all who participate in making these profits. Too often welfare
secretaries teach employees how to be happy in the director's way,
rather than in their own way. This adventitious position increases
suspicion on both sides, disturbs the discipline of the foreman,
weakens rather than strengthens the worker's efficiency, because it
depends upon other things than work well done and the relation of
health to efficiency. In a small factory town the owner of a large
cotton mill has recognized the financial benefit of physically strong
workers, and is trying the experiment of a welfare director. The man
himself works "with his sleeves up." The social worker has an office in
the factory. A clubhouse is fitted up for the mill hands to make merry
in. A room in the factory is reserved for a lunch room, with plants,
tables, and chairs for the comfort of the women. Parties are given by
the employer to the employees, which he himself attends. He has thrown
himself into whatever schemes his director has suggested. The director
complained that the reason the new lunch room was not more popular was
because a piano was needed. A second-hand one would not do, for that
would cultivate bad taste in music. This showed the employer that soon
everything would be expected from the "big house on the hill." An event
which happened at the time when the pressure was greatest on him for
the piano, convinced him that his employees could supply their real
needs without any trouble or delay. The assistant manager was about to
leave, and in less than a week five hundred dollars was raised among
the workers for his farewell gift. Walking home that night late from
his office the owner was attracted by the sound of jollity, and saw a
little room jammed full of mill people enjoying the improvised music of
a mouth organ played to the accompaniment of heels. He resolved
henceforth to train his employees to do his work well and to earn more
pay,--and to let them amuse themselves. From that time on he refused to
be looked upon as the _deus ex machina_ of the town. He decided that
the best way to give English lessons to foreigners was to improve the
school. His beneficence in supplying them with pure water at the mill
did not prevent a ravaging typhoid epidemic because the town water was
not watched. He saw that the best way to improve health was to
strengthen the health board and to make his co-workers realize that
they were citizens responsible for their own privileges and rights.
Emergency hospitals and Y.M.C.A. buildings are sad substitutes for
safety devices and automatic couplers. Christmas shopping in November
is less kind than prevention of overwork in December. Night school and
gymnastic classes are a poor penance for child labor and for work
unsuited to the body. The left hand cannot dole favors enough to offset
the evils of underpay, of unsanitary conditions, of inefficient
enforcement of health laws tolerated by the right hand.
Just because a man is taking wages for work done, is no reason why he
should forfeit his rights as a citizen, or allow his children, sisters,
neighbors, to work in conditions which decrease their efficiency and
earning power. What the employee can do for himself as a citizen,
having equal health rights with employers, he has never been taught to
see. Factory legislation is state direction of industries so far as
relates to the safety, health, and moral condition of the people,--and
which embraces to-day, more than in any other epoch, the opinion of the
workers themselves. No government, however strong, can hope
successfully to introduce social legislation largely affecting personal
interests until public opinion has been educated to the belief that the
remedies proposed are really necessary. Until schools insist upon a
better ventilation than the worst factories, how can we expect to find
children of working age sensitive to impure air? Where work benches are
more comfortable than school desks, where drinking water is cleaner and
towels more sanitary, however unsanitary they may be, than those found
in the schoolhouse, the worker does not realize that they menace his
right to earn a living wage as much as does a temporary shut-down.
Employers are by no means solely to blame for unhealthy working
conditions. A shortsighted employee is as anxious to work overtime for
double pay as a shortsighted employer is to have him. Among those who
are agitating for an eight-hour day are many who, from self-interest or
interest in the cause, work regularly from ten to sixteen hours.
Would it help to punish employees for working in unhealthy places? The
highest service that can be rendered industrial hygiene is to educate
the industrial classes to recognize hygienic evils and to coöperate
with other citizens in securing the enforcement of health rights.
CHAPTER XXIV
THE LAST DAYS OF TUBERCULOSIS
If the historian Lecky was right in saying that the greatest triumphs of
the nineteenth century were its sanitary achievements, the Lecky of the
twenty-first century will probably honor our generation not for its
electricity, its trusts, and its scientific research, but for its
crusade against the white plague and for its recognition of health
rights. Thanks to committees for the prevention of tuberculosis,--local,
state, national, international,--we are fast approaching the time when
every parent, teacher, employer, landlord, worker, will see in
tuberculosis a personal enemy,--a menace to his fireside, his income,
and his freedom. Just as this nation could not exist half slave, half
free, we of one mind now affirm that equal opportunity cannot exist
where one death in ten is from a single preventable disease.[13]
Of no obstacle to efficient living is it more true than of
tuberculosis, that the remedy depends upon enforcing rather than upon
making law, upon practice rather than upon precept, upon health habits
rather than upon medical remedies, upon coöperation of lay citizens
rather than upon medical science or isolated individual effort. Without
learning another fact about tuberculosis, we can stamp it out if we
will but apply, and see that officers of health apply, lessons of
cleanliness and natural living already known to us.
[Illustration: DR. TRUDEAU'S "LITTLE RED COTTAGE" AT
SARANAC--BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA]
Perhaps the most striking results yet obtained in combating
tuberculosis are those of the Massachusetts General Hospital in Boston.
To visit its tuberculosis classes reminds one more of the sociable than
the clinic. In fact, one wonders whether the milk diet and the rest
cure or the effervescing optimism and good cheer of the physicians and
nurses should be credited with the marvelous cures. The first part of
the hour is given to writing on the blackboard the number of hours that
the class members spent out of doors the preceding week. So great was
the rivalry for first place that the nurse protested that a certain boy
in the front row gave himself indigestion by trying to eat his meals in
ten or fifteen minutes. It was then suggested that twenty hours a day
would be enough for any one to stay out of doors, and that plenty of
time should be taken for meals with the family and for cold baths,
keeping clean, etc. Interesting facts gathered by personal interviews
of two physicians with individual patients are explained to the whole
class. Next to the number of hours out of doors, the most interesting
fact is the number of hours of exercise permitted. A man of forty, the
head of a family, beamed like a school child when told that, after
nearly a year of absolute rest, he might during the next week exercise
ten minutes a day. A graduate drops in, the very picture of health,
weighing two hundred pounds. An apparently hopeless case would brighten
up and have confidence when told that this strong, handsome man has
gained fifty pounds by rest, good cheer, fresh air, all on his own
porch. One young man, just back from a California sanatorium where he
progressively lost strength in spite of change of climate, is now
returning to work and is back at normal weight.
[Illustration: OUTDOOR LIFE CHART.]
[Illustration: FIGHTING TUBERCULOSIS IN THE MOUNTAINS--SARANAC]
Every patient keeps a daily record, called for by the following
instructions:
Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock,
daily; movements of bowels; hours in open air; all food taken;
total amount of milk; total amount of oil and butter; appetite;
digestion; spirits; cough (amount, chief time); expectoration
(amount in 24 hours, color, nature); exercise (if allowed), with
temperature and pulse 15 minutes after exercise; sweats; visitors.
The following simple instructions can be followed in any home, even
where open windows must take the place of porches:
Rest out of doors is the medicine that cures consumption. Absolute
rest for mind and body brings speedy improvement. It stops the
cough and promotes the appetite. The lungs heal more quickly when
the body is at rest. Lie with the chest low, so the blood flow in
the lungs will aid to the uttermost the work of healing. The rest
habit is soon acquired. Each day of rest makes the next day of
rest easier, and shortens the time necessary to regain health. The
more time spent in bed out of doors the better. Do not dress if
the temperature is above 99 degrees, or if there is blood in the
sputum. It is life in the open air, not exercise, that brings
health and strength. Just a few minutes daily exercise during the
active stage of the disease may delay recovery weeks or months.
Rest favors digestion, exercise frequently disturbs digestion.
When possible have meals served in bed. Never think the rest
treatment can be taken in a rocking-chair. If tired of the cot,
shift to the reclining chair, but sit with head low and feet
elevated. Do not write letters. Dictate to a friend. Do not read
much and do not hold heavy books. While reading remain in the
recumbent posture.
[Illustration: FIGHTING TUBERCULOSIS IN DAY CAMPS--BOSTON]
Once having learned the simple facts that must be noted and the simple
laws that must be followed, once having placed oneself in a position
to secure the rest, the fresh air, and the health diet, no better next
steps can be taken than to observe the closing injunction in the rules
for rest:
There are few medicines better than clouds, and you have not to
swallow them or wear them as plasters,--only to watch them.
Keeping your eyes aloft, your thoughts will shortly clamber after
them, or, if they don't do that, the sun gets into them, and the
bad ones go a-dozing like bats and owls.
[Illustration: THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW
YORK CITY]
+--------------------------------------------------------------------+
| CONSUMPTION IN EARLY STAGES CAN BE CURED |
| |
| Take your case in time to a good physician or to a dispensary and |
| you may be cured--DO NOT WAIT. |
| |
| Consumption is "caught" mainly through the spit of consumptives. |
| |
| Friends of Consumption--Dampness, Dirt, Darkness, Drink. |
| |
| Enemies of Consumption--Sun, Air, Good Food, Cleanliness. |
| |
| If you have tuberculosis do not give it to others by spitting; |
| even if you have not, set a good example by refraining from a |
| habit always dirty and often dangerous. |
| |
| _The Committee on the Prevention of Tuberculosis_ |
| _Of the Charity Organization Society_ |
| |
| (By Courtesy of Siegel Cooper Co.) |
+--------------------------------------------------------------------+
Important as are sanatoriums in mountain and desert, day or night camps
within and near cities, milk and egg clinics, home visiting, change of
air and rest for those who are known to be tuberculous, their
importance is infinitesimal compared with the protection that comes
from clean, healthy environment and natural living for those not known
to be tuberculous. This great fact has been recognized by the various
bodies now engaged in popularizing the truth about tuberculosis by
means of stationary and traveling exhibits, illustrated lectures,
street-car transfers, advertisements, farmers' institutes,
anti-spitting signs in public vehicles and public buildings, board of
health instructions in many languages, magazine stories, and press
reports of conferences. This brilliant campaign of education shows what
can be done by national, state, and county superintendents of schools,
if they will make the most of school hygiene and civics.
[Illustration: AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS
CRUSADERS SHOULD FOLLOW]
+-------------------------------------------------------------------+
| CIRCULAR ISSUED BY |
| |
| The Committee of Sanitation of the Central Federated Union of |
| New York |
| |
| The Committee on the Prevention of Tuberculosis of the Charity |
| Organization Society |
| |
| 105 East 22d Street, New York City |
| |
| * * * * * |
| |
| Don't Give Consumption to Others |
| |
| Don't Let Others Give It to You |
| |
| * * * * * |
| |
| =How to Prevent Consumption= |
| |
| =The spit and the small particles coughed up and sneezed out by |
| consumptives, and by many who do not know that they have |
| consumption, are full of living germs too small to be seen. THESE |
| GERMS ARE THE CAUSE OF CONSUMPTION.= |
| |
| |
| =DON'T SPIT on the sidewalks--it spreads disease, and it is |
| against the law.= |
| |
| =DON'T SPIT on the floors of your rooms or hallways.= |
| |
| =DON'T SPIT on the floors of your shop.= |
| |
| =WHEN YOU SPIT, spit in the gutters or into a spittoon.= |
| |
| =Have your own spittoons half full of water, and clean them |
| out at least once a day with hot water.= |
| |
| =DON'T cough without holding a handkerchief or your hand |
| over your mouth.= |
| |
| =DON'T live in rooms where there is no fresh air.= |
| |
| =DON'T work in rooms where there is no fresh air.= |
| |
| =DON'T sleep in rooms where there is no fresh air.= |
| |
| =Keep at least one window open in your bedroom day and |
| night.= |
| |
| =Fresh air helps to kill the consumption germ.= |
| |
| =Fresh air helps to keep you strong and healthy.= |
| |
| =DON'T eat with soiled hands--wash them first.= |
| |
| =DON'T NEGLECT A COLD or a cough.= |
| |
| |
| =How to Cure Consumption= |
| |
| =DON'T WASTE YOUR MONEY on patent medicines or advertised |
| cures for consumption, but go to a doctor or a |
| dispensary. If you go in time YOU CAN BE CURED; if you |
| wait until you are so sick that you cannot work any |
| longer, or until you are very weak, it may be too late; |
| at any rate it will in the end mean more time out of work |
| and more wages lost than if you had taken care of |
| yourself at the start.= |
| |
| =DON'T DRINK WHISKY, beer, or other intoxicating drinks; |
| they will do you no good, but will make it harder for you |
| to get well.= |
| |
| =DON'T SLEEP IN THE SAME BED with any one else, and, if |
| possible, not in the same room.= |
| |
| =GOOD FOOD, FRESH AIR, AND REST are the best cures. Keep in |
| the sunshine as much as possible, and KEEP YOUR WINDOWS |
| OPEN, winter and summer, night and day. Fresh air, night |
| and day, is good for you.= |
| |
| =GO TO A HOSPITAL WHILE YOU CAN AND BEFORE IT IS TOO LATE. |
| There you can get the best treatment, all the rest, all |
| the fresh air, and all the food which you need.= |
| |
| =THE CAREFUL AND CLEAN CONSUMPTIVE IS NOT DANGEROUS TO THOSE |
| WITH WHOM HE LIVES AND WORKS= |
+-------------------------------------------------------------------+
Is it not significant that America's national movement is due primarily
to the organizing capacity of laymen in the New York Charity
Organization Society rather than to schools or hospitals? Most of the
local secretaries are men whose inspiration came from contact with the
non-medical relief of the poor in city tenements. The secretary of the
national association is a university professor of anthropology, who has
also a medical degree. The child victim's plea--Little Jo's Smile--was
nationalized by an association of laymen, aided by the advertising
managers of forty magazines. The smaller cities of New York state are
being aroused by a state voluntary association that for years has
visited almshouses, insane asylums, and hospitals. These facts I
emphasize, for they illustrate the opportunity and the duty of the lay
educator, whether parent, teacher, labor leader, or trustee of
hospital, orphanage, or relief society.
Three fundamental rules of action should be established as firmly as
religious principles:
1. The public health authorities should be told of every known and
every suspected case of tuberculosis.
2. For each case proved by examination of sputum to be
tuberculous, the public-health officers should know that the germs
are destroyed before being allowed to contaminate air or food.
3. Sick and not yet sick should practice habits of health that
build up vitality to resist the tubercle bacilli and that abhor
uncleanliness as nature abhors a vacuum.
[Illustration: FIGHTING TUBERCULOSIS WITH A NATIONAL
ORGANIZATION]
All laws, customs, and environmental conditions opposed to the
enforcement of these three principles must be modified or abolished. If
the teachers of America will list for educational use in their own
communities the local obstacles to these rules of action, they will see
exactly where their local problem lies. The illustrations that are
given in this book show in how many ways these rules of action are now
being universalized. Three or four important steps deserve especial
comment:
1. Compulsory notification of all tuberculous cases.
2. Compulsory removal to hospital of those not able at home to
destroy the bacilli, or compulsory supervision of home care.
3. Examination of all members of a family where one member is
discovered to be tuberculous.
4. Special provision for tuberculous teachers.
5. Protection of children about to enter industry but predisposed
to tuberculosis.
6. Prohibition of dry cleaning of schools, offices, and streets.
7. Tax provision for educational and preventive work.
Compulsory notification was introduced first in New York City by
Hermann M. Biggs, M.D., chief medical officer: 1893, partially
voluntary, partially compulsory; 1897, compulsory for all. Physicians
who now hail Dr. Biggs as a statesman called him persecutor, autocrat,
and violator of personal freedom fifteen years ago. Foreign sanitarians
vied with American colleagues in upbraiding him for his exaggeration of
the transmissibility of consumption and for his injustice to its
victims. As late as 1899 one British expert particularly resented the
rejection of tuberculous immigrants at Ellis Island, and said to me,
"Perhaps if you should open a man's mouth and pour in tubercle bacilli
he might get phthisis, but compulsory notification is preposterous." In
1906 the International Congress on Tuberculosis met in Paris and
congratulated New York upon its leadership in securing at health
headquarters a list of the known disease centers within its borders; in
1906 more than twenty thousand individual cases were reported, ten
thousand of these being reported more than once. To know the nature and
location of twenty thousand germ factories is a long step toward
judging their strength and their probable product. To compulsory
notification in New York City is largely due the educational movements
of the last decade against the white plague, more particularly the
growing ability among physicians to recognize and to treat conditions
predisposing to the disease. As in New York City, the public should
provide free of cost bacteriological analysis of sputum to learn
positively whether tuberculosis is present. Simpler still is the
tuberculin test of the eyes, with which experiments are now being made
on a large scale in New York City, and which bids fair to become cheap
enough to be generally used wherever physical examinations are made.
This test is known as Calmette's Eye Test. Inside the eyelid is placed
a drop of a solution--95 per cent alcohol and tuberculin. If
conjunctivitis develops in twenty-four hours, the patient is proved to
have tuberculosis. Some physicians still fear to use this test. Others
question its proof. The "skin test" is also being thoroughly tried in
several American cities and, if finally found trustworthy, will
greatly simplify examination for tuberculosis. Dr. John W. Brannan,
president of Bellevue and Allied Hospitals, New York City, is to report
on skin and eye tuberculin tests for children at the International
Congress on Tuberculosis, mentioned later.
[Illustration: FIGHTING TUBERCULOSIS BY ORGANIZED COÖPERATIVE
DISPENSARY WORK]
[Illustration: FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE
EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE]
Compulsory removal of careless consumptives is yet rare. One obstacle
is the lack of hospitals. In New York ten thousand die annually from
tuberculosis and fifty thousand are known to have it, yet there are
only about two thousand beds available. So long as the patients anxious
for hospital care exceed the number of beds, it does not seem fair to
give a bed to some one who does not want it. On the other hand, it
should not be forgotten that patients are taken forcibly to smallpox
and scarlet-fever hospitals, not for their own good, but for the
protection of others. The last person who should be permitted to stay
at home is the tuberculous person who is unable, unwilling, or too
ignorant to take the necessary precautions for others' protection. A
rigid educational test should be applied as a condition of remaining at
home without supervision.
The objections to compulsory removal are two: (1) it is desired to make
sanatorium care so attractive that patients will go at the earliest
stage of the disease; (2) an unwilling patient can defeat the
sanitarian's effort to help him and others. The alternative for
compulsory removal is gratuitous, and, if need be, compulsory,
supervision of home care, such as is now given in New York City. In
Brighton, England, Dr. Newsholme treats his municipal sanatorium as a
vacation school, giving each patient one month only. Thus one bed helps
twelve patients each year. Almost any worker can spare one month and in
that time can be made into a missionary of healthy living.
Family examining parties were begun in New York by Dr. Linsly R.
Williams, for the relief agency that started the seaside treatment of
bone tuberculosis. Many of the crippled children at Sea Breeze were
found to have consumptive fathers or mothers. In one instance the
father had died before Charlie had "hip trouble." Long after we had
known Charlie his mother began to fail. She too had consumption. Family
parties were planned for 290 families. Weights were taken and careful
examination made, the physician explaining that predisposition means
defective lung capacity or deficient vitality. Of 379 members,
supposedly free from tuberculosis, sixteen were found to have
well-marked cases. (Of twenty Boston children whose parents were in a
tuberculosis class, four had tuberculosis.) In one instance the father
was astonished to learn not only that he was tuberculous, but that he
had probably given the disease to the mother, for whom he was tenderly
concerned. Of special benefit were the talks about teeth and
nourishment, and about fresh air and water as germ killers. One
examination of this kind will organize a family crusade against
carelessness.
[Illustration: FIGHTING TUBERCULOSIS IN SMALL CITIES
New York State Charities Aid Association]
Tuberculous teachers ought to be excluded from schoolrooms not merely
because they may spread tuberculosis, but because they cannot do
justice to school work without sacrifices that society ought not to
accept. A tuberculous teacher ought to be generous enough to permit
public hospitals to restore her strength or enterprising enough to
join tuberculosis classes. It is selfish to demand independence at the
price which is paid by schools that employ tuberculous teachers.
[Illustration: FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND
SALT AIR]
Predisposition to tuberculosis should be understood by every child
before he is accepted as an industrial soldier. Many trades now
dangerous would be made safe if workers knew the risk they run, and if
society forbade such trades needlessly to exhaust their employees. A
perfectly sound man is predisposed to tuberculosis if he elects to work
in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack
of exercise in the open air, prepare lungs to give a cordial reception
to tubercle bacilli. Rooms as well as persons become infected.
Fortunately, opportunities to work are so varied in most localities
that workers predisposed to tuberculosis may be sure of a livelihood in
an occupation suited to their vitality. Destruction of germs in the
air, in carpets, on walls, on streets, is quite as important as
destruction of germs in lungs. Why should not tenants and workers
require health certificates stating that neither house nor working
place is infected with tubercle bacilli? Some cities now compel the
disinfection of premises occupied by tuberculous persons _after_ their
removal. Landlords, employers, tenants, and employees can easily be
taught to see the advantage of disinfecting premises occupied by
tuberculous cases _before_ detection.
[Illustration: FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR
HOSPITALS FOR BONE TUBERCULOSIS]
Dry cleaning, feather dusters, dust-laden air, will disappear from
schoolrooms within twenty-four hours after school-teachers declare that
they shall disappear. We have no right to expect street cleaners,
tenement and shop janitors, or overworked mothers to be more careful
than school-teachers. Last year I said to a janitress, "Don't you
realize that you may get consumption if you use that feather duster?"
Her reply caused us to realize our carelessness: "I don't want any more
than I've got now." Shall we some day have compulsory examination and
instruction of all cleaners, starting with school cleaners?
[Illustration: FIGHTING TUBERCULOSIS IN OPEN TENTS]
Taxing is swift to follow teaching in matters of health. Teachers can
easily compute what their community loses from tuberculosis. The totals
will for some time prove a convincing argument for cleanliness of air,
of body, and of building wherever the community is responsible for air,
building, and body. The annual cost of tuberculosis to New York City is
estimated at $23,000,000 and to the United States at $330,000,000. The
cost of exterminating it will be but a drop in the bucket if
school-teachers do their part this next generation with the twenty
million children whose day environment they control for three fourths
of the year, and whose habits they can determine.
The first meeting in America of the International Congress on
Tuberculosis was held at Washington, D.C., September 21 to October 12,
1908. For many years the proceedings of this congress will undoubtedly
be the chief reference book on the conquest of tuberculosis.[14]
How many aspects there are to this problem, and how many kinds of
people may be enlisted, may be seen from the seven section names: I.
Pathology and Bacteriology; II. Sanatoriums, Hospitals, and
Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in
Children--Etiology, Prevention, and Treatment; V. Hygienic, Social,
Industrial, and Economic Aspects; VI. State and Municipal Control of
Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man.
[Illustration: FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER
BED, OTISVILLE, NEW YORK]
How many-sided is the responsibility of each of us for stamping out
tuberculosis is shown by the preliminary programme of the eight
sessions of Section V. These topics suggest an interesting and
instructive year's study for clubs of women, mothers, or teachers, or
for advanced pupils.
I. ECONOMIC ASPECTS OF TUBERCULOSIS
1. The burdens entailed by tuberculosis:
a. On individuals and families.
b. On the medical profession.
c. On industry.
d. On relief agencies.
e. On the community.
f. On social progress.
2. The cost of securing effective control of tuberculosis:
a. In large cities.
b. In smaller towns.
c. In rural communities.
II. ADVERSE INDUSTRIAL CONDITIONS
1. Incidence of tuberculosis according to occupation.
2. Overwork and nervous strain as factors in tuberculosis.
3. Effect of improvements in factory conditions on the health of
employees.
4. Legitimate exercise of police power in protecting the life and
health of employees.
III. THE SOCIAL CONTROL OF TUBERCULOSIS
1. Outline of a comprehensive programme for:
a. National, state, and municipal governments.
b. Departments of health and departments of public relief.
c. Private endowments.
d. Voluntary associations for educational propaganda.
e. Institutions, such as schools and relief agencies, which
exist primarily for other purposes.
2. A symposium on the relative value of each of the features in an
aggressive campaign against tuberculosis:
a. Compulsory registration.
b. Free sputum examination.
c. Compulsory removal of unteachable and dangerous cases.
d. Laboratory research.
e. Hospital.
f. Sanatorium.
g. Dispensary.
h. The tuberculosis class.
i. Day camp.
j. Private physician.
k. Visiting nurse.
l. After-care of arrested cases.
m. Relief fund.
n. Climate.
o. Hygienic instruction,--personal and in class.
p. Inspection of schools and factories.
q. Educational propaganda.
IV. EARLY RECOGNITION AND PREVENTION
1. Importance of discovering the persons who have tuberculosis
before the disease has passed the incipient stage.
2. Examination of persons known to have been exposed or presumably
predisposed.
3. Systematic examination of school children during their course
and on leaving school to go to work.
4. Professional advice as to choice of occupation in cases where
there is apparent predisposition to disease.
V. AFTER-CARE OF ARRESTED CASES
1. Instruction in healthful trades in the sanatorium.
2. Training for professional nursing in institutions for the care
of tuberculous patients.
3. Farm colonies.
4. Convalescent homes or cottages.
5. Aid in securing suitable employment on leaving the sanatorium.
6. How to deal with the danger of a return to unfavorable home
conditions.
VI. EDUCATIONAL METHODS AND AGENCIES
1. Special literature for general distribution.
2. Exhibits and lectures.
3. The press.
4. Educational work of the nurse.
5. Labor organizations.
6. Instruction in schools of all grades.
7. Presentation and discussion of leaflets awarded prizes by the
congress.
VII. PROMOTION OF IMMUNITY
1. Development of the conception of physical well-being.
2. Measures for increasing resistance to disease:
a. Parks and playgrounds.
b. Outdoor sports.
c. Physical education.
d. Raising the standards of living: housing, diet,
cleanliness.
3. Individual immunity and social conditions favorable to general
immunity.
VIII. RESPONSIBILITY OF SOCIETY FOR TUBERCULOSIS
1. A symposium of representative
a. Citizens.
b. Social workers.
c. Employers.
d. Employees.
e. Physicians.
f. Nurses.
g. Educators.
h. Others.
Cash prizes of one thousand dollars each are offered: (1) for the best
evidence of effective work in the prevention or relief of tuberculosis
by any voluntary association since 1905; (2) for the best exhibit of a
sanatorium for working classes; (3) for the best exhibit of a furnished
home for the poor, designed primarily to prevent, but also to permit
the cure of tuberculosis.
[Illustration: BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN
_A-D, F, H-J_, private hospitals and agencies reporting cases to
the official center; _E_, home care; _K, L, M_, day camp and
hospitals for incipient and advanced cases]
A white-plague scrapbook containing news items, articles, and
photographs will prove an interesting aid to self-education or to
instruction of children, working girls' clubs, or mothers' meetings.
Everybody ought to enlist in this war, for the fight against
tuberculosis is a fight for cleanliness and for vitality, for a fair
chance against environmental conditions prejudicial to efficient
citizenship.
So sure is the result and so immediate the duty of every citizen that
Dr. Biggs wrote in 1907: _In no other direction can such large results
be achieved so certainly and at such relatively small cost. The time is
not far distant when those states and municipalities which have not
adopted a comprehensive plan for dealing with tuberculosis will be
regarded as almost criminally negligent in their administration of
sanitary affairs and inexcusably blind to their own best economic
interests._
FOOTNOTES:
[13] The best literature on tuberculosis is in current magazines and
reports of anti-tuberculosis crusaders. For a scientific, comprehensive
treatment, libraries and students should have _The Prevention of
Tuberculosis_ (1908) by Arthur Newsholme, M.D. A popular book is _The
Crusade against Tuberculosis_, by Lawrence F. Flick, of the Henry Phipps
Institute for the Study, Treatment, and Prevention of Tuberculosis.
[14] Those desiring copies this year or hereafter will do well to write
to The National Association for the Study and Prevention of
Tuberculosis, 105 East 22d St., New York City. The congress is under the
control of the National Association and is managed by a special
committee appointed by it. Even after a national board of health is
established, the National Association for the Study and Prevention of
Tuberculosis will continue to be a center for private interest in public
protection against tuberculosis. One of its chief functions is the
preparation and distribution of literature to those who desire it.
CHAPTER XXV
THE FIGHT FOR CLEAN MILK
"With the approval of the President and with the coöperation of the
Department of Agriculture,[15] the [national quarantine] service has
undertaken to prepare a complete report upon the milk industry from
farm to the consumer in its relation to the public health." This
promise of the United States Treasury insures national attention to the
evils of unclean milk and to the sanitary standards of farmer and
consumer. Nothing less than a national campaign can make the vivid
impression necessary to wean dairymen of uncleanly habits and mothers
of the ignorant superstition that babies die in summer just because
they are babies. When two national bureaus study, learn, and report,
newspapers will print their stories on the first page, magazines will
herald the conclusions, physicians will open their minds to new truths,
state health secretaries will carry on the propaganda, demagogues and
quacks will become less certain of their short-cut remedies, and
_everybody will be made to think_.
The evolution of this newly awakened national interest in clean milk
follows the seven stages and illustrates the seven health motives
presented in Chapter II. I give the story of Robert M. Hartley because
he began and prosecuted his pure-milk crusade in a way that can be
duplicated in any country town or small city.
Robert M. Hartley was a strong-bodied, strong-minded, country-bred man,
who started church work in New York City almost as soon as he arrived.
He distributed religious tracts among the alleys and hovels that
characterized lower New York in 1825. Meeting drunken men and women one
after another, he first wondered whether they were helped by tracts,
and then decided that the mind befogged with alcohol was unfit to
receive the gospel message. Then for fifteen years he threw himself
into a total-abstinence crusade, distributing thousands of pamphlets,
calling in one year at over four thousand homes to teach the industrial
and moral reasons for total abstinence. Finally, he began to wonder
whether back of alcoholism there was not still a dark closet that must
be explored before men could receive the message of religion and
self-control. So in 1843 he organized the New York Association for
Improving the Condition of the Poor, which ever since has remembered
how Hartley found alcoholism back of irreligion, and how back of
alcoholism and poverty and ignorant indifference he found indecent
housing, unsanitary streets, unwholesome working conditions, and impure
food.
[Illustration: FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS
IN THE HEART OF NEW YORK CITY,--JUNIOR SEA BREEZE]
[Illustration: PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK
TO THE INDIVIDUAL BABY'S NEED,--ROCHESTER'S MODEL DAIRY]
Hartley's instinct started the first great pure-milk agitation in this
country. While visiting a distillery for the purpose of trying to
persuade the owner to invest his money in another business, he noticed
that "slops smoking hot from the stills" were being carried to cow
stables. He followed and was nauseated by the sights and odors. Several
hundred uncleaned cows in low, suffocating, filthy stables were being
fed on "this disgusting, unnatural food." Similar disgust has in many
other American cities caused the first effort to better dairy
conditions. Hartley could never again enjoy milk from distillery cows.
Furthermore, his story of 1841 made it impossible for any readers of
newspapers in New York to enjoy milk until assured that it was not
produced by distillery slops. The instinctive loathing and the
discomfort of buyers awakened the commerce motives of milk dealers, who
covered their wagons with signs declaring that they "no longer" or
"never" fed cows on distillery refuse. But Hartley could not stop when
the anti-nuisance stage was reached. He did not let up on his fight
against impure or adulterated milk until the state legislature declared
in 1864 that _every baby, city born or country born, no matter how
humble its home, has the right to pure milk_.
+-------------------------------------------------------------------+
| =Clean Milk for New York City= |
| |
| =CONFERENCE= |
| |
| =ROOM 44, N.Y. ACADEMY OF MEDICINE= |
| =No. 17 WEST 43D STREET= |
| |
| =November 20th, 1906, Tuesday 3 p.m. and 8 p.m.= |
| |
| |
| =ESSENTIAL FACTS AS TO NEW YORK CITY= |
| |
| =Manhattan's Infant Mortality= |
| (=UNDER 5 YRS.=) |
| |
| June to September, 1904, 4428 |
| June to September, 1905, 4687 |
| June to September, 1906, 4428 |
| |
| =Daily Consumption of Milk= |
| |
| 1,600,000 qts. |
| ¼ in quart bottles |
| ¾ in 40-quart cans |
| "Certified," 10,000 quarts |
| "Inspected," 3,000 quarts |
| 24 to 48 hours old on arrival |
| |
| =Comes from= |
| |
| 30,000 dairies, 40 to 400 miles distant |
| 600 creameries--105 proprietors |
| 10 city railroad depots |
| |
| =Sold in= |
| |
| 12,000 places, mostly from cans |
| Sale of skim milk prohibited |
| |
| =Milk Law Violations, 1905= |
| |
| Destroyed, 39,618 quarts |
| Arrests, 806 |
| Fines, $16,435 |
| |
| =New York City Inspectors= |
| |
| 14 in country since July; might make rounds not oftener than |
| once a year |
| (For 3 yrs. before, only 2; previously none) |
| 16 in city, might make rounds in 30 to 40 days |
| (Before July, 14) |
| |
| |
| =POINTS OF AGREEMENT= |
| |
| =Cleanliness is the supreme requisite, from cow to consumer= |
| |
| Cows must be healthy, persons free from contagious diseases, |
| premises clean, water pure, utensils clean, cans and bottles |
| sterile, shops sanitary |
| |
| =Temperature is second essential= |
| |
| 50° F. or lower at dairy |
| 45° F. at creamery |
| 45° F. or less during transportation |
| Not above 50° when sold to the consumer |
| |
| =As to Pasteurization= |
| |
| Not necessary for absolutely clean milk |
| Destroys benign as well as harmful germs |
| Disease germs develop more rapidly than in pure raw milk |
| True, 155° for 30 minutes to 167° for 20 minutes |
| Cost per quart, estimated, ¼ to ½ ct. |
| Commercial, 165° for 15 seconds |
| Cost per quart, negligible |
| |
| =As to Inspection= |
| |
| _Some_ inspection needed within the city |
| _Some_ inspection needed of dairy and creamery |
| |
| |
| =WHAT NEXT STEPS SHOULD NEW YORK TAKE?= |
| |
| =Skim Milk= |
| |
| Should its sale be permitted? |
| Under what conditions? |
| How would this affect price of whole milk? |
| |
| =Pasteurization= |
| |
| Should pasteurization be made compulsory? |
| For what portion of the supply? |
| At whose expense? |
| Would it increase price of milk? |
| Does it render inspection unnecessary? |
| Does it reduce need for inspection? |
| Should sale of repasteurized milk or cream be permitted? |
| Should bottles show whether true or commercial pasteurization |
| is used? |
| |
| =Infants' Milk Depots= |
| |
| Should they use pasteurized or clean milk? |
| Are municipal depots desirable? |
| Should private philanthropy support depots? |
| How many depots would be required in New York City? |
| Is Rochester experience applicable to New York City? |
| What educational work is possible in connection with milk |
| depots? |
| |
| |
| =Model Milk Shops= |
| |
| What may safely be sold in connection with milk? |
| Should law discourage other than model shops? |
| Are present sanitary laws rigid enough? |
| Should private capital be encouraged to establish shops? |
| Is it practicable to prohibit use of cans? |
| What provision can be demanded for proper refrigeration? |
| What for receiving milk before business hours when delivered |
| from stations? |
| What for sterilization of utensils and bottles? |
| What for attendants' dress and care of person? |
| Would such restrictions increase price? |
| |
| =Inspection= |
| |
| Is it practicable by inspection alone to secure a clean milk |
| supply? |
| Will it protect against more dangerous forms of infection? |
| How many inspectors does New York City need? |
| Within the city? |
| Among country dairies and creameries? |
| How many inspectors should the state employ? |
| |
| =Legislation= |
| |
| What needed as to diseased cattle? |
| What as to diseases of persons producing or handling milk? |
| Is present sanitary code sufficient? |
| Shall law require sterilization of all milk cans and bottles |
| by milk company or creamery before returned to farms or |
| refilled? |
| Shall sealing cans at creameries be required? |
| Shall transferring from one can to another or from can to |
| bottle in open street be made a misdemeanor? |
| Shall pollution of milk cans and bottles be made a |
| misdemeanor? |
| Shall bacterial standard be established? |
| Is state supervision now adequate? |
| What further legislation is needed? |
| Does present law prescribe adequate penalties? |
| |
| =Education= |
| |
| Should state system of lectures before agricultural institutes |
| be extended? |
| Should Maryland plan of traveling school be adopted as means |
| of reaching producer? |
| What can be done to assist Teachers College in its plan for |
| milk exhibit? |
| What can be done to teach mothers to detect unclean milk and |
| to care properly for milk purchased? |
| How can tenement mothers keep milk at proper temperature? |
| Can nothing be done to increase the supply and cheapen the |
| price of ice? |
| Is it desirable that a local committee be formed to coöperate |
| with the Department of Health and County Medical Society? |
+-------------------------------------------------------------------+
Unfortunately Hartley and his contemporaries had never heard of disease
germs that are carried by unclean milk into the human stomach. Science
had not yet proved that many forms of barnyard filth could do quite as
much harm as distillery refuse. Commerce had not invented milk bottles
of glass or paper. The law of 1864 failed in two particulars: (1) it
did not demand cleanliness from cow to consumer; (2) it did not provide
means for its own enforcement, for learning whether everything and
everybody that had to do with milk was clean. Not knowing of germs and
their love for a warm climate and warm food, they naturally did not
prohibit a temperature above fifty degrees from the time of milking to
the time of sale. How much has been left for our generation to do to
secure pure milk is illustrated by the opening sentence of this
chapter, and more specifically by the programme of a milk conference
held in New York in November, 1906, the board of health joining in the
call. The four-page folder is reproduced in facsimile (excepting the
names on the fourth page), because it states the universal problem, and
also because it suggests an effective way to stimulate relevant
discussion and to discourage the long speeches that spoil many
conferences.
This conference led to the formation of a milk committee under the
auspices of the association founded by Hartley. Business men,
children's specialists, journalists, clergymen, consented to serve
because they realized the need for a continuing public interest and a
persisting watchfulness. Such committees are needed in other cities and
in states, either as independent committees or as subcommittees of
general organizations, such as women's clubs, sanitary leagues, county
and state medical societies. Teachers' associations might well be
added, especially for rural and suburban districts where they are more
apt than any other organized body to see the evils that result from
unclean milk. The New York Milk Committee set a good example in paying
a secretary to give his entire time to its educational programme,--a
paid secretary can keep more volunteers and consultants busy than could
a dozen volunteers giving "what time they can spare." Thanks chiefly to
the conference and the Milk Committee's work, several important results
have been effected. The general public has realized as never before
that two indispensable adjectives belong to safe milk,--_clean_ and
_cool_. Additional inspectors have been sent to country dairies;
refrigeration, cans, and milk have been inspected upon arrival at
night; score cards have been introduced, thanks to the convincing
explanations of their effectiveness by the representatives of the
Bureau of Animal Industry of the national Department of Agriculture;
8640 milch cows were inspected by veterinary practitioners (1905-1907),
to learn the prevalence of bovine tuberculosis (of these thirty-six per
cent reacted to the tuberculin test); state societies and state
departments have been aroused to demand an efficient live-stock
sanitary board; magistrates have fined and imprisoned offenders against
the milk laws, where formerly they "warned"; popular illustrated milk
lectures were added to the public school courses; illustrated cards
were distributed by the thousand, telling how to keep the baby well;
finally, private educational and relief societies, dispensaries,
settlements, have been increasingly active in teaching mothers at home
how to prepare baby's milk. In 1908 a Conference on Summer Care of
Babies was organized representing the departments of health and
education, and fifty private agencies for the care of sick babies and
the instruction of mothers. The superintendent of schools instructed
teachers to begin the campaign by talks to children and by giving out
illustrated cards. Similar instructions were sent to parochial schools
by the archbishop.
[Illustration: NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN
NEW YORK CITY]
As elsewhere, there are two schools of pure-milk crusaders: (1) those
who want cities to _do things_, to pasteurize all milk, start milk
farms, milk shops, or pure-milk dispensaries; and (2) those who want
cities and states to _get things done_. So far the New York Milk
Committee has led the second school and has opposed efforts to
municipalize the milk business. The leader of the other school is the
noted philanthropist, Nathan Strauss, who has established
pasteurization plants in several American and European cities. The
discussion of the two schools, similar in aim but different in method,
is made more difficult, because to question philanthropy's method
always seems to philanthropy itself and to most bystanders an
ungracious, ungrateful act. