, and all eye users that eyes are constantly changing; that eyes may need glasses six months after they are examined and found sound; that glasses change or develop the eye, so that they may be unnecessary and harmful six months after they are prescribed, or the eye may require a stronger glass; that eyeglasses become bent and scratched, so that they worry and strain the eye; that a periodic examination is essential to the health of the eye.

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

CHAPTER VIIIToC

EAR TROUBLE, MALNUTRITION, DEFORMITIES

The presence of adenoids is a frequent cause of both slight and aggravated deafness. Of 156 deaf mutes examined 59 per cent had adenoids, while only 6 per cent of the general run of the children in the neighborhood had this trouble. In mouth breathing, the current of air entering the mouth draws out some of the air from the Eustachian tube which ventilates the middle ear and unequalizes the atmospheric pressure on the eardrum, causing it to sink in and to blunt the hearing. An examination of the eardrums of school children in New York who are mouth breathers showed a high percentage of deafness, incipient or pronounced, accompanying adenoids. For example, of 9 mouth breathers selected from one class (average age 7-8 years), 6 were well-marked cases of deafness. Of 8 mouth breathers (average age 8-9 years), and of 5 mouth breathers (average age 5-6 years), all had noticeable defects of hearing. Many adults that suffer from deafness maintain that they never had any trouble in childhood. Yet the evidences of nose and throat trouble in childhood persist and disprove such statements. The foundations of deafness in later life are, in most instances, laid in childhood. Since the majority of cases of ear trouble occurring in school children accompany diseased conditions of the nose and throat, the proper care of nose and throat will, in large measure, balance the shortcomings of the aural examinations. Since the examination of the drum itself is not practicable, especial care should be given to the examination of the nose and throat.

[84]The figures published by New York City's department of health show that of 274,641 children examined from March, 1905, to January, 1908, 3540, or 1.2 per cent, gave evidence of defective hearing. Ear specialists suggest that this small percentage results from employing the whisper test at twenty feet. The whisper test at sixty feet has been set by experts as a test of normal hearing. But preciseness with this test is well-nigh impossible when we consider that the acoustics, the quality of the examiner's voice, the weather, the vowel or consonant sounds, all are variable quantities. The watch test is frequently used, but since a young teacher in her enthusiasm used an alarm clock to make the test, specialists have decided that the volume of sound differs in watches to such a degree as to make the watch test unreliable. The examination of the eye has been reduced to mathematical precision, due altogether to the anatomy of that organ. As yet there is no instrument for the ear comparable to the ophthalmoscope. The acoumeter is largely used by aurists and can be obtained from the optician. This instrument has an advantage over the whisper or watch tests in that its tick is uniform.

Each ear should be tested separately. Let the child place his finger against the flap of one ear while the other is being tested. Then compare the farthest distance from the ear at which the tick can be heard with the normal, standard distance. During the test all sound should be eliminated as far as possible and the eyes should be closed. At a demonstration of ear testing at Teachers College, one student stated that she could not hear the tick of the watch at a distance greater than twenty inches. Then the tester walked noisily toward her, leaving the watch on the desk, five feet away from the patient. She heard it now. When the class burst out laughing she opened her eyes, and, seeing the watch so far away, exclaimed, "Why, [85]I thought I imagined it." Be careful in testing a child to distinguish between what he "thinks he imagines" and what he really hears. Because of the difficulties of this test a doubt should be sufficient to warn the teacher to send the child to be tested by an expert. Detection of slight deafness may lead to the discovery of serious defects of nose or throat. Inflammation from cold or catarrh may cause deafness, which if neglected may permanently injure the ear. Often deafness is due to an accumulation of wax. A running ear should receive immediate attention, as it is an indication of inflammation which may imperil the integrity of the eardrum, and, if neglected, may eat its way through the thin partition between the ear and the brain and cause death.

It should never be assumed that deafness is incurable. Stupidity, inattention, and slowness to grasp a situation accompany difficulty of hearing and should cause the teacher to examine the ears. No ear trouble is negligible. Children and parents should be taught that the normal ear is intended to hear for us, not to divert our attention to itself. When the ear aches or "runs" or rumbles there is something wrong, and it should be examined together with the throat and nose.

Nervousness

In New York City one child in ninety-one already examined has had the form of nervous disease known as St. Vitus's Dance, or chorea. So prone are we to overlook moderate evils and moderate needs that the child with aggravated St. Vitus's Dance is apt to be cured sooner than the child who is just "nervous." Teachers cannot know whether twitching eyes, emotional storms, constant motion of the fingers or feet are due to chorea, to malnutrition, to eye strain, or to habits acquired in babyhood or early childhood and continued for the advantage that [86]accrues when discipline impends. Many a child treasures as his chief asset in time of trouble the ability to lose his temper, to have a "fit," to exhibit nervousness that frightens parent, teacher, or playmate, incites their pity, and wards off punishment. The school examination will settle once for all whether the trouble can be cured. The family physician will explain what steps to take.

Tests of Malnutrition

We Americans were first interested in the physical examination of school children by exaggerated estimates of the number of children who are underfed. As fast as figures were obtained for eye defects, breathing defects, bad teeth, some one was ready to declare that these were results of underfeeding. Hence the conclusion: give children at least one meal a day at school. Scientific men began to set us straight and to give undernourishment a technical meaning,—soft bones, flabby tissue, under size, anæmia. While too little food might cause this condition, it was also explained that too much food of the wrong sort, or even food of the right sort eaten irregularly or hurriedly or poisoned by bad teeth, might also cause undernourishment, including the extreme type known as malnutrition. In extreme instances the symptoms enable an observant teacher who has learned to distinguish between the pretty hair ribbon and clean collar and the sunken, pale, or hectic cheek and lusterless eyes to detect the cause. But as with eyes and nose, an unhealthy condition [87]of nourishment may exist long before outward symptoms are noticeable. Therefore the value of the periodic searching examination by the school physician.

SAME AGE, SAME SCHOOL, DIFFERENT NUTRITION

Bone Tuberculosis; Orthopedic Tests

Only recently have we laymen learned that knee trouble, clubfoot, ankle sores, spine and hip troubles, scrofula, running sores at joints, etc., are not hereditary and inevitable, but are rather the direct result of carelessness on the part of adult consumptives. These conditions in school are indices of homes and houses where tuberculosis is or has been active, and of health boards that are or have been inactive in checking the white plague. Early examination may disclose the small lump on the child's spine,—which one mother diagnosed as inherited "round shoulders,"—and save a child from being a humpback for life. Moreover, the examination of the crippled child's brothers and sisters will often show the beginnings of pulmonary tuberculosis.

A GRIEVOUS PENALTY FOR NEGLECT BY ADULT CONSUMPTIVES

Enlarged Glands—Tuberculosis

In almost every class are one or more children who are proud of small or big lumps under one or more jaws. Only physicians can find very small lumps. Many family doctors will say, "Oh, he will outgrow those," or "Those lumps will be absorbed." Like most other evils that we "outgrow" or that pass away, these lumps shriek not to be neglected. They mean interference with nourishment and prevent proper action of the lymphatic system, as adenoids prevent free breathing. Even when not actually infected with tubercle bacilli, they are fertile soil for the production of these germs. If detected early, they point to home conditions and personal habits that can be easily corrected. In New York one child in four has these enlarged glands. If the same proportion prevails in other parts of the United States, there are 5,400,000 children whose strength is being needlessly drained, many of whom, if neglected, will need repeated operations.

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 IXToC

DENTAL SANITATION

"Have their teeth attended to first, and many of the eye defects will disappear." This was an unexpected contribution to the debate upon free eyeglasses for the school children of New York City. So little do most of us realize the importance of sound, clean teeth, and the interrelation of stomach and sense nerves, that even the school principals thought the eye specialist was exaggerating when he declared that bad teeth cause indigestion and indigestion causes eye strain.

"Bad" teeth mean to most people dirty teeth and offensive odors, loose, crooked, or isolated teeth, or black stumps. Even among dentists a great many, probably the majority, do not appreciate that "bad" teeth mean indigestion, lowered vitality, plague spots for contaminating sound teeth and for breeding disease germs. Until recently the only rule about the teeth of new recruits in the United States army was: "There must be two opposing molars on each side of the mouth. It doesn't matter how rotten these molars may be." The surgeon general was persuaded to change to "four opposing molars on each side"; still nothing as to the condition of the two additional molars! In the German army there is a regular morning inspection of teeth and toothbrushes. Several German insurance companies give free dental treatment to policy holders, not to bestow charity but to increase profits.

Neglecting "baby teeth" and adenoids may mean crooked second teeth that will cause: (1) hundreds of dollars for straightening; (2) permanent business handicap because crooked teeth are disagreeable to others, because mastication [90]is less perfect, and because a disfigured mouth means dis-arranged nerves; or perhaps (3) large dental bills because it is difficult to clean between cramped, crooked teeth.

Unfortunately the great majority of parents rarely think of their children's teeth until too late to preserve them intact. Even among families where the rule of brushing the teeth twice daily prevails, regular dental examination is often not required. Doctors and dentists themselves have not been trained to realize that the teeth are a most dangerous source of infection when unclean. Does your dentist insist upon removing tartar and food particles beyond your reach, upon polishing and cleansing, or does he regard these as vanity touches, to be omitted if you are in a hurry?

INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL

Physicians send tuberculosis patients to hospitals or camps without correcting the mouth conditions that make it impossible for the patient to eat or swallow without infecting [91]himself. Tonics are given to women whose teeth are breeding and harboring disease germs that tear down vitality. Nurses watch their suffering patients and do the heavier tasks heroically, but are not trained to teach the simple truths about dental hygiene. The far-reaching results of neglect of teeth will not be understood until greater emphasis is placed on the bacteriology, the economics, the sociology, and the æsthetics of clean, sound teeth. Whether or not there is at present a tendency to exaggerate the importance of sound teeth, there is no difference of opinion as to the fact that the teeth harbor virulent germs, that the high temperature of the mouth favors germ propagation, that the twenty to thirty square inches of surface constantly open to bacterial infection offer an extensive breeding ground, and that the formation of the teeth invites the lodgment of germs and of particles of food injurious both to teeth and to other organs.

By scraping the teeth with the finger nail and noticing the odor you can convince yourself of the presence of decomposing organic matter not healthful to be carried into the stomach. By applying a little iodine and then washing it off with water, your teeth may show stains. These stains are called gelatinous plaques, which are transparent and invisible to the naked eye except when colored by iodine. These plaques protect the germs, which ferment and create the acid which destroys tooth structure. Their formation can be prevented by vigorous brushing and by eating hard food.

The individual with decayed teeth, even with unclean teeth, is open to infection of the lungs, tonsils, stomach, glands, ears, nose, and adenoid tissues. Every time food is taken, and at every act of swallowing, germs flow over the tonsils into the stomach. Mouth breathers with teeth in this condition cannot get one breath of uncontaminated air, for every breath becomes infected with poisonous emanations from the teeth. Bad teeth are frequently the sole [92]cause of bad breath and dyspepsia, and can convey to the system tuberculosis of the lungs, glands, stomach, or nose, and many other transmissible diseases. They may also cause enlarged tonsils and ear trouble.

Apart from decomposing food and stagnant septic matter from saliva injured by indigestion, and by sputum which collects in the healthy mouth, there are in many infected mouths pus, exudations from the irritated and inflamed gum margins, gaseous emanations from decaying teeth, putrescent pulp tissue, tartar, and chemical poisons. Every spray from such a mouth in coughing, sneezing, or even talking or reading, is laden with microbes which vitiate the air to be breathed by others. Indigestion from imperfect mastication and imperfect salivation (themselves often due solely to bad teeth) is far less serious than indigestion from germ infection. Germs taken into the stomach can so change the composition of saliva (a natural disinfectant when healthy) as to render it no longer able to kill germs. Indigestion may result in excess of uric acid and toxic material, so that the individual becomes subject to gout and rheumatism, which in turn frequently destroy the bony support of the teeth and bring about Riggs's Disease. The last named is a prevalent and disfiguring disease, whose symptom is receding gums. The irritating toxins deposited on the teeth cause inflammation of the tissues at the gum margins. The gums withdraw more and more from sections of the teeth; the poisons get underneath and work back toward the roots; the infection increases and hastens the loosening of the teeth. I know of a man who had all of his teeth extracted at twenty-one years of age, because he was told that this was the only treatment for this disease, which was formerly thought to be incurable. Yet thorough cleansing and removal of this matter from under the edges of the gums, disinfection, a few visits to the dentist, will stop the recession but cannot regain lost ground.

[93]Among those who regularly use the toothbrush, instinct, comfort, or display is the ruling motive, while a small percentage have evolved to the anti-nuisance stage, where the æsthetic standard of their group forbids any member to neglect his teeth. The anti-slum and pro-slum motives for mouth cleanliness and dental sanitation have been awakened in but one or two places. A significant pro-slum activity is the dental clinic organized by forty volunteer dentists, acting for an industrial school maintained by the New York Children's Aid Society.

NEW YORK CHILDREN'S AID SOCIETY'S DENTAL CLINIC FOR SCHOOL CHILDREN

Here 550 children have been examined, 447 teeth extracted, 284 teeth filled, 200 teeth treated for diseased pulp (and only 24 sets cleaned), 40 dentists taking turns in giving time to this work. The equipment cost but $239; cards and stationery, $72; incidentals, $33. The principal attends the clinic, because in her presence no child is willing to confess fear or unwillingness. To supplement this work, the dentists have prepared for free distribution a leaflet which tells in short, clear sentences how to care for the teeth.

Such a leaflet should be given out at dispensaries, hospitals, dental offices, schools, and from many Sunday schools and missions.[5]

[95]The time for the schools to begin is when the child is first registered. Examination and reëxamination must be accompanied by explanation of the serious disadvantages of neglected teeth, and the physical, social, and economic advantages of clean, sound teeth. Instruction at school must be followed by education of parents. The school or health authorities should examine the teeth of all children before issuing work certificates. Finally, the dental, medical, and nursing professions and the press must be enlisted in the school's campaign for dental hygiene. The Dental Hygiene Council of Massachusetts should be copied in all states.

A preliminary examination of teeth can be made by parent or teacher. Crooked, loose, dirty, or black teeth or receding gums can be detected by a layman's naked eye. In fact, children can be interested in finding the most obvious defects in their own or their brothers' teeth. There could be no better first lesson than to ask each pupil to look in a hand mirror and to count each tooth obviously needing a cleaning or a filling. The most urgent need can thus be ascertained without expert aid. But because parent, teacher, or child cannot discover defects does not prove that dental care is not imperative; hence the importance of examination by a dentist or by a physician competent to discover dental needs. If a private, public, or parochial school has no paid visiting dentist, a zealous school officer can, at least in large towns, persuade one or more dentists or physicians to make a few first tests to confirm the teacher's findings, and to persuade the community that regular examination and reëxamination are necessary and a saving of pain, beauty, and money.

Reëxamination is necessary because decay may start the day after a dentist has pronounced a tooth sound. For most of us twice a year is often enough. A reëxamination should be made upon the slightest suspicion of decay, breaking, or loosening.

[96]Educational use should be made by the teacher of the results of school examination. Children cannot be made self-conscious and cleanly by telling them that their teeth will ache three or five years from now. They can be made to brush or wash their teeth every morning and every night if they once realize that cavities can be caused only by mouth garbage. All decay of human teeth starts from the outside through the enamel that covers the soft bone of the tooth. This enamel can be destroyed by accidentally cracking or breaking it, or by acids eating into it. These acids come from (1) particles of food allowed to remain in the teeth; (2) tartar, etc., that adheres to the teeth and can be removed only by a dentist; (3) saliva brought up from an ill-conditioned stomach. Even where the enamel is destroyed, absolute cleanliness will prevent serious decay of the tooth. A perfectly clean tooth will not decay. Generally speaking, unless particles of food or removable acids remain on or between the teeth long enough to decompose, teeth cannot decay. Decay always means, therefore, uncleanliness. To unclean teeth is due in large part the offensive odor of many schoolrooms.

AN ARMENIAN SCHOOL GIRL

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

Habits of cleanliness are easily fixed. In the most crowded, most overworked section of large cities visitors from "uptown" are surprised by the children's bright hair ribbons, clean aprons, clean faces, and smoothly combed hair. It will be easy to add clean teeth to the list of things necessary to personal and family standing. Armenian children [97]are taught to clean their teeth after eating, even if only an apple between meals. They covet "beautiful teeth." American standards will soon prevent these Armenians from cleaning their teeth in public, but desire for beautiful teeth will stay, and will remind them to care for their teeth in private. As coarse food gives way to sugars and soft foods, stiff toothbrushes must supplement tongue and toothpicks.

Strong as are the instinct and display motives in cleaning teeth, both parents and children need to be reached through the commerce motive. Instinct makes children afraid of the dentist, or content when the tooth stops aching. Display may be satisfied with cleaning the front teeth, as many boys comb only the front hair or as girls hide dirty scalps under pompadours and pretty ribbons. Desire to save money may give stronger reasons for not going to the dentist than instinct and comfort can urge for going. But parents can be made to see, as can children after they begin to picture themselves as wage earners, that a dentist in time saves nine, and that no regular family investment will earn more money than the price of prompt and regular dental care. A problem in arithmetic would be convincing, if, by questions such as those on page 98, we could compare the family cost of neglecting teeth with the cost of toothbrushes, bicarbonate of soda, pulverized chalk or tooth powder, early and repeated examination by a dentist, and treatment when needed.

The result will show that the money spent for one good "house cleaning" of one child at fourteen or eighteen exceeds the cost of keeping clean and in repair the teeth of the entire family. How effective and economical is thorough cleaning is confessed by an eminent dentist, who taught an assistant to clean his patients' teeth. "Do you know," he said, "I had to stop it, so perceptibly did my work decrease." The total time required to examine school children for teeth needing attention is much less than the time now lost by absence from school or wasted at school on account of toothache.

WON BY THE ECONOMIC ARGUMENT

To remind school children regularly of dental hygiene is not more important than for the school to remind parents repeatedly of the many reasons for attending to their children's teeth. It is not enough, however, to send one message to parents. Illustrated lectures, mothers' meetings, demonstrations at hospitals and fresh-air homes are all very serviceable, but listening is a poor substitute for understanding. Schools should see that parents understand the æsthetics, the economics, the humanity of dental hygiene. [99]The best test of whether the parent has understood is the child's tooth.

Dental examination of children applying for work certificates gives the health and school authorities a means of enforcing their precepts. When no child is allowed to go to work whose teeth cause malnutrition or disgust, the news will spread, and both child and parent will see clearly the grave need for dental care.

Finally, local papers can be interested. They will print almost anything the teacher sends about the need for dental care. They like particularly facts about the number of cavities found, the number of children needing care, efforts made to procure care, and new facts about diseases that can be caused by bad teeth or about diseases that can injure teeth. Teachers can persuade dentists and physicians to write stories. No newspaper will refuse to print such statements as this: "A tuberculous patient in six weeks lost ground steadily. I persuaded him to go to a dentist to clean the vestibule to his digestive system, and to have a set of false teeth. He enjoys his meals, and has gained twelve pounds in six weeks." Popular magazines and newspapers mention teeth seldom, because those who best know the interesting vital things are making money, not writing articles or otherwise concerning themselves with dental education. It is said that of forty thousand American dentists not over eleven thousand are readers of dental journals, and probably not three hundred contribute to professional [100]literature. One dentist who is working for the children's clinic described above, when asked by the board of education to lecture to the people on the care of the teeth and to recommend simple, readable books, told me that he knew no good books to suggest.

Five obstacles exist to practicing what is here preached:

Additional reasons these for cleanliness that will make the dentist serviceable for his knowledge rather than for his time and gold.

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

The "free-extraction" dental parlors undoubtedly are doing a vast amount of harm. In every city are dental quacks that injure wage-earning adults as much as soothing-sirup quacks injure babies. Instead of teaching people to preserve their teeth, they extract, and then, by dint of overpersuading by a pretty cashier hired for the purpose, make a contract for a gold crown or a false set at an exorbitant price. A reputable dentist has said that a dental parlor can do more damage to the welfare of the race in a few months than a well-intentioned man in the profession can repair in a lifetime. Its question is not, What can I do for this patient? but What is there in this mouth for me? Many "parlors" never expect to see the same [101]person twice, because they do not make him comfortable or gain his confidence; they put a filling in on top of decayed matter or even diseased pulp; put in plates and bridges that do not fit; charge more than the examination at first leads one to expect; refuse to correct mistakes; deny having ever seen the patient before. Yet true and severe as this arraignment is, many of these parlors, with their liveried "runners in," are doing an educational service not otherwise provided; it is conceivable that in many cities they are doing less harm by their malpractice than well-intentioned men in the profession by neglect of public needs or by failure to organize facilities for meeting those needs.

I realize that advertising is "unethical" among dentists as among physicians. Humbug and imposition are supposed to go inevitably with self-advertising by the methods used in selling shoes or automobiles. Therefore such advertising is prohibited. But what seems to be forgotten in this definition of ethics is that the need and the opportunity for dental care must be advertised in some way, if we are ever to control diseases and evils due to bad teeth. The rich that one dentist can help are able to pay for his good taste, his neat attendants, his automobile, his club dues, his vacations at fashionable resorts, his hours without work, his standard of living. All of these things advertise him, just as hospital appointments and social position may and do advertise successful physicians. The patients of moderate means that one dentist can treat cannot afford to pay for rent, time disengaged, and indirect advertising. Either they must have free treatment, must go without treatment, or must go to a dental parlor where dental needs are organized so that a very large number will contribute to rent and display. It is out of the question to have both dentists and patients so distributed and prices so adjusted that dentists can make a good living by charging what the patient can afford, and at the same time admit of every [102]patient being properly treated when necessary. Judging from every other branch of work, the solution of the problem lies partly in free care for those who can pay nothing or very little, and partly in coöperative treatment through the heretofore objectionable dental parlors. If instead of inveighing against advertisers, honorable and capable dentists worked through dental and medical societies to secure adequate public supervision of dental practice, more progress would be made against dental malpractice.

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

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

Of fourteen dental journals in America, only one has the advancement of dental science as its first reason for [103]existence. Thirteen are trade journals. Not one of these would print articles proving that the supplies advertised by their backers were inimical to dental hygiene. Many dental colleges still retain on their faculties agents or editors in the pay of supply houses, Harvard's new dental school being a notable exception. This trade motive tolerates and encourages the disreputable practices of existing dental parlors. Largely because of this prostitution of the dental profession, patients generally neglect the repairing and cleansing of the teeth and the sterilizing of the mouth from which germs are carried to all parts of the body. Dental journalism for the sale of supplies cannot outlive the dentist's reading of the school's index.

Many dentists will say that they must learn dentistry before they learn the economics and sociology of clean teeth. Being a young profession, it is natural that dentistry should first devote itself to learning its own mechanics,—the tricks of the trade—how to fill teeth. But the fact that it took the medical profession centuries to begin to feel responsibility for community health is no reason why the social sense of the dentist should be dormant for centuries or decades. We need training and exercise to determine what kind of filling will be most comfortable and most serviceable; whether the pulp of the teeth needs treating or removing before the filling is inserted; whether it is worth while to fill a deciduous or baby tooth. Sociology will never take the place of dental technic. The few dentists who have studied the social significance and social responsibility of their profession declare, however, that careless workmanship and indifferent education of patients continue chiefly because dentists themselves do not see the community's interest in dental hygiene. The school can socialize or humanize the dental profession if teachers themselves possess the social sense and make known the facts about the need for dental care among school children.

FOOTNOTES:

CHAPTER XToC

ABNORMALLY BRIGHT CHILDREN

What is commonly considered abnormal brightness in a school child is often a tendency to live an abnormal physical life. Being a child bookworm means that time is spent indoors that should be spent playing games with one's fellows. Excellence in the activities of children, not ability to imitate the activities of adults, should be the test of child brightness. To be able to hit a bull's-eye, to throw a ball accurately, to calculate the swing of a curve or the bound of a "grounder," these are tests of brightness quite as indicative of mental power as the ability to win highest marks in school, while less injurious to physical power. The child who is abnormally bright requires special treatment just as much as the child who is abnormally dull. The former as well as the latter must have his abnormal condition corrected if he is to grow into a normally bright man.

The college man who sacrifices health to "marks" is thus described by the director of physical training at Harvard University:

For the protection of these physical defective grinds it is suggested to put a physical qualification upon the candidates of Phi Beta Kappa and their awards of scholarship. If scholarship men cannot be induced to take time to improve their physique for fear of lowering their college standing, then give them credit for standing in physical work.

[105]The abnormally bright, at whatever age, is as much a subject for examination and treatment as the child with adenoids and pulmonary tuberculosis. Such attention will increase the percentage of abnormally bright schoolmates who figure in active business in later life. Moreover, it will decrease the number of high school superintendents who declare that their honor pupils are physical wrecks.

There are children who develop very rapidly, both physically and mentally, and whose mental superiority is not at the expense of their bodies. Protection of such children requires that their minds be permitted to progress as rapidly as bodily health justifies. It is as cruel to keep back a physically and mentally superior child, as to push the physically or mentally defective beyond his powers. Worry and fatigue can be produced by lack of interest as well as by overwork. "Normal" should not be confused with "average." To keep a bright child back with the average child—marking time till the dull ones catch up—is to make him abnormal. The tests that we have employed for grading pupils are either the tests of age in years or of mental capacity. The first takes no account of slowness or rapidity of physiological development,—of physiological age. The second encourages mental activity at the expense of physique. The entrance of a child into school, the promotion from one class to another, the entrance into college, are thus determined either by the purely artificial test of age or by the individual teacher's discretion. There is nothing to prevent the ambitious teacher or the ambitious parent from pushing a child into kindergarten at four, high school at twelve, college at fifteen. If this cannot be done at the public school, a private school is resorted to. A community of college professors once started a school for faculty children. A tremendous pressure was put upon these scions of intellectual aristocracy to enter the high school at twelve. No thought was given to the ventilation of the school. The [106]windows were so arranged that they could not be opened without the air blowing on some child's back. "You could cut the air with a knife" was a description given by one sensible professor who had taken his sturdy girl of seven away from the school, because he feared that in this environment she would become like the other little puny, pale, undersized children of that school.

