As laymen become more intelligent regarding their own bodies and healthy living, it grows harder and harder for quacks and incompetents to mislead and exploit them. Better than any possible outside safeguard is hygienic living. Fortunately, we can all learn the simple tests of environment and of living necessary to the selection of physicians, dentists, and opticians, or other "architects of health" whose efficiency and integrity are beyond question.



PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS



CHAPTER XXVII

DEPARTMENTS OF SCHOOL HYGIENE

The term "school hygiene" generally suggests no other school than the public school. State laws say nothing about compulsory hygiene in military academies, ladies' seminaries, or other preparatory and finishing schools. Yet when one thinks of it, one must conclude that the right to health and to healthful school environment cannot equitably be confined to the children whose tuition is given at public expense. There is a better way to check "swollen" fortunes than by ruining the health of "fortune's children." The waste and danger of slow-minded, noticeably inefficient children are no less when parents are rich than when parents are poor. There is no justification for neglecting the health of children in parochial schools, in private schools for the well-to-do or rich, or in commercial schools for the ambitious youth of lower income strata. Nor has the commercial, parochial, private school, or college, any clearer right than the public school to injure or to fail to promote pupils' health. So far as school hygiene is advisable, so far as it is right to make hygiene compulsory, its personal and social benefits should be shared by children of school age without regard to income, and its laws should be enforced by all teachers, principals, and officers that have to do with school. In presenting a programme for school hygiene this chapter refers to the hygiene taught, the hygiene practiced, the hygiene not taught, and the hygiene not practiced in buildings and on grounds where children and youth are at school, whether these children are in kindergarten or high school, in reformatory or military academy, in charitable school, or in finishing and preparing center for society's juniors.

The question of the local, state, and national machinery by which proper standards of school hygiene shall be made effective will be taken up after we have considered individual steps in a comprehensive programme for school hygiene.

1. Thorough physical examination of all candidates for teachers' positions and periodic reexamination of accepted teachers.

Teachers would be grateful to be told in time their own physical needs and the relations of their vitality to the vitality of their pupils. Are your teachers examined? Do they know the laws of health and the signs of child health? Are they permitted to continue in schoolrooms after tuberculosis is discovered? Are normal graduates given physical tests before being permitted to teach and before being permitted to give four years to preparation for teaching?

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

We believe a vast number of things that "ain't so" about the health of country children as compared with city children, of private-school children as compared with public-school children. Where do we find more degenerate men, physically and morally, than in so-called "American settlements," where, for generations, children have had all outdoors to play in, except when in homes and schoolhouses that are seldom cleansed and seldom ventilated? Open mouths and closed minds clog the "little red schoolhouse"; there headaches do not suggest eye strain; there deafness and running ears are frankly attributed to scarlet fever which everybody must have with all the other "catching" diseases, the earlier the better; there colds begin in December and run until March, to the serious injury of attendance and promotion records; there bone tuberculosis is called "knee trouble" or "spine trouble in the family"; there boys like my little friend Fred count the bottles of cod-liver oil they take to cure adenoids that could be removed in two minutes.

The index to community life and community living conditions should be read in the country, not only for the country's sake, but also for the sake of the city whose milk and water, poisoned in the country, cause thousands of deaths annually, besides annual sick bills exceeding many times over the Russell Sage and Carnegie Foundations, which we rightly call munificent. Reading the index of private schools and colleges is important for their children and youth, but still more important for the community upon which unbridled passion, inability to work or to spend properly, inconsequential thinking, mediaeval ideals of caste, etc., can inflict greater injuries than can typhoid fever or cholera.

The physical record of each child should be kept from date of entrance to date of leaving school, showing condition at successive examinations, absence because of illness, etc.

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

To give working papers to children seriously handicapped by physical defects is to buy future industrial trouble, hospital and poorhouse bills. A boy with adenoids, a girl with eye trouble, should not be permitted to begin the fight for self-support without at least being clearly shown that the correction of these defects will increase their earning power. At present a schoolgirl with incipient tuberculosis, or predisposed to that disease, can get working papers, go to a hammock or tobacco factory, work long hours, breathe bushels of dust, deplete her vitality, spread tuberculosis among her co-workers and home associates, infect a tenement,—and all this without any help or advice or any protection from society until she is too sick to work and her physician notifies the health department that she is a danger center. We may disagree about society's right to control a child's act after the defects are discovered, but who will question society's duty to tell that child and her parents the truth about her physical needs before it accepts her labor or permits her to "enter society"?

4. Supervision by physicians of hygiene practiced in schoolrooms and on playgrounds.

Superintendent Maxwell, of New York City, and other educational leaders urge teachers to do their utmost to learn the physical conditions and home environment of the individual child, and to fit school treatment to the individual possibilities and handicaps. But experience proves conclusively that try as they will, teachers and principals have neither the special knowledge nor the time to acquire the special knowledge requisite to use the facts disclosed by the physical examination of school children. Physicians and nurses are needed, not so much for treating children, as for teaching children, parents, teachers, family and dispensary physicians.

Private schools have visiting physicians who may be consulted; they need physicians to supervise, with power to examine or to require certificates of examination. The Committee on the Physical Welfare of School Children found that when a visitor was detailed for that purpose it was easy to secure the cooeperation of parents, teachers, family physicians, dispensaries, school boards, and charitable societies. The Hawthorne Club's school secretary has been similarly successful in Boston, as have those of Hartley House, Greenwich House, and the Public Education Association in New York.

5. Restriction of study hours at school and at home to limits compatible with health.

Whether the hours of study at school and at home are excessive cannot be learned from treatises on pedagogics or physiology. Because children differ in vitality as in ability to learn, the maximum limit for study hours should be determined by the individual child's physical condition. When the Japanese went to war with Russia the highest authority in the field was the army surgeon. To this fact was largely due the astonishingly small amount of sickness and the high fighting capacity and endurance of the Japanese, working under unfavorable conditions. No board of school superintendents or board of directors, no state superintendent of schools or college professor, has the right to compel or to allow study hours beyond the maximum compatible with the individual student's physical condition and endurance. The physician responsible for school hygiene should have an absolute veto upon any educational policy, method, or environment demonstrably detrimental to children's vitality.

6. Establishment of a "follow-up" plan to insure action by parents to correct physical defects and to attend to physical needs.

The advantages of getting things done over doing things have been repeatedly emphasized. In smaller cities and in rural districts it is particularly important for schools to get things done better by existing local agencies, such as churches, health and street-cleaning departments, hospitals, clinics, medical and sanitary societies, trade unions, young people's societies, and women's clubs. Where parents who have been followed up and taught, obstinately or ignorantly refuse to attend to their children's needs, the segregation of the physically defective or needy will encourage the cooeperation of children themselves in persuading parents to act intelligently for the child's sake. No child wants to remain "queer" or "dopey" or behind his peers. The city superintendent of schools for New York City has asked for laws compelling parents to permit operations and punishing them for neglecting to take steps, within their power, to remove physical defects discovered at school.



7. Physiological age should influence school classification and school curriculum. On this subject the studies of Dr. C. Ward Crampton, referred to in the chapter on Vitality Tests, are invaluable and as convincing as they are revolutionary. Scientists accept his proof that our present high school curriculum is ill adapted to a large proportion of children; the "physiologically too young" drop out; only the physiologically mature succeed. The two physiological ages should be given different work. Children whose bodies yearn for pictures, muscular and sense expression, should be given a chance in school for normal development. Analysis should wait for action. Organized play and physical training antedated physical examination in our schools. Like the curriculum they often disregard physiological age, doing harm instead of good. Facts as to physical condition and physiological development would enable us to utilize the momentum of these two to broaden school hygiene and to insure proper physical supervision. Only good would result from adopting Leipsic's plan of having school children examined without clothing, in the presence of parents if parents desire. Expensive? Not so expensive as high school "mortality" due to maladjusted curriculums that force the great majority of boys and girls to drop out before graduation and ruin the health of a large fraction of those who remain.

8. Construction of school building and of curriculum so that, when properly conducted, they shall neither produce nor aggravate physical defects.

When the state for its own protection compels a child to go to school, it pledges itself not to injure itself by injuring the child. Thousands of children are now being subjected to conditions in school far more injurious than the factory and shop conditions against which the national and state child labor committees have aroused universal indignation. Two illuminating studies of school buildings in New York City were made last year by the Committee on the Physical Welfare of School Children, and later by the Board of Education. Similar studies should be made of every schoolroom. Whereas our discussions of buildings and curriculum have hitherto proceeded largely from abstract principles of light, ventilation, heating, and pedagogics, these two reports deal with rooms, equipment, courses of study, and school habits as they are, with obvious detrimental effects on child victims. Numerous questions that it is practicable to answer are given in Chapter XIV.

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

In passing it is worth while to note that in large cities teachers are frequently forced to choose between bad ventilation and street noises. From Boston comes the suggestion that we avoid noises and evils of congestion by building schoolhouses for city children on the outskirts in the midst of fields, transporting, and, if necessary, feeding children at public expense. While it is true that the public funds now spent in attempting to cure physical and moral ills would purchase ample country reservations, the practical next step seems to be to provide ample play space and breathing space within the city for every school building already erected, and without fail for all buildings to be erected hereafter.

9. Hygiene should be so taught that children will cultivate habits of health and see clearly the relation of health and vitality to present happiness and future efficiency. Social rather than personal, public rather than private, health needs emphasis. Children can be shown how their health affects their neighbor; why money spent for health boards is a better investment than money given to corrupt politicians; that the cost of accepting Thanksgiving turkey or a park picnic from a political leader who encourages inefficient government is sickness, misery, deficient schooling, lifelong handicap; that children and adults have health rights in school and factory, on street and playground, which the law will protect if only they know when these rights are infringed.

10. Central supervision of school hygiene. In private and public, boarding and day, country and city, reformatory and military, commercial and high schools, the index—physical welfare of school children—should be read and interpreted. Headquarters should learn whether or not physical examinations are made and whether harmful conditions are corrected. So far as public schools are concerned, "headquarters" means for cities the fact center that informs city superintendent or school board; for rural schools, it means the county superintendent's office. Whether city or county headquarters have the facts and act accordingly should be known by state superintendents. Whether state superintendents are demanding the facts and educating the county and city headquarters of their states should be known to the national commissioner of education and by him published for all the world. Some people think the state health board should be responsible, others the state educational authority. The important thing is to make some one officer responsible. Methods can be easily worked out if the need is conceded. Legislatures will gladly confer the powers necessary to reading the index of all public schools.

As for parochial and private schools, they may resent for a time public supervision of their hygiene teaching and practice. However, the case could be so presented that they would ask for it, because it would help not only their pupils and society but the schools themselves. No religious belief or private investment can afford to admit that it disregards child health; state supervision would require nothing more than evidence of adequate school hygiene.

11. Information gained at school regarding conditions prejudicial to community health should be published and made the basis of an aggressive campaign for the enforcement of sanitary laws. Ten thousand uses can be made of the information gained at school, ten thousand forces can be made to do educational work, but only a few kinds of work can be done effectively at school. Franklin Ford has said: "You can relate school to all life, but you cannot bring all life under the school roof." As Chapters XVI-XVIII make clear, to socialize the point of view of dispensaries and hospitals is more effective than to put clinics in school buildings. To do for or give to people who can help themselves is to give up and do up power of self-help.

Machinery that must some day exist for the execution of this programme will be approximately the following:

I. NATIONAL MACHINERY

1. Clearing house for facts regarding school hygiene as taught and practiced in all schools under the Stars and Stripes; this to be a part of the National Bureau of Education.

2. Scientific research to be conducted by the National Bureau of Education or by the future National Board of Health.

II. STATE MACHINERY

1. Clearing house for facts regarding school hygiene taught and practiced in all schools within state limits; this to be maintained by the state educational authorities.

2. Agents to make special inquiries as to practice and teaching of school hygiene.

3. Agents to inspect and to instruct county superintendents, county physicians, teachers, normal schools, etc.

4. A bureau of experts—architect, sanitarian, teacher—whose approval must be obtained before any school building can be erected. (A plan which brought excellent results when applied by state boards to charitable institutions, hospitals for the insane, etc.)

5. Standard making by normal schools, state universities, hospitals, or other educational and correctional institutes under direct state management.

III. COUNTY MACHINERY

1. Clearing house for facts regarding school hygiene taught and practiced in all schools within county limits; this to be maintained by the county superintendent of schools.

2. Physician and nurse to organize inspection and instruction for rural schools, to give lessons and make demonstrations at county institutes, to show teachers how to interest physicians, dentists, health officers, and parents in the physical welfare of school children.

IV. TOWN AND TOWNSHIP MACHINERY

1. Teachers intelligent as to physical needs, as to sanitation of buildings, etc.

2. An examining physician, to be salaried where the population justifies; elsewhere to work as a volunteer in cooeperation with teacher and with county physician.

3. Physical history of each child from date of entrance to date of leaving school, to be kept up to date by teacher.

V. CITY MACHINERY

1. A division to be known as the Department of School Hygiene, headed by an officer who gives his entire time to that department.

2. A subcommittee of the Board of Education.

3. Clearing house for facts regarding school hygiene taught and practiced in all schools within city limits.

4. Specialists to examine applicants for teaching positions, and to reexamine teachers to determine fitness for continuance, for promotion, and for special assignments.

5. A bureau for inspection and control of all hygiene of school buildings, old and new, with power to compel repairs or to reject plans that do not make adequate sanitary provision.

6. Similar supervision of curriculum and of study hours prescribed.

7. A bureau for the inspection and control of curriculum, required home study, exercise, physical training, etc., so far as relates to the health of pupils, and to the physical ability of children to be in certain grades or to be promoted. This will decide the duration of lessons, frequency of intermissions, sequence of subjects, time and method of recess throughout the various grades.

8. Supervision of indoor and outdoor playgrounds, roof gardens, indoor and outdoor gymnasiums, swimming pools, etc.

9. Supervision of instruction in school hygiene.

10. A staff of inspectors for communicable diseases of pupils and teachers, to be subject to the board of education or the board of health.

11. A staff of examiners adequate to examine all children and teachers at least once a year for defects of eye, ear, teeth, nose, throat, lungs, spine, bones, glands, etc., and for weight and height to be under the control of the board of education or the board of health. The expense would not be as great as the penalty paid for omitting such examination.

12. A staff of nurses to assist medical examiners to give children practical demonstrations in cleanliness, to teach mothers the care of children both at their homes and in mothers' meetings, to enlist the cooeperation of family physician and neighborhood facilities, such as hospitals, dispensaries and relief agencies, magistrates' courts and probation officers,—all to be under the control of the board of education or the board of health.

Whether inspectors, examiners, and nurses shall be directed by the board of education or the board of health is a question that it is impossible to decide without knowledge of local conditions. So far as state and county organizations are concerned, it is clear that whatever the boards of health may do, it will be necessary for state and county superintendents of education to equip themselves with the machinery above recommended. In cities it is quite clear that a board of education should be responsible for all of the machinery suggested, excepting the three divisions that have to do with work hitherto considered as protection against transmissible diseases, namely, inspection, examination, district visiting. In Cleveland these are school duties. In New York they are duties of the health department. Boston has school nurses and health department physicians. The state law of Massachusetts provides that where health boards do not examine school children, school boards may spend money for the purpose.

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

Dr. Biggs feels that responsibility for the physical welfare of school children will strengthen health work in all cities, and, given proper interest on the part of school officials, should make possible universal cooeperation in a constructive programme. On the other hand, he believes that division of responsibility between school and health boards will weaken both in their appeals for funds and for support of a constructive programme. I have heard principals and superintendents maintain also that the moral effect of a visit to the school by a representative of the health board vested with powers of that board was much greater than a visit by a representative of the school board. They further allege that a physician coming from the outside is more apt to see things that need correction and less apt to accept excuses than an inspector who feels that he belongs to the same working group as the school-teacher. Because the follow-up work in the homes incident to successful use of knowledge gained at school involves so many sanitary remedies, it is theoretically better organization to hold the health authority responsible.



CHAPTER XXVIII

PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY

Many of the elements of the machinery outlined in the preceding chapter already exist in New York City. All of them brought together, either by amalgamation or by proper cooerdination, would present a very strong front. Unfortunately, however, there is not only unsatisfactory team work, but the efficiency of individual parts is seriously questioned by the heads of the health and school departments.

The inspection for contagious diseases, the examination for physical defects, the follow-up work by nurses and physicians, are in charge of the department of health. Physical training and athletics for elementary and high schools, winter recreation centers, and vacation playgrounds are under directors and assistants employed by the board of education. Heretofore inadequate powers and inadequate assistance for training or for research have been given to the physical director.

The city superintendent of schools, in his report for the year 1907, presented to the board of education in January, 1908, declares that the "present arrangements have been inadequate.... In only 248 schools—less than half the total number—were any examinations for possible diseases made. In these 248 schools not more than one third of the pupils were examined. It is only a few months since any examinations for physical defects were made outside of the boroughs of Manhattan and The Bronx, and then only on account of the New York Committee on the Physical Welfare of School Children."

As is so often the case, it is difficult to decide the merits of a method that has not been efficiently executed. The department of health has not hitherto done its best in its school relations. The commissioner of health, in a public interview, expresses resentment at the strictures by the school authorities. Yet in 1907 he permitted to accumulate an unexpended balance of $33,000 specifically voted for school inspectors, and repeatedly tried to have this amount transferred to other purposes. The interest of the Bureau of Municipal Research in municipal budgets that tell for what purposes money is voted and then prevent transfers without full publicity, preserved this particular fund. Moreover, the discussion that prevented its diversion from physical examinations strengthened the health department's interest in this important responsibility. Neither physicians nor nurses have been adequately supervised. Instead of seeing that defects were removed, the department of health sent out postal cards like the following:



- "This Notice Does NOT Exclude This Child From School" DEPARTMENT OF HEALTH THE CITY OF NEW YORK Oct. 2, 1906 The parent or guardian of ofattending P.S.51 is hereby informed that a physical examination of this child seems to show an abnormal condition of the Eyes, Nose, Throat and Teeth RemarksIs Anaemic Take this child to your family physician for treatment and advice. Take this card with you to the family physician. THOMAS DARLINGTON, M.D., Commissioner of Health. HERMANN M. BIGGS, M.D., General Medical Officer -

From 118,000 such notices sent out only 9600 replies were received, of which only one in twenty stated that attention had actually been given the needy child. The department had been satisfied with evidence that family physicians had advised parents properly, as in the case of the child above reported:



TAKE THIS CARD TO YOUR PHYSICIAN The Physician in charge is requested to fill out and forward this postal after he has examined this child. I have this day examined ________ of P.S. _51___ and find the following condition: _As reported, Also enlarged (unclear) glands_____ and advised as follows:_operation for adenoids and tonsils__ __Dental treatment at Cornell. Fresh air ____ __outing at Sea Breeze Eyes wait.______ Respectfully yours, __P.L. OB___ Date _Oct. 9, 1906_ _____

For a candid, complete criticism of the medical examination work up to June, 1908, consult the report of the Bureau of Municipal Research, presented to the Washington Congress of Public Education Associations in October, 1908, by Commissioner of Health, Dr. Darlington. The bureau's study is entitled A Bureau of Child Hygiene, and, in addition to the story of medical examination in New York City schools, gives the blank forms adopted for use in September, 1908. Important as are the facts given in this study, its greatest value, its authors declare, is in its account of "the method of intelligent self-criticism and experiment which alone enables a public department to keep its service abreast of public needs."

The Bureau of Municipal Research made its study for the purpose of learning whether the disappointing results emphasized by the school authorities were due to "dual responsibility in the school—that of the board of education and that of the department of health"—and to "lack of power or inclination to compel parents to remedy defects," or to deficient administration of power and inclination by health officials. Cooeperating with school physicians and nurses in three schools, 1442 children were examined, of whom 1345, or 93.2 per cent, had 3458 defects that needed treatment. The postal-card notice was followed by an interview with the parent either at school or at home. Only 4.2 per cent of the total number of parents refused to act, 81 per cent secured or permitted treatment for one or more defects, while 15 per cent promised to take the proper steps at the earliest possible date. Three fourths of the parents acted after one personal interview. "The net average result of a day's work by a nurse was the actual treatment of over five children, three of them completely, and two of them for one or more defects,"—sixty cents per child!



Having established the willingness—even eagerness—of parents to do all in their power to remove defects that handicapped their children, it was obviously the duty of the health department so to organize its work that it could insure the education of parents. The new Bureau of Child Hygiene gives foremost place to instruction of parents in care of babies, in needs of school children, and in the importance of physical examination when enlisting in the industrial army. Whether this work is well done is learned by result tests applied at headquarters, where work done and results are reported daily and summarized weekly. No longer will it be possible, without detection, for one physician to find only eye trouble and to neglect all other defects; for two inspectors examining different children in the same school to report results differing by 100 per cent; for physicians in different schools to find one 18 per cent, another 100 per cent with defects; for two inspectors examining identical children to agree on 51 out of 101 cases of vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases of skin disease.

So conclusive were the results of follow-up work efficiently supervised by the department of health, that school officials are, for the present, inclined to waive the demand for the transfer of physicians and nurses to the board of education, and to substitute education for compulsion with parents who obstinately refuse to take proper remedial measures for their children when reported defective.

This present plan requires the entire working time of inspectors and nurses for school work. Thus New York has for the present definitely abandoned the plan of having the district inspection for contagious diseases done by school physicians. The purpose of the change is not to reduce danger of infection, which was negligible, but to increase the probability of scientific attention to school children.

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

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



CHAPTER XXIX

OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS

The argument for getting things done presumes adequate active machinery, official and private, for doing things that schools are being urged to do. The chapter on Departments of School Hygiene suggests local, county, state, and national machinery necessary (1) to protect the child from injuries due to school environment, school methods, and school curriculum; (2) to getting those things done for the child at home and on the street, need for which is disclosed by physical and vitality tests at school. It is unreasonable to confine the school to the activities above outlined unless health machinery, adequate to the demands placed upon it by school and other community needs, is devised and kept in order.

Generally speaking, adequate health machinery is already provided for by city charters and by the state laws under which villages, townships, and counties are organized. Quite as generally, however, machinery and methods of adequate administration are undeveloped. How much machinery has already been set to work by New York City is shown by the accompanying chart. A useful exercise for individuals or school classes wishing to study health administration would be to chart in this way the machinery actually at work in their locality, county, and state. Even for New York it should be remembered that this chart does not include national quarantine, the state protection of the port, the state dairy and health commissions, or the state and national food inspection. To get an idea of the vast amount of attention given to health in New York City there should be added to this chart the work of many departments other than the department of health. The building bureau, tenement-house department, board of water supply, sewage commission, street cleaning, public baths and comfort stations, the department of water, gas, and electricity, and finally the department of hygiene and physical training in the public schools.



Five elements of adequate machinery are generally lost sight of:

1. The voter.

2. The nonvoter, subject to health laws and often apt to violate them.

3. The mayor, governor, or president who appoints health officers.

4. The council, board of aldermen, legislature, or congress that enacts health laws.

5. The police courts and the judiciary—police, circuit and supreme—that decide whether society has suffered from violation of law and what penalties should be inflicted for such violation.

Legislative bodies have hitherto slighted their responsibilities toward public health. The chairman of a committee on public health of a state legislature was heard to remark, "I asked for that committee because there isn't a blooming thing to do." If voters, nonvoters, and health officials will follow the suggestion of this book to secure school and health reports that will disclose community and health needs, it will be increasingly difficult for legislators to refuse funds necessary to efficient health administration.

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

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

In order to have health machinery work properly, the appointing officer should not be allowed to shift responsibility for failure to his subordinates. For example, it was recently found in New York City that while the tenement-house commissioner was being condemned for failing to enforce the law, he had turned over to the corporation counsel, also appointed by the mayor, for prosecution ten thousand "violations" to which no attention whatever had been paid!

The voter, nonvoter, appointing officer, legislative officer, and judicial officer determine the character and purpose of machinery and are analogous to the surveyors, stock-holders, directors, and constructors who provide railroads with tracks and with running stock. The actual running force of health department or railroad is what is meant by its official machinery. What this machinery should be depends, of course, upon the amount of business to be done, and differs with the size of the district and the character of population to be served.



Local health machinery should guarantee protection against the evils mentioned in preceding chapters. In general, one man is better than three to execute, although three may be better than one to legislate. Where small communities do not wish to have the entire state sanitary code rigidly administered, they can adopt New York's method of a legislative board of three members, headed by an executive, whose business it is to act, not talk; to watch subordinates, and to enforce rigidly and continuously ordinances passed by the board. The National Bureau of Census places under the general heading Health and Sanitation the following activities: health administration, street cleaning and refuse disposal, sewers and sewage disposal. Sanitarians generally emphasize also the health significance of efficient water service.

A community's health programme should be clearly outlined in the annual budget. Where health work is given funds without specification of the kinds of work to be done, serious evils may be overlooked and lesser evils permitted to monopolize the energies of health officers. Again, after money has been voted to prevent an evil, records should be made of work done when done, and of money spent when spent, so that any diversion will be promptly made known. The best present guides to budget making, to educational health reports, and to records that show efficiency or inefficiency of health administrators are the budget and report of the department of health for New York City, and the story of their evolution told in Making a Municipal Budget, by the Bureau of Municipal Research.

To find out whether local machinery is adequate, the reader must enumerate the things that need to be done in his community, remembering that in all parts of the United States to-day there are sanitary laws offering protection against dangers to health, excepting some dangers not understood until recently, such as child labor, dangerous trades, lack of safety devices. Adequate local protection, however, will not become permanent until adequate state machinery is secured.

State health machinery should be of two kinds,—fact-gathering and executive supervision through inspection. The greatest service of state boards of health is to educate localities as to their own needs, using the experience of all communities to teach each community in how far its health administration menaces itself and its neighbors. In addition to registration of contagious diseases, facts as to deaths and births should be registered. State health boards should "score" communities as dairies and milk shops are now being scored by the National Bureau of Animal Industries and several boards of health. When communities persist in maintaining a public nuisance and in failing to enforce health laws, state health machinery should be made to accomplish by force what it has failed to accomplish by education.



States alone can cope adequately with dangers to milk and water sources and to food. The economic motive of farmers has developed strong veterinary boards for the protection of cattle. Similar executive precaution must soon be taken by cities for the protection of babies and adults of the human species. It is far more economical to insure clean dairies, clean water sources, and wholesome manufactured foods by state inspectors than by local inspectors. At present the task of obtaining clean milk and clean water falls upon the few cities enlightened enough and rich enough to finance the inspection of community foods. Once tested, it would be very easy to prove that properly supported state health authorities will save many times the cost of their health work in addition to thousands of lives.

County or district machinery is little known in America. For that reason rural sanitary administration is neglected and rural hospitals are lacking. In the British Isles rural districts are given almost as careful inspection as are cities. Houses may not be built below a certain standard of lighting, ventilation, and conveniences. Outbuildings must be a safe distance from wells. Dairies must be kept clean. Patients suffering from transmissible diseases may be removed by force to hospitals. What is more to the point, rural hospitals have proved that patients cared for by them are far more apt to recover than patients cared for much more expensively and less satisfactorily at home, while less likely to pollute water and milk sources or otherwise to endanger health.

With national machinery the chapter on Vital Statistics has already dealt. We shall undoubtedly soon have a national board of health. Like the state boards, its first function should be educative. In addition, however, there are certain administrative functions where inefficiency may result in serious losses to nation, state, and locality. National quarantine, national inspection of meats, foods, and drugs are administrative functions of vital consequence to every citizen. Authorities are acquainted at the present time with the fact that the sanitary administration of the army and navy is unnecessarily and without excuse wasteful of human energy and human life. In the Spanish American War 14 soldiers died of disease for 1 killed in battle; in the Civil War 2 died of disease to 1 killed in battle; during the wars of the last 200 years 4 have died of disease for 1 killed in battle. Yet Japan in her war with Russia, by using means known to the United States Army in 1860, gave health precedence over everything else and lost but 1 man to disease for 4 killed in battle. Diseases are still permitted to make havoc with American commerce because the national government does not apply to its own limits the standards which it has successfully applied to Cuba and Panama.

"The Japanese invented nothing and had no peculiar knowledge or skill; they merely took occidental science and used it. The remarkable thing is not what they did, but that they were allowed to do it. It is a terrible thing that Congress should choose to make one of its rare displays of economy in a matter where a few thousand dollars saved means, in case our army should have anything to do, not only the utterly needless and useless loss of thousands of lives, but an enormous decrease of military efficiency, and might, conceivably, make all the difference between victory and defeat."

FOOTNOTES:

[16] The technic and principles of municipal engineering have been treated in detail in Principles of Sanitary Science and the Public Health, by William T. Sedgwick, and in Municipal Sanitation in the United States, by Charles N. Chapin, M.D.



CHAPTER XXX

SCHOOL AND HEALTH REPORTS

For every school-teacher or school physician responsible for the welfare of children at school, there are fifty or more parents responsible for the physical welfare of children at home. Therefore it is all important for parents to know how to read the index for their own children, for their children's associates, and for their community. School reports and health reports should tell clearly and completely the story of the school child's physical needs.



It is impracticable at the present time to expect a large number of men and women to be interested in the reports published by school and health boards, for, with few exceptions, little effort is made to write these reports so that they will interest the parent. Fortunately, a small number of persons wishing to be intelligent can compel public officials to ascertain the necessary facts and to give them to the public. So backward is the reporting of public business that at the present time there is probably no service that a citizen can render his community which would prove of greater importance than to secure proper publicity from health and school boards.

Generally speaking, these published reports fail to interest the citizen, not because officials wish to conceal, but because officials do not believe that the public is interested. A mayor of Philadelphia once furnished a notable exception. He called at the department of health and complained against publishing the number of cases of typhoid and smallpox lest stories in the newspapers "frighten the city and injure business." A sanitary inspector who was in the room asked if Philadelphia's business was more important than the health of Philadelphia's citizens. As a result of her "impertinence" the inspector was removed. That same year an epidemic of smallpox spread through all the rural districts and cities of Pennsylvania, because physicians thought it would be kinder to the patients not to make known to their neighbors the presence of so disagreeable a disease. Almost all health and school authorities, however, can be made to see the advantage of taking the public into their confidence, because public confidence means both public recognition and greater success in obtaining funds. With more funds comes the power to do more work.

Other details with regard to health reports will be found in the chapter on Vital Statistics. As to school reports, little thought has been given in the past to their educational possibilities. A book was recently published—School Reports and School Efficiency—by the Committee on the Physical Welfare of School Children, which tells the origins of school reports; contains samples of reports from one hundred cities; gives lists of questions frequently answered, occasionally answered, and never answered; and shows how to study a particular report so as to learn whether or not important questions are answered. The United States commissioner of education has organized among state and city superintendents special committees on uniform and adequate reporting. His aggressive leadership is welcomed by school men generally, and promises vast benefits.

Just because the physical welfare of the school child is an index to health needs, the school report can put into one statement for a city or a state the story told by the index. The accompanying card tells facts that the individual teacher and individual parent want to know about a child, what a superintendent wants to know about all children, and what a community wants to know about all children. A modification of this card will soon be adopted in New York City. It is both a card index and a card biography of the individual boy or girl. It is expected to follow the child from class to class, each teacher telling the story of his physical welfare and his progress. When the boy goes to a new school or new grade, his new teacher can see at a glance not only what subjects have given him trouble, but what diseases or physical defects have kept him out of school or otherwise retarded his progress. With this card it is easy to take a hundred children of the same age and the same grade, to put down in one column those who have eye defects, and in another those who have no eye defects, for every school, every district, and for the schools as a whole. Schools that use these record cards are enabled, by thus classifying the total, to learn where the defects of children are, how serious the problem is, how many days children lose from school because of preventable defects, and in what section of the city the defects are most prevalent.

The mere reporting of facts will stimulate teachers, principals, and parents to give attention. For example, assume a table:

FIELD OF INSPECTION

Total number of public schools 7 Public schools under inspection 3 Public schools not under inspection 4

The reader wonders why four schools are neglected and which particular schools they are. Let the next table read:

EXAMINATION

Total registration in all schools 1500 Number of children examined 500 Number of children not examined 1000

Parents begin to wonder whether or not their children were examined, and why the taxes spent for school examination of all children go to one third of the children. The next table arrests attention:

TREATMENT

Number needing treatment 200 Number known to have been treated 50 Number not known to have been treated 150

We ask, at once, if examination is worth while, and if treatment really corrects the defects, saves the pupil's time and teacher's time, discovers many defects; and we want to find out whether the one hundred and fifty reported not treated have since been attended to.





Again, if three out of five of those examined need treatment, people will wonder whether among the thousand not examined there is the same proportion—three out of five, or six hundred—who have some trouble that needs attention. Having begun to wonder, they will ask questions, and will expect the board of health or the school physicians to see that the questions are answered. As has been proved in New York, taxpayers and the press will go farther and will demand that the annual budget provide for making general next year the benefits found to result last year from a test of health policies.

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

TABLE XII

PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN

(Case rate schools)

KEY: A: In School B: Among Absentee ======================================================================= COMMUNICABLE GENERAL COMMUNICABLE DISEASES[1] DISEASES OF EYE SCHOOL AND SKIN[2] + - NUMBER + - -+ Number per Number Found by Reported 1000 Number per 1000 Inspectors by Registered found by Registered + - Attending + + in Schools+Inspectors in Schools A B Physician Total Inspected and Nurses Inspected - - - - - - A B C ================================================================== [1] Smallpox, diphtheria, scarlet fever, measles, chicken pox, mumps, and whooping cough; excluded when found. [2] Trachoma and other contagious eye diseases, ringworm, impetigo, scabies, favus, and pediculosis; excluded only for persistent nontreatment.

Another table shows the following facts for each disease:

TABLE XIII

CONTAGIOUS DISEASES FOUND IN SCHOOLS BY INSPECTORS AND NURSES

(Number and disposition of cases)

KEY: A: Diphtheria J: Other B: Scarlet fever K: Ringworm C: Measles L: Impetigo D: Smallpox M: Scabies E: Chicken pox N: Favus F: Whooping cough O: Pediculosis G: Mumps P: Miscellaneous H: Total Q: Total I: Trachoma

===================================================================== GENERAL COMMUNICABLE DISEASES COMMUNICABLE OF EYE AND SKIN DISEASES -+ - EYE SKIN + - A B C D E F G H I J K L M N O P Q - - Cases found in school Cases excluded from school Cases treated in school Cases instructed in school or evidence of treatment furnished Number of treatments Number of instructions ======================================================

The story of noncontagious physical defects found and treated is set forth in the following table:

TABLE XIV

MEDICAL EXAMINATION OF SCHOOL CHILDREN: NONCONTAGIOUS PHYSICAL DEFECTS FOUND AND TREATED, 1906

============+==========================+============================+ SCHOOL A SCHOOL B + + + Found Reported Found Reported Treated Treated -+ + -+ + -+ + -+ DEFECTS No. % of No. % of No. % of No. % of Total Defects Total Defects Defects Found Defects Found Found Found + -+ + -+ + -+ + -+ + Adenoids Nasal breathing Hyper-trophied tonsils Defective palate Defective hearing Defective vision Defective teeth Bad nutrition Diseased anterior cervical glands Diseased posterior cervical glands Heart disease Chorea Pulmonary disease Skin disease Deformity of spine Deformity of chest Deformity of extremities Defective mentality Total ==============+====+======+====+========+====+======+====+========+

======================================= SCHOOL C Found Reported Treated - - DEFECTS No. % of No. % of Total Defects Defects Found Found - - + Adenoids Nasal breathing Hyper-trophied tonsils Defective palate Defective hearing Defective vision Defective teeth Bad nutrition Diseased anterior cervical glands Diseased posterior cervical glands Heart disease Chorea Pulmonary disease Skin disease Deformity of spine Deformity of chest Deformity of extremities Defective mentality Total ==============+==========================

The effect of a report telling what schools have enough seats, proper ventilation, adequate medical inspection, safe drinking water, ample play space, and what schools are without these necessities is to cause the reader to rank the particular school that he happens to know; i.e. he says, "School A is better equipped than School B; or, School C is neglected." County and state superintendents in many states have acquired the habit of ranking schools according to the number of children who pass in arithmetic, algebra, etc. It would greatly further the cause of public health and, at the same time, advance the interest of education if state superintendents would rank individual schools, and if county superintendents would rank individual schools, according to the number of children found to have physical defects, the number afflicted with contagious diseases, and the number properly treated.

It is difficult to compare one school with another, because it is necessary to make subtractions and divisions and to reduce to percentages. It would not be so serious for a school of a thousand pupils as for a school of two hundred, to report 100 for adenoids. To make it possible to compare school with school without judging either unfairly, the state superintendent of schools for Connecticut has made tables in which cities are ranked according to the number of pupils, average attendance, per capita cost, etc. As to each of these headings, cities are grouped in a manner corresponding to the line up of a battalion, "according to height." A general table is then shown, which gives the ranking of each city with respect to each important item. Applied to schools, this would work out as follows:

TABLE XV

TABLE OF RANKING-SCHOOLS ARRANGED ALPHABETICALLY

============================================================= SCHOOL RANK IN -+ + + + + - Register Defects Children Children Children Found Needing Treated not Treatment Treated -+ + + + + - A 10 11 11 12 6 B 20 22 22 24 12 C 30 33 30 36 18 =======+==========+==========+==========+==========+=========

Such a table fails to convey its significance unless the reader is reminded that rank 18 in children not treated is as good a record for a school that ranks 30 in register as is rank 6 for a school that ranks 10 in register.

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

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

TABLE XVI

TABLE OF RANKING-SCHOOLS ARRANGED ACCORDING TO REGISTER, NOT ALPHABETICALLY

============================================================= RANK IN SCHOOL + + + + + - Register Defects Children Children Children Found Needing Treated not Treatment Treated -+ + + + + - A 9 9 9 9 9 X 10 10 10 14 6 H 11 11 11 17 3 =======+==========+==========+==========+==========+=========

If the number of schools in a state is so large that it is unlikely that people will read the table of ranking because of the difficulty of finding their own school, an alphabetical table might be given that would show where to look in the general ranking table for the school or schools in which the reader is interested.

Experience will demonstrate to public school superintendents the strategic advantage of putting together all the things they need and of telling the community over and over again just what needs there are, what penalties are paid for want of them, and what benefits would result from obtaining them. If health needs of school children were placed side by side with mental results, the relation would come out so clearly that parents, school boards, and taxpayers would realize how inextricably they are bound together and would see that health needs are satisfied. To this end superintendents should require teachers to keep daily reports of school conditions.

TABLE XVII

WEEKLY CLASS-ROOM SCHEDULE

===========+================+========================+============== Temperature Cleaning Exercise + -+ -+ -+ -+ -+ + + - In Out of 10.30 12.00 2.00 Dry Wet Disinfecting Room Room + -+ -+ -+ -+ -+ + + - Monday Tuesday Wednesday Thursday Friday ==========+=====+=====+=====+=====+=====+============+======+=======

The teacher's daily report of the temperature of a schoolroom, taken three times a day, tells the parent exactly what is the efficiency of the ventilating and heating apparatus in the particular school in which he is interested; whereas the report of the department of buildings gives only the number of schools which have an approved system of ventilation and steam heat. School authorities may or may not know that this system of ventilation is out of order, that the thermometer in the indoor playground of School A stood at forty degrees for many days in winter. But they must know it when the principal of School A sends in a daily record; the school board, the parents, or the press will then see that the condition is remedied. If the condition is due to lack of funds, funds will never be forthcoming so long as the condition is concealed.

Similar results will follow publicity of overcrowding, too little play space, dry cleaning of school buildings, etc. The intent of such reporting is not to "keep tabs" on the school-teacher, the school child, the janitor, the principal, superintendent, or board, but to insure favorable conditions and to correct bad conditions. This is done best by giving everybody the facts. The objective test of the efficiency of a method throws emphasis on the method, not on the motive of those operating it. The blackboard method of publishing facts concentrates attention upon the importance of those facts and enlists aid in the attainment of the end sought.



CHAPTER XXXI

THE PRESS

The president of Princeton University declares that for several decades we have given education that does not instruct and instruction that does not educate. Others tell us that because we read daily papers and magazines our minds become superficial, that our power to concentrate or memorize is weakened,—that we read so much of everything that we learn little of anything. As the habit of reading magazines and newspapers is constantly increasing, I think we must assume that it has come to stay. If we cannot check it, we can at least turn it to good advantage, systematize it, and discipline ourselves.

Among the subjects continually described in newspapers and magazines, and even on billboards and in street-car advertising, is the subject of hygiene. No greater service can be rendered the community than for those who are conducting discussions of health to teach people how to read correctly this mass of information regarding health, to separate misinformation from information, and to apply the lessons learned to personal and public hygiene. There is no better way of doing this than to teach a class or a child to clip out of magazines and newspapers all important references to health, and then to classify these under the subject-matter treated. A teacher, parent, or club leader might practice by using the classification of subjects outlined in the Contents of this book. It is surprising how rapidly one builds up a valuable collection serviceable for talks or papers, but more particularly for giving one a vital and intelligent interest in practical health topics.

Interested in comparing the emphasis placed on health topics in a three-cent paper having a small circulation with a penny paper having twenty times the circulation, I made during one week thirty-eight clippings from the three-cent paper and ninety-five from the penny paper. The high-priced paper had no editorial comment within the field of health, whereas the penny paper had three columns, in which were discussed among other things: The Economics of Bad Teeth; Need for Individual Efficiency; "Good Fellows" Lower Standard of Living by Neglecting their Families. The penny paper advertised fifty-two foods, garments, whiskies, patent medicines, or beautifiers urged upon health grounds. In the three-cent paper twenty-six out of thirty-eight items advertised food, clothing, patent medicine, or whisky. One issue of a monthly magazine devoted to woman's interests contained twenty-eight articles and editorials and fifty-five advertisements that concern health,—thirty-seven per cent of total reading matter and thirty-seven per cent of total advertisement.

Excellent discipline is afforded by this clipping work. It is astonishing how few men and women, even from our better colleges, know how to organize notes, clippings, or other data, so that they can be used a few weeks later. There is a satisfaction in seeing one's material grow, as is remembered by all of us, in making picture scrapbooks or collections of picture postal cards and stamps. "Collections" have generally failed for want of classification,—putting things of a kind together. Chronological arrangement is uninteresting because unprofitable. One never knows where to find a picture, or a stamp, or a health clipping. Clippings, like libraries, will be little used if not properly catalogued so that use is easy. If a health-clipping collection is attempted, there are four essentials: (1) arrangement by topic; (2) inclusion of advertisements; (3) inclusion of items from magazines; (4) cross references.

For classification, envelopes can be used or manila cards 10x12 inches. The teacher, parent, or advanced student will probably think the envelope most useful because most easily carried and filed,—most likely to be used. But clippings should be bound together in orderly appearance, or else it will be disagreeable working with them. Children, however, will like the pasting on sheets, which show clearly the growth of each topic. Envelopes or cards should not have clippings that deal with only one health topic. Unless a test is made to see how many health references there are in a given period, it should be made a rule not to clip any item that does not contain something new,—some addition to the knowledge already collected.

Advertisements will prove interesting and educative. When newspapers and magazines announce some new truth, the commercial motive of manufacturer or dealer sees profit in telling over and over again how certain goods will meet the new need. Children will soon notice that the worst advertisements appear in the papers that talk most of "popular rights," "justice," and "morality." They will be shocked to see that the popular papers accept money to tell falsehoods about fake cures. They will be pleased that the best monthly magazines contain no such advertisements. They will challenge paper or magazine, and thus will be enlisted while young in the fight against health advertisements that injure health.

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

The art of cross-referencing is invaluable to the organized mind. The purpose of classifying one's information is not to show how much there is, but to answer questions quickly and to guide constructive thinking. A clipping that deals with alcoholism, patent medicine, and tuberculosis must be posted in three places, or cross-referenced; otherwise it will be used to answer but one question when it might answer three. If magazines may not be cut, it will be easy to record the fact of a useful article by writing the title, page, and date on the appropriate index card, or inclosing a slip so marked in the proper envelope.

While it is true that the most important bibliography one can have in his private library is a classification of the material of which he himself has become a part while reading it, there are a number of health journals that one can profitably subscribe for. In fact, it is often true that the significant discoveries in scientific fields, or the latest public improvements, such as parks, bridges, model tenements, will not be appreciated until one has read in health journals how these improvements affect the sickness rate and the enjoyment rate of those least able to control their living conditions. The physician and nurse in their educational work for hospitals are distributors of health propaganda.

Wherever there is a local journal devoted to health, parents, teachers, educators, and club leaders would do well to subscribe and to hold this journal up to a high standard by quoting, thanking, criticising it. In New Jersey, for example, is a monthly called the New Jersey Review of Charities and Corrections that deals with every manner of subject having to do with public health as well as with private and public morality and education.

A similar journal, intended for national instruction, is The Survey, whose topical index for last year enumerates two hundred and thirty-two articles dealing with subjects directly connected with public hygiene, e.g.:

Schools, 6; school inspection, 3; eyes,—school children, 1; sex instruction in the schools, 2; psychiatric clinic, special children, 2; industrial education, 5; child labor, 18; playgrounds, 26; alley, crap, playing in streets, 3; labor conditions, 18; industrial accidents, 10; wage-earner's insurance, 4; factory inspection, 1; consumer's league, 3; women's work, 6; tuberculosis, 23; hospitals, dispensaries (social), 5; tenement reform, 10; living conditions, 2; baths, 1; public comfort stations, 2; lodging houses, 1; clean streets, 6; clean milk, 6; smoke, 1; noises, 1; parks, 1; patent medicines, 2; sanitary code, 1; mortality statistics, 2; social settlements and public health, 1; midwives, 1; children's bureau, 1; juvenile and adult delinquent, 25; dependent, defective, and insane, 7; blind, 5; cripples, 1; homes for aged, 1; inebriates, 3; Traveler's Aid Committee, 1; infant mortality, 2; social diseases, 2.

* * * * *

The National Hospital Record, the Dietetic and Hygienic Gazette, the Journal of Nursing, are three other magazines primarily intended for nurses and physicians, but full of suggestive material for unprofessional readers. National magazines concerned with health, but seeking popular circulation, are Good Health and Physical Culture. In England there is a special magazine called Children's Diseases, which could be of great help to a school library for special reference. The same can be said of the Psychological Clinic, Pediatrics, and other technical journals published in this country. For many persons, to make the best use of any one copy of these magazines, clipping is of course impossible, but noting on a card or envelope is practicable.

Of late many of the national popular magazines have several columns devoted to health. We have not appreciated the educational possibilities of these columns. In most large cities there are monthly book reviews which may be profitably consulted in learning the new thought in the health field. If teachers would either write their experience or ask questions, if children knew that in a certain magazine or newspaper questions as to ventilation, bathing, exercise, would be answered, they would take a keen interest in the progress of discussions. The large daily papers make a great feature of their health hints. It is not their fault if questioners care more about cosmetics and hair bleaches than about the fresh-air cure of headaches. They will cooeperate with teachers and parents in securing more general discussion of other problems than beauty doctoring.

Finally, persons wanting not only to have intelligence as to matters promoting health, but actually to exert a helpful influence in their community, ought to want the published reports of the mayor, health department, the public schools, and other institutions, noting carefully all that is said about conditions relating to health and about efforts made to correct all unfavorable conditions. The best literature of our day, with regard to social needs, appears in the reports of our public and private institutions and societies. Of increasing value are the publications of the national government printing office. Because it is no one's business to find out what valuable material is contained in such reports, and because no educational museum is comparing report with report, those who live nearest to our health problems and who see most clearly the health remedies, are not stimulated to give to the public their special knowledge in an interesting, convincing way.

Teaching children how to find health lessons in public documents will advance the cause of public ethics as well as of public health. At the New York State Conference of Charities, of 1907, one official complained that the physicians made no educational use of their valuable experience for public education. He stated that a study of medical journals and health articles in popular magazines revealed the fact that the number of papers prepared by physicians in state hospitals averaged one to a doctor for every five or six years of service. This state of affairs is even more exaggerated in strictly educational institutions. Columbia University has recently instituted a series of lectures to be given by its professors to its professors, so that they may have a general knowledge of the work being done in other fields besides their own at their own university. This is equally important for teachers and heads of departments in elementary schools. It is now admitted by most educators that elementary schools and young children present more pedagogical difficulties and pressing biological problems than higher schools. If teachers and parents would realize that their method of solving the health problems that arise daily in the schoolroom and in the home would interest other mothers and teachers, their spirit of cooeperation would soon be reflected in school journals, popular magazines, and daily newspapers.



PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION



CHAPTER XXXII

DO-NOTHING AILMENTS

"Men have died, from time to time, and worms have eaten them, but not for love"—nor for work. Work of itself never killed anybody nor made anybody sick. Work has caused worry, mental strain, and physical breakdown, only when men while working have been deprived of air, sun, light, exercise, sleep, proper food at the proper time, opportunity to live and work hygienically. Fortunately for human progress, doing nothing brings ailments of its own and has none of the compensations of work. As the stomach deprived of substantial food craves unnatural food,—sweets, stimulants,—so the mind deprived of substantial, regular diet of wholesome work turns to unwholesome, petty, fantastic, suspicious, unhappy thoughts. This state of mind, combined with the lack of bodily exercise that generally accompanies it, reacts unfavorably on physical health. An editor has aptly termed the do-nothing condition as a self-inflicted confinement:

A great deal of the misery and wretchedness among young men that inherit great fortunes is caused by the fact that they are practically in jail. They have nothing to do but eat, drink, and enjoy themselves, and they cannot understand why their lives are dull.

We have had the owner of a great railroad system pathetically telling the public that he is unhappy. That is undoubtedly true, because with all his race horses, and his yachts, and all the things that he imagines to be pleasures, he is not really doing anything.

If he were running one little railroad station up the road, handling the freight, fussing about dispatches, living above the railroad station in two rooms, and buying shoes in a neighboring village for fifteen children he would be busy and happy.

But he cannot be happy because he is in prison,—in a prison of money, a prison that is honorable because it gives him everything that he wants, and he wants nothing.

A New York newspaper that circulates among the working classes where young men and women are inclined to associate health and happiness with doing nothing recently gave two columns to "Dandy Jim," the richest dog in the world. Dandy Jim's mistress left him a ten-thousand-dollar legacy. During his lifetime he wore diamonds. Every day he ate candy that cost eighty cents a pound. The coachman took him driving in the park sunny afternoons. He had no cares and nothing to work for. His food came without effort. He had fatty degeneration of the vital organs. He was pampered, coddled, and killed thereby. Thousands of men and women drag out lives of unhappiness for themselves and others because, like Dandy Jim, they have nothing to work for, are pampered, coddled victims of fatty degeneration. When President Butler of Columbia University finds it necessary to censure "the folly and indifference of the fathers, vanity and thoughtless pride of the mothers" who encourage do-nothing ailments; and when the editor of the Psychological Clinic protests that the fashionable private schools and the private tutor share with rich fathers and mothers responsibility for life failures,—it is time that educators teach children themselves the physical and moral ailments and disillusions that come from doing nothing.

Ten years ago a stenographer inherited two hundred and fifty thousand dollars. Her dream of nothing to do was realized. She gave up her strenuous business life. Possessions formerly coveted soon clogged her powers of enjoyment. She imagined herself suffering from various diseases, shut herself up in her house, and refused to see any one. She grew morbid and was sure that every person who approached her had some sneaking, personal, hostile motive. Though always busy, she accomplished little. Desultory work, procrastination, and self-indulgence destroyed her power of concentration. She could not think long enough on one subject to think it out straight, therefore she was constantly deceived in her friends and interests. She first trusted everybody, then mistrusted everybody. Infatuation with every new acquaintance was quickly followed by suspicion. For years she was a very sick woman, a victim of do-nothing ailments.

Doing nothing has of late been seriously recommended to American business men. They are advised to retire from active work as soon as their savings produce reasonable income. It is true, this suggestion has been made as an antidote to greed rather than for the happiness of the business man. What retiring from business is apt to mean, is indicated by a gentleman who at the age of sixty decided to sell his seat on the New York Stock Exchange and to enjoy life. He became restless and very miserable. He threw himself violently into one thing after another; in less than a year he became an ill, broken old man, after trying vainly to buy back his business.

Both mind and body were made to work. The function of the brain is to think to a purpose, just as the function of the heart is to pump blood. The habit of doing nothing is very easily formed. The "out-of-work" soon become "the work-shy." Having too little to do is worse for the body and mind than having too little to eat. Social reformers emphasize the bad effect on society of vagrancy. Evils of indiscriminate relief to the poor are vividly described year after year. The philanthropist is condemned, who, by his gifts, encourages an employee's family to spend what they do not earn, and to shun work. Yet the idleness of the tramp, street loafer, and professional mendicant is a negligible evil compared with the hindrance to human progress caused by the idleness of the well-to-do, the rich, the educated, the refined, the "best" people. It is as much a wrong to bring up children in an atmosphere of do-nothingism, as to refuse to have their teeth attended to or to have glasses fitted to weak eyes.

From the point of view of community welfare it is far more serious for the rich child to be brought up in idleness or without a purpose than for the poor child to become a public charge. Not only has society a right to expect more from rich children in return for the greater benefits they enjoy, but so long as rich children control the expenditure of money, they control also the health and happiness of other human beings. Unless taught the value and joy of wholesome work they cannot themselves think straight, nor are they likely to want to understand how they can use their wealth for the benefit of mankind. To quote President Butler again:

The rich boy who receives a good education and is trained to be a self-respecting member of the body politic might in time share on equal terms the chance of the poor boy to become a man of genuine influence and importance on his own account, just as now by the neglect, or worse, of his parents the very rich boy is apt to be relegated to the limbo of curiosities, and too often of decadence.

Nervous invalids make life miserable for themselves and for others, when often their sole malady is lack of the right kind of work to do.

Suiting work to interest and interest to work is an economy that should not be overlooked. The energy spent in forcing oneself to do a distasteful task can be turned to productive channels when work is made pleasurable. The fact is frequently deplored that whereas formerly a man became a full-fledged craftsman, able to perform any branch of his trade, he is now confined to doing special acts because neither his interest nor his mind is called into play. Work seems to react unfavorably on his health. He has not the pride of the artisan in the finished product, for he seldom sees it. He does a task. His employer is a taskmaster. He decides that work is not good for him as easily as when a school-boy he grasped the meaning of escape from his lessons. By failing to fit studies to a student's interest, or by failing to insure a student's interest in his studies, schools and colleges miseducate young men and young women to look upon all work as tasks, as discipline, necessary but irksome, and to be avoided if possible. Just as there is a way of turning all the energy of the play instinct into school work, so there is a way of interesting the factory and office worker in his job. However mechanical work may be, there is always the interest in becoming the most efficient worker in a room or a trade. Routine—accurate and detailed work—does not mean the stultification of the imagination. It takes more imagination to see the interesting things in statistical or record work than to write a novel. Therefore employers should make it a point to help their employees to realize the significance of the perfection of each detail and the importance of each man's part. The other day a father said to me, "I want my boys to be as ashamed to do work in which they are not interested as to accept graft." When interest in work and efficiency in work are regarded as of more importance than the immediate returns for work, when it is as natural for boys and girls to demand enjoyment and complete living in work as it is to thrill at the sight of the Stars and Stripes, do-nothing ailments will be less frequent and less costly.

Work—that one enjoys—is an invaluable unpatented medicine. It can make the sick well and keep the well from getting sick. It is the chief reliance of mental hygiene. "I should have the grippe if I had time," said a business woman to me the other day; but she did not have time, hence she did not have the grippe.

If you're sick with something chronic, And you think you need a tonic, Do something. There is life and health in doing, There is pleasure in pursuing; Doing, then, is health accruing— Do something.

And if you're seeking pleasure, Or enjoyment in full measure, Do something. Idleness, there's nothing in it; 'Twill not pay you for a minute— Do something.



CHAPTER XXXIII

HEREDITY BUGABOOS AND HEREDITY TRUTHS

One of the red-letter days of my life was that on which I learned that I could not have inherited tuberculosis from two uncles who died of consumption. For years I had known that I was a marked victim. Silently I carried my tragedy, suspecting each cold and headache to be the telltale messenger that should let others into my secret. He was a veritable emancipator who informed me that heredity did not work from uncle to nephew; that not more than a predisposition to consumption could pass even from parent to child; that a predisposition to consumption would come to nothing without the germ of the disease and the environmental conditions which favor its development; and that if those so predisposed avoid gross infection, lead a healthy life, and breathe fresh air they are as safe as though no tuberculous lungs had ever existed in the world. Some years later I learned to understand the other side of the case; I realized how I had been in real danger of contracting consumption in the darkened, ill-ventilated sick room of the uncle who taught me my letters and gave me my ideal of God's purpose in sending uncles to small boys.

There are two distinct things which make each individual life: the living stuff, the physical basis of life, handed down from parent to child; and the environmental conditions which surround it and play upon it and rouse its reactions and its latent possibilities. It is like the seed and the cultivation. You cannot grow corn from wheat, but you can grow the best wheat, or you may let your crop fail through careless handling.

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

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

In the second place, if science has shown anything more clearly than the importance of heredity, it is the importance of environment. This influence upon human lives is within our control, and it is a grave error to neglect what lies clearly within our power and to bemoan what does not. Science has wrought no benefits greater than those which result from drawing a clear line between heredity bugaboos and heredity truths. An overemphasis on the hereditary factor in development at the expense of the environmental factor, I call a heredity bugaboo; and it is a tendency which cannot be too strongly condemned. To fight against the sins and penalties of one's grandfather is a forlorn task that quickly discourages. To overcome diseases of environment, of shop and street, of house and school, seems, on the contrary, an easy task. Heredity bugaboos dishearten, enervate, encourage excesses and neglect. Heredity truths stimulate remedial and preventive measures.

We may well watch with interest the progress of eugenics, that new science which biologists and sociologists hope will some day remake the very living stuff of the human race. But meanwhile let us take up with hope and courage and enthusiasm the great hemisphere of human fate which lies within our grasp. Good food and fresh air, well-built cities, enlightened schools and well-ordered industries, stable and free and expert government,—given these things, we can transform the world with the means now at our disposal. We can reap, if we will, splendid possibilities now going to waste, and by intelligent biological and sociological engineering we can hand on to the next generation an environmental inheritance which will make their task far easier than ours.

"Physical deterioration" is a bugaboo that is discovered by some in heredity and by others in modern industrial evils. The British director general called attention a few years ago to the fact that from forty to sixty per cent of the men who were being examined for military service were physically unfit. A Commission on Physical Deterioration was appointed to investigate the cause, and to learn whether the low physical standard of the would-be Tommy Atkins was due to inherited defects. The results of this study were published in a large volume called Report on Physical Deterioration, 1904, in which is set forth a positive programme for obtaining periodically facts as to the physique of the nation. In the course of the commission's exhaustive investigation there was found no evidence that any progressive deterioration was going on in any function of the body except the teeth. "There are happily no grounds for associating dental degeneracy with progressive physical deterioration." The increase in optical defects is attributed not to the deterioration of the eye, but to greater knowledge, more treatment, and better understanding of the connection between optical defects and headache.



DEFINITIONS OF TERMS USED IN HOUSE SCORE CARD LIGHT Light enough to read easily in every part. GLOOMY Not light enough to read easily in every part, but enough readily to see one's way about when doors are closed. DARK Too dark to see one's way about easily when doors are closed. WELL VENTILATED With window on street or fair-sized yard (not less than 12 ft. deep for a five-story tenement house not on a corner), or on a "large," "well-ventilated" court open to the sky at the top: "large" being for a court entirely open on one side to the street or yard in a five-story tenement, not less than 6 ft. wide from the wall of the building to the lot line; for a court inclosed on three sides and the other on the lot line in a five-story tenement, not less than 12x24 ft., "well ventilated" meaning either entirely open on one side to the street or yard, or else having a tunnel at the bottom connecting with the street or yard. FAIRLY VENTILATED With window opening on a shallow yard or on a narrow court, open to the sky at the top, or else with 5x3 inside window (15 ft. square) opening on a well-ventilated room in same apartment. BADLY VENTILATED With no window on the street, or on a yard, or on a court open to the sky, and with no window, or a very small window, opening on an adjoining room. IN GOOD REPAIR No torn wall paper, broken plaster, broken woodwork or flooring, nor badly shrunk or warped floor boards or wainscoting, leaving large cracks. IN FAIR REPAIR Slightly torn or loose wall paper, slightly broken plaster, warped floor boards and wainscoting. IN BAD REPAIR Very badly torn wall paper or broken plaster over a considerable area, or badly broken woodwork or flooring. (Rooms not exactly coinciding with any of the three classes are to be included in the one the description of which comes nearest to the condition.) SINKS: GOOD Iron, on iron supports with iron back above to prevent splashing of water on wall surface, in light location, used for one family. Water direct from city water mains or from a CLEAN roof tank. BAD Surrounded by wood rims with or without metal flushings, space beneath inclosed with wood risers; dark location, used by more than one family; water from dirty roof tank. FAIR Midway between above two extremes. (Sinks not exactly coinciding with any of the three classes are to be included in the one the description of which comes nearest to the condition.) WATER-CLOSET: GOOD Indoor closet. In well lighted and ventilated location, closet fixture entirely open underneath, abundant water flush. FAIR Indoor closet, poor condition badly lighted and ventilated location, fixture inclosed with wood risers, or poor flush. POOR Yard closet separate water-closet in individual compartment in the yard. BAD School sink sewer-connected privy, having one continuous vault beneath the row of individual toilet compartments.