PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS
CHAPTER XVI[ToC]
EUROPEAN REMEDIES: DOING THINGS AT SCHOOL
Recently I traveled five hundred miles to address an audience on methods of fitting health remedies to local health needs. I told of certain dangers to be avoided, of results that had always followed certain remedies, of motives to be sought and used, of community ends to seek. Not knowing the local situation, I could not tell them exactly what to do next, or how or with whom to do it; not seeing the patient or his symptoms, I did not diagnose the disease or prescribe medicine. Several members of the audience who were particularly anxious to start a new organization on a metropolitan model were disappointed because they were told, not just how to organize, but rather how to find out what sort of organization their town needed. They were right in believing that it was easier to copy on paper a plan tried somewhere else, than to think out a plan for themselves. They had forgotten for the time being their many previous disappointments due to copying without question some plan of social work, just as they copy Paris or New York fashions. They had not expected to leave this meeting with the conviction that while the ends of sanitary administration may be the same in ten communities, health machinery should fit a particular community like a tailor-made suit.
American-like, they had a mania for organization. I once heard an aged kindergartner—the savant of an isolated German village—describe my fellow-Americans as follows: "Every American belongs to some organization. The total abstainers are organized, the brewers are organized, the teachers are organized, the parents are organized, the young people and even the juniors are organized. Finally, those who belong to no organization go off by themselves and organize a society of the unorganized." Love of organization and love of copying have given us Americans a feverish desire for what we see or read about in Europe. When we talk about our European remedies we try to make ourselves believe that we are broad-minded and want to learn from others' experience. In a large number of cases our impatient demand for European remedies is similar to the schoolboy's desire to show off the manners, the slang, or the clothes picked up on his first visit away from home. With many travelers and readers European remedies or European ways are souvenirs of a pleasant visit, to be described like a collection of postal cards, a curious umbrella, a cane associated with Alpine climbing, or a stolen hymnal from an historic cathedral.
Experience proves, however, that just as Roman walls and Norman castles look out of place in New York and Kansas, so European laws and European remedies are too frequently misfits when tried by American schools, hospitals, or city governments. Yesterday a Canadian clergyman, after preaching an eloquent sermon, met a professional beggar on the street in New York City and emptied his purse—of Canadian money! Quite like this is the enthusiastic demand of the tourist who has seen or read about "the way it's done in Germany." The trouble is that European remedies are valued like ruins, by their power to interest, by their antiquity or picturesqueness, or, like the beggar, by their power to stimulate temporary emotion. But we do not sleep in ruins, go to church regularly in thirteenth-century abbeys, or live under the remedies that fire our imagination. We do not therefore see their everyday, practical-result side.
The souvenir value of European remedies is due to the assumption that no better way was open to the European, and that the remedy actually does what it is intended to do. Because free meals are given at school to cure and prevent undernourishment, it is taken for granted that undernourishment stops when free meals are introduced; therefore America must have free meals. Because it is made compulsory in a charming Italian village for every child to eat the free school meal, it is taken for granted that the children of that village have no physical defects; therefore let Kansas City, Seattle, and Boston introduce compulsory free meals. But when one goes to Europe to see exactly how those much-advertised, eulogized remedies operate from day to day, it is often necessary to write, as did a great American sanitarian recently, of health administration in foreign cities continually held up as models to American cities: "In spite of the rules and theories over here, the patient has better care in New York City."
We have been asked of late to copy several very attractive European remedies for the physiological ills of school children, and for the physical deficiencies of the next generation of adults: breakfasts or lunches, or both, at school for all children, rich as well as poor, whether they want school nourishment or not; school meals for the poor only; school meals to be given the poor, but to be bought by those who can afford the small sum required; free eyeglasses for the poor, for poor and well-to-do, for those who wish them, for those who need them whether they want to wear eyeglasses or not; free dental care; free surgical treatment; free rides and outings during summer and winter; country children to visit the metropolis, city children to visit country and village; free treatment in the country of all children whose parents are consumptives; free rides on street cars to and from school; city-owned street railways that will prevent congestion by making the country accessible; city-built tenements to prevent overcrowding, dark rooms, insufficient air and light; free coal, free clothes, free rent for those whose parents are unable to protect them properly against hunger and cold. Every one of these remedies is attractive. Every one is being tried somewhere, and can be justified on emotional, economic, and educational grounds, if we think only of its purpose. Let us view them with the eyes of their advocates.
Would it not be nice for country children to know that toward the end of the school year they would be given an excursion to the largest city of their state, to its slums, its factories, parks, and art galleries? They would grow up more intelligent about geography. They would read history, politics, sociology, and civil government with greater interest. They would have less contracted sympathies. They might even decide that they would rather live their life in the spacious country than in the crowded, rushing city.
City children, on the other hand, would reap worlds of physical benefit and untold inspiration from periods of recreation and study in the country, with its quiet, its greens and bronzes and yellows, its birds and animals, its sky that sits like a dome on the earth, its hopefulness. Winter sleigh rides and coasting would give new vigor and ambition. Why spend so much on teaching physiology, geography, and nature study, if in the end we fail to send the child where alone nature and hygiene tell their story? Why tax ourselves to teach history and sociology and commercial geography out of books when excursions to the city and country will paint pictures on the mind that can never be erased? What more attractive or more reasonable than appetizing, warm meals, or cool salads and drinks for the boys and girls who carry their little dinner pails and baskets down the long road where everything runs together in summer and everything freezes in winter? One needs little imagination to see the "smile that won't come off," health, punctuality, and school interest resulting from the school meal.
Again, if children must have teeth filled and pulled, eyes tested and fitted for glasses, adenoids and enlarged tonsils removed, surely the school environment offers the least affrighting spot for the tragedy. Thence goblins long ago fled. There courage, real or feigned, is brought to the surface by the anxious, critical, competitive interest of one's peers.
A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"
The economic defense of these remedies is many-sided. An English drummer once instructed me during a railroad journey from southern to northern Ireland. As we entered the fertile fields of Lord Dunraven's estate near Athlone, I expressed sympathy for other countries impoverished of soil, of wealth, and of thrift. My instructor replied: "It would pay the government to bring them all to this land free once a year, just to show them what they are missing." That his idea of an investment is sound has been proved by railroads and land companies and even by states, who give away excursions to entice settlers and buyers. Ambition at almost any cost is cheaper than indifference to opportunity. It would be cheaper for our American taxpayer to send school children to city and country than to pay the penalty for having a large number of citizens with narrow interests, unconscious of the struggles and joys of their co-citizens. Free meals, free books, free rides, free eyeglasses, are cheaper than free instruction for the second, third, and sixth terms in studies not passed because of physical defects,—infinitely cheaper than jails and almshouses, truant officers and courthouses.
The demoralizing results of giving "something for nothing" did not follow free schooling or free text-books. Perhaps they would not follow the free remedies that we are asked to copy from Europe. In fact, the word "free" is the wrong word. These remedies rather require coöperation of parent with parent. It has demoralized nobody because the streets are cleaned by all of us, country roads made by the township, police paid for by taxes and not by volunteer subscription.
The man whose children do not need glasses or nourishment or operation for adenoids would find it cheaper to pay for European remedies than for the useless schooling of boys unable to get along in school because of removable defects. An unruly, uninterested boy sitting beside your boy in public school, a pampered, overfed, undisciplined child sitting beside yours at private school, is taxing you without your consent and doing your child injury that may prove irreparable.
It costs $2.50 to furnish a child with eyeglasses. It costs $25 to $50 to give that child a year's schooling. If the child cannot see right and fails in his studies, we have lost a good investment and, after one year so lost, we are out $22.50. In two years we have lost $47.50. But, what is more serious, we have discouraged that boy. Used to failure in school, his mind turns to other things. He is made to think that it is useless for him to try for first place. Perhaps he can play ball, and excels. He chooses a career of ball playing. Valuable years are lost.
Initiative and competition are not interrupted any more by free eyeglasses and free operation for adenoids than by free schooling. There is only one place in the world where there is less competition or less struggle than among the ignorant, and that is among the ignorant and unwell. The boy who can't see the blackboard, who can't learn to spell, who can't breathe through his nose, and can't be interested, doesn't compete at all with the bright, healthy boy. Remove the adenoids, give glasses, make interest possible, and fitness to survive takes a higher level because larger numbers become fit to survive.
Professor Patten says that it is easier to support in the almshouse than in competitive industry a man who cannot earn more than $1.50 a day. The question, therefore, regarding European remedies is not, To what general theory do they belong? but, What will they accomplish? How do they compare with other remedies of which we know?
CHAPTER XVII[ToC]
AMERICAN REMEDIES: GETTING THINGS DONE
In New York City there is a committee called the Committee on the Physical Welfare of School Children. The word "welfare" was used rather than "condition" because the committee proposed to use whatever facts it could gather for the improvement of home and school conditions prejudicial to child welfare. The following programme was adopted:
1. Study of the physical welfare of school children.
a. Examination of board of health records of children needing medical, dental, or ocular care, and better nourishment.
b. Home visitation of such children, in order to ascertain whether their need arises from deficient income or from other causes.
c. Effort to secure proper treatment, either from parents or from free clinics or other established agencies.
d. Effort to secure proper physical surroundings of children while at school—playgrounds, baths, etc.
2. Effort to secure establishment of such a system of school records and reports as will disclose automatically significant school facts,—e.g. regarding backward pupils, truancy, regularity of attendance, registered children not attending, sickness, physical defects, etc.
3. Effort to utilize available information regarding school needs so as to stimulate public interest and thus aid in securing adequate appropriations to meet school needs.
The committee grew out of the discussion, in the year 1905, of the following proposition: To insure a race physically able to receive our vaunted free education, we must provide at school free meals, free eyeglasses, free medical and dental care. Thanks to the superintendent of schools of New York City, to Robert Hunter's Poverty, to John Spargo's Bitter Cry of the Children, hundreds of thousands of American citizens were made to realize for the first time that a large proportion of our school children are in serious need of medical, dental, or ocular attention, or of better nourishment.
Because physicians, dentists, oculists, hospitals, dispensaries, relief agencies, had seemingly been unconscious of this serious state of affairs, they had no definite, constructive remedy to propose. Their unpreparedness served to strengthen the arguments for the European method of doing things. France, Germany, Italy, England, had found it necessary to do things at school. Arguing from their experience, it was only a matter of time when American cities must follow their example. Why not, therefore, begin at once to deal radically with the situation and give school meals, school eyeglasses, etc.? Those who organized the Committee on the Physical Welfare of School Children realized the danger of trying to settle so great a question with the little definite information then available. If doing things at school were to be adopted as a principle and logically carried out, vast sums must be added to the present cost of the public school system. Complications would arise with private and parochial schools, whose children might have quite as serious physical defects, even though not educated by public funds. It would be difficult to obtain proper rooms for medical and dental treatment and meals, and perhaps still more difficult to insure proper food, skilled oculists, dentists, surgeons, and physicians. No one was clear as to how the problem was to be solved by small cities and rural districts, whose needy children are no less entitled to public aid simply because their numbers are smaller. Great as were the difficulties, however, the committee saw that difficulties are in themselves no reason for not doing the right thing. On the other hand, if doing things at school is wrong, if school meals fail to correct and remove physical defects, great social and educational wrong would result from New York's setting an example that would not only misdirect funds and attention in that city, but would undoubtedly lead other cities to move in the wrong direction. Right could be hastened, wrong could be prevented more effectually by facts than by any amount of theory. School meals had been made a political issue in England. The arguments supporting them were stronger than any possible arguments against them, except proof that they would be less effective in helping children than other means that might be proposed. If the American people must choose between sickly, unteachable, dull children without school meals, on the one hand, and bright, teachable, healthy children plus school meals, on the other hand, they will not hesitate because of expense or eighteenth-century objections to "socialism."
During one year of investigation and of getting things done the committee has prepared three studies for publication: (1) a report on the home conditions of fourteen hundred school children of different nationalities, found by school physicians to have defects of vision, breathing, hearing, teeth, and nourishment; (2) an examination of fifty schools—curriculum, buildings, home-study requirements, play space and playtime, physical culture—in an attempt to answer the question, How far does school environment directly cause or aggravate physical defects of school children; (3) a comparative study of methods now employed in a hundred cities to record, classify, and make public significant school facts.
The results of the first year's work prove conclusively that physical defects are not caused solely by the inability of parents to pay for proper food. Among the twenty significant facts reported by the committee are the following:
1. Physical defects found in public schools are, for the most part, such as frequently occur in wealthy families and do not of themselves presume as the cause insufficient income. Of 145 reported for malnutrition, 44 were from families having over $20 weekly.
2. Few of the defects can be corrected by nourishment alone; plenty of fresh air, outside nourishment at school, or extra nourishment at home will not entirely counteract the influences of bad ventilation and bad light in school buildings. Country children have adenoids, bad teeth, and malnutrition. Plenty of food will not prevent bad teeth and bad ventilation from causing adenoids, enlarged tonsils, and malnutrition.
3. Children whose parents have long lived in the United States need attention quite as much as the recent immigrant.
4. A large part of the defects reported could be produced by conditions due directly to neglect of teeth.
From twenty such statements of fact and from its experience in getting things done for one year, the committee drew fifteen practical conclusions, among which the following deserve emphasis here:
1. The only new thing about the physical defects of school children is not their existence, but our recent awakening to their existence, their prevalence, their seriousness if neglected, and their cost to individual children, to school progress, to industry, and to social welfare.
2. Physical deterioration, applied to America's school children, is a misnomer. No evidence whatever has been given that the percentage of children suffering from physical defects in 1907 is greater than the percentage of children suffering from such defects in 1857. On the contrary, the small proportion of defects that are not easily removable, as well as a vast amount of evidence from medical experience and vital statistics, indicates that, if a comparison were possible, the children of 1907 would be found to have sounder bodies and fewer defects than their predecessors of fifty years ago. If there is an exception to this statement, it is probably defects of vision, with regard to which school authorities and oculists seem to agree that confinement in school for longer hours and more constant application under unfavorable lighting conditions have caused a marked increase. Positive evidence as to tendencies will be easily obtained after thorough physical examination has been carried on for a generation.