The University of Pennsylvania has instituted a psychological clinic. Parents and teachers are invited to bring any deviation from the usual or the expected to the attention of this clinic. Every month a bulletin is published called the Psychological Clinic, which will be found of great service in dealing with the abnormally bright as well as with the abnormally dull. Naturally the well-to-do and the rich are the first to take advantage of these special facilities for ascertaining just what work should be done by a precocious child or by the mentally and morally retarded.

Abnormal brightness means power to be happy and to be serviceable that is above the average. Every school can be a miniature psychological clinic. While every teacher cannot be an expert, national and state superintendents can constantly remind teachers that the abnormally bright are also abnormally apt to neglect physical welfare and to endanger future mental power.

CHAPTER XIToC

NERVOUSNESS OF TEACHER AND PUPIL

Nervousness of teacher and pupil deserves special mention. So universal is this physical defect that we take it for granted, especially for teachers. Teachers themselves feel that they need not even apologize for nervousness, in fact they too frequently use it as an excuse for impatience, ugly temper, discourtesy, and unfairness. Children, slates, papers, parents, blackboards "get on their nerves." Nervousness of teacher causes nervousness of pupils and adds to the evil results of mouth breathing, bad teeth, eye strain, and malnutrition. These conditions, added to bad ventilation, bad light, and an overcrowded schoolroom, render the atmosphere thoroughly charged with electricity—nerves—toward the end of the day. Lack of oxygen to breathe as well as inability to breathe it; lack of well-printed books and good light, as well as lack of the power to use them; toothache, earache, headache, deplete the vitality of both teacher and pupil.

Most of the disturbances at school are but outward signs of unwholesome physical conditions. If the teacher attempts to treat these causes by crushing the child, she makes confession of her own nervousness and inadequacy and visits her own suffering upon her pupils. A transfixing glance prolonged into an overbearing stare, a loud, sharp voice, a rough manner, are successful only so far as they work on the nervousness of her pupil. She finds that it is temporarily effective, and so by her example and practice sets the child an example in losing control of himself. The position often assumed by school children when before authority, [108]of hands held stiffly at the side, head drooped, and roving eye, does not mean control: it means a crushed spirit, hypocrisy, or brooding anarchy. The mother or teacher who obtains obedience by clapping her hands, pointing her finger, distorting her face, is copying in her own home the attitudes of caste in India, of serfdom in Russia, the discipline of the prison the world over, a modern reminder of the power of life and death or of physical torture.

A young college girl unfamiliar with the ways of the public school was substituting in the highest grammar grade. The time for civics arrived. Here, she thought, is a subject in which I can interest them. The boys showed a vast amount of press information, as well as decided opinions on the politics of the day. The candidates which they elected for the position of ideal American patriot were Rockefeller, Lincoln, and Sharkey the prize fighter. During the ensuing debate, which gave back to Lincoln his proper rank, the boys in the back of the room had moved forward and were sharing seats with the boys in the front. Every boy was engrossed in the discussion. The room was in perfect order,—not, however, according to the ideas of the principal, who entered at that moment to see how the new substitute was managing the class, famed for its bad boys. With the stern look of a Simon Legree she demanded, "How dare you leave your seats!" When one child started to explain she shouted: "How dare you speak without permission! Don't you know your teacher never permits it? Every boy take his own seat at his own desk." This principal was far more to be pitied than the boys, for they had before them the prospect of "work papers" and a grind less monotonous and more productive than the principal's discipline. She was a victim of a nerve-racking system, more sinned against than sinning.

There is nothing in school life per se to cause nervousness. Given a well-aired, sunny room, where every child [109]has enough fresh air to breathe, where he can see without strain, where he has a desk fitted to his body and work fitted to his maximum abilities, a teacher who is physically strong and mentally inspiring, and plenty of play space and play time, there will be no nervousness. One who visits vacation schools is struck with the difference in the atmosphere from that of the winter day schools. Here are the same rooms, the same children, and in many cases the same teachers, but different work. Each child is busy with a bright, interested, happy expression and easy attitude. Some are at nature study, some are weaving baskets, making dresses, trimming hats, knitting bright worsted sacks and mittens for the winter. Boys are at carpentering, raffia, or wrought-iron work. In none of the rooms is the absolute unity or the methodical order of the winter schoolroom, but rather the hum of the workroom and the order that comes from a roomful of children interested in the progress of their work. This condition only illustrates what a winter schoolroom might be were physical defects corrected or segregated, windows open, light good, and work adapted to the child.

VACATION SCHOOL INTEREST: AN ANTIDOTE TO NERVOUSNESS

[110]Nervousness is not a monopoly of city teachers and city pupils. In country schools that I have happened to know, nervous children were the chief problem. Nervousness led in scholarship, in disorder, in absences, in truancy, and in backwardness. After reading MacDonald's Annals of a Quiet Neighborhood, I became interested in one or two particularly nervous children, just to see if I could overcome my strong dislike for them. To one boy I gave permission to leave the room or to go to the library whenever he began to lose his self-control. My predecessors had not been able to control him by the rod. A few weeks after Willie's emancipation from rules, the county superintendent was astonished to see that the county terror led my school in history, reading, and geography.

Had I known what every teacher should be taught in preparation,—the relation of eye strain, bad teeth, adenoids, "overattention," and malnutrition to nervousness and bad behavior,—I could have restored many "incorrigibles" to nerve control. Had I been led at college to study child psychology and child physiology, I should not have expected a control that was possible only in a normal adult.[6] In its primary aspect the question of nervousness in the schoolroom is purely physiological, and the majority of principals and teachers are not trained by professional schools how to deal with it. Normal schools should teach the physical laws which govern the child's development; should show that the pupil's mental, moral, and physical nature are one and inseparable; that children cannot at one time be docile, sickly, and intelligent,—perfect mentally and imperfect physically. Until teachers are so taught, the condition cannot be changed that makes of our schools manufactories of nervous teachers and pupils.

[111]Country nervousness, like city nervousness, is of three kinds: (1) that caused by defective nervous systems; (2) that resulting from physical defects other than defects of the nervous system, but reacting upon it; (3) that due to habit or to lack of self-control. Children who suffer from a defective nervous system should, in city schools, be segregated where they can have special care under constant medical supervision. Such children in schools too small for special classes should be given special treatment. Their parents should know that they have chorea, which is the same trouble as St. Vitus's Dance, although often existing in a degree too mild to attract attention. Special treatment does not mean that such children should be permitted to interfere with the school progress of other children. In many rural schools, where special privileges cannot be given children suffering with chorea without injury to other children, it would be a kindness to the unfortunates, to their parents, and to all other children, were the parents requested to keep such children at home.

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

Preventable nervousness due to "habit" can be quite as serious in its effects upon the mind and health as the other two forms of nervousness. Twitching the face, biting the nails, wetting the lips, blinking the eyelids, continually toying with something, being in perpetual motion and never relaxing, always changing from one thing to the next, being forever on the rush, never accomplishing anything, are common faults of both teacher and pupil. We call them mannerisms or tricks of personality. They are readily imitated by children. I once knew a young lawyer who had started life as an oyster dealer, whose power of imitation helped to make him responsive to both helpful and harmful influences. After [112]being at the same table for two weeks with a talented man whom he admired, he acquired the latter's habit of constantly twitching his shoulder and making certain gestures. These habits in turn quickly produced a nervousness that interfered with his power to reason straight.

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

It is said that the confusion of city life causes habits of nervousness. Unfortunately no one knows whether the city children or the country children have the highest percentage of nervousness. There is a general feeling that city life causes an unwholesome degree of activity, yet one finds that those people in the city who least notice the elevated railway are those whose windows it passes. City noises irritate those who come from the country, or the city man on returning to the city from the country, but a similar irritation is felt by the city-bred man on coming to the country. Mr. Dooley's description of a night in the country with the crickets and the mosquitoes and the early birds shows that it is the unusual noise rather than the volume or variety of noises that wreck nerves. At the time of the opening of the New York schools in 1907 a newspaper published an editorial on "Where can the city child study?" showing that in New York the curriculum, the schoolhouse, and the tenements are so crowded and so noisy that study is practically impossible. Lack of sleep, lack of a quiet place in which to study at school and at home, are causes for nervousness, whether these conditions are in the city or in the country. What evidence is there that the country curriculum is less crowded or country work better adjusted to the psychological and physiological age of the country pupil? The index is there; it should be read.

[113]In breaking habits of nervousness the first step is to explain how easily habits are formed, why their effects may be serious, and how a little attention will correct them. When a habit loses its mystery it becomes unattractive. Children will take an interest in coöperating with each other and with the teacher in curing habits acquired either at home or at school. My pupils greatly enjoyed overcoming the habit of jumping or screaming after some sudden noise. I told them how, when a boy, my imagination had been very much impressed by one of Thackeray's characters, the last remnant of aristocratic traditions, almost a pauper, but possessing one attribute of nobility,—absolute self-control. When his house burned he stood with his ankles crossed, leaning on his cane, the only onlooker who was not excited. For months I imitated that pose, using sticks and rakes and fork handles. The result was that when I taught school, a scream, a broken desk, or unusual noise outside reminded me of my old aristocrat in time to prevent my muscles from jumping. In a very short time several fidgety and nervous girls and boys had learned to think twice and to relax before jumping.

One test of thorough relaxation in a dentist's chair proves the folly of tightening one's muscles. When in school or out the remedy for nervousness is relaxation. The discipline that prohibits a pupil from stretching or changing his posture or seat is as much to be condemned as that which flourishes the rod. It has been said of our schools that children are not worked to death but bored to death. Wherever a room must be stripped of all beauty and interest to induce concentration, wherever the greater part of the teacher's time must be spent in keeping order, there is confession either of inappropriateness of the present curriculum or of the failure of teacher and text-book to present subjects attractive to the pupils. Nervous habits will be inevitable until the pupil's attention is obtained through interest. [114]Sustained interest will be impossible until teacher and pupil alike practice relaxation, not once a morning or twice a day, not during recess or lunch hour, but whenever relaxation is needed.

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

FOOTNOTES:

CHAPTER XIIToC

HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING

A boy without play means a father without a job. A boy without physical training means a father who drinks. When people have wholesome, well-disciplined bodies there will be less demand for narcotics as well as for medicines. On these three propositions enthusiasm has built arguments for city parks and playgrounds, for school gymnastics, and for temperance instruction. We have tried the remedies and now realize that too much was expected of them. Neither movement appreciated the mental and physical education of spontaneous games and play.

Like hygiene instruction, physical training was made compulsory by law in many states, and, like hygiene instruction, physical training had to yield to the pressure of subjects in which children are examined. At the outset both were based upon distorted psychology and physiology. Of late physical training has been revived "to correct defects of the school desk and to relieve the strain of too prolonged study periods." In New York grammar schools ten minutes a day for the lower grades, and thirty minutes a week for the higher grades, are set aside for physical training. With the exception of eighteen schools where apparatus is used, the exercise has been in the class rooms. It consists of what are known as "setting-up exercises,"—deep breathing and arm movements for two minutes between each study period, often forgotten until it is time to go home, when the children are tired and need it least. Many teachers so conduct these exercises that children keenly enjoy them.

[116]

SERVICEABLE RELIEF FROM SCHOOL STRAIN, BUT A POOR SUBSTITUTE FOR OUTDOOR PLAY

Like hygiene instruction, physical training preceded physical examination. Generally speaking, it has not yet, either in schools or in colleges, been related to physical needs of the individual pupil. In fact, there is no guarantee that it is not in many schools working a positive injury on defective children or imposing a defective environment on healthy children. Formal exercises in cramped space, in ill-ventilated rooms, with tight belts and heavy shoes, are conceded to be pernicious. Formal exercises should never be given to any child without examination and prescription by a physician. Children with heart weakness, enlarged tonsils, adenoid growths, spinal curvature, uneven shoulders, are frequently seen doing exercises for which they are physically unfit, and which but serve to deplete further their already low vitality. Attention might be called to many a class engaged in breathing exercises when by actual count over half the boys were holding their mouths open. Special exercises are needed by children who show some marked [117]defect like flat foot, flat chest, weak abdominal muscles, habitual constipation, uneven shoulders, spinal trouble, etc.

That no physical training should be provided for normal children is the belief of many leading trainers. This special training is useful to develop athletes or to correct defects. Like massage, osteopathy, or medicine, it should follow careful diagnosis. The time is coming when formal indoor gymnasium exercises for normal pupils or normal students will be considered an anomaly. There is all the difference in the world between physical development and what is called physical training. The test of physical development is not the hours spent upon a prescribed course of training, but the physical condition determined by examination. To be refused permission to substitute an hour's walk for an hour's indoor apparatus work is often an outrage upon health laws. Given a normal healthy body, plenty of space, and plenty of playtime, the spontaneous exercise which a child naturally chooses is what is really health sustaining and health giving.

Mere muscular development artificially obtained through the devices of a gymnasium is inferior to the mental and moral development produced by games and play in the open air. Eustace Miles, M.D., amateur tennis player of England, says:

The "healthy-mindedness" and "physical morality" which play and games foster rarely result from physical training as a business, at stated times, indoors, under class direction. It is too much like taking medicine. A certain breakfast food is said to have lost much of its [118]popularity since advertised as a health food. When the National Playground Association was organized President Roosevelt cautioned its officers against too frequent use of the word "supervision" on the ground that supervision and direction were apt to defeat the very purpose of games and to stultify the play spirit. Is the little girl on the street who springs into a hornpipe or a jig to the tune of a hurdy-gurdy, or even the boy who runs before automobiles or trolley cars or under horses' noses, getting less physical education than those who play a round game in silence under the supervision of a teacher in the school basement, or who stretch their arms up and down to the tune of one, two, three, four, five, six? Who can doubt that the much-pitied child of the tenement playing with the contents of the ash can in the clothes yard or with baby brother on the fire escape is developing more originality, more lung power, and better arteries than the child of fortune who is led by the hand of a governess up and down Fifth Avenue.

Children have not forgotten how to play, but adults have forgotten to leave space in cities, and time out of school, home work, and factory work in which children may play. Again, the child—whether a city child or a country child—rarely needs to be taught how to play. Teaching him games will not produce vitality. Games are the spontaneous product of a healthy body, active mind, and a joy in living. Give the children parks and piers, roof gardens and playgrounds in which they may play, and leave the rest to them. Give them time away from school and housework, and leave the rest to them. Instead of lamenting the necessity for playing in the streets, let us reserve more streets for children's play. There are too many students of child welfare whose reasoning about play and games is like that of a lady of Cincinnati, who, upon reading the notice of a child-labor meeting, said: "Well, I am glad to see there is going to be a meeting here for child labor. It is high time [119]some measure was taken to keep the children off the streets." Physical examinations would prove that streets are safer and better than indoor gymnasiums for growing children. Intelligent physical training will train children to go out of doors during recess; will train pupils and teachers not to use recess for study, discipline, or eating lunch.

SPONTANEOUS PLAY ON ONE OF NEW YORK CITY'S SCHOOL ROOF PLAYGROUNDS

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

[120]The educational value of games and outdoor play should be weighed against the advantages of lowering the compulsory school age, and of bridging over the period from four to seven with indoor kindergarten training. Neither physical training nor education is synonymous with confinement in school. The whole tendency of Nature's processes in children is nutritional; it is not until adolescence that she makes much effort to develop the brain. Overuse of the young mind results, therefore, in diverting natural energy from nutritive processes to hurried growth of the overstimulated brain. The result is a type of child with a puny body and an excitable brain,—the neurotic. The young eye, for example, is too flat (hypermetropic)—made to focus only on objects at a distance. Close application to print, or even to weaving mats or folding bits of paper accurately, causes an overstrain on the eye, which not only results in the chronic condition known as myopia,—short-sightedness,—so common to school children, but which acts unfavorably on the constitution and on the whole development of the child. At the recent International Congress of School Hygiene in London, Dr. Arthur Newsholme, medical officer of health of Brighton, made a plea for the exclusion of children under five years of age from schools. "During the time the child is in the infant department it has chiefly to grow. Nutrition and sleep are its chief functions. Paints, pencils, paper, pins, and needles should not be handled in school by children below six." Luther Burbank, in an article on "The Training of the Human Plant," says:

Not every child can have these blessings of the country, but every child can be protected from the stifling of the nature instinct of play by formal indoor "bossed" exercises, whether called games, physical training, gymnastics, or Delsarte.

NEW YORK CITY'S SCHOOL FARM DOES NOT STIFLE NATURE INSTINCT

The answer to the protest against too early and too constant confinement in school has always been: "Where will the child be if out of school? Will its environment at home not work a worse injury to its health? Will not the street injure its morals?" Because we have not yet worked out a method of supervising the health of those children who are not in school, it does not follow that such supervision is impossible. Perhaps the time will come when there will be state supervision over the health of children from birth, parents being expected to present them once a year at school for examination by the school physician. In this way defects can be corrected and health measures [122]devised to build up a physique that should not break down under the strain of school life. For children whose mothers work during the day, and for those whose home environment is worse than school, it might be cheaper in the long run to assign teachers to protect them from injury while they play in a park, roof garden, or out-of-door gymnasium. If parks and playgrounds come too slowly, why not adopt the plan advocated by Alida S. Williams, a New York principal, of reserving certain streets for children between the hours of three and five, and of diverting traffic to other streets less suitable for children's play? So great is the value—mentally, morally, and physically—of out-of-door play that it has even been suggested that the substitution of such play for school for all children up to the age of ten would insure better minds and sounder physiques at fifteen. It is generally admitted that the child who enters school at eight rather than at six will be the gainer at twelve. What a travesty upon education to insist upon schooling for children because they are apt to be run over on the street, or to be neglected at home, to shoot craps, or belong to a gang and develop bad morals.

Educators will some day be ashamed to have made the schools the catch-all or the court-plaster for the evils of modern industry. Instead of pupils and mothers going to the school, enough hygiene teachers, and play teachers, and district physicians could be employed with the money now spent on indoor instruction to do the house-to-house visiting urged in many chapters of this book. Such a course of action would have an incalculable effect on the reduction of tuberculosis, not only in making healthier physiques but by inculcating habits of outdoor life and love of fresh air. The danger of those contagious diseases which ravish childhood would be greatly reduced. An ambition for physical integrity would make unnatural living unpopular. Competition in games with children of the same [123]physical class develops accuracy, concentration, dispatch, resourcefulness, as much as does instruction in arithmetic. Smoking can easily be discredited among boys trying to hit the bull's-eye. A boy would sooner give up a glass of beer than the championship in rifle shooting or a "home run."

The influence of the "spirit of the game" on practical life has been described thus by New York's director of physical training, Dr. Luther H. Gulick:

CHAPTER XIIIToC

VITALITY TESTS AND VITAL STATISTICS

Two things will disclose the strength or weakness of a bank and the soundness or unsoundness of a nation's banking policy, namely, a financial crisis or an expert audit. A searching audit that analyzes each debit and each credit frequently shows that a bank is solvent only because it is not asked to pay its debts. It continues to do business so long as no obvious weaknesses appear, analogous to measles, adenoids, or paralysis. A frequent disorder of banking results from doing too big a business on too little capital, in making too many loans for the amount of cash held ready to pay depositors upon demand. This disorder always comes to light in a crisis—too late. It can be discovered if looked for in advance of a crisis. Many individuals and communities are likewise physically solvent only because their physical resources are not put to the test. Weaknesses that lie near the surface can be discovered before a crisis by physical examination for individuals and sanitary supervision for communities. Whether individuals or communities are trying to do too much business for their health capital, whether the health reserves will pay debts that arise in a crisis, whether we are ill or well prepared to stand a run on our vitality, can be learned only by carefully analyzing our health reserves. Health debits are compared with health credits for individuals by vitality tests, for communities by vital statistics.

Of the many vitality tests none is practicable for use in the ordinary class room. Scientific training is just as necessary for such tests as for discovering the quality of [125]the blood, the presence or absence of tubercle bacilli in the sputum, diphtheria germs in throat mucus, or typhoid germs in milk. But scientific truth, the results of scientific tests, can be made of everyday use in all class rooms. State and national headquarters for educators, and all large cities, can afford to engage scientists to apply vitality tests to school children for the sake of discovering, in advance of physical breakdown and before outward symptoms are obvious, what curriculum, what exercise, what study, recreation, and play periods are best suited to child development. It will cost infinitely less to proceed this way than to neglect children or to fit school methods to the loudest, most persistent theory.

The ergograph is an interesting strength tester. It takes a picture (1) of the energy exerted, and (2) of the regularity or fitfulness of the manner in which energy is exerted. Perhaps the time will come when science and commerce will supply every tintype photographer with an ergograph and the knowledge to use it. Then we shall hear at summer resorts and fairs, "Your ergograph on a postal card, three for a quarter." We can step inside, harness our middle finger to the ergograph, lift it up and down forty-five times in ninety seconds, and lo! a photograph of our vitality! If we have strong muscles or good control, the picture will be like this:

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.

[126]If weak and nervous, we shall look like this before taking exercise:

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:

Fig. 3. Ergogram of C.E. after taking 40 minutes' work in the gymnasium, showing that the exercise proved very exhausting. Weight used, 3.5 kg. Distance lifted, 55 cm.

In Chicago, two of whose girls are above photographed, the physician was surprised to have four pupils show more strength late in the day than in the morning. "Upon investigation it was found that the teacher of the four pupils had been called from school, and that they had no regular work, but had been sent to another room and employed themselves, as they said, in having a good time." The chart on page 127 shows the effect of the noon recess and of the good time after three o'clock.

Chicago's child-study experts concluded after examining a large number of children:

Fig. 4.

To these conclusions certain others should be added, not as settled beyond any possibility of modification, but as being fairly indicated by these tests.

Physiological age, according to studies made in New York City, should be considered in grading, not only for physical culture classes but for all high school or continuation classes. Dr. C. Ward Crampton, assistant physical director, while examining boys in the first grade of the High School of Commerce, noticed a greater variation in physical advancement than in years. He kept careful watch of the educational progress and discovered three clear divisions: (1) boys arrived at puberty,—postpubescent; (2) boys approaching maturity,—pubescent; (3) boys not yet approaching maturity,—prepubescent.

The work in lower grades they had all passed satisfactorily, but in high school only the most advanced class [130]did well. Practically none of the not-yet-maturing boys survived and few of the almost mature. In other words, the high school course was fitted to only one of the three classes of boys turned out of the grammar schools. The others succumbed like hothouse azaleas at Christmas time, forced beyond their season. Physiological age, not calendar years or grammar school months, should determine the studies and the companions of children after the tenth year. Physiological strength and vitality, not ability to spell or to remember dates, should be the basis of grading for play and study and companionship among younger children. Vitality, power to endure physically, should be the test of work and recreation for adults. Physicians may be so trained to follow directions issued by experts that physical examinations will disclose the chief enemies of vitality and the approximate limits of endurance.

Teachers may train themselves to recognize signs of fatigue in school children and to adapt each day's, each hour's work to the endurance of each pupil. One woman principal has written:

Because adults at work and at play reluctantly submit themselves to vitality tests, because few scientists are beseeching individuals to be tested, because almost no one yearns to be tested, the promotion of adult vitality and of community vitality can best be hastened by demanding complete vital statistics. Industrial insurance companies and mutual benefit societies are doing much to educate laborers regarding the effect upon vitality of certain dangerous and unsanitary trades, and of certain unhygienic habits, such as alcoholism and nicotinism. Progress is slower than it need be because state boards of health are not gathering sufficiently complete information about causes of sickness and death. American health and factory inspection is not even profiting, as it should, from British, German, and French statistics. Statistics are in ill repute because the truth is not generally known that our boasted sanitary improvements are due chiefly to the efficient use of vital statistics by statesmen sanitarians.[7]

The vital statistics of greatest consequence are not the number of deaths or the number of births, not even the number of deaths from preventable diseases, but rather the number of cases of sickness from transmissible diseases. The cost and danger to society from preventable diseases, such as typhoid, diphtheria, scarlet fever, measles, are imperfectly represented by the number of deaths. Medical skill could gradually reduce death rates in the face of [132]increasing prevalence of infectious disease. With few exceptions, only those patients who refuse to follow instructions will die of measles, diphtheria, or smallpox. The scarlet-fever patient who recovers and goes to church or school while "peeling" can cause vastly more sickness from scarlet fever than a patient who dies. Dr. W. Leslie Mackenzie, who has recently written The Health of the School Child, said ten years ago, while health officer of Leith:

The best guarantee against such loss, the best protection of health, and the most essential element of vital statistics is prompt, complete record of cases of sickness. Statistics of sickness are confined to sickness from transmissible diseases, because we have not yet arrived at the point where we recognize the state's right to require information, except when the sick person is a menace to the health of other persons.

The annual report of a board of health should give as clear a picture of a community's health during the past week or past quarter as the ergograph gives of the pupils mentioned on page 126. As ragged, rapidly shortening lines show nervousness and depleted vitality, so charts and diagrams can be made to show the needless waste of infant life during the summer months, the price paid for bad ventilation in winter time, when closed windows cause the sickness-and-death line from diphtheria and scarlet fever to shoot up from the summer level. In cities it is now customary for health boards to report weekly the number of deaths from transmissible diseases. Health officers will [133]gladly furnish facts as to cases of sickness, if citizens request them. Newspapers will gladly publish such information if any one will take the pains to supply it. Wherever newspapers have published this information, it quickly takes its place with the weather reports among the news necessities. Marked changes are commented on editorially. Children can easily be interested, as can adults, in filling out week by week a table that will show increases and decreases in preventable sickness due to transmissible diseases.

Table X

Cases of Infectious and Contagious Diseases Reported

In cities where physicians are not compelled to notify the health board of danger centers,—that is, of patients sick from measles, smallpox, or diphtheria,—and in smaller communities where notices are sent only to state boards of health, parents will find it difficult to take a keen interest in vital statistics. But if teachers would start at the beginning of the year to record in such a table the days of absence from school because of transmissible disease, both they and their pupils would discover a new interest in efficient health administration. After a national board of [134]health is organized we may reasonably expect that either state boards of education or state boards of health will regularly supply teachers with reports that will lead them to compare the vitality photographs of their own schools and communities with the vitality photographs of other schools and other communities working under similar conditions. Then children old enough to study physiology and hygiene will be made to see the happiness-giving possibilities of vitality tests and vital statistics.

VITAL STATISTICS CAN MAKE DISEASE CENTERS AS OBVIOUS AND AS OFFENSIVE AS THE SMOKE NUISANCE

Instead of discussing the theory of vital statistics, or the extent to which statistics are now satisfactory, it would be better for us at this point to make clear the significance of the movement for a national fact center for matters pertaining to personal, industrial, and community vitality. [135]Five economic reasons are assigned for establishing a national department of health:

Among the branches of the work proposed for the national bureau are the following: infant hygiene; health education in schools; sanitation; pure food; registration of physicians and surgeons; registration of drugs, druggists, and drug manufacturers; registration of institutions of public and private relief, correction, detention and residence; organic diseases; quarantine; immigration; labor conditions; [136]disseminating health information; research libraries and equipment; statistical clearing house for information.

Given such a national center for health facts or vital statistics, there will be a continuing pressure upon state, county, and city health officers, upon physicians, hospitals, schools, and industries to report promptly facts of birth, sickness, and death to national and state centers able and eager to interpret the meaning of these facts in such simple language, and with such convincing illustrations, that the reading public will demand the prompt correction of preventable evils.

Our tardiness in establishing a national board of health that shall do this great educational work is due in part to the fact that American sanitarians have frequently chosen to do things when they should have chosen to get things done. Almost every state has its board of health, with authority to require registration of births, deaths, and sickness due to transmissible disease; with few exceptions the heads of these state boards have spent their energies in abating nuisances. In a short time they have degenerated into local scavengers, because they have shown the public neither the meaning of the vital statistics gathered nor its duty to support efficient health administration.

The state reports of vital statistics have not been accurate; therefore in many states we have the anomalous situation of an aggressive veterinary board arousing the farmer and the consumer of milk to the necessity of protecting the health of cattle, and an inactive, uninformed state board of health failing to protect the health of the farmer and the consumer.

Vital statistics presume efficient health administration. An inefficient health officer will not take the initiative in gathering health statistics. If some one else compels him to collect vital statistics, or furnishes him with statistics, they are as a lantern to a blind man. Unless some one [137]also compels him to make use of them, unless we remove the causes of transmissible or infectious diseases and check an epidemic when we first hear of it, the collection of information is of little social value. "Statistics" is of the same derivation as "states" and "statesmen." Statistics have always been distinguished from mere facts, in that statistics are instruments in the hands of the statesman. Wherever the term "statistics" is applied to social facts it suggests action, social control of future contingencies, mastery of the facts whose action they chronicle. The object of gathering social facts for analysis is not to furnish material for future historians. They are to be used in shaping future history. They are facts collected with a view to improving social vitality, to raising the standard of life, and to eliminating permanently those forces known to be destructive to health. Unless they are to be used this way, they are of interest only to the historical grub. No city or state can afford to erect a statistical office to serve as a curiosity shop. Unless something is to be done to prevent the recurrence of preventable diseases annually experienced by your community or your school, it is not reasonable to ask the public printer to make tables which indicate the great cost of this preventable sickness. A tax collector cannot discharge his duties unless he knows the address of every debtor. The police bureau cannot protect society unless it knows the character and haunts of offenders. A health officer cannot execute the law for the protection of society's health unless he knows the haunts and habits of diseases. For this he must look to vital statistics.

But the greatest service of vital statistics is the educational influence. Health administration cannot rise far above the hygienic standards of those who provide the means for administering sanitary law. The taxpaying public must believe in the economy, utility, and necessity of efficient health administration. Power and funds come [138]from town councils and state legislatures. To convince and move these keepers of the purse, trustworthy vital statistics are indispensable. Information will be used for the benefit of all as soon as it is possessed by all.

Fortunately the gathering of vital statistics is not beyond the power of the kind of health officer that is found in small cities and in rural communities. If years of study of mathematics and of the statistical method were required, we should despair of obtaining light within a century. But the facts we want are, for the most part, common, everyday facts, easily recognizable even by laymen; for example, births, deaths, age at death, causes of death, cases of transmissible diseases, conditions found upon examination of children applying for work certificates, etc. Where expert skill is required, as at state and national headquarters, it can be found. Every layman can train himself to use skillfully the seven ingredients of the statistical method which it is his duty to employ, and to know when to pay for expert analysis and advice. We can all learn to base judgment of health needs upon the seven pillars,—desire to know, unit of inquiry, count, comparison, percentages, classification, and summary.

FOOTNOTES:

CHAPTER XIVToC

IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?

Last year a conference on the physical welfare of school children was told by a woman principal: "Of course we need physicians to examine our children and to teach the parents, but many of us principals believe that our school curriculum and our school environment manufacture more physical defects in a month than all your physicians and nurses will correct in a year." At the same meeting the physical director of schools of New York City appealed eloquently for "biological engineers" at school, who would test the child's strength as building engineers are employed to test the strength of beams and foundations.[8] As explanation for the need of the then recently organized National School Hygiene Association, he elaborated the proposition that school requirements and school environment damage child health. "Ocular defects are in direct ratio to the length of time the pupil has attended school.... A desk that is too high may easily be the indirect agent for causing scoliosis, producing myopia or astigmatism.... Physically examine school children by all means, but do not fail to examine school desks."

Fifty schools in different parts of New York City were examined last year with especial reference to the factors likely to cause or to aggravate physical defects.[9] The results, [140]tabulated and analyzed, prove that the woman principal was right; many schools are so built or so conducted, many school courses are so devised or so executed, that children are inevitably injured by the environment in which the compulsory education law forces them to spend their formative years.

ONE OF NEW YORK CITY'S ROOF PLAYGROUNDS

Recently I noticed that our little office girl, so anæmic and nervous when she left school that we hesitated to employ her, was becoming rosy and spirited. The child herself explained the change: "I like it better. I have more money to spend. I get more outdoor exercise, and then, oh, the room is so much sunnier and there is more air and the people are all so nice!" And these were just the necessities which were lacking in the school from which she came. Moreover, it is a fair commentary on the school work and the school hygiene in too many of our towns and cities to-day. "I like it better" means that school work is not adapted to the dominant interests of the child, that the curriculum includes subjects remote from the needs and ambitions of the modern school child, and fails to include certain other subjects which it recognizes as useful and necessary, and [141]therefore finds interesting. "I have more money to spend" means that this little girl was able to have certain things, like a warm, pretty dress, rubbers, or an occasional trolley ride, which she longed for and needed. "I get more outdoor exercise" means that there was no open-air playground for her school, that "setting up" exercises were forgotten, that recess was taken up in rushing home, eating lunch, and rushing back again, and that "after school" was filled up with "helping mother with the housework." "The office is so much sunnier and I get more air" accounts for the increase in vitality; and "the people are all so nice," for the happy expression and initiative which the undiscriminating discipline at school had crushed out.

BONE TUBERCULOSIS IS ONE OF THE PENALTIES FOR DRY SWEEPING AND FEATHER DUSTERS

For such unsanitary conditions crowded sections of great cities have no apologies to make to rural districts. A wealthy suburb recently learned that there was overcrowding in every class room, and that one school building was so unsanitary as to be a menace to the community. Unadjustable desks, dry sweeping, feather dusters, shiny blackboards, harassing discipline that wrecks nerves, excessive home study and subjects that bore, are not peculiar to great [142]cities. In a little western town a competition between two self-governing brigades for merit points was determined by the amount of home study; looking back fifteen years, I can see that I was encouraging anæmic and overambitious children to rob themselves of play, sleep, and vitality. Many a rural school violates with impunity more laws of health than city factories are now permitted to transgress.

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

Many of the evils of school environment the teacher can avert, others the school trustee should be expected to correct. So far as unsanitary conditions are permitted, the school accentuates home evils, whereas it should counteract them by instilling proper health habits that will be taken home and practiced. Questions such as were asked in Miss North's study will prove serviceable to any one desiring to know the probable effect of a particular school environment upon children subject to it. Especially should principals, superintendents, directors, and volunteer committeemen apply such tests to the public, parochial, or private school, orphanage or reformatory for which they may be responsible.

I. Neighborhood Health Resources

VACATION-SCHOOL PLAY CLINIC ON A "VACANT" CITY LOT
OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH

II. Effect of School Equipment upon Health

AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF CONGESTION—A BOYS' HIGH SCHOOL, NEW YORK CITY

[146]III. The Class Room as a Place of Confinement

IV. Exercise and Recreation

HOME WORKSHOPS NEED FRESH AIR

V. The School Janitor and Cleaners

SCHOOL WORKSHOPS ALSO NEED FRESH AIR

VI. Requirements of Curriculum

By reducing the harm done by old buildings and by the traditions of curriculum and discipline, teachers can do a great deal. Perhaps they cannot move the windows or the desks, but they can move the children. If they cannot insure sanitary conditions for home study, they can cut down the home study. If the directors do not provide proper blackboards, they can do less blackboard work. They can make children as conscious, as afraid, and as resentful of dirty air as of dirty teeth. They can make janitors believe that "dry sweeping" or "feather dusting" may give them consumption, and leave most of the dirt in the room to make work for the next day; that adjustable desks are made to fit the child's legs and back, not the monkey wrench; that the thermometer in the schoolroom is a safer guide to heat needed than a boiler gauge in the basement; that fresh air heated by coal is cheaper for the school fund than stale air heated by bodies and by bad breath. Finally, they can make known to pupils, to parents, to principals and superintendents, to health officials and to the public, the extent to which school environment violates the precepts of school hygiene.

If the state requires the attendance of all children between the ages of five and fourteen at school for five hours a day, for five days in the week, for ten months in the year, then it should undertake to see that the machinery it provides for the education of those children for the greater part of the time for nine years of their lives—the formative years of their lives—is neither injuring their health nor retarding their full development.

If the amount of "close-range" work is rapidly manufacturing myopic eyes; if bad ventilation, whether due to [151]faulty construction or to faulty management, is preparing soil for the tubercle bacillus; if children with contagious diseases are not found and segregated; if desks are so ill adapted to children's sizes and physical needs that they are forming crooked spines; if too many children are crowded into one room; if lack of air and light is producing strained eyes and malnutrition; if neither open air, space, nor time is provided for exercise, games, and physical training; if school discipline is adapted neither to the psychology nor the physiology of child or teacher, then the state is depriving the child of a greater right than the compulsory education law forces it to endure. Not only is the right to health sacrificed to the right to education, but education and health are both sacrificed.

In undertaking to enforce the compulsory education law, to put all truants and child laborers in school, the state should be very sure for its own sake that it is not depriving the child of the health on which depends his future usefulness to the state as well as to himself.

Table XI

Effects of a Child Labor Law

Increase in Chicago Attendance

FOOTNOTES:

CHAPTER XVToC

THE TEACHER'S HEALTH

"Teachers, gentlemen, no less than pupils, have a heaven-ordained right to work so adjusted that the highest possible physical condition shall be maintained automatically." This declaration thundered out by an indignant physician startled a well-meaning board of school directors. The teacher's right to health was, of course, obvious when once mentioned, and the directors concluded:

Too little concern has hitherto been shown for the vitality of teachers in private or public schools and colleges. Without protest, and without notice until too late, teachers often neglect their own health at home and at school,—recklessly overwork, undersleep, and undernourish; ruin their eyes, their digestion, and their nerves. School-teachers are frequently "sweated" as mercilessly as factory operatives. The time has come to admit that a school environment which destroys the health of the teacher is as unnecessary and reprehensible as an army camp that spreads typhoid among a nation's defenders. A school curriculum or a college tradition that breaks down teachers is as inexcusable as a gun that kills the gunner when discharged. [153]Experience everywhere else proves that periodic physical examinations and health precautions, not essays about "happy teachers—happy pupils," are indispensable if teachers' health rights are to be protected.

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

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

The advantages of physical examination upon beginning and during the courses that prepare one for a teacher are so obvious that but little opposition will be given by prospective teachers. The disadvantages to teacher and pupil alike of suffering from physical defects are so obvious that every school which prepares men and women for teachers should make registration and certification dependent upon passing a satisfactory physical test. No school should engage a teacher who has not good proof that she can do the [154]required work without injury to her own or her pupils' health. Long before physicians can discover pulmonary tuberculosis they can find depleted vitality which invites this disease. Headaches due to eye trouble, undernourishment due to mouth breathing, preventable indigestion, are insidious enemies that cannot escape the physical test.

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

1. A sickly teacher is often the most efficient teacher in a school or a county. It is true that some sickly teachers exert a powerful influence over their pupils, but in most instances their influence and their efficiency are due to powers that exist in spite of devitalizing elements. Rarely does sickness itself bring power. It must be admitted that many a man is teaching who would be practicing law had his health permitted it. Many a woman's soul is shorn of its self-consciousness by suffering. But even in these exceptional instances it is probable that children are paying too dearly for benefits directly or indirectly traceable to defects that physical tests would exclude.

2. There are not enough healthy candidates to supply our schools. This is begging the question. In fact, no one knows it is true. On the contrary, it is probable that the teacher's opportunity will make even a stronger appeal to competent men and women after physical soundness and vitality are made conditions of teaching,—after we all believe what leading educators now believe, that the highest fulfillment of human possibilities requires a normal, sound body, abounding in vitality.

3. Examination by a physician, especially if a social acquaintance, is an unnecessary embarrassment. The false modesty that makes physical examination unwelcome to many adults, men as well as women, is easily overcome when the advantages of such examination are understood. [155]It is likewise easy to prove to a teacher that the loss of time required in having the examination is infinitesimal compared with the loss of time due to ignoring physical needs. The programme for school hygiene outlined in Chapter XXVII, Part IV, assumes that state and county superintendents will provide for the examination of teachers as well as of pupils.

TEACHERS WILL PREFER PHYSICAL EXAMINATIONS TO FORCED VACATIONS
Boston Society for Relief and Study of Tuberculosis

Because the health of others furnishes a stronger motive for preventive hygiene than our own health, it is probable that the general examination of teachers will come first as the result of a general conviction that unhealthy teachers positively injure the health of pupils and retard their mental development. Children at school age are so susceptible and imitative that their future habits of body and mind, their dispositions, their very voices and expressions, are influenced by those of their teachers. Experts in child [156]study say that a child's vocal chords respond to the voices and noise about him before he is able to speak, so that the tones of his voice are determined before he is able to express them. This influence is also marked when the child begins to talk. Babies and young children instinctively do what adults learn not to do only by study,—follow the pitch of others' voices. Can we then overestimate the effect upon pupils' character of teachers who radiate vitality?

The character and fitness, aside from scholarship, of applicants for teachers' licenses are now subjected by the board of examiners of New York City to the following tests:

These tests probably exclude few applicants who should be admitted. Experience proves that they include many who, for their own sake and for children's sake, should be rejected. The moral character, physical fitness, quality of voice, personal bearing, self-command, executive ability, [157]capacity for supervision, are qualities that are modified by conditions. The voice that is satisfactory in conference with an examiner may be strident and irritating when the teacher is impatient or is trying to overcome street noises. On parade applicants are equally cleanly; this cannot be said of teachers in the service, coming from different home environments. Self-command is much easier in one school than in another. Physical fitness in a girl of twenty may, during one short year of teaching, give way to physical unfitness. Therefore the need for periodic tests by principal, superintendent, and school board, to determine the continuing fitness of a teacher to do the special task assigned to her, based upon physical evidence of her own vitality and of her favorable influence upon her pupils' health and enjoyment of school life. Shattered nerves due to overwork may explain a teacher's shouting: "You are a dirty boy. Your mother is a dirty woman and keeps a dirty store where no decent people will go to buy." A physical examination of that unfortunate teacher would probably show that she ought to be on leave of absence, rather than, by her overwork and loss of control, to cause the boys of her class to feel what one of them expressed: "Grandmother, if she spoke so of my mother I would strike her."

Just as there should be a central bureau to count and correct the open mouths and closed minds that clog the little old red schoolhouse of the country, so a central bureau should discover in the city teacher as well as in the country teacher the ailments more serious than tuberculosis that pass from teacher to pupil; slovenliness, ugly temper, frowning, crossness, lack of ambition, cynicism,—these should be blackballed as well as consumption, contagious morphine habit, and contagious skin disease. Crooked thinking by teacher leads to crooked thinking by pupil. Disregard of health laws by teacher encourages unhygienic living by pupils. A man whose fingers are yellow, nerves [158]shaky, eyes unsteady, and mind alternately sleepy and hilarious from cigarettes, cannot convey pictures of normal, healthy physical living, nor can he successfully teach the moral and social evils of nicotinism. Both teacher and pupil have a right to the periodic physical examination of teachers that will give timely warning of attention needed. Until there is some system for giving this right to all teachers in private, parochial, charitable, and public schools, we shall produce many nervous, acrid, and physically threadbare teachers, where we should have only teachers who inspire their pupils with a passion for health by the example of a good complexion, sprightly step, bounding vitality, and forceful personality born of hygienic living.

PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS

CHAPTER XVIToC

EUROPEAN REMEDIES: DOING THINGS AT SCHOOL

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

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

Experience proves, however, that just as Roman walls and Norman castles look out of place in New York and Kansas, so European laws and European remedies are too frequently misfits when tried by American schools, hospitals, or city governments. Yesterday a Canadian clergyman, after preaching an eloquent sermon, met a professional beggar on the street in New York City and emptied his purse—of Canadian money! Quite like this is the enthusiastic demand of the tourist who has seen or read about "the way it's done in Germany." The trouble is that European remedies are valued like ruins, by their power to interest, by their antiquity or picturesqueness, or, like the beggar, by their power to stimulate temporary emotion. [161]But we do not sleep in ruins, go to church regularly in thirteenth-century abbeys, or live under the remedies that fire our imagination. We do not therefore see their everyday, practical-result side.

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

We have been asked of late to copy several very attractive European remedies for the physiological ills of school children, and for the physical deficiencies of the next generation of adults: breakfasts or lunches, or both, at school for all children, rich as well as poor, whether they want school nourishment or not; school meals for the poor only; school meals to be given the poor, but to be bought by those who can afford the small sum required; free eyeglasses for the poor, for poor and well-to-do, for those who wish them, for those who need them whether they want to wear eyeglasses or not; free dental care; free surgical treatment; free rides and outings during summer and winter; country children to visit the metropolis, city children to visit country [162]and village; free treatment in the country of all children whose parents are consumptives; free rides on street cars to and from school; city-owned street railways that will prevent congestion by making the country accessible; city-built tenements to prevent overcrowding, dark rooms, insufficient air and light; free coal, free clothes, free rent for those whose parents are unable to protect them properly against hunger and cold. Every one of these remedies is attractive. Every one is being tried somewhere, and can be justified on emotional, economic, and educational grounds, if we think only of its purpose. Let us view them with the eyes of their advocates.

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

City children, on the other hand, would reap worlds of physical benefit and untold inspiration from periods of recreation and study in the country, with its quiet, its greens and bronzes and yellows, its birds and animals, its sky that sits like a dome on the earth, its hopefulness. Winter sleigh rides and coasting would give new vigor and ambition. Why spend so much on teaching physiology, geography, and nature study, if in the end we fail to send the child where alone nature and hygiene tell their story? Why tax ourselves to teach history and sociology and commercial geography out of books when excursions to the city and country will paint pictures on the mind that can never be erased? What more attractive or more reasonable than appetizing, warm meals, or cool salads and drinks for [163]the boys and girls who carry their little dinner pails and baskets down the long road where everything runs together in summer and everything freezes in winter? One needs little imagination to see the "smile that won't come off," health, punctuality, and school interest resulting from the school meal.

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

A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"

The economic defense of these remedies is many-sided. An English drummer once instructed me during a railroad journey from southern to northern Ireland. As we entered the fertile fields of Lord Dunraven's estate near Athlone, I expressed sympathy for other countries impoverished of soil, of wealth, and of thrift. My instructor replied: "It would pay the government to bring them all to this land free once a year, just to show them what they are missing." That his idea of an investment is sound has been proved by railroads and land companies and even by states, who give away excursions to entice settlers and buyers. Ambition at almost any cost is cheaper than indifference to opportunity. It would be cheaper for our American taxpayer to send school children to city and country than to pay the penalty for having a large number of citizens with narrow interests, unconscious of the struggles and joys of [164]their co-citizens. Free meals, free books, free rides, free eyeglasses, are cheaper than free instruction for the second, third, and sixth terms in studies not passed because of physical defects,—infinitely cheaper than jails and almshouses, truant officers and courthouses.

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

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

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

Initiative and competition are not interrupted any more by free eyeglasses and free operation for adenoids than by [165]free schooling. There is only one place in the world where there is less competition or less struggle than among the ignorant, and that is among the ignorant and unwell. The boy who can't see the blackboard, who can't learn to spell, who can't breathe through his nose, and can't be interested, doesn't compete at all with the bright, healthy boy. Remove the adenoids, give glasses, make interest possible, and fitness to survive takes a higher level because larger numbers become fit to survive.

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

CHAPTER XVIIToC

AMERICAN REMEDIES: GETTING THINGS DONE

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

The committee grew out of the discussion, in the year 1905, of the following proposition: To insure a race physically able to receive our vaunted free education, we must provide at school free meals, free eyeglasses, free medical [167]and dental care. Thanks to the superintendent of schools of New York City, to Robert Hunter's Poverty, to John Spargo's Bitter Cry of the Children, hundreds of thousands of American citizens were made to realize for the first time that a large proportion of our school children are in serious need of medical, dental, or ocular attention, or of better nourishment.

Because physicians, dentists, oculists, hospitals, dispensaries, relief agencies, had seemingly been unconscious of this serious state of affairs, they had no definite, constructive remedy to propose. Their unpreparedness served to strengthen the arguments for the European method of doing things. France, Germany, Italy, England, had found it necessary to do things at school. Arguing from their experience, it was only a matter of time when American cities must follow their example. Why not, therefore, begin at once to deal radically with the situation and give school meals, school eyeglasses, etc.? Those who organized the Committee on the Physical Welfare of School Children realized the danger of trying to settle so great a question with the little definite information then available. If doing things at school were to be adopted as a principle and logically carried out, vast sums must be added to the present cost of the public school system. Complications would arise with private and parochial schools, whose children might have quite as serious physical defects, even though not educated by public funds. It would be difficult to obtain proper rooms for medical and dental treatment and meals, and perhaps still more difficult to insure proper food, skilled oculists, dentists, surgeons, and physicians. No one was clear as to how the problem was to be solved by small cities and rural districts, whose needy children are no less entitled to public aid simply because their numbers are smaller. Great as were the difficulties, however, the committee saw that difficulties are in themselves no reason for not doing the right thing. On the [168]other hand, if doing things at school is wrong, if school meals fail to correct and remove physical defects, great social and educational wrong would result from New York's setting an example that would not only misdirect funds and attention in that city, but would undoubtedly lead other cities to move in the wrong direction. Right could be hastened, wrong could be prevented more effectually by facts than by any amount of theory. School meals had been made a political issue in England. The arguments supporting them were stronger than any possible arguments against them, except proof that they would be less effective in helping children than other means that might be proposed. If the American people must choose between sickly, unteachable, dull children without school meals, on the one hand, and bright, teachable, healthy children plus school meals, on the other hand, they will not hesitate because of expense or eighteenth-century objections to "socialism."

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

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

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

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

2. Physical deterioration, applied to America's school children, is a misnomer. No evidence whatever has been given that the percentage of children suffering from physical defects in 1907 is greater than the percentage of children suffering from such defects in 1857. On the contrary, the small proportion of defects that are not easily removable, as well as a vast amount of evidence from medical experience and vital statistics, indicates that, if a comparison were possible, the children of 1907 would be found to have sounder bodies and fewer defects than their predecessors of fifty years ago. If there is an exception to this statement, it is probably defects of vision, with regard to which school authorities and oculists seem to agree that confinement in school for longer [170]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.

THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.

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 [171]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.

How the committee got things done is often referred to. There is something about a request for coöperation, whether by schools or by any other agency, that enlists the interest of those whose help is asked. The reason is not that people are flattered by requests to serve on committees, or that human nature finds it difficult to be unfriendly or unkind. On the contrary, men and women are by nature social; there is more joy in giving than in withholding, in working with others than in working alone. Men and women, official and volunteer agencies, will coöperate with school-teachers when invited, for the same reason and [172]with the same readiness that ninety-nine farmers out of a hundred, on the prairie or in the mountain, will welcome a request for food and lodging.

WHERE "GETTING THINGS DONE" IS POSSIBLE BUT "DOING THINGS" INEFFECTIVE

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

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

CHAPTER XVIIIToC

COÖPERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES

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

ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE UNIT

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

It seems easier for a teacher to give twenty-five cents to a child in distress than to see that the cause of the misery is removed. In New York City there are over five hundred school principals, under them are over fifteen thousand [175]teachers, and the average attendance of children is about six hundred thousand, representing one hundred and fifty thousand homes. If teachers give only to those children who ask for help, many will be neglected. In certain sections of the city principals have combined to establish a relief fund to be given out to children who need food, clothes, shoes, etc. One principal had to stop replacing stolen overcoats because, when it was known that he had a fund, an astonishingly large number of overcoats disappeared. At Poughkeepsie school children get up parties, amateur vaudeville, minstrel shows, basket picnics, to obtain food and clothing for children in distress. They are, of course, unable to help parents or children not in school. Of this method a district superintendent in New York said to his teachers and principals: "For thirty-two years I have been working in the schools of this district. I have given food and shoes to thousands of children. I know that however great our interest in a particular child when it comes to us with trouble at home, our duty as teachers prevents us from following our gift into the home and learning the cause of the child's trouble. This last winter we have made an experiment in using a central society, which makes it a business to find out what the family needs, to supply necessaries, country board, medicine, etc. We now know that we can put a slip of paper with the [176]name and address of the child into a general hopper and it will come out eyeglasses, food, rent, vacation parties, as the need may be."

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

FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID CHILDREN IN ORDER OF NEED

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

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

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

[177]

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

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

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

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

In none of these instances could the teachers have accomplished equal results for the individual children or for the families without neglecting school duties. By informing other agencies as to children's needs, teachers started movements that have since helped practically every school child in New York City. Dispensaries are setting aside separate hours for school children; fresh-air agencies are giving preference to children found by teachers or school physicians to be in physical need; relief agencies are making "rush orders" of every note from teachers; the health board is more active because volunteer agencies [179]have added their voice to that of teacher and health officer in demanding adequate funds for physical examination of school children.

"CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL, THE FATHER KILLED—THE CHILDREN WERE BOARDED IN THE COUNTRY UNTIL THE MOTHER RECOVERED

Coöperation is at present easier in New York than in any other city. Charitable societies, hospitals, dispensaries, are probably more keenly alive to their responsibilities and are at least more apt to have acquired the habit of coöperation when asked. Yet even here I have been told repeatedly by teachers: "If we have to wait for that hospital or that charitable society, our children will go barefoot." In small communities where hospital and relief agencies are for emergencies only and generally inactive, it seems that the first thing to do is to ask some friends to establish a small relief fund, just as it is easier to give a child a five-cent [180]meal than to teach its mother how to prepare its food. But the school-teacher will find that it takes very much less energy to arouse the relief society than to maintain her own relief work. In fact, in many cities nothing could do more to strengthen hospitals and charitable societies than to put them in touch with the needs of school children. For a principal to make known the fact that school children are neglected will help the charitable society and hospital to get the funds necessary to do their part better than they are now doing it and better than the school could ever do it. Finally, one reason for a breakdown of charitable societies is not their own inadequacy, but rather the failure of the [181]school and church to make use of an agency better equipped than themselves to give material relief. The teacher sees the child every day, while the relief society will never see it and has no reason to see it until some one calls attention to it. The very first step, and an indispensable one in relief policy, is for teachers to be on the lookout for children not adequately provided for, and then have the physical evidence discovered at school followed to the home for the cause of the child's distress.

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

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

[182]

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

FOOTNOTES:

CHAPTER XIXToC

SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE

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

Facts prove, as we have seen, that there is more than one way to prevent malnutrition. Parents can be taught to attend to their children; hospitals and dispensaries will furnish eyeglasses where parents are unable to pay for them; charitable societies will go back of the need for eyeglasses to the conditions that produce that need and will do vastly more for the child than can eyeglasses alone. If [185]parents, hospitals, dispensaries, and charitable societies will attend to children's needs, then relief at school is unnecessary, even though it may seem desirable.

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

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

"DOING THINGS" THROUGH MODEL TENEMENTS

Do we want to make of our schools miniature hospitals, dispensaries, relief bureaus, parks? Or shall we use the [186]momentum of society's interest in the school child to put within the reach of every school building adequate hospitals, dispensaries, relief centers, and parks for school child and adult? Shall every little school have its library, or shall the child be taught at school how to use the same library that [187]is available to his parents and older brothers and sisters? If the library is to be under the school roof, if dispensary and relief hospital are to be conducted on the same site as the school, shall they be known as dispensary, library, relief bureau, each under separate management, or shall [188]they be known as school under the management of school principal and superintendent? So complicated and many-sided is the problem of working together with one's neighbor for mutual benefit that it is a safe rule for the schools to adopt: We shall do nothing that is unnecessary or extravagant. We shall have done our part if we do well what no one else can do. Whatever any agency can do better than we, we shall leave to that agency. Work that another agency ought to have done and has left undone, we shall try to have done by that agency.

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

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

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

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

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

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

CHAPTER XXToC

PHYSICAL EXAMINATION FOR WORKING PAPERS

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

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

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

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

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

At the close of school last spring I had my secretary look in upon the New York board of health and see what demands that city makes upon its boys and girls before allowing them to drive its machinery, to run its elevators, to match its colors, to sew on its buttons, to set its type, to carry its checks to the bank. The officer at the door of the room where the children were being examined, greeted her as follows: "You must bring your child with you; bring his birth certificate or swear that he is fourteen years old, and bring a signed statement from his teacher that he has been in school for one hundred and thirty consecutive days [192]within twelve months." "Is there no physical examination or test?" she asked. "No, no," he answered impatiently. Yet the board of health certifies that "said child has in our opinion reached the normal development of a child of its age, and is in sound health and is physically able to perform the work which it intends to do." In addition the blank calls for place and date of birth, color of hair and of eyes, height, weight, and facial marks. Volunteer societies in practically every state in the Union have been working for years to have it made a criminal offense to employ a child who has not been in school a minimum of days after a stated age (12, 13, 14, 15). Even in New York, however, the center of this agitation, no strong demand was made upon the board of health to apply a physical-fitness test as well as an age test until 1908 when examination for working papers was added to the programme for child hygiene. Yet who does not know girls and boys of sixteen less fit for factory or shop work than other boys and girls of twelve? It is the fetich of age which has made possible the "democracy" that permits a child of fourteen to work all day on condition that he go to school at night!

CHILDREN ENLISTING IN THE INDUSTRIAL ARMY

[193]

WAITING TO BE EXAMINED FOR WORKING PAPERS
An excellent opportunity for physical-fitness tests

So great is the risk of defective, sickly, or intemperate employees, that in some trades employers take every precaution to exclude them. One man with defective eyesight or unsteady nerves may cost a railroad thousands of dollars. As insurance companies rank trades as first-, second-, or third-class risks, so many factories, from long experience, debar men with certain characteristics which have been found detrimental to business. The Interborough Rapid Transit Company of New York City examines all applicants for employment, as to age, weight, height, keenness of vision, hearing, color perception, lungs, hearts, arteries, alcoholism, and nicotinism. Those who fall below the standard are rejected, but in each case the physical condition is explained to the applicant. Where defects are removable or correctable, the applicant is told what to do and invited to take another test after treatment. Moreover, accepted employees are periodically reëxamined. While designed to [194]increase company profits and to reduce company losses, this examination obviously decreases the employees' losses also, and increases the certainty of work and prospect of promotion.

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

Because the apprentice's future is of no value to the manufacturer, the state must restrict the manufacturer's freedom to spend like water society's capital,—the health of the coming generation. Could there be a grosser mis-management of society's business than to permit trade to waste children on whose education society spends so many millions yearly? The most effective and most timely remedy is physical examination as a condition of the work certificate. A simple, easily applied, inexpensive measure that imposes only a legitimate restriction upon individual freedom, it is absolutely necessary in order to get to the bottom of the child labor problem. If thoroughly applied, children of the nation will no longer be exploited by unscrupulous or indifferent employers, nor will their health be hazarded by lack of discriminating examination that rejects the obviously sick and favors the apparently robust. Furthermore, knowledge [195]that this test will be applied when work certificates are required, will be an incentive to the school boy and girl to keep well. Tell a boy that adenoids or weak lungs will keep him from getting a job, and you will make him a strong advocate of operation and of fresh air. Show him that his employers will not wish his services when his week is out if he is physically below par, and he will gladly submit to a [196]board of health examination and ask to be told what his defects are and how to correct them.

CHILDREN AT WORK BELOW BOTH AGE LIMIT AND VITALITY LIMIT
National Child Labor Committee

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

When boys and girls go for work certificates to Dr. Goler, medical officer of health at Rochester, he requires not merely evidence of age and of schooling, but examines their eyes for defective vision and for disease, their teeth for cavities and unhealthy gums, and their noses and throats for adenoids and enlarged tonsils. If a boy has sixteen decayed teeth, Dr. Goler explains to him that teeth are meant to be not only ornaments and conveniences, but money getters as well. The boy learns that decayed teeth breed disease, contaminate food, interfere with digestion, make him a disagreeable companion and a less efficient worker. If he will go and have them put into proper condition he will enjoy life better and earn good wages sooner. After the teeth are attended to the boy secures his work [197]certificate. If the boy's mother protests in tears or in anger that her boy does not work with his teeth, she learns what she never learned at school, that sound teeth help pay the rent. If a girl applicant for working papers has adenoids, she is asked to look in the mirror and to notice how her lips fail to meet, how the lower jaw drops, how much better she looks with her jaws and lips together. She is told that other people breathe through the nose, and that perhaps the reason she dislikes school and does not feel as she used to about play is that she cannot breathe through her nose as she used to. She is shown that her nose is stopped up by a spongy substance, as big as the end of her little finger, which obstruction can be easily removed. She is shown adenoids and enlarged tonsils that have been removed from some other girl, and is so impressed with the before-operation and after-operation contrast and by the story of the other girl's rapid increase in wages, that she and her mother both decide not to wait for the adenoids to disappear by absorption. After the operation they come back with proof that the trouble is gone, and get the "papers." Similar instruction is given when defects of vision seriously interfere with a child's prospects of getting ahead in his work, or when evidence of incipient tuberculosis makes it criminal to put a child in a store or factory.

THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT WORK IN LABRADOR

No law as yet authorizes the health officer of Rochester to refuse work certificates to children physically unfit to become wage earners. A higher law than that which any legislature can pass or revoke, has given Dr. Goler power [198]over children and parents, namely, interest in children and knowledge of the industrial handicap that results from physical defects. This higher law authorizes every health officer in the United States to examine the school child before issuing a work certificate, to tell the child and his parents what defects need to be removed, for what trades he is physically unfitted, what trades will not increase his physical weakness, and to what trade he is physically adapted.

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

Parochial and private schools, the ultra-religious and ultra-rich, may resent for a time public supervision of the physical condition of children who do not ask for work certificates. This position will be short-lived, because however much we may disagree about society's right to control a child's act after his physical defects are discovered, few of us will question the state's duty to tell that child and his [199]parents the truth about his physical needs before it accepts his labor or permits him to go to college, to "come out," to "enter society," or to live on an income provided by others. Thus an invaluable commencement present can be given by the state to children in country schools and to those compelled to drop out of fourth or fifth grades of city schools.

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

A brief test of this method of helping children, such as is now being made by several boards of health at the instance of the National Bureau of Labor, will prove conclusively that parents are grateful for the timely discovery of these defects which handicap because of their existence, not because of their discovery. Of the cadets preparing for war at West Point, it has recently been decided that those "who in the physical examinations are found to have deteriorated below the prescribed physical standard will be dropped from the rolls of the academy." Shall not cadets preparing [200]for an industrial life and citizenship be given at least a knowledge of an adequate physical standard? To allow the school child to deteriorate whether before or after going to work is only to waste potential citizenship. Citizens who use themselves up in the mere getting of a living have no surplus strength or interest for overcoming incompetence in civic business, or for achieving the highest aim of citizenship,—the art of self-government for the benefit of all the governed.

CHAPTER XXIToC

PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE

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

Adults are now examined when applying for insurance or accident policies, for work on railroads, for service in the army and on the police and fire forces of cities that provide pensions. It is somewhat surprising that the hundreds of thousands who carry life insurance policies have not realized that a test which is rigorously imposed for business reasons by insurance companies can be applied by individuals for [202]business reasons. Generations hence the state will probably require of every person periodic physical examination after school age. Decades hence business enterprises will undoubtedly require evidence of health and vitality from employees before and during employment, just as schools will require such evidence from teachers. It is, after all, but a step from the police passport to the health passport. Why should we not protect ourselves against enemies to health and efficiency as well as against enemies to order? But for the present we must rely upon the intelligence of individuals to recognize the advantage to themselves, their families, and their employers, of knowing that their bodies do not harbor hidden enemies of vitality and efficiency. From a semi-annual examination of teeth to a semi-annual physical examination is but a short step when once its effectiveness is seen by a few in each community.

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

[203]Ignorance of one's physical condition is a luxury no one can afford. No society is rich enough to afford members ignorant of physical weaknesses prejudicial to others' health and efficiency. Every one of us, even though to all appearances physically normal, needs the biological engineer. New conditions come upon us with terrific rapidity. The rush of work, noise, dust, heat, and overcrowding of modern industry make it important to have positive evidence that we have successfully adapted ourselves to these new conditions. Only by measuring the effects of these environmental forces upon our bodies can we prevent some trifling physical flaw from developing into a chronic or acute condition. As labor becomes more and more highly specialized, the body of the laborer is forced to readapt itself. The kind of work a man does determines which organs shall claim more than their share of blood and energy. The man who sets type develops keenness of vision and manual dexterity. The stoker develops the muscles of his arms and back, the engineer alertness of eye and ear. All sorts of devices have been invented to aid this specialization of particular organs, as well as to correct their imperfections: the magnifying glass, the telescope, the microscope, extend the powers of the eye; the spectacle or an operation on the eye muscles enables the defective eye to do normal work. A man with astigmatism might be a policeman all his life, win promotion, and die ignorant of his defect; whereas if the same man had become a chauffeur, he might have killed himself and his employer the first year, or, if an accountant, he might have been a chronic dyspeptic from long-continued eye strain. It is a soul tragedy for a man to attempt a career for which he is physically unadapted.[11] It is a social tragedy when men and women squander their health. A great deal of the success attributed to luck and opportunity, or unusual [204]mental endowment, is in reality due to a chance compatibility of work with physique. To secure such compatibility is the purpose of physical examination after school age.

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

The reader's observation will suggest numerous illustrations of pain, prolonged sickness, loss of life, that could have been prevented had the physician been semi-annually visited. A strong man, well educated, with large income, personally acquainted with several of the foremost physicians of New York City, after suffering two weeks from pains "that would pass away," was hurriedly taken to a hospital at three o'clock in the morning, operated upon immediately, and died at nine. A business man of means put off going to a physician for fifteen years, for fear he would be told that his throat trouble was tobacco cancer, or incipient tuberculosis, or asthma; a physical examination showed that a difficulty of breathing and chronic throat [205]trouble were due to a growth in the nose, corrected in a few minutes by operation.

A celebrated economist was forced to give up academic work, and consecrated his life to painful and chronic dyspepsia because of eye trouble detected upon the first physical examination. A woman secretary suffered from alleged heart trouble; paralysis threatened, continuous headache and blurred vision forced her to give up work and income; a physical examination found the cause in nasal growths, whose removal restored normal conditions. A woman lecturer on children's health heard described last summer a friend's experience with receding gums: "'Why, I never heard of that disease.' she said. 'Don't you know you have it yourself'? I asked. She had never noticed that her gums were growing away in little points on her front teeth. I touched the uncovered portion and she winced. That ignorance has meant intense pain and ugly fillings. If it had gone longer, it might have meant the loss of her front teeth." A teacher lost a month from nervous prostration; physical examination would have discovered the eye trouble that deranged the stomach and produced the nerve-racking shingles which forced him to take a month's vacation. A journalist lost weeks each year because of strained ankles; since being told that he had flat foot, and that the arch of his foot could be strengthened by braces and specially made shoes, he has not lost a minute. A relief visitor, ardent advocate of the fresh-air, pure-milk treatment for tuberculosis, had a "little cough" and an occasional "cold sweat"; medical friends knew this, but humored her aversion to examination; when too late, she submitted to an examination and to the treatment which, if taken earlier, would most certainly have cured her. A mother's sickness cost a wage-earning daughter nearly $3000; softening of the brain was feared; after six years of suffering and unnecessary expense, physical examination disclosed an easily removable cause, [206]and for two years she has contributed to the family income instead of exhausting it. Untold suffering is saved many a mother by knowledge of her special physical need in advance [207]of her baby's birth. Untold suffering might be saved many a woman in business if she could be told in what respects she was transgressing Nature's law.

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

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

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

FOOTNOTES:

CHAPTER XXIIToC

HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY

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

Eight different elements of industrial efficiency are concerned with the individual's health habits,—the industrial worker, his industrial product, his employer, his employer's [209]profit, his trade or profession, its product, his nation, national product. Obviously few men have so little to do that they have time to think out in detail how this act or that indulgence will affect each of these eight factors of industrial efficiency. Once convinced, however, that all of these elements are either helped or injured by the individual's method of living, each one of us has a strong reason for imposing habits of health upon all industries, upon employees and operatives, upon all who are a part of industrial efficiency. When these eight relations are seen, parents and teachers have particularly strong reasons for inculcating habits of health in their children.

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

In the aggregate, milder forms of unhealthy living interfere with industrial efficiency even more than alcoholism. Many capable men and women, even those who have had thorough technical training, fail to win promotion because their persons are not clean, their breath offensive, their clothes suggestive of disorderly, uncleanly habits. Persons [210]of extraordinary capacity not infrequently achieve only mediocre results because they fail to cultivate habits of cleanliness and health. An employer can easily protect his business from loss due to alcoholism among his own employees; but loss through employees' constipation, headache, bad ventilation at home, irregular meals, improper diet, too many night parties, nicotinism, personal uncleanliness, is loss much harder to anticipate and avoid. Because evil results are less vivid, it is also hard to convince a clerk that intemperance in eating, sleeping, and playing will interfere with his earning capacity and his enjoyment capacity quite as surely as intemperance in the use of alcohol and nicotine. Where employees are paid by the piece, instead of by the hour, day, or week, the employer partially protects himself against uneven, sluggish, slipshod workmen; but, other things being equal, he awards promotion to those who are [211]most regular and who are most often at their best, for he finds that the man who does not "slump" earns best profits and deserves highest pay.

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

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

HABITS OF HEALTH AMONG DAIRYMEN MEAN SAFE MILK FOR BABIES

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

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

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

Health habits do not become instinctive until a continued, conscious effort is made to accustom the body to them. When this is once done, however, the body not only [214]attends to its primary health needs automatically, but it rebels at their omission, as surely as does the stomach at the omission of dinner. Witness the discomfort of the consumptive, trained to fresh air at a sanatorium, when he returns to his overheated and underventilated home, or the actual pain experienced in readjusting our own healthy bodies to the stuffy workroom or schoolroom after a summer vacation out of doors. I heard a consumptive say that he left a sanatorium for a day class after trying for three nights to sleep in an unventilated ward. For many people the regular morning bath is at first a trial, then a pleasure, and finally a need; if omitted, the body feels thirsty and dissatisfied, the eyes sleepy, and the spirit flags early in the day.

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

Cold baths are not essential or even good for everybody. The same diet or the same amount of food or time for eating is not of equal value for all. The temperature of bath [215]water, the kind and quality of food, are influenced by one's work and one's cook. Set rules about these things do more harm than good. Such questions must be decided for each individual,—by his experience or by the advice of a physician,—but they must be decided and the decisions converted into health habits if he would attain the highest efficiency of which he is capable. Here again our old contrast between "doing things" and "getting things done" applies. Get your body to attend to the essential needs for you, and get it to remind you when you let the exigencies of life interfere. Don't burden your mind every day with work that your body will do for you if properly trained.

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

Obstacles to habits of health are numerous; therefore the importance of correcting those habits of factory, family, trade, city, or nation that make health habits impracticable. [216]We must change others' prejudices before we can breathe clean air on street cars without riding outside. When one's co-workers are afraid of fresh air, ventilation of shop, store, and office is impossible. So long as parents fear night air, children cannot follow advice to sleep with windows open. Unless the family coöperates in making definite plans for the use of toilet and bath for each member, constipation and bad circulation are sure to result. Indigestion is inevitable if employees are not given lunch periods and closing hours that permit of regular, unhurried meals. Cleanliness of person costs more than it seems to be worth where cities fail either to compel bath tubs in rented apartments or to erect public baths. A temperate subsistence on adulterated, poisonous, or drugged foods might be better for one's health than gormandizing on pure foods. No recipe has ever been found for bringing up a healthy baby on unclean, infected milk; for avoiding tuberculosis among people who are [217]compelled to work with careless consumptives in unclean air; or for making a five-story leap as safe as a fire escape. Perfect habits of health on the part of an individual will not protect him against enervation or infection resulting from inefficient enforcement of sanitary codes by city, county, state, and national authorities.

AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH ROUTINE FOR BABIES

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

FOOTNOTES:

CHAPTER XXIIIToC

INDUSTRIAL HYGIENE

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

Catastrophes, however, have dominated the vocabulary that describes factory "welfare work." Because accidents such as gas in mines, fire in factories, fever in towns, and epidemics of diseases incident to certain trades were beyond the power of the workers themselves to control or prevent, wage earners have come to be looked upon as helpless victims of the cupidity and inhumanity of their employers. [219]This attitude has weakened the usefulness of many bodies organized to promote industrial hygiene. Although the term "industrial hygiene" is broad enough to include all sanitary and hygienic conditions that surround the worker while at work, it is restricted by some to the efforts made by altruistic or farsighted employers in the interest of employees; others think of prohibitions and mandates, in the name of the state, that either prevent certain evils or compel certain benefits; for too few it refers to what the wage earner does for himself.

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

Knowing that a light, well-aired, clean, safe factory would not of itself insure healthy men, many employers have built and supplied houses for their workmen at low rents. Just as these employers failed to see that they could reach more people and secure more permanent results if they demanded that tenement laws and the sanitary code be enforced as well as the laws for the instruction of children in hygiene, so the employee has failed to see that he is a part of the public that passes laws and determines the efficiency of factory inspection. The enforcement of state legislation for working hours, proper water and milk supply, proper teaching of children, proper tenement conditions, efficient health administration, is dependent upon the interest and [220]activity of the public, of which the working class is no small or uninfluential part.

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

The first and most important step in securing hygienic rights for workingmen is to make sure that they know the rights that the law already gives them. Men still throw out their chests when talking of their rights. The posting of the game laws in a club last summer, and the instruction of all the natives of the countryside in regard to their rights as against those of outsiders, meant that for the first time in their history the game laws were enforced. All the natives, instead of poaching as has been their wont, joined together in protecting club property from intruding outside sportsmen. Poachers were caught and served with the full penalties of the law. Over winter fires these people's heroism will grow, but their respect for law will grow also, and it is doubtful if the game laws can be violated in that section so long as the tradition of this summer's work [221]lives. And so it would be in a factory, if employees once realized that by uniting they could, as citizens, enforce health rights in the factory.

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

The manner in which many organizations have tried to better working conditions is similar to the manner in which Europeans are trying to help defective school children. Here, as there, is the difference between doing things and getting things done. Here more than there is the tendency to exaggerate legislation and to neglect enforcement of law. Instead of harnessing the whole army of workingmen to the crusade and strengthening civic agencies such as factory, health, and tenement departments, houses are built and given to men, clubs are formed to amuse factory girls, amateur theatricals are organized. All this is called "welfare work." "What is welfare work?" reads the pamphlet of a large national association. "It is especial consideration [222]on the part of the employer for the welfare of his employees." In the words of this pamphlet, the aim of this association "is to organize the best brains of the nation in an educational movement toward the solution of some of the great problems related to social and industrial progress." The membership is drawn from "practical men of affairs, whose acknowledged leadership in thought and business makes them typical representatives of business elements that voluntarily work together for the general good." As defined by this organization, welfare work is something given to the employee by the employer for the welfare of both. It is not something the employee himself does to improve his own working conditions.

[223]

FIRST LESSONS IN INDUSTRIAL HYGIENE

[224]

WELFARE WORK THAT COUNTS

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

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

Welfare work at its best is a method of dividing business profits among all who participate in making these profits. Too often welfare secretaries teach employees how to be happy in the director's way, rather than in their own way. This adventitious position increases suspicion on both sides, [226]disturbs the discipline of the foreman, weakens rather than strengthens the worker's efficiency, because it depends upon other things than work well done and the relation of health to efficiency. In a small factory town the owner of a large cotton mill has recognized the financial benefit of physically strong workers, and is trying the experiment of a welfare director. The man himself works "with his sleeves up." The social worker has an office in the factory. A clubhouse is fitted up for the mill hands to make merry in. A room in the factory is reserved for a lunch room, with plants, tables, and chairs for the comfort of the women. Parties are given by the employer to the employees, which he himself attends. He has thrown himself into whatever schemes his director has suggested. The director complained that the reason the new lunch room was not more popular was because a piano was needed. A second-hand one would not do, for that would cultivate bad taste in music. This showed the employer that soon everything would be expected from the "big house on the hill." An event which happened at the time when the pressure was greatest on him for the piano, convinced him that his employees could supply their real needs without any trouble or delay. The assistant manager was about to leave, and in less than a week five hundred dollars was raised among the workers for his farewell gift. Walking home that night late from his office the owner was attracted by the sound of jollity, and saw a little room jammed full of mill people enjoying the improvised music of a mouth organ played to the accompaniment of heels. He resolved henceforth to train his employees to do his work well and to earn more pay,—and to let them amuse themselves. From that time on he refused to be looked upon as the deus ex machina of the town. He decided that the best way to give English lessons to foreigners was to improve the school. His beneficence in supplying them with pure water at the mill did [227]not prevent a ravaging typhoid epidemic because the town water was not watched. He saw that the best way to improve health was to strengthen the health board and to make his co-workers realize that they were citizens responsible for their own privileges and rights.

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

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

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

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

CHAPTER XXIVToC

THE LAST DAYS OF TUBERCULOSIS

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

DR. TRUDEAU'S "LITTLE RED COTTAGE" AT SARANAC—BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA

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

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

[231]

OUTDOOR LIFE CHART.

[232]

FIGHTING TUBERCULOSIS IN THE MOUNTAINS—SARANAC

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

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

FIGHTING TUBERCULOSIS IN DAY CAMPS—BOSTON

Once having learned the simple facts that must be noted and the simple laws that must be followed, once [234]having placed oneself in a position to secure the rest, the fresh air, and the health diet, no better next steps can be taken than to observe the closing injunction in the rules for rest:

THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW YORK CITY

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

[235]

AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS CRUSADERS SHOULD FOLLOW

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

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

[237]

FIGHTING TUBERCULOSIS WITH A NATIONAL ORGANIZATION

All laws, customs, and environmental conditions opposed to the enforcement of these three principles must be modified or abolished. If the teachers of America will list for educational use in t