3. The effect of massing facts as to physical defects of school children should not be to cause alarm, but to stimulate remedial and preventive measures, to invoke congratulations and aggressive optimism, not doleful pessimism and palliative measures born of despair.
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 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 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.
Where clubs and social gatherings are held in school buildings, it is not unusual for a thousand mothers, recent immigrants, to meet together in one hall to hear talks on the care of children. Thus, instead of principals, teachers, and physicians taking the place of mothers (which they nowhere have succeeded in doing), they do succeed in harnessing mothers to the school programme. It may take two, three, or ten visits to get a particular mother to do the necessary thing for her child, but when once convinced and once inspired to do that thing, she will go on day in and day out doing the right thing for that child and for all others in her home. It may take a year to convert a police magistrate whose sympathy for delinquent parents and truant children is an active promoter of disorder; but a magistrate convinced, efficient, and interested is worth a hundred volunteer visitors. To get things done in this way for a hundred thousand children costs less in time and money than to do the necessary things for one thousand children.
CHAPTER XVIII[ToC]
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 teachers, and the average attendance of children is about six hundred thousand, representing one hundred and fifty thousand homes. If teachers give only to those children who ask for help, many will be neglected. In certain sections of the city principals have combined to establish a relief fund to be given out to children who need food, clothes, shoes, etc. One principal had to stop replacing stolen overcoats because, when it was known that he had a fund, an astonishingly large number of overcoats disappeared. At Poughkeepsie school children get up parties, amateur vaudeville, minstrel shows, basket picnics, to obtain food and clothing for children in distress. They are, of course, unable to help parents or children not in school. Of this method a district superintendent in New York said to his teachers and principals: "For thirty-two years I have been working in the schools of this district. I have given food and shoes to thousands of children. I know that however great our interest in a particular child when it comes to us with trouble at home, our duty as teachers prevents us from following our gift into the home and learning the cause of the child's trouble. This last winter we have made an experiment in using a central society, which makes it a business to find out what the family needs, to supply necessaries, country board, medicine, etc. We now know that we can put a slip of paper with the name and address of the child into a general hopper and it will come out eyeglasses, food, rent, vacation parties, as the need may be."
Relief at home through existing agencies was brought about by the distribution of cards like those on opposite page, which offer winter and summer coöperation.
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.
A little girl was unruly and truant. No attempt was made to keep her at school, but she was reported to the Committee on the Physical Welfare of School Children. The parents could not control her. The girl was taken for examination by a specialist and found to be feeble-minded. Later she was sent to a custodial institute.
Another little girl was nine years old, but could not talk. A University Extension Society worker found that she was not kept at school because it was too much trouble. The child was taken to a physician who operated and corrected the tongue-tie.
A girl of twelve said she must stay home to "help mother." The mother was found to be a janitress, temporarily incapacitated by rheumatism. A substitute was provided until the mother was well, and all the children were properly clad for school.
After the adenoid operations in a New York school that occasioned the East Side riots of 1906, the physicians and principals who had persuaded parents to permit the operations were fearful lest the summer in unsanitary surroundings might make the demonstration less complete. Over forty children in three parties were sent away for the summer, where they had wholesome food and all the milk they could drink and fresh air day and night. When they returned in the fall the principal wrote: "The improvement in each individual is simply marvelous. We shall try to continue this condition and shall constantly urge the parents to keep up the good work by means of proper food and fresh air."
In none of these instances could the teachers have accomplished equal results for the individual children or for the families without neglecting school duties. By informing other agencies as to children's needs, teachers started movements that have since helped practically every school child in New York City. Dispensaries are setting aside separate hours for school children; fresh-air agencies are giving preference to children found by teachers or school physicians to be in physical need; relief agencies are making "rush orders" of every note from teachers; the health board is more active because volunteer agencies have added their voice to that of teacher and health officer in demanding adequate funds for physical examination of school children.
"CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL, THE FATHER KILLED—THE CHILDREN WERE BOARDED IN THE COUNTRY UNTIL THE MOTHER RECOVERED
Coöperation is at present easier in New York than in any other city. Charitable societies, hospitals, dispensaries, are probably more keenly alive to their responsibilities and are at least more apt to have acquired the habit of coöperation when asked. Yet even here I have been told repeatedly by teachers: "If we have to wait for that hospital or that charitable society, our children will go barefoot." In small communities where hospital and relief agencies are for emergencies only and generally inactive, it seems that the first thing to do is to ask some friends to establish a small relief fund, just as it is easier to give a child a five-cent meal than to teach its mother how to prepare its food. But the school-teacher will find that it takes very much less energy to arouse the relief society than to maintain her own relief work. In fact, in many cities nothing could do more to strengthen hospitals and charitable societies than to put them in touch with the needs of school children. For a principal to make known the fact that school children are neglected will help the charitable society and hospital to get the funds necessary to do their part better than they are now doing it and better than the school could ever do it. Finally, one reason for a breakdown of charitable societies is not their own inadequacy, but rather the failure of the school and church to make use of an agency better equipped than themselves to give material relief. The teacher sees the child every day, while the relief society will never see it and has no reason to see it until some one calls attention to it. The very first step, and an indispensable one in relief policy, is for teachers to be on the lookout for children not adequately provided for, and then have the physical evidence discovered at school followed to the home for the cause of the child's distress.
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.
In country districts no plan has yet been worked out for adequate relief. Fortunately, however, the distress is generally of such a kind, and the teacher so well acquainted with all the parents of her district, that it will not be difficult to procure such attention as is necessary. Country schools should be furnished by county and state superintendents with clear directions for getting the treatment afforded in the immediate vicinity. Where teachers are alone in seeing the need for coöperation they can quickly interest young and old, physicians, dentists, pastors, health officers, in home visiting, street cleaning, nursing, helping truants, needed changes of curriculum, etc. Getting things done is easy because it is human to love the doing; getting things done is doing of the highest order.
FOOTNOTES:
[10] The importance of recognizing the family as the unit of social treatment is presented in Edward T. Devine's Principles of Relief, and in Homer Folks's Care of Dependent, Defective, and Delinquent Children.
CHAPTER XIX[ToC]
SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE
The popular arguments for free meals, free relief, free medical treatment at school, are based upon the assumption that there are but two ways to travel, one leading to a physically sound, moral, teachable child, the other to an undernourished, subnormal, backward child. They tell us we must choose either school meals or malnutrition, school eyeglasses or defective vision, free coal or freezing poor, free rent or people sleeping on the streets, free dental clinics at school or indigestion and undernourishment, free operation at school for adenoids or backward, discouraged pupils. If there is no other alternative than neglect of the child, if we must either waste fifty dollars in giving a child education that he is physically unable to take, or pay two, three, four, or even fifty dollars to fit him for that education, the American people will not hesitate. Whether there are other roads to healthy children, whether it is cheaper and better for the school to see that outside agencies prepare the child for education rather than itself to take the place of those outside agencies, is a question of fact, not of theory.
Facts prove, as we have seen, that there is more than one way to prevent malnutrition. Parents can be taught to attend to their children; hospitals and dispensaries will furnish eyeglasses where parents are unable to pay for them; charitable societies will go back of the need for eyeglasses to the conditions that produce that need and will do vastly more for the child than can eyeglasses alone. If parents, hospitals, dispensaries, and charitable societies will attend to children's needs, then relief at school is unnecessary, even though it may seem desirable.
The objection to school surgery should be clearly before us, so that we can judge of the two methods that are open to us,—treatment at school vs. treatment away from school.
Society is so organized that the treatment of serious physical defects and social needs at school would upset the machinery a very great deal. For the school to do for its children whatever they may need during their school years will require the setting up of a miniature society in every school building or under every school board. Unless schools are to equip themselves to take the place of all existing facilities for relief and surgery, children would not be so well taken care of as at present. It should not be forgotten that the physical welfare of the school child is the most accurate index to the physical needs of the community. After all, the child lives for six important years before coming to the school and leaves at the early age of fourteen or fifteen; even while attending school it sleeps at home and is influenced more by home and street standards of ventilation, cleanliness, and morality than by conditions at school. It would seem, therefore, the wider use of the school's influence to use the child's appeal to strengthen every agency having to do with community health, rather than to concentrate upon the child himself. If babies were properly cared for up to the sixth year, the protection of the school child's health would be infinitely easier. To take our eyes from the child not yet in school and from the child just out of school is to make the mistake that so many advocates of the child labor movement have made of going whither and only so far as our interest leads us and of not continuing until our work is accomplished.
"DOING THINGS" THROUGH MODEL TENEMENTS
Do we want to make of our schools miniature hospitals, dispensaries, relief bureaus, parks? Or shall we use the momentum of society's interest in the school child to put within the reach of every school building adequate hospitals, dispensaries, relief centers, and parks for school child and adult? Shall every little school have its library, or shall the child be taught at school how to use the same library that is available to his parents and older brothers and sisters? If the library is to be under the school roof, if dispensary and relief hospital are to be conducted on the same site as the school, shall they be known as dispensary, library, relief bureau, each under separate management, or shall they be known as school under the management of school principal and superintendent? So complicated and many-sided is the problem of working together with one's neighbor for mutual benefit that it is a safe rule for the schools to adopt: We shall do nothing that is unnecessary or extravagant. We shall have done our part if we do well what no one else can do. Whatever any agency can do better than we, we shall leave to that agency. Work that another agency ought to have done and has left undone, we shall try to have done by that agency.
IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT UNINFLUENCED
"Getting things done" by the Tenement House Department their special need
I know a hospital where a welfare nurse was recently employed. Within a few blocks were three different relief agencies and two visiting-nurse's associations, having among them over one hundred visitors and nurses going to all sections of Manhattan. This nurse had the choice of telephoning to one of these agencies and asking it to call at the needy home of one of her hospital patients, or of going to the home herself. Had she chosen to use another agency, she could have been the means of furnishing the kind of help needed in every needy home discovered in her hospital rounds, but she chose to do the running about herself and thus of helping ten families where she ought to have helped five hundred. Much the same condition confronts the school that tries to do all extra work for its child instead of seeing that the work is done. Illustration is afforded by the New York tenement department. Whereas European cities have built a few model tenements, New York City secured a law declaring that everybody who built a tenement and everybody who owned a tenement should provide sanitary surroundings. At the present time a philanthropist, by spending two million dollars, could give sanitary surroundings to thirty-five families; by spending each year the interest on one tenth that sum he could insure the enforcement of the tenement laws affecting every tenement resident in New York City.
If schools are to perform surgical operations, they are in danger of being sued for malpractice; discipline will be interfered with. Finally, let us not forget that we are dealing with buildings, teachers, and school institutions as they exist. Where education is made compulsory, the unpleasant and the controversial should be kept out of school. Because a democratic institution, the American school should represent at all times a maximum of general agreement.
To take palliative measures to public schools not only leaves undone remedial work necessary for the health of public school children but neglects entirely the still large numbers who go to parochial, private pay, and private free schools; no one has had the temerity to suggest that the public shall force upon nonpublic schools a system of free operations, free eyeglasses, free meals.
Civilization has painstakingly developed a large number of agencies for the education and protection of mankind. Of these agencies the school is but one. Its first and peculiar function is to teach and to train. This it can do better than any other agency or combination of agencies. In attempting to "bring all life under the school roof," we use but a small part of our resources. Instead of persuading each of the agencies for the promotion of health to do its part for school children, we set up the school in competition with them. Thus in trying to do things for school children we are in danger of crippling agencies equipped to do things for both school children and their parents, for babies before they come to school, and for wage earners after they leave school.
Getting things done will lead schools to study underlying causes; doing things has heretofore caused schools to confine themselves to symptoms. Getting things done will leave the school free to concentrate its attention upon school problems; doing things will lead it afield into the problem of medicine, surgery, restaurant keeping, and practical charity.
CHAPTER XX[ToC]
PHYSICAL EXAMINATION FOR WORKING PAPERS
There is no sacred right to work when our work involves injury to ourselves and to our neighbor. Work at the expense of health is an unjustifiable tax upon the state. It is the duty of society to protect itself against such depletion of national efficiency.
Three classes of workmen need special attention: (1) those who are physically unfit to work; (2) those who are physically unfitted for the work they are doing; (3) those who are subjected to unhealthful surroundings while at work. Viewing these three classes from the standpoint of their neighbors, we have three social rights that should be enforced by law: (1) the right to freedom from unhealthy work; (2) the right to work fitted to the body; (3) the right to healthy surroundings at work.
It is undoubtedly true that just as the sick child may be found at the head of his class, so unhealthy men and women are often good business managers, good salesmen, good typewriters, successful capitalists. They excel, however, not because of their ill health, but in spite of it, excepting of course those instances where men and women, because of ill health, have devoted to business an attention that would have been given to recreation if bad health had not deprived recreation of its pleasure. As statistics in school have proved that the majority of mentally superior children are also physically superior, so statistics will probably prove that the number of the "sick superior" among the working classes is very small, while the danger of inefficiency that comes from physical defect is very great.
There is one time in the individual's working life when the state may properly step in and demand an inventory of physical resources, and that is when the child asks the state for permission to go to work. Strategically, this is probably the most important of all contact as yet provided between society and the future wage earner. Here at the threshold of his industrial career the boy may be told for what work he is physically fitted, what physical defects need to be remedied, what physical precautions he needs to take, in order to do justice to himself and his opportunity.
Every year from two to three million children leave the public schools of this country to join the army of workers. The percentage of those recruits who have physical defects needing attention is undoubtedly great; how great we shall never know until the benefits of physical examination are given to all of them. What steps is your state taking to ascertain the physical fitness of the children who present themselves each year for working papers? How does it insure itself against the risk of their defective eyesight, chorea, deafness, or general debility? Does it inform children of their defects, or tell them how they may increase their earning power by correcting these defects? What effort does it make to induce children to avoid dangerous trades, or trades that are particularly dangerous for their physiques?
At the close of school last spring I had my secretary look in upon the New York board of health and see what demands that city makes upon its boys and girls before allowing them to drive its machinery, to run its elevators, to match its colors, to sew on its buttons, to set its type, to carry its checks to the bank. The officer at the door of the room where the children were being examined, greeted her as follows: "You must bring your child with you; bring his birth certificate or swear that he is fourteen years old, and bring a signed statement from his teacher that he has been in school for one hundred and thirty consecutive days within twelve months." "Is there no physical examination or test?" she asked. "No, no," he answered impatiently. Yet the board of health certifies that "said child has in our opinion reached the normal development of a child of its age, and is in sound health and is physically able to perform the work which it intends to do." In addition the blank calls for place and date of birth, color of hair and of eyes, height, weight, and facial marks. Volunteer societies in practically every state in the Union have been working for years to have it made a criminal offense to employ a child who has not been in school a minimum of days after a stated age (12, 13, 14, 15). Even in New York, however, the center of this agitation, no strong demand was made upon the board of health to apply a physical-fitness test as well as an age test until 1908 when examination for working papers was added to the programme for child hygiene. Yet who does not know girls and boys of sixteen less fit for factory or shop work than other boys and girls of twelve? It is the fetich of age which has made possible the "democracy" that permits a child of fourteen to work all day on condition that he go to school at night!
CHILDREN ENLISTING IN THE INDUSTRIAL ARMY
WAITING TO BE EXAMINED FOR WORKING PAPERS
An excellent opportunity for physical-fitness tests
So great is the risk of defective, sickly, or intemperate employees, that in some trades employers take every precaution to exclude them. One man with defective eyesight or unsteady nerves may cost a railroad thousands of dollars. As insurance companies rank trades as first-, second-, or third-class risks, so many factories, from long experience, debar men with certain characteristics which have been found detrimental to business. The Interborough Rapid Transit Company of New York City examines all applicants for employment, as to age, weight, height, keenness of vision, hearing, color perception, lungs, hearts, arteries, alcoholism, and nicotinism. Those who fall below the standard are rejected, but in each case the physical condition is explained to the applicant. Where defects are removable or correctable, the applicant is told what to do and invited to take another test after treatment. Moreover, accepted employees are periodically reëxamined. While designed to increase company profits and to reduce company losses, this examination obviously decreases the employees' losses also, and increases the certainty of work and prospect of promotion.
Our states, and many of our industries, still have the attitude of a certain manufacturer who employs several hundred boys and girls. I asked him what tests he employed. "I look over a long line of the applicants and say," pointing his finger, "I want you, and you, and you; the rest may go." I asked him if he made a point of picking out those who looked strong. "No. The work is easy, sitting down all day long and picking over things. I select those whose faces I like. Yes, there is one question we now ask of all the girls. One day a girl in the workroom had an epileptic fit and it frightened everybody and upset the work so that the foreman always asks, 'Do you have fits? Because if you do, you can't work here.'" He makes no attempt to determine the physical fitness and endurance of the children employed, because when the strength of one is spent there is always another to step into her place.
Because the apprentice's future is of no value to the manufacturer, the state must restrict the manufacturer's freedom to spend like water society's capital,—the health of the coming generation. Could there be a grosser mis-management of society's business than to permit trade to waste children on whose education society spends so many millions yearly? The most effective and most timely remedy is physical examination as a condition of the work certificate. A simple, easily applied, inexpensive measure that imposes only a legitimate restriction upon individual freedom, it is absolutely necessary in order to get to the bottom of the child labor problem. If thoroughly applied, children of the nation will no longer be exploited by unscrupulous or indifferent employers, nor will their health be hazarded by lack of discriminating examination that rejects the obviously sick and favors the apparently robust. Furthermore, knowledge that this test will be applied when work certificates are required, will be an incentive to the school boy and girl to keep well. Tell a boy that adenoids or weak lungs will keep him from getting a job, and you will make him a strong advocate of operation and of fresh air. Show him that his employers will not wish his services when his week is out if he is physically below par, and he will gladly submit to a board of health examination and ask to be told what his defects are and how to correct them.
CHILDREN AT WORK BELOW BOTH AGE LIMIT AND VITALITY LIMIT
National Child Labor Committee
Some there are who will object to this appeal to the child's economic instinct. This objection does not remove the instinct. The normal child is greedy for a job. His greed, as well as that of the manufacturer and parent, is responsible for much of the child labor; his greed for activity, for association, for money, and so for work. A little boy came into my office and wanted to hire as an office boy. I looked at him and said: "My little fellow, you ought to be in school. What do you want to hire out here for?" He said, "I am tired of school; nothing doing." He doesn't care about work for its own sake; he doesn't care about wealth for its own sake; he wants to get into life; to be where there is "something doing." In this lies one potent argument for vocational training. To tell a boy of his physical needs just before he has taken his first business step is to put him everlastingly in our debt. Then he is responsive, and, fortunately for the extreme cases, necessarily dependent, for he knows that his refusal would stand between himself and his ambition.
When boys and girls go for work certificates to Dr. Goler, medical officer of health at Rochester, he requires not merely evidence of age and of schooling, but examines their eyes for defective vision and for disease, their teeth for cavities and unhealthy gums, and their noses and throats for adenoids and enlarged tonsils. If a boy has sixteen decayed teeth, Dr. Goler explains to him that teeth are meant to be not only ornaments and conveniences, but money getters as well. The boy learns that decayed teeth breed disease, contaminate food, interfere with digestion, make him a disagreeable companion and a less efficient worker. If he will go and have them put into proper condition he will enjoy life better and earn good wages sooner. After the teeth are attended to the boy secures his work certificate. If the boy's mother protests in tears or in anger that her boy does not work with his teeth, she learns what she never learned at school, that sound teeth help pay the rent. If a girl applicant for working papers has adenoids, she is asked to look in the mirror and to notice how her lips fail to meet, how the lower jaw drops, how much better she looks with her jaws and lips together. She is told that other people breathe through the nose, and that perhaps the reason she dislikes school and does not feel as she used to about play is that she cannot breathe through her nose as she used to. She is shown that her nose is stopped up by a spongy substance, as big as the end of her little finger, which obstruction can be easily removed. She is shown adenoids and enlarged tonsils that have been removed from some other girl, and is so impressed with the before-operation and after-operation contrast and by the story of the other girl's rapid increase in wages, that she and her mother both decide not to wait for the adenoids to disappear by absorption. After the operation they come back with proof that the trouble is gone, and get the "papers." Similar instruction is given when defects of vision seriously interfere with a child's prospects of getting ahead in his work, or when evidence of incipient tuberculosis makes it criminal to put a child in a store or factory.
THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT WORK IN LABRADOR
No law as yet authorizes the health officer of Rochester to refuse work certificates to children physically unfit to become wage earners. A higher law than that which any legislature can pass or revoke, has given Dr. Goler power over children and parents, namely, interest in children and knowledge of the industrial handicap that results from physical defects. This higher law authorizes every health officer in the United States to examine the school child before issuing a work certificate, to tell the child and his parents what defects need to be removed, for what trades he is physically unfitted, what trades will not increase his physical weakness, and to what trade he is physically adapted.
We should not forget that a large proportion of our children never apply for work certificates; some because they never intend to work; some because they expect to remain in school until sixteen or later; some because they live on farms, in small towns, or in cities and states where prohibition of child labor is not enforced. Because there is no reason for this large proportion of children to visit a board of health, some substitute must be found. This substitute has been already suggested by principals and district superintendents in New York City, who claim that the natural place for the examination of children is the school and not health headquarters. Developing the idea that the school should pronounce the child's fitness to leave school and to engage in work, we are led to the suggestion that the state, which compels evidence that every child, rich or poor, is being taught during the compulsory school age, shall also at the age of fourteen or sixteen require evidence that the child is physically fit to use his education, and that it shall not, because of preventable ill health, prove a losing investment.
Parochial and private schools, the ultra-religious and ultra-rich, may resent for a time public supervision of the physical condition of children who do not ask for work certificates. This position will be short-lived, because however much we may disagree about society's right to control a child's act after his physical defects are discovered, few of us will question the state's duty to tell that child and his parents the truth about his physical needs before it accepts his labor or permits him to go to college, to "come out," to "enter society," or to live on an income provided by others. Thus an invaluable commencement present can be given by the state to children in country schools and to those compelled to drop out of fourth or fifth grades of city schools.
THE HEALTH DEPARTMENT'S CLINICAL CARE AND HOME INSTRUCTION COME AFTER WAGE LOSSES, WHILE WORK CERTIFICATES PRECEDE BREAKDOWNS FROM TUBERCULOSIS
A brief test of this method of helping children, such as is now being made by several boards of health at the instance of the National Bureau of Labor, will prove conclusively that parents are grateful for the timely discovery of these defects which handicap because of their existence, not because of their discovery. Of the cadets preparing for war at West Point, it has recently been decided that those "who in the physical examinations are found to have deteriorated below the prescribed physical standard will be dropped from the rolls of the academy." Shall not cadets preparing for an industrial life and citizenship be given at least a knowledge of an adequate physical standard? To allow the school child to deteriorate whether before or after going to work is only to waste potential citizenship. Citizens who use themselves up in the mere getting of a living have no surplus strength or interest for overcoming incompetence in civic business, or for achieving the highest aim of citizenship,—the art of self-government for the benefit of all the governed.
CHAPTER XXI[ToC]
PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE
Governor Hughes, in his address to the students in Gettysburg College, pleaded for such lives that strength would be left for the years of achievement. How many men and women can you count who are squandering their health bank account? How many do you know who are now physically bankrupt? The man who is prodigal of his health may work along all right for years, never realizing until the test comes that he is running behind in his vitality. The test may be hard times, promotion, exposure to cold, heat, fever, or a sudden call for all his control in avoiding accident. If his vitality fails to stand the test, his career may be ruined, "all for the want of a horseshoe nail": because of no health bank account to draw upon in time of need,—failure; because of vitality depleted by alcohol, tobacco, overeating, underexercise, or too little sleep,—no power to resist contagious diseases; because of ignorance of existing lung trouble,—a year or more of idleness, perhaps poverty for his family; or there is neglected ear or eye trouble,—and thousands of lives may be lost because the engineer failed to read the signals.
Adults are now examined when applying for insurance or accident policies, for work on railroads, for service in the army and on the police and fire forces of cities that provide pensions. It is somewhat surprising that the hundreds of thousands who carry life insurance policies have not realized that a test which is rigorously imposed for business reasons by insurance companies can be applied by individuals for business reasons. Generations hence the state will probably require of every person periodic physical examination after school age. Decades hence business enterprises will undoubtedly require evidence of health and vitality from employees before and during employment, just as schools will require such evidence from teachers. It is, after all, but a step from the police passport to the health passport. Why should we not protect ourselves against enemies to health and efficiency as well as against enemies to order? But for the present we must rely upon the intelligence of individuals to recognize the advantage to themselves, their families, and their employers, of knowing that their bodies do not harbor hidden enemies of vitality and efficiency. From a semi-annual examination of teeth to a semi-annual physical examination is but a short step when once its effectiveness is seen by a few in each community.
THE OLD SOUTHFIELD, NOW ANCHORED AT BELLEVUE HOSPITAL'S DOCK, NEW YORK CITY, GIVES DAILY LESSONS IN THE PREVENTABLE TAX LEVIED BY TUBERCULOSIS
Ignorance of one's physical condition is a luxury no one can afford. No society is rich enough to afford members ignorant of physical weaknesses prejudicial to others' health and efficiency. Every one of us, even though to all appearances physically normal, needs the biological engineer. New conditions come upon us with terrific rapidity. The rush of work, noise, dust, heat, and overcrowding of modern industry make it important to have positive evidence that we have successfully adapted ourselves to these new conditions. Only by measuring the effects of these environmental forces upon our bodies can we prevent some trifling physical flaw from developing into a chronic or acute condition. As labor becomes more and more highly specialized, the body of the laborer is forced to readapt itself. The kind of work a man does determines which organs shall claim more than their share of blood and energy. The man who sets type develops keenness of vision and manual dexterity. The stoker develops the muscles of his arms and back, the engineer alertness of eye and ear. All sorts of devices have been invented to aid this specialization of particular organs, as well as to correct their imperfections: the magnifying glass, the telescope, the microscope, extend the powers of the eye; the spectacle or an operation on the eye muscles enables the defective eye to do normal work. A man with astigmatism might be a policeman all his life, win promotion, and die ignorant of his defect; whereas if the same man had become a chauffeur, he might have killed himself and his employer the first year, or, if an accountant, he might have been a chronic dyspeptic from long-continued eye strain. It is a soul tragedy for a man to attempt a career for which he is physically unadapted.[11] It is a social tragedy when men and women squander their health. A great deal of the success attributed to luck and opportunity, or unusual mental endowment, is in reality due to a chance compatibility of work with physique. To secure such compatibility is the purpose of physical examination after school age.
If the periodic visit to the doctor is the first law of adult health, still more imperative is the law that competent physicians should be seen at the first indication of ill health. Even when competent physicians are at hand, parents and teachers should be taught what warning signs may mean and what steps should be taken. In Germany insurance companies find that it saves money to provide free medical and dental care for the insured. Department stores, many factories and railroads, have learned from experience that they save money by inducing their employees to consult skilled physicians at the first sign of physical disorder. Many colleges, schools, and "homes" have a resident physician. Wherever any large number of people are assembled together,—in a hotel, factory, store, ship, college, or school,—there should be an efficient consulting physician at hand. If people are needlessly alarmed, it is of the utmost importance to show them that there is nothing seriously wrong. Therefore visits to the consulting physician should be encouraged.
The reader's observation will suggest numerous illustrations of pain, prolonged sickness, loss of life, that could have been prevented had the physician been semi-annually visited. A strong man, well educated, with large income, personally acquainted with several of the foremost physicians of New York City, after suffering two weeks from pains "that would pass away," was hurriedly taken to a hospital at three o'clock in the morning, operated upon immediately, and died at nine. A business man of means put off going to a physician for fifteen years, for fear he would be told that his throat trouble was tobacco cancer, or incipient tuberculosis, or asthma; a physical examination showed that a difficulty of breathing and chronic throat trouble were due to a growth in the nose, corrected in a few minutes by operation.
A celebrated economist was forced to give up academic work, and consecrated his life to painful and chronic dyspepsia because of eye trouble detected upon the first physical examination. A woman secretary suffered from alleged heart trouble; paralysis threatened, continuous headache and blurred vision forced her to give up work and income; a physical examination found the cause in nasal growths, whose removal restored normal conditions. A woman lecturer on children's health heard described last summer a friend's experience with receding gums: "'Why, I never heard of that disease.' she said. 'Don't you know you have it yourself'? I asked. She had never noticed that her gums were growing away in little points on her front teeth. I touched the uncovered portion and she winced. That ignorance has meant intense pain and ugly fillings. If it had gone longer, it might have meant the loss of her front teeth." A teacher lost a month from nervous prostration; physical examination would have discovered the eye trouble that deranged the stomach and produced the nerve-racking shingles which forced him to take a month's vacation. A journalist lost weeks each year because of strained ankles; since being told that he had flat foot, and that the arch of his foot could be strengthened by braces and specially made shoes, he has not lost a minute. A relief visitor, ardent advocate of the fresh-air, pure-milk treatment for tuberculosis, had a "little cough" and an occasional "cold sweat"; medical friends knew this, but humored her aversion to examination; when too late, she submitted to an examination and to the treatment which, if taken earlier, would most certainly have cured her. A mother's sickness cost a wage-earning daughter nearly $3000; softening of the brain was feared; after six years of suffering and unnecessary expense, physical examination disclosed an easily removable cause, and for two years she has contributed to the family income instead of exhausting it. Untold suffering is saved many a mother by knowledge of her special physical need in advance of her baby's birth. Untold suffering might be saved many a woman in business if she could be told in what respects she was transgressing Nature's law.
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:
[11] See Dangerous Trades, compiled by Thomas Oliver; also list of reports by the United States Bureau of Labor.
CHAPTER XXII[ToC]
HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY
Education's highest aim is to train us to do the right thing at the right moment without having to think. The technic of musician, stenographer, artist, electrician, surgeon, orator, is gained only from patient training of the body's reflex muscles to do brain work.[12] The lower nerve centers are storehouses for the brain energy, just as central power houses are used for storing electric energy to be spent upon demand. From habit, not from mental effort, we turn to the right, say "I beg pardon" when we step on another's foot, give our seats to ladies or to elderly persons, use acceptable table manners. No person seems "to the manner born" who has to think out each act necessary to "company manners." How numerous are the mental and physical processes essential to good manners no one ever recognizes but the very bashful or the uncouth person trying to cultivate habits of unconsciousness in polite society. The habit of living ethically enables us to go through life without being tempted to steal or lie or do physical violence. No person's morals can be relied upon who is tempted constantly to do immoral acts; ethical training seeks to incapacitate us for committing unethical deeds and to habituate us to ethical acts alone.
Eight different elements of industrial efficiency are concerned with the individual's health habits,—the industrial worker, his industrial product, his employer, his employer's profit, his trade or profession, its product, his nation, national product. Obviously few men have so little to do that they have time to think out in detail how this act or that indulgence will affect each of these eight factors of industrial efficiency. Once convinced, however, that all of these elements are either helped or injured by the individual's method of living, each one of us has a strong reason for imposing habits of health upon all industries, upon employees and operatives, upon all who are a part of industrial efficiency. When these eight relations are seen, parents and teachers have particularly strong reasons for inculcating habits of health in their children.
That industrial inefficiency results from chronic habits of unhealthy living is generally recognized. The alcoholic furnishes the most vivid illustration. The penalties suffered by him and his family are grave enough, but because he has not full possession of his faculties he is unpunctual, wastes material, disobeys instructions, endangers others' lives, decreases the product of his trade and of his employer, lessens the profits of both, depresses wages, increases insurance and business risks. Because no one can foresee when the "drop too much" will be taken, industry finds it important to know that the habit of drinking alcoholics moderately has not been acquired by train dispatcher, engineer, switchman, chauffeur. Because the habit of drinking moderately is apt, among lower incomes, to go hand in hand with other habits injurious to business and fatal to integrity, positions of trust in industry seek men and women who have the habit of declining drink.
In the aggregate, milder forms of unhealthy living interfere with industrial efficiency even more than alcoholism. Many capable men and women, even those who have had thorough technical training, fail to win promotion because their persons are not clean, their breath offensive, their clothes suggestive of disorderly, uncleanly habits. Persons of extraordinary capacity not infrequently achieve only mediocre results because they fail to cultivate habits of cleanliness and health. An employer can easily protect his business from loss due to alcoholism among his own employees; but loss through employees' constipation, headache, bad ventilation at home, irregular meals, improper diet, too many night parties, nicotinism, personal uncleanliness, is loss much harder to anticipate and avoid. Because evil results are less vivid, it is also hard to convince a clerk that intemperance in eating, sleeping, and playing will interfere with his earning capacity and his enjoyment capacity quite as surely as intemperance in the use of alcohol and nicotine. Where employees are paid by the piece, instead of by the hour, day, or week, the employer partially protects himself against uneven, sluggish, slipshod workmen; but, other things being equal, he awards promotion to those who are most regular and who are most often at their best, for he finds that the man who does not "slump" earns best profits and deserves highest pay.
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
What are the health habits that should become instinctive and effortless for every worker? What acts can we make our lower nerve centers—our subconscious selves—do for us or remind us to do? The following constitutes a daily routine that should be as involuntary as the process of digestion:
1. Throw the bedding over the foot of the bed.
2. Close the window that has been open during the night.
3. Drink a glass of water.
4. Bathe the face, neck, crotch, chest, armpits (finishing if not beginning with cold water), and particularly the eyes, ears, and nose. If time and conveniences permit, bathe all over.
5. Cleanse the finger nails.
6. Cleanse the teeth, especially the places that are out of sight and hard to reach.
7. Breakfast punctually at a regular hour. Eat lightly and only what agrees with you. If you read a morning paper, be interested in news items that have to do with personal and community vitality.
8. Visit the toilet; if impracticable at home, have a regular time at business.
9. Have several minutes in the open air, preferably walking.
10. Be punctual at work.
11. As your right by contract, insist upon a supply of fresh air for your workroom with the same emphasis you use in demanding sufficient heat in zero weather.
12. Eat punctually at noon intermission; enjoy your meal and its after effects.
13. Breathe air out of doors a few minutes, preferably walking.
14. Resume business punctually.
15. Stop work regularly.
16. Take out-of-door exercise—indoor only when fresh air is possible—that you enjoy and that agrees with you.
17. Be regular, temperate, and leisurely in eating the evening meal; eat nothing that disagrees with you.
18. Spend the evening profitably and pleasantly and in ways compatible with the foregoing habits.
19. Retire regularly at a fixed hour, making up for irregularity by an earlier hour next night.
20, 21, 22. Repeat 4, 6, 8.
23. Turn underclothes wrong side out for ventilation.
24. Open windows.
25. Relax mind and body and go to sleep.
No man chronically neglects any one of the above rules without reducing his industrial efficiency. No man chronically neglects all of them without becoming, sooner or later, a health bankrupt.
In addition to this daily routine, there are certain other acts that should become habitual:
1. Bathing less frequently than once a week is almost as dangerous to health as it is to attractiveness.
2. Distaste for unclean linen or undergarments and for acts or foods that interfere with vitality should become instinctive.
3. Excesses in eating or playing should be automatically corrected the next day and the next. Parties we shall continue to have. It will be some time before reasonable hours and reasonable refreshments will prevail. Meanwhile it is probably better for an individual to sacrifice somewhat his own vitality for the sake of the union, the class, or the church. While trying to improve group habits, one can acquire the habit of not eating three meals in one, of eating less next day, of sleeping longer next night, of being particularly careful to have plenty of outdoor air.
4. Visits to the dentist twice a year at least, and whenever a cavity appears, even if only a week after the dentist has failed to find one; whenever the gums begin to recede; and whenever anything seems to be wrong with the teeth.
5. Periodic physical examination by a physician.
6. Examination by a competent physician whenever any disorder cannot be satisfactorily explained by violation of the daily routine or by interruption of business or domestic routine.
Health habits do not become instinctive until a continued, conscious effort is made to accustom the body to them. When this is once done, however, the body not only attends to its primary health needs automatically, but it rebels at their omission, as surely as does the stomach at the omission of dinner. Witness the discomfort of the consumptive, trained to fresh air at a sanatorium, when he returns to his overheated and underventilated home, or the actual pain experienced in readjusting our own healthy bodies to the stuffy workroom or schoolroom after a summer vacation out of doors. I heard a consumptive say that he left a sanatorium for a day class after trying for three nights to sleep in an unventilated ward. For many people the regular morning bath is at first a trial, then a pleasure, and finally a need; if omitted, the body feels thirsty and dissatisfied, the eyes sleepy, and the spirit flags early in the day.
IMPROVISED SEASIDE HOSPITAL FOR NONPULMONARY TUBERCULOSIS AT SEA BREEZE TEACHES PASSERS-BY THE FRESH-AIR GOSPEL
Cold baths are not essential or even good for everybody. The same diet or the same amount of food or time for eating is not of equal value for all. The temperature of bath water, the kind and quality of food, are influenced by one's work and one's cook. Set rules about these things do more harm than good. Such questions must be decided for each individual,—by his experience or by the advice of a physician,—but they must be decided and the decisions converted into health habits if he would attain the highest efficiency of which he is capable. Here again our old contrast between "doing things" and "getting things done" applies. Get your body to attend to the essential needs for you, and get it to remind you when you let the exigencies of life interfere. Don't burden your mind every day with work that your body will do for you if properly trained.
CRIPPLED CHILDREN LEAVING SEA BREEZE HOSPITAL FOR BONE TUBERCULOSIS FIND STALE AIR OFFENSIVE BY NIGHT OR BY DAY
Obstacles to habits of health are numerous; therefore the importance of correcting those habits of factory, family, trade, city, or nation that make health habits impracticable. We must change others' prejudices before we can breathe clean air on street cars without riding outside. When one's co-workers are afraid of fresh air, ventilation of shop, store, and office is impossible. So long as parents fear night air, children cannot follow advice to sleep with windows open. Unless the family coöperates in making definite plans for the use of toilet and bath for each member, constipation and bad circulation are sure to result. Indigestion is inevitable if employees are not given lunch periods and closing hours that permit of regular, unhurried meals. Cleanliness of person costs more than it seems to be worth where cities fail either to compel bath tubs in rented apartments or to erect public baths. A temperate subsistence on adulterated, poisonous, or drugged foods might be better for one's health than gormandizing on pure foods. No recipe has ever been found for bringing up a healthy baby on unclean, infected milk; for avoiding tuberculosis among people who are compelled to work with careless consumptives in unclean air; or for making a five-story leap as safe as a fire escape. Perfect habits of health on the part of an individual will not protect him against enervation or infection resulting from inefficient enforcement of sanitary codes by city, county, state, and national authorities.
AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH ROUTINE FOR BABIES
The "municipalization" or "public subsidy" of health habits is indispensable to protecting industrial efficiency. Public lavatories, above or below ground, have done much to reduce inefficiency due to alcoholism, constipation of the bowels, and congestion of the kidneys. Theaters, churches, and assembly rooms could be built so as to drill audiences in habits of health instead of fixing habits of uncleanly breathing. Street flushing, drinking fountains, parks and breathing spaces, playgrounds and outdoor gymnasiums, milk, food, and drug inspection, tenement, factory, and shop supervision, enforcement of anti-spitting penalties, restriction of hours of labor, prohibition of child labor,—these inculcate community habits of health that promote community efficiency. It is the duty of health boards to compel all citizens under their jurisdiction to cultivate habits of health and to punish all who persistently refuse to acquire these habits, so far as the evils of neglect become apparent to health authorities. The unlimited educational opportunity of health boards consists in their privilege to point out repeatedly and cumulatively the industrial and community benefits that result from habits of health, and the industrial and community losses that result from habits of unhealthy living.
FOOTNOTES:
[12] Serviceable guides to personal habits of health are Aristocracy of Health by Mary Foote Henderson, and Efficient Life by Dr. Luther H. Gulick.
CHAPTER XXIII[ToC]
INDUSTRIAL HYGIENE
To call the movement for better factory conditions the "humanizing of industry" implies that modern industry not influenced by that movement is brutalized. The brutalizing of industry was due chiefly to a general ignorance of health laws,—an ignorance that registers itself clearly and promptly in factory and mine. It is not that a man is expected to do too much, but that too little is expected of the human body. The present recognition of the body's right to vitality is not because the employer's heart is growing warmer, or because competition is less vicious, but because the precepts of hygiene are found to be practical. Where better ventilation used to mean more windows and repair bills, it now means greater output. Where formerly a comfortable place in which to eat lunch meant giving up a workroom and its profits, it now means 25 per cent more work done in all workrooms during the afternoon. The general enlightenment as to industrial hygiene has been accelerated by the awakening that always follows industrial catastrophes, by the splendid crusade against tuberculosis, and by compulsory notification and treatment of communicable diseases.
Catastrophes, however, have dominated the vocabulary that describes factory "welfare work." Because accidents such as gas in mines, fire in factories, fever in towns, and epidemics of diseases incident to certain trades were beyond the power of the workers themselves to control or prevent, wage earners have come to be looked upon as helpless victims of the cupidity and inhumanity of their employers. This attitude has weakened the usefulness of many bodies organized to promote industrial hygiene. Although the term "industrial hygiene" is broad enough to include all sanitary and hygienic conditions that surround the worker while at work, it is restricted by some to the efforts made by altruistic or farsighted employers in the interest of employees; others think of prohibitions and mandates, in the name of the state, that either prevent certain evils or compel certain benefits; for too few it refers to what the wage earner does for himself.
Pity for the employee has caused the motive power of the employee to be wastefully allowed to atrophy. Yet when a man becomes an employee, he does not forfeit any right of citizenship, nor does being an employee relieve him from the duties of citizenship. In too many cases it has been overlooked that a worker's carelessness about habits of health, as well as about his machinery, causes accidents and increases industrial diseases. Too often the worker himself is responsible for uncleanliness and lack of ventilation and his own consequent lack of vitality. A study into the conditions of ventilation and cleanliness of workers' homes will prove this.
Knowing that a light, well-aired, clean, safe factory would not of itself insure healthy men, many employers have built and supplied houses for their workmen at low rents. Just as these employers failed to see that they could reach more people and secure more permanent results if they demanded that tenement laws and the sanitary code be enforced as well as the laws for the instruction of children in hygiene, so the employee has failed to see that he is a part of the public that passes laws and determines the efficiency of factory inspection. The enforcement of state legislation for working hours, proper water and milk supply, proper teaching of children, proper tenement conditions, efficient health administration, is dependent upon the interest and activity of the public, of which the working class is no small or uninfluential part.
COUNTRY CLUB HOUSE FOR NEW YORK SOCIAL WORKERS
Given by the founder of Caroline Rest Educational Fund
The first and most important step in securing hygienic rights for workingmen is to make sure that they know the rights that the law already gives them. Men still throw out their chests when talking of their rights. The posting of the game laws in a club last summer, and the instruction of all the natives of the countryside in regard to their rights as against those of outsiders, meant that for the first time in their history the game laws were enforced. All the natives, instead of poaching as has been their wont, joined together in protecting club property from intruding outside sportsmen. Poachers were caught and served with the full penalties of the law. Over winter fires these people's heroism will grow, but their respect for law will grow also, and it is doubtful if the game laws can be violated in that section so long as the tradition of this summer's work lives. And so it would be in a factory, if employees once realized that by uniting they could, as citizens, enforce health rights in the factory.
The hygiene of the workshop is not the same problem as the hygiene of the home and schoolhouse, because there are by-products of factory work that contaminate the air, overheat the room, and complicate the ordinary problems of ventilation. Certain trades are recognized as "dangerous trades." The problem of adequate government control of factories is one for a sanitary engineer. It has to do with disease-bearing raw material that comes to a factory, disease-producing processes of manufacture. There is need for revision of the dangerous-trade list. Many of the industries not so classed should be; many of the so-called dangerous trades can be made comparatively harmless by devices for exhausting harmful by-products. Industrial diseases should be made "notifiable," so that they can be controlled by the factory or health department. It is those trades that are dangerous because of remediable unsanitary and unhygienic conditions which demand the employer's attention. Complaints should be made by individuals when carelessness or danger becomes commonplace.
The manner in which many organizations have tried to better working conditions is similar to the manner in which Europeans are trying to help defective school children. Here, as there, is the difference between doing things and getting things done. Here more than there is the tendency to exaggerate legislation and to neglect enforcement of law. Instead of harnessing the whole army of workingmen to the crusade and strengthening civic agencies such as factory, health, and tenement departments, houses are built and given to men, clubs are formed to amuse factory girls, amateur theatricals are organized. All this is called "welfare work." "What is welfare work?" reads the pamphlet of a large national association. "It is especial consideration on the part of the employer for the welfare of his employees." In the words of this pamphlet, the aim of this association "is to organize the best brains of the nation in an educational movement toward the solution of some of the great problems related to social and industrial progress." The membership is drawn from "practical men of affairs, whose acknowledged leadership in thought and business makes them typical representatives of business elements that voluntarily work together for the general good." As defined by this organization, welfare work is something given to the employee by the employer for the welfare of both. It is not something the employee himself does to improve his own working conditions.
We are told that employees should assume the management of welfare work.
Should they install sanitary conveniences? Of course not.
Would they know the need of a wash room in a factory if they never had had one? No.
Should they manage lunch rooms? A few employers have attempted unsuccessfully to turn over the management of the lunch rooms to the employees, the result being that one self-sacrificing subofficial in each concern would find the burden entirely on his shoulders before working hours, during working hours, and after working hours. Employees cannot attend committee meetings during working hours, and they are unwilling to do so afterwards, for they generally have outside engagements. Furthermore, the employees know nothing about the restaurant business. If they did, they would probably be engaged in it instead of in their different trades. All experiments along this line of which we have heard have failed. The so-called "democratic idea," purely a fad, never has been successfully operated.
Many employers would introduce welfare work into their establishments were it not for the time and trouble needed for its organization. The employment of a welfare director removes this obstacle. Successful prosecution of welfare work requires concentration of responsibility. All of its branches must be under the supervision of one person, or efforts in different directions may conflict, or special and perhaps pressing needs may escape attention. Pressure of daily business routine usually relegates welfare work to the last consideration, but the average employer is interested in his men and is willing to improve their condition if only their needs are brought to his attention.
FIRST LESSONS IN INDUSTRIAL HYGIENE
WELFARE WORK THAT COUNTS
This method of promoting the welfare of the worker may have been a necessary step in the development of industrial hygiene. Undoubtedly it has succeeded, in many cases, in bringing to an employer's consciousness the needs of his workmen, in accustoming employees to higher sanitary standards, and in teaching them to demand health rights from their employers. In many cases, however, "welfare work" has miseducated both employer and employee. The fact that "the so-called democratic idea, purely a fad, has never been successfully operated," is due to the interpretation given to "democratic idea." The two alternatives in the paragraph above quoted are lunch rooms, wash rooms, as gifts from employers to employees, or lunch rooms and wash rooms to be furnished by employees at their own expense. The true democratic idea, however, is that factory conditions detrimental to health shall be prohibited by factory legislation, and this legislation enforced by efficient factory inspectors, regardless of what may be given to employees above the requirement of hygiene.
Until employees are more active as citizens and more sensitive to hygienic rights, it is desirable that welfare directors be employed in factories to arbitrate between employer and employee, to raise the moral standard of a factory settlement, to organize amusements.
Welfare work at its best is a method of dividing business profits among all who participate in making these profits. Too often welfare secretaries teach employees how to be happy in the director's way, rather than in their own way. This adventitious position increases suspicion on both sides, disturbs the discipline of the foreman, weakens rather than strengthens the worker's efficiency, because it depends upon other things than work well done and the relation of health to efficiency. In a small factory town the owner of a large cotton mill has recognized the financial benefit of physically strong workers, and is trying the experiment of a welfare director. The man himself works "with his sleeves up." The social worker has an office in the factory. A clubhouse is fitted up for the mill hands to make merry in. A room in the factory is reserved for a lunch room, with plants, tables, and chairs for the comfort of the women. Parties are given by the employer to the employees, which he himself attends. He has thrown himself into whatever schemes his director has suggested. The director complained that the reason the new lunch room was not more popular was because a piano was needed. A second-hand one would not do, for that would cultivate bad taste in music. This showed the employer that soon everything would be expected from the "big house on the hill." An event which happened at the time when the pressure was greatest on him for the piano, convinced him that his employees could supply their real needs without any trouble or delay. The assistant manager was about to leave, and in less than a week five hundred dollars was raised among the workers for his farewell gift. Walking home that night late from his office the owner was attracted by the sound of jollity, and saw a little room jammed full of mill people enjoying the improvised music of a mouth organ played to the accompaniment of heels. He resolved henceforth to train his employees to do his work well and to earn more pay,—and to let them amuse themselves. From that time on he refused to be looked upon as the deus ex machina of the town. He decided that the best way to give English lessons to foreigners was to improve the school. His beneficence in supplying them with pure water at the mill did not prevent a ravaging typhoid epidemic because the town water was not watched. He saw that the best way to improve health was to strengthen the health board and to make his co-workers realize that they were citizens responsible for their own privileges and rights.
Emergency hospitals and Y.M.C.A. buildings are sad substitutes for safety devices and automatic couplers. Christmas shopping in November is less kind than prevention of overwork in December. Night school and gymnastic classes are a poor penance for child labor and for work unsuited to the body. The left hand cannot dole favors enough to offset the evils of underpay, of unsanitary conditions, of inefficient enforcement of health laws tolerated by the right hand.
Just because a man is taking wages for work done, is no reason why he should forfeit his rights as a citizen, or allow his children, sisters, neighbors, to work in conditions which decrease their efficiency and earning power. What the employee can do for himself as a citizen, having equal health rights with employers, he has never been taught to see. Factory legislation is state direction of industries so far as relates to the safety, health, and moral condition of the people,—and which embraces to-day, more than in any other epoch, the opinion of the workers themselves. No government, however strong, can hope successfully to introduce social legislation largely affecting personal interests until public opinion has been educated to the belief that the remedies proposed are really necessary. Until schools insist upon a better ventilation than the worst factories, how can we expect to find children of working age sensitive to impure air? Where work benches are more comfortable than school desks, where drinking water is cleaner and towels more sanitary, however unsanitary they may be, than those found in the schoolhouse, the worker does not realize that they menace his right to earn a living wage as much as does a temporary shut-down.
Employers are by no means solely to blame for unhealthy working conditions. A shortsighted employee is as anxious to work overtime for double pay as a shortsighted employer is to have him. Among those who are agitating for an eight-hour day are many who, from self-interest or interest in the cause, work regularly from ten to sixteen hours.
Would it help to punish employees for working in unhealthy places? The highest service that can be rendered industrial hygiene is to educate the industrial classes to recognize hygienic evils and to coöperate with other citizens in securing the enforcement of health rights.
CHAPTER XXIV[ToC]
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.
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.
OUTDOOR LIFE CHART.
FIGHTING TUBERCULOSIS IN THE MOUNTAINS—SARANAC
Every patient keeps a daily record, called for by the following instructions:
Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock, daily; movements of bowels; hours in open air; all food taken; total amount of milk; total amount of oil and butter; appetite; digestion; spirits; cough (amount, chief time); expectoration (amount in 24 hours, color, nature); exercise (if allowed), with temperature and pulse 15 minutes after exercise; sweats; visitors.
The following simple instructions can be followed in any home, even where open windows must take the place of porches:
Rest out of doors is the medicine that cures consumption. Absolute rest for mind and body brings speedy improvement. It stops the cough and promotes the appetite. The lungs heal more quickly when the body is at rest. Lie with the chest low, so the blood flow in the lungs will aid to the uttermost the work of healing. The rest habit is soon acquired. Each day of rest makes the next day of rest easier, and shortens the time necessary to regain health. The more time spent in bed out of doors the better. Do not dress if the temperature is above 99 degrees, or if there is blood in the sputum. It is life in the open air, not exercise, that brings health and strength. Just a few minutes daily exercise during the active stage of the disease may delay recovery weeks or months. Rest favors digestion, exercise frequently disturbs digestion. When possible have meals served in bed. Never think the rest treatment can be taken in a rocking-chair. If tired of the cot, shift to the reclining chair, but sit with head low and feet elevated. Do not write letters. Dictate to a friend. Do not read much and do not hold heavy books. While reading remain in the recumbent posture.
FIGHTING TUBERCULOSIS IN DAY CAMPS—BOSTON
Once having learned the simple facts that must be noted and the simple laws that must be followed, once having placed oneself in a position to secure the rest, the fresh air, and the health diet, no better next steps can be taken than to observe the closing injunction in the rules for rest:
There are few medicines better than clouds, and you have not to swallow them or wear them as plasters,—only to watch them. Keeping your eyes aloft, your thoughts will shortly clamber after them, or, if they don't do that, the sun gets into them, and the bad ones go a-dozing like bats and owls.
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.
AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS CRUSADERS SHOULD FOLLOW
Is it not significant that America's national movement is due primarily to the organizing capacity of laymen in the New York Charity Organization Society rather than to schools or hospitals? Most of the local secretaries are men whose inspiration came from contact with the non-medical relief of the poor in city tenements. The secretary of the national association is a university professor of anthropology, who has also a medical degree. The child victim's plea—Little Jo's Smile—was nationalized by an association of laymen, aided by the advertising managers of forty magazines. The smaller cities of New York state are being aroused by a state voluntary association that for years has visited almshouses, insane asylums, and hospitals. These facts I emphasize, for they illustrate the opportunity and the duty of the lay educator, whether parent, teacher, labor leader, or trustee of hospital, orphanage, or relief society.
Three fundamental rules of action should be established as firmly as religious principles:
1. The public health authorities should be told of every known and every suspected case of tuberculosis.
2. For each case proved by examination of sputum to be tuberculous, the public-health officers should know that the germs are destroyed before being allowed to contaminate air or food.
3. Sick and not yet sick should practice habits of health that build up vitality to resist the tubercle bacilli and that abhor uncleanliness as nature abhors a vacuum.
FIGHTING TUBERCULOSIS WITH A NATIONAL ORGANIZATION
All laws, customs, and environmental conditions opposed to the enforcement of these three principles must be modified or abolished. If the teachers of America will list for educational use in their own communities the local obstacles to these rules of action, they will see exactly where their local problem lies. The illustrations that are given in this book show in how many ways these rules of action are now being universalized. Three or four important steps deserve especial comment:
1. Compulsory notification of all tuberculous cases.
2. Compulsory removal to hospital of those not able at home to destroy the bacilli, or compulsory supervision of home care.
3. Examination of all members of a family where one member is discovered to be tuberculous.
4. Special provision for tuberculous teachers.
5. Protection of children about to enter industry but predisposed to tuberculosis.
6. Prohibition of dry cleaning of schools, offices, and streets.
7. Tax provision for educational and preventive work.
Compulsory notification was introduced first in New York City by Hermann M. Biggs, M.D., chief medical officer: 1893, partially voluntary, partially compulsory; 1897, compulsory for all. Physicians who now hail Dr. Biggs as a statesman called him persecutor, autocrat, and violator of personal freedom fifteen years ago. Foreign sanitarians vied with American colleagues in upbraiding him for his exaggeration of the transmissibility of consumption and for his injustice to its victims. As late as 1899 one British expert particularly resented the rejection of tuberculous immigrants at Ellis Island, and said to me, "Perhaps if you should open a man's mouth and pour in tubercle bacilli he might get phthisis, but compulsory notification is preposterous." In 1906 the International Congress on Tuberculosis met in Paris and congratulated New York upon its leadership in securing at health headquarters a list of the known disease centers within its borders; in 1906 more than twenty thousand individual cases were reported, ten thousand of these being reported more than once. To know the nature and location of twenty thousand germ factories is a long step toward judging their strength and their probable product. To compulsory notification in New York City is largely due the educational movements of the last decade against the white plague, more particularly the growing ability among physicians to recognize and to treat conditions predisposing to the disease. As in New York City, the public should provide free of cost bacteriological analysis of sputum to learn positively whether tuberculosis is present. Simpler still is the tuberculin test of the eyes, with which experiments are now being made on a large scale in New York City, and which bids fair to become cheap enough to be generally used wherever physical examinations are made. This test is known as Calmette's Eye Test. Inside the eyelid is placed a drop of a solution—95 per cent alcohol and tuberculin. If conjunctivitis develops in twenty-four hours, the patient is proved to have tuberculosis. Some physicians still fear to use this test. Others question its proof. The "skin test" is also being thoroughly tried in several American cities and, if finally found trustworthy, will greatly simplify examination for tuberculosis. Dr. John W. Brannan, president of Bellevue and Allied Hospitals, New York City, is to report on skin and eye tuberculin tests for children at the International Congress on Tuberculosis, mentioned later.
FIGHTING TUBERCULOSIS BY ORGANIZED COÖPERATIVE DISPENSARY WORK
FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE
Compulsory removal of careless consumptives is yet rare. One obstacle is the lack of hospitals. In New York ten thousand die annually from tuberculosis and fifty thousand are known to have it, yet there are only about two thousand beds available. So long as the patients anxious for hospital care exceed the number of beds, it does not seem fair to give a bed to some one who does not want it. On the other hand, it should not be forgotten that patients are taken forcibly to smallpox and scarlet-fever hospitals, not for their own good, but for the protection of others. The last person who should be permitted to stay at home is the tuberculous person who is unable, unwilling, or too ignorant to take the necessary precautions for others' protection. A rigid educational test should be applied as a condition of remaining at home without supervision.
The objections to compulsory removal are two: (1) it is desired to make sanatorium care so attractive that patients will go at the earliest stage of the disease; (2) an unwilling patient can defeat the sanitarian's effort to help him and others. The alternative for compulsory removal is gratuitous, and, if need be, compulsory, supervision of home care, such as is now given in New York City. In Brighton, England, Dr. Newsholme treats his municipal sanatorium as a vacation school, giving each patient one month only. Thus one bed helps twelve patients each year. Almost any worker can spare one month and in that time can be made into a missionary of healthy living.
Family examining parties were begun in New York by Dr. Linsly R. Williams, for the relief agency that started the seaside treatment of bone tuberculosis. Many of the crippled children at Sea Breeze were found to have consumptive fathers or mothers. In one instance the father had died before Charlie had "hip trouble." Long after we had known Charlie his mother began to fail. She too had consumption. Family parties were planned for 290 families. Weights were taken and careful examination made, the physician explaining that predisposition means defective lung capacity or deficient vitality. Of 379 members, supposedly free from tuberculosis, sixteen were found to have well-marked cases. (Of twenty Boston children whose parents were in a tuberculosis class, four had tuberculosis.) In one instance the father was astonished to learn not only that he was tuberculous, but that he had probably given the disease to the mother, for whom he was tenderly concerned. Of special benefit were the talks about teeth and nourishment, and about fresh air and water as germ killers. One examination of this kind will organize a family crusade against carelessness.
FIGHTING TUBERCULOSIS IN SMALL CITIES
New York State Charities Aid Association
Tuberculous teachers ought to be excluded from schoolrooms not merely because they may spread tuberculosis, but because they cannot do justice to school work without sacrifices that society ought not to accept. A tuberculous teacher ought to be generous enough to permit public hospitals to restore her strength or enterprising enough to join tuberculosis classes. It is selfish to demand independence at the price which is paid by schools that employ tuberculous teachers.
FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND SALT AIR
Predisposition to tuberculosis should be understood by every child before he is accepted as an industrial soldier. Many trades now dangerous would be made safe if workers knew the risk they run, and if society forbade such trades needlessly to exhaust their employees. A perfectly sound man is predisposed to tuberculosis if he elects to work in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack of exercise in the open air, prepare lungs to give a cordial reception to tubercle bacilli. Rooms as well as persons become infected. Fortunately, opportunities to work are so varied in most localities that workers predisposed to tuberculosis may be sure of a livelihood in an occupation suited to their vitality. Destruction of germs in the air, in carpets, on walls, on streets, is quite as important as destruction of germs in lungs. Why should not tenants and workers require health certificates stating that neither house nor working place is infected with tubercle bacilli? Some cities now compel the disinfection of premises occupied by tuberculous persons after their removal. Landlords, employers, tenants, and employees can easily be taught to see the advantage of disinfecting premises occupied by tuberculous cases before detection.
FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR HOSPITALS FOR BONE TUBERCULOSIS
Dry cleaning, feather dusters, dust-laden air, will disappear from schoolrooms within twenty-four hours after school-teachers declare that they shall disappear. We have no right to expect street cleaners, tenement and shop janitors, or overworked mothers to be more careful than school-teachers. Last year I said to a janitress, "Don't you realize that you may get consumption if you use that feather duster?" Her reply caused us to realize our carelessness: "I don't want any more than I've got now." Shall we some day have compulsory examination and instruction of all cleaners, starting with school cleaners?
FIGHTING TUBERCULOSIS IN OPEN TENTS
Taxing is swift to follow teaching in matters of health. Teachers can easily compute what their community loses from tuberculosis. The totals will for some time prove a convincing argument for cleanliness of air, of body, and of building wherever the community is responsible for air, building, and body. The annual cost of tuberculosis to New York City is estimated at $23,000,000 and to the United States at $330,000,000. The cost of exterminating it will be but a drop in the bucket if school-teachers do their part this next generation with the twenty million children whose day environment they control for three fourths of the year, and whose habits they can determine.
The first meeting in America of the International Congress on Tuberculosis was held at Washington, D.C., September 21 to October 12, 1908. For many years the proceedings of this congress will undoubtedly be the chief reference book on the conquest of tuberculosis.[14]
How many aspects there are to this problem, and how many kinds of people may be enlisted, may be seen from the seven section names: I. Pathology and Bacteriology; II. Sanatoriums, Hospitals, and Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in Children—Etiology, Prevention, and Treatment; V. Hygienic, Social, Industrial, and Economic Aspects; VI. State and Municipal Control of Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man.
FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER BED, OTISVILLE, NEW YORK
How many-sided is the responsibility of each of us for stamping out tuberculosis is shown by the preliminary programme of the eight sessions of Section V. These topics suggest an interesting and instructive year's study for clubs of women, mothers, or teachers, or for advanced pupils.
I. Economic Aspects of Tuberculosis
1. The burdens entailed by tuberculosis:
a. On individuals and families.
b. On the medical profession.
c. On industry.
d. On relief agencies.
e. On the community.
f. On social progress.
2. The cost of securing effective control of tuberculosis:
a. In large cities.
b. In smaller towns.
c. In rural communities.
II. Adverse Industrial Conditions
1. Incidence of tuberculosis according to occupation.
2. Overwork and nervous strain as factors in tuberculosis.
3. Effect of improvements in factory conditions on the health of employees.
4. Legitimate exercise of police power in protecting the life and health of employees.
III. The Social Control of Tuberculosis
1. Outline of a comprehensive programme for:
a. National, state, and municipal governments.
b. Departments of health and departments of public relief.
c. Private endowments.
d. Voluntary associations for educational propaganda.
e. Institutions, such as schools and relief agencies, which exist primarily for other purposes.
2. A symposium on the relative value of each of the features in an aggressive campaign against tuberculosis:
a. Compulsory registration.
b. Free sputum examination.
c. Compulsory removal of unteachable and dangerous cases.
d. Laboratory research.
e. Hospital.
f. Sanatorium.
g. Dispensary.
h. The tuberculosis class.
i. Day camp.
j. Private physician.
k. Visiting nurse.
l. After-care of arrested cases.
m. Relief fund.
n. Climate.
o. Hygienic instruction,—personal and in class.
p. Inspection of schools and factories.
q. Educational propaganda.
IV. Early Recognition and Prevention
1. Importance of discovering the persons who have tuberculosis before the disease has passed the incipient stage.
2. Examination of persons known to have been exposed or presumably predisposed.
3. Systematic examination of school children during their course and on leaving school to go to work.
4. Professional advice as to choice of occupation in cases where there is apparent predisposition to disease.
V. After-Care of Arrested Cases
1. Instruction in healthful trades in the sanatorium.
2. Training for professional nursing in institutions for the care of tuberculous patients.
3. Farm colonies.
4. Convalescent homes or cottages.
5. Aid in securing suitable employment on leaving the sanatorium.
6. How to deal with the danger of a return to unfavorable home conditions.
VI. Educational Methods and Agencies
1. Special literature for general distribution.
2. Exhibits and lectures.
3. The press.
4. Educational work of the nurse.
5. Labor organizations.
6. Instruction in schools of all grades.
7. Presentation and discussion of leaflets awarded prizes by the congress.
VII. Promotion of Immunity
1. Development of the conception of physical well-being.
2. Measures for increasing resistance to disease:
a. Parks and playgrounds.
b. Outdoor sports.
c. Physical education.
d. Raising the standards of living: housing, diet, cleanliness.
3. Individual immunity and social conditions favorable to general immunity.
VIII. Responsibility of Society for Tuberculosis
1. A symposium of representative
a. Citizens.
b. Social workers.
c. Employers.
d. Employees.
e. Physicians.
f. Nurses.
g. Educators.
h. Others.
Cash prizes of one thousand dollars each are offered: (1) for the best evidence of effective work in the prevention or relief of tuberculosis by any voluntary association since 1905; (2) for the best exhibit of a sanatorium for working classes; (3) for the best exhibit of a furnished home for the poor, designed primarily to prevent, but also to permit the cure of tuberculosis.
BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN
A-D, F, H-J, private hospitals and agencies reporting cases to the official center; E, home care; K, L, M, day camp and hospitals for incipient and advanced cases
A white-plague scrapbook containing news items, articles, and photographs will prove an interesting aid to self-education or to instruction of children, working girls' clubs, or mothers' meetings. Everybody ought to enlist in this war, for the fight against tuberculosis is a fight for cleanliness and for vitality, for a fair chance against environmental conditions prejudicial to efficient citizenship.
So sure is the result and so immediate the duty of every citizen that Dr. Biggs wrote in 1907: In no other direction can such large results be achieved so certainly and at such relatively small cost. The time is not far distant when those states and municipalities which have not adopted a comprehensive plan for dealing with tuberculosis will be regarded as almost criminally negligent in their administration of sanitary affairs and inexcusably blind to their own best economic interests.
FOOTNOTES:
[13] The best literature on tuberculosis is in current magazines and reports of anti-tuberculosis crusaders. For a scientific, comprehensive treatment, libraries and students should have The Prevention of Tuberculosis (1908) by Arthur Newsholme, M.D. A popular book is The Crusade against Tuberculosis, by Lawrence F. Flick, of the Henry Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis.
[14] Those desiring copies this year or hereafter will do well to write to The National Association for the Study and Prevention of Tuberculosis, 105 East 22d St., New York City. The congress is under the control of the National Association and is managed by a special committee appointed by it. Even after a national board of health is established, the National Association for the Study and Prevention of Tuberculosis will continue to be a center for private interest in public protection against tuberculosis. One of its chief functions is the preparation and distribution of literature to those who desire it.
CHAPTER XXV[ToC]
THE FIGHT FOR CLEAN MILK
"With the approval of the President and with the coöperation of the Department of Agriculture,[15] the [national quarantine] service has undertaken to prepare a complete report upon the milk industry from farm to the consumer in its relation to the public health." This promise of the United States Treasury insures national attention to the evils of unclean milk and to the sanitary standards of farmer and consumer. Nothing less than a national campaign can make the vivid impression necessary to wean dairymen of uncleanly habits and mothers of the ignorant superstition that babies die in summer just because they are babies. When two national bureaus study, learn, and report, newspapers will print their stories on the first page, magazines will herald the conclusions, physicians will open their minds to new truths, state health secretaries will carry on the propaganda, demagogues and quacks will become less certain of their short-cut remedies, and everybody will be made to think.
The evolution of this newly awakened national interest in clean milk follows the seven stages and illustrates the seven health motives presented in Chapter II. I give the story of Robert M. Hartley because he began and prosecuted his pure-milk crusade in a way that can be duplicated in any country town or small city.
Robert M. Hartley was a strong-bodied, strong-minded, country-bred man, who started church work in New York City almost as soon as he arrived. He distributed religious tracts among the alleys and hovels that characterized lower New York in 1825. Meeting drunken men and women one after another, he first wondered whether they were helped by tracts, and then decided that the mind befogged with alcohol was unfit to receive the gospel message. Then for fifteen years he threw himself into a total-abstinence crusade, distributing thousands of pamphlets, calling in one year at over four thousand homes to teach the industrial and moral reasons for total abstinence. Finally, he began to wonder whether back of alcoholism there was not still a dark closet that must be explored before men could receive the message of religion and self-control. So in 1843 he organized the New York Association for Improving the Condition of the Poor, which ever since has remembered how Hartley found alcoholism back of irreligion, and how back of alcoholism and poverty and ignorant indifference he found indecent housing, unsanitary streets, unwholesome working conditions, and impure food.
FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS IN THE HEART OF NEW YORK CITY,—JUNIOR SEA BREEZE
PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK TO THE INDIVIDUAL BABY'S NEED,—ROCHESTER'S MODEL DAIRY
Hartley's instinct started the first great pure-milk agitation in this country. While visiting a distillery for the purpose of trying to persuade the owner to invest his money in another business, he noticed that "slops smoking hot from the stills" were being carried to cow stables. He followed and was nauseated by the sights and odors. Several hundred uncleaned cows in low, suffocating, filthy stables were being fed on "this disgusting, unnatural food." Similar disgust has in many other American cities caused the first effort to better dairy conditions. Hartley could never again enjoy milk from distillery cows. Furthermore, his story of 1841 made it impossible for any readers of newspapers in New York to enjoy milk until assured that it was not produced by distillery slops. The instinctive loathing and the discomfort of buyers awakened the commerce motives of milk dealers, who covered their wagons with signs declaring that they "no longer" or "never" fed cows on distillery refuse. But Hartley could not stop when the anti-nuisance stage was reached. He did not let up on his fight against impure or adulterated milk until the state legislature declared in 1864 that every baby, city born or country born, no matter how humble its home, has the right to pure milk.
Unfortunately Hartley and his contemporaries had never heard of disease germs that are carried by unclean milk into the human stomach. Science had not yet proved that many forms of barnyard filth could do quite as much harm as distillery refuse. Commerce had not invented milk bottles of glass or paper. The law of 1864 failed in two particulars: (1) it did not demand cleanliness from cow to consumer; (2) it did not provide means for its own enforcement, for learning whether everything and everybody that had to do with milk was clean. Not knowing of germs and their love for a warm climate and warm food, they naturally did not prohibit a temperature above fifty degrees from the time of milking to the time of sale. How much has been left for our generation to do to secure pure milk is illustrated by the opening sentence of this chapter, and more specifically by the programme of a milk conference held in New York in November, 1906, the board of health joining in the call. The four-page folder is reproduced in facsimile (excepting the names on the fourth page), because it states the universal problem, and also because it suggests an effective way to stimulate relevant discussion and to discourage the long speeches that spoil many conferences.
This conference led to the formation of a milk committee under the auspices of the association founded by Hartley. Business men, children's specialists, journalists, clergymen, consented to serve because they realized the need for a continuing public interest and a persisting watchfulness. Such committees are needed in other cities and in states, either as independent committees or as subcommittees of general organizations, such as women's clubs, sanitary leagues, county and state medical societies. Teachers' associations might well be added, especially for rural and suburban districts where they are more apt than any other organized body to see the evils that result from unclean milk. The New York Milk Committee set a good example in paying a secretary to give his entire time to its educational programme,—a paid secretary can keep more volunteers and consultants busy than could a dozen volunteers giving "what time they can spare." Thanks chiefly to the conference and the Milk Committee's work, several important results have been effected. The general public has realized as never before that two indispensable adjectives belong to safe milk,—clean and cool. Additional inspectors have been sent to country dairies; refrigeration, cans, and milk have been inspected upon arrival at night; score cards have been introduced, thanks to the convincing explanations of their effectiveness by the representatives of the Bureau of Animal Industry of the national Department of Agriculture; 8640 milch cows were inspected by veterinary practitioners (1905-1907), to learn the prevalence of bovine tuberculosis (of these thirty-six per cent reacted to the tuberculin test); state societies and state departments have been aroused to demand an efficient live-stock sanitary board; magistrates have fined and imprisoned offenders against the milk laws, where formerly they "warned"; popular illustrated milk lectures were added to the public school courses; illustrated cards were distributed by the thousand, telling how to keep the baby well; finally, private educational and relief societies, dispensaries, settlements, have been increasingly active in teaching mothers at home how to prepare baby's milk. In 1908 a Conference on Summer Care of Babies was organized representing the departments of health and education, and fifty private agencies for the care of sick babies and the instruction of mothers. The superintendent of schools instructed teachers to begin the campaign by talks to children and by giving out illustrated cards. Similar instructions were sent to parochial schools by the archbishop.
NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN NEW YORK CITY
As elsewhere, there are two schools of pure-milk crusaders: (1) those who want cities to do things, to pasteurize all milk, start milk farms, milk shops, or pure-milk dispensaries; and (2) those who want cities and states to get things done. So far the New York Milk Committee has led the second school and has opposed efforts to municipalize the milk business. The leader of the other school is the noted philanthropist, Nathan Strauss, who has established pasteurization plants in several American and European cities. The discussion of the two schools, similar in aim but different in method, is made more difficult, because to question philanthropy's method always seems to philanthropy itself and to most bystanders an ungracious, ungrateful act. As the issue, however, is clean milk, not personal motive, it is important that educators and parents in all communities benefit from the effective propaganda of both schools, using what is agreed upon as the basis for local pure-milk crusades, reserving that which is controversial for final settlement by research over large fields that involve hundreds of thousands of tests.
A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND SCHOOL FOR MOTHERS
Pasteurization, municipal dairies, municipal milk shops, municipal infant-milk depots, are the four chief remedies of the doing things school. European experience is cited in support of each. We are told that cow's milk, intended by nature for an infant cow with four stomachs, is not suited, even when absolutely pure, to the human infant's single stomach. Cow's milk should be modified, weakened, diluted, to fit the digestive powers of the individual infant; hence the municipal depot or milk dispensary that provides exactly the right milk for each baby, prescribed by municipal physicians and nurses who know. That the well-to-do and the just-past-infancy may have milk as safe as babies receive at the depot, municipalization of farm and milk shop is advocated. Some want the city to run only enough farms and milk shops to set a standard for private farmers, as has been done in Rochester. This is city ownership and operation for educational purposes only. Finally, because raw milk even from clean dairies may contain germs of typhoid, scarlet fever, or tuberculosis, pasteurization is demanded to kill every germ. There are advocates of pasteurization that deprecate the practice and deny that raw milk is necessarily dangerous; they favor it for the time being until farms and shops have acquired habits of cleanliness. Likewise many would prefer private pasteurization or laws compelling pasteurization of all milk offered for sale; but they despair of obtaining safe milk unless city officials are held responsible for safety. Why wait to discuss political theories about the proper sphere for government, when, by acting, hundreds of thousands of lives can be saved annually? These methods of doing things will not add to the price of milk; it is, in fact, probable that the reduction in the cost of caring for the sick and for inspecting farms and shops will offset the net cost of depots, farms, and dairies.
ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS
ROCHESTER'S MODEL DAIRY FARM
As to pasteurization, its cost is negligible, while the cost of cleanliness is two, four, or ten cents a quart. Whether ideally clean milk is safe or not, raw milk that is not clean is unfit for human consumption. All cities should compel evidence of pasteurization as a condition of sale. Large cities should have their own pasteurizing plants, just as many cities now have their own vaccine farms and antitoxin laboratories. Parents in small towns and in the country should be taught to pasteurize all milk.
The getting things done school admits the need for modified milk of strength suited to the infant's stomach; affirms the danger of milk that contains harmful germs; demands educational work by city, state, and nation; confesses that talk about cleanliness will not make milk safe. On the other hand, it denies that raw milk is necessarily dangerous; that properly modified, clean, raw milk is any safer when pasteurized; that talking about germ-proof milk insures germ extinction. It maintains that pasteurization kills benign germs essential to the life of milk, and that after benign germs are killed, pasteurized milk, if exposed to infection, is more dangerous than raw milk, for the rapid growth of harmful germs is no longer contested by benign germs fighting for supremacy. While it is admitted that raw milk produced under ideal conditions may become infected by some person ignorant of his condition, and before detection may cause typhoid, scarlet fever, or consumption, it has not been proved that such instances are frequent or that the aggregate of harm done equals that which pasteurized milk may do. Pasteurization does not remove chemical impurities; boiling dirt does not render it harmless. The remedy for germ-infected milk is to keep germs out of milk. The remedy for unclean milk is cleanliness of cow, cow barn, cowyard, milker, milk can, creamery, milk shop, bottle, nipple. If the sale of unclean milk is prevented, farmers will, as a matter of course, supply clean milk. By teaching farmers and milk retailers the economic advantages of cleanliness they will cultivate habits that guarantee a clean milk supply. By punishing railroads and milk companies that transport milk at a temperature which encourages germ growth, and by dumping in the gutter milk that is offered for sale above 50 degrees, the refrigerating of milk will be made the rule. Purging magistrates' courts of their leniency toward dealers in impure, dangerous milk is better than purging milk of germs. Boiling milk receptacles will save more babies than boiling milk. Teaching mothers about the care of babies will bring better results than giving them a false sense of safety, because only one of many dangers has been removed by pasteurization. Educating consumers to demand clean milk and to support aggressive work by health departments leaves fewer evils unchecked than covering up uncleanliness by pasteurization.
NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF SHOWING BABIES' PROGRESS
PRODUCING WINTER CONDITIONS IN MIDSUMMER BY PROPER REFRIGERATION FOR MILK IN FREIGHT CARS
When doctors disagree what are we laymen to do? We can take an intelligent interest in the inquiries that are now being made by city, state, and national governments. Because everybody believes that clean milk is safer than unclean milk, that milk at 50 degrees will not breed harmful germs, we can demand milk inspection that will tell our health officers and ourselves which dealers sell only clean milk at 50 degrees and never more than 60 degrees, that never shows over 100,000 colonies to the cubic centimeter. We can get our health departments to publish the results of their scoring of dairies and milk shops in the papers, as has been done in Montclair. We can tell our health officers that the best results in fighting infant mortality are at Rochester, which city, winter and summer, by inspection, correspondence, and punishment, educates farmers and dealers in cleanliness, not only censuring when dirty or careless, but explaining how to make more money by being clean. Finally, mothers can be taught at home how to cleanse the bottles, the nipples, all milk receptacles, and all things in rooms where milk is kept. Absolutely clean milk of proper temperature at the shop may not safely be given to a baby in a dirty bottle. Infant milk depots, pasteurization, the best medical and hospital care, breast feeding itself, cannot prevent high baby mortality if mothers are not clean. The most effective volunteer effort for pure milk is that which first makes the health machinery do its part and then teaches, teaches, teaches mothers and all who have to do with babies.
NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS
"Clean air, clean babies, clean milk," has been the slogan of Junior Sea Breeze,—a school for mothers right in the heart of New York's upper East Side. In the summer of 1907 twenty nurses went from house to house telling 102,000 mothers how to keep the baby well. This was the only district that had fewer baby deaths than for 1906. Had other parts of the city shown the same gain, there would have been a saving of 1100 babies. The following winter a similar work was conducted by nurses from the recently founded Caroline Rest, which has an educational fund for instruction of mothers in the care of babies, especially babies not yet born and just born. Heretofore the baby has been expected to cry and to have summer complaint before anybody worried about the treatment it received. If the baby lived through its second summer, it was considered great good fortune. Junior Sea Breeze and Caroline Rest start their educational work before the baby is sick, in fact, before it is born. Their results have been so notable that several well-to-do mothers declare that they wish they too might have a school. Dispensaries and diet kitchens and more particularly maternity wards of hospitals, family physicians, nurses, and midwives, should be required to know how to teach mothers to feed babies regularly, the right quantities, under conditions that insure cleanliness whether the breast or the bottle is used. Perhaps some day no girl will be given a graduating certificate, or a license for work, teaching, or marriage, until she has demonstrated her ability to give some mother's baby "clean air, clean body, clean milk."
FOOTNOTES:
[15] Libraries should obtain all reports on milk, Bureau of Animal Industry, Washington, D.C.
CHAPTER XXVI[ToC]
PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER
No profession, excepting possibly the ministry, is regarded with greater deference than the medical profession. Our ancestors listened with awe and obedience to the warnings and behests of the medicine man, bloodletter, bonesetter, family doctor. In modern times doctors have disagreed with each other often enough to warrant laymen in questioning the infallibility of any individual healer or any sect, whether homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day most of us surround the medical profession or the healing art with an atmosphere of necromancy. Even after we have given up faith in drugs or after belief is denied in the reality of disease and pain, we revere the calling that concerns itself, whether gratuitously or for pay, with conquering bodily ills.
Self-laudation continues this hold of the medical profession upon the lay imagination. One physician may challenge another's faults, ridicule his remedies, call his antitoxin dangerous poison, but their common profession he proudly styles "the most exalted form of altruism." Young men and women beginning the study or the practice of medicine are exhorted to continue its traditions of self-denial, and in their very souls to place human welfare before personal or pecuniary advancement. Newspapers repeat exhortation and laudation. We laymen pass on the story that we know is not universally true,—physicians know, physicians apply what they know without consciousness of error, physicians must be implicitly trusted.
For a physician to give poison when he means to give food is worse, not better, than for a layman to make the same mistake. Neither the moral code nor the law of self-preservation enjoins a tuberculous mother to take alcohol or to sleep in an unventilated room, even if an uninformed physician prescribes it. Instruction in physiology and hygiene would be futile if those who are educated as to the elementary facts of hygiene and physiology must blindly follow blind physicians. A family doctor who gives cod-liver oil for anæmia due to adenoids may do a child as much harm as a nurse who drugs the baby to make it sleep. The physician who refuses to tell the board of health when smallpox or typhoid fever first breaks out takes human life just as truly as if he tore up the tracks in front of an express train. This is another way of saying that parents and teachers must fit themselves to know whether the family physician and their community's physicians are efficient practitioners and teachers. Every one can learn enough about the preventable causes of sickness and depleted vitality to insist upon the ounce of education and prevention that is better than a pound of cure.
For its sins of omission, as for its sins of commission, the medical profession shares responsibility with laymen. For years leading educators, business men, hospital directors, public officials, have known that communicable diseases could be stamped out. The methods have been demonstrated. There is absolutely no excuse to-day for epidemics of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet fever in the small towns of Minnesota, for uninterrupted epidemics of tuberculosis everywhere. Had either laymen, physicians, or school-teachers made proper use of the knowledge that has been in text-books for a generation, this country would be saving thousands of lives and millions of dollars every year. Our doing and getting done have lagged behind our knowing.
The failure of physicians to "socialize" or "humanize" their knowledge is due to two causes: (1) no one has been applying result tests to the profession as a whole and to the state in its capacity as doctor, testing carefully the sickness rate, the death rate, and the expense rate of preventable diseases; (2) physicians themselves have not needed to know, either at college or in practice, the tax levied upon their communities by preventable sickness. Public schools can do much to secure result tests for individual physicians, for the profession as a whole, and for boards of health. Schooling in preventive medicine, or, better named, schooling in preventive hygiene, will fit physicians to do their part in eradicating preventable disease.
Preventive hygiene is not an essential part of the training of American physicians or nurses to-day. Not only are there no colleges of preventive hygiene, but medical schools have not provided individual courses. It is possible for a man to graduate with honors from our leading medical colleges without knowing what "vital statistics" means. Even boards of health, their duties and their educational opportunities, are not understood by graduates; it is an accident if the "social and economic aspects of medical practice," "statistical fallacies," "hospital administration," "infant mortality," are familiar terms. It is for this reason, rather than because physicians are selfish, that indispensable and beneficent legislation is so generally opposed by them when the prerogatives of their profession seem in danger. Practically every important sanitary advance of the past century has been fought at the outset by those whose life work should have made them see the need. Physicians bitterly attacked compulsory vaccination, medical inspection of schools, compulsory notification of communicable diseases. What is perhaps more significant of the physician's indifference to preventive hygiene is the fact that most of the sanitary movements that have revolutionized hygienic conditions in America owe their inception and their success to laymen, for example, tenement-house reform, anti-child labor and anti-tuberculosis crusades, welfare work in factories, campaigns for safety appliances, movement for a national board of health, prison, almshouse, and insane-asylum reform, schools for mothers, and milk committees. The first hospital for infectious diseases, the first board of health, the first out-of-door sea-air treatment of bone tuberculosis in the United States, were the result of lay initiative.
Dr. Hermann M. Biggs says that in America the greatest need of the medical profession and of health administration is training that will enable physicians and lay inspectors to use their knowledge of preventive hygiene for the removal of living and working conditions that cause preventable sickness. A physician without knowledge of preventive hygiene is simply doing a "general repair" business.
For a few months in 1907 New York City had a highly efficient commissioner of street cleaning, who, in spite of the unanimous protests and appeals of the press, refused to give up the practice of medicine. Hitherto the board of health of that city has been unable to obtain the full time of its physicians because professional standards give greater credit to the retail application of remedies than to the wholesale application of preventives.
Statesmanship as well as professional ability is expected of physicians in the leading European cities, more particularly of those connected with health departments. There it is not felt that a medical degree is of itself a qualification for sanitary or health work. After the professional course, physicians must take courses in preventive hygiene and in health administration. Medical courses include such subjects as vital statistics, duties of medical officers of health, sanitary legislation, state medicine.
The needless cost for one year of "catching" diseases in New York City would endow in perpetuity all the schools and lectureships and journals necessary to teach preventive hygiene in every section of this great country. That city alone sacrifices twenty-eight thousand lives annually to diseases that are officially called preventable. The yearly burial cost of these victims of professional and community neglect is more than a million dollars. When to the doctor bills, wages lost, burial cost of those who die are added the total doctor bills, wages lost, and other expenses of the sick who do not die, we find that one city loses in dollars and cents more every year from communicable diseases than is spent by the whole United States for hospitals and boards of health.
Many diseases and much sickness are preventable that are not communicable. Indigestion due to bad teeth is not itself communicable, but it can be prevented. One's vitality may be sapped by irregular eating or too little sleep; others will not catch the trouble, although too often they imitate the harmful habits. Adenoids and defective vision are preventable, but not contagious. Spinal curvature and flat foot are unnecessary, but others cannot catch them. Preventive hygiene, however, should teach the physician's duty to educate his patient and his community regarding all controllable conditions that injure or promote the health.
In the absence of special attention to preventive medicine new truth is forced to fight its way, sometimes for generations, before it is accepted by the medical profession. So strong are the traditions of that profession and so difficult is it for the unconventional or heterodox individual to retain the confidence of conservative patients, that the forces of honorable medical practice tend to discourage research and invention. The man who discovers a surgical appliance is forced by the ethics of his profession either to commercialize it and lose his professional standing, or to abide the convenience of his colleagues and their learned organizations in testing it. Rather than be branded a quack, charlatan, or crank, the physician keeps silent as to convictions which do not conform to the text-books. Many a life-saving, health-promoting discovery which ought to be taken up and incorporated into general practice from one end of the country to the other, and which should be made a part of the minimum standard of medical practice and medical agreement, must wait twenty-five or fifty years for recognition.
THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS STILL AN OUTCAST IN SCORES OF HOSPITALS
For want of a school of preventive medicine to emphasize universally every new truth, the medical colleges are permitted to remain twenty-five or fifty years behind absolutely demonstrated facts as to medical truth and medical practice. In 1761 a German physician, Avenbruger, after discovering that different sounds revealed diseased tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815 Lëannec discovered that sound from the chest was more distinct through a paper horn. On that principle the modern stethoscope is built. He made an accurate diagnosis of tuberculosis, and while suffering from that disease treated himself as a living clinical study. In 1857 Pasteur proved the presence of germs "without which no putrefaction, no fermentation, no decay of tissue takes place." In 1884 Trudeau started the first out-of-door care of pulmonary tuberculosis in America. In 1892 Biggs secured the compulsory notification of pulmonary tuberculosis. In 1904 began our first out-of-door sea-air treatment for bone tuberculosis. Yet there are thousands of physicians to-day who sincerely believe that they are earning their fees, who, from houses shut up like ovens, give advice to patients for treatment of tuberculosis, who prescribe alcohol and drugs, who diagnose the disease as malaria for fear patients will be scared, who oppose compulsory registration, and who never look for the tuberculous origin of crippled children. Just think of its being possible, in 1908, for a tuberculous young man of thirty to pay five dollars a day to a sanatorium whose chief reliance is six doses of drugs a day!
In 1766 America's first dentist came to the United States. By 1785 itinerant dentists had built up a lucrative practice. In 1825 a course of lectures on dentistry was delivered before the medical class at the University of Maryland. As early as 1742 treatises were written "Upon Dentition and the Breeding of Teeth in Children." In 1803 the possibility of correcting irregularities was pointed out, as was the pernicious effect of tartar on the teeth in 1827. In 1838 attempts were made to abolish, "in all common cases, the pernicious habit of tooth drawing." In 1841 treatises were written on the importance of regulating the teeth of children before the fourteenth year and on the importance of preserving the first teeth. Yet in 1908 it is necessary to write the chapter on Dental Sanitation. Few physicians, whether in private practice or hospitals or just out of medical college, consider it necessary to know the conditions of the mouth before prescribing drugs for physical illness.
Osteopathy furnishes an up-to-date illustration. Discredited by the medical profession, by medical journals and medical schools, it has in fifteen years built up a practice of eight thousand men, having from one to three years' training, including over one hundred physicians with full medical training plus a course in osteopathy. There were means of learning fifteen years ago what was truth and what was quackery about the practice of osteopathy. By refusing to look for its truth and by concentrating attention upon its quackery the medical profession has lost fifteen years. Whereas the truth of osteopathy should have been adopted by the medical colleges and a knowledge of its possibilities and limitations required of every practicing physician, a position has been reached where alleged quackery seems in several important points to be discrediting the sincerity, the intelligence, and the efficiency of orthodox medicine. No appeal to the natural can be stronger, no justification of schools of preventive medicine more complete, than the following paragraph from an osteopathic physician who is among the small number who, having both the medical and osteopathic degrees, see both the possibilities and limitations of manual surgery and demand the inclusion of this new science in the medical curriculum.
The physical method of treating disease presents a tremendous and significant departure from the empiricism of medicine and the experimentation of dietetics, the restricted fields of electricity, suggestion, water cures, and massage. The patient as an individual is not treated; the disease as a disease is not treated; the symptoms are not treated; but the entire physical organism, with its many parts and diverse functions, is exhaustively examined until each and every abnormal condition, whether of structure or of function, causing disease and maintaining symptoms, is found and administered to with the skill of a definite art, based upon the data of an exact science.
Likewise the truths underlying Christian Science have been disdained by medical schools and medical experts, just as its spiritual truth has been disdained by religious leaders, until it has grown to such strength that laymen are almost forced to question the sincerity and the efficacy of the conventional in religion as well as medicine. In May, 1907, the Emmanuel Church in Boston organized a clinic for the purpose of utilizing for neurasthenics particularly both the spiritual and the physical truths underlying religion and the various branches of medical science. Daily papers and magazines are giving a great deal of space to this experiment in "psychotherapy," which is discussed in the chapter on Mental Hygiene. Schools and chairs in preventive hygiene would soon give to the medical profession a point of view that would welcome every new truth, such as the alliance of religion and medicine, and estimate its full worth promptly. Truth seeking would be not only encouraged but made a condition of professional standing.
Just what attitude any particular physician takes can be learned by the teacher or parents whose children he treats. If he pooh-poohs or resents board of health regulations as to isolation of scarlet-fever patients, he is a dangerous man, no matter how noble his personal character. If he says cross-eyes will straighten, weak eyes will strengthen, or nose-stopping adenoids "absorb," he is bound to do harm. If he says tuberculosis is incurable, noncommunicable, hereditary, or curable by drugs, or if he tries to cure cancer by osteopathy, he can do more injury than an insane criminal. If he fails to teach a mother how to bathe, feed, and clothe the baby, how to ventilate a room for the sick or the well, he is an expensive luxury for family or for school, and belongs to an age that knew neither school nor preventive hygiene. If he takes no interest in health administration; if he overlooks unclean milk or unclean streets, open sewers, and unsanitary school buildings, street cars, churches, and theaters; if he does not help the health board, the public hospitals, the schools, the factory, and tenement departments enforce sanitary laws, he is derelict as a citizen and as a member of an "exalted profession." If he sees only the patients he himself treats or one particular malady, he is derelict as a teacher, no matter how charming his personality or how skilled in his specialty. If a school physician is slovenly in his work, if he spends fifteen minutes when he is paid for an hour, should the efficient school-teacher conceal the fact from her superiors because he is a physician? If private hospitals misrepresent facts or compromise with political evils for the sake of a gift of public money, their offense is more heinous because of their exalted purpose. The test of a physician's worth to his patients and to his community is not what he is or what he has learned, and not what his profession might be, but what happens to patient and to community. Human welfare demands that the medical profession be judged by what it does, not by what it might do if it made the best possible use of its knowledge or its opportunity.
TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN
Caroline Rest Educational Fund was given to show the value of such teaching
A dispensary that treats more patients than it can care for properly is no better than a street-car company that chronically provides too few seats and too many straps. Unless physicians test themselves and their profession by results, we shall be compelled to "municipalize the medical man." Preventable sickness costs too much, causes too much wretchedness, and hampers too many modern educational and industrial activities to be neglected. If the medical profession does not fit itself to serve general interests, then cities, counties, and states will take to themselves the cure as well as the prevention of communicable and other preventable sickness. Human life and public health are more precious than the medical profession, more important even than theories and traditions against public interference in private matters. The unreasoning opposition of medical men to government protection of health, their concentration on cure, and their tardy emphasis on prevention have forced many communities to stumble into the evil practices mentioned in Chapter XVI. Incidentally, the best physicians have learned that the prosperity of their profession increases with every increase in the general standard of living. It is the man in the ten-room house not the man in one room who supports physicians in luxury. It is the healthy man and the healthy community that value efficient medical service.
Many American cities maintain dispensaries and hospitals for the poor. Whether they will go to the logical conclusion of engaging physicians to give free treatment to all regardless of income depends largely upon what the next generation of private physicians do. The state already says when a physician's training fits him to practice. It will soon expect him to pass rigid examinations in the social and economic aspects of his profession,—its educational opportunity, vital statistics, sick and death rates. Will it need to municipalize him in order to protect itself?
Obviously the teacher or parent should not begin cooperation with physicians by lecturing them or by assuming that they are selfish and unwilling to teach. The best first step is to ask questions that they should be able to answer:
What causes cholera morbus or summer complaint? When does milk harm the baby? How can unclean milk be made safe? Whose fault is it that the milk is sold unclean and too warm? What agencies help sick babies? What is the health board doing to teach mothers?
Or, if a school physician, the teacher can ask:
Why not remove these adenoids? What causes them? When will they disappear by absorption? What harm can they do in the meantime? How long would an operation take? Would it hurt very much? What would be the immediate effects? Why not act at once? What provisions are there in town for such operations? Why have the physicians paid so little attention to breathing troubles? What could your state do to interest physicians in school hygiene? Will the school physician talk to a mothers' meeting? What agencies will give outings to sick children? What dispensaries are accessible? Who is the proper person to organize a public health league?
Physicians love to teach. If teachers and parents will love to learn and will ask the right questions, all physicians can be converted into hygiene missionaries, heralds of a statesmanship that guarantees health rights to all.
Licensing the Practitioner
Three parties are interested in setting a high standard for physicians, dentists, druggists, nurses, and veterinary surgeons—the profession itself, the schools that educate, and the general public on whom the arts are practiced. The schools and the practitioners are, for the most part, primarily interested in protecting a monopoly of skill. Their interest in restrictive legislation is analogous to that of the labor union which limits the number of apprentices. This trade unionism among professional colleges and professional graduates of these colleges has gradually developed a higher and higher standard that results in greater protection to the public. The first step is generally to demand that all persons entering a profession after a given date shall prove to the state their ability to "practice" without injury to clients. It is almost impossible to get such laws through unless the original law exempts all persons by whatever name, who are practicing the art in question at the time the law is passed. Whether we are speaking of medicine, law, dentistry, accountancy, osteopathy, or barbering, this has been the history of compulsory restriction and of state examinations.
As with regard to most other legislation, the enforcement of the law lags behind its definition. Moreover nothing is done after a man has passed a certain examination to see that he remains fit and safe to treat the public. Because no supervision is provided except on the day of examination, it is possible for men and women to fill their brains for a week or two weeks with the information necessary to pass what coaches and tutors have learned will, in all probability, be asked. Forever after, the public is left to protect itself. Out of this condition have arisen the evil, unethical, and unprofessional practices represented particularly by painless dentists, by ignorant or dishonest physicians, and by osteopaths and careless nurses.
The machinery for preventing these evils is discussed in Chapter XXIX. Suffice it here to present to parents and teachers the need for examination in advance of certification that will show whether or not those who make a livelihood by caring for others' health are equipped to mitigate rather than aggravate evils, and for further tests by which the public can learn from time to time which, among those professional men who are protected by the public against competition, continue to be safe. Finally, if, as will be clearly seen, it is desirable that what we call professional ethics persist and that self-advertisement be discouraged, society must, for its own protection, adopt some other means than epithets to correct the evils of self-advertisement and quackery. Even though we admit the responsibility of each citizen when he goes to the house of a private practitioner who has made no other effort to lure him thither than to place a card in the window, it must be seen that we cannot hold responsible for their choice men and women who receive through newspapers, magazines, or circulars convincing notices that Dr. So-and-So or the Integrity Company or the Peerless Dental Parlor will place at their disposal, at prices within their reach, skill and devotion absolutely beyond their reach at the office of an efficient private practitioner. Some way must be found by which departments of health will currently impose tests of methods and results upon physicians, opticians, pharmacists, manufacturers of medicine, and dentists.
As laymen become more intelligent regarding their own bodies and healthy living, it grows harder and harder for quacks and incompetents to mislead and exploit them. Better than any possible outside safeguard is hygienic living. Fortunately, we can all learn the simple tests of environment and of living necessary to the selection of physicians, dentists, and opticians, or other "architects of health" whose efficiency and integrity are beyond question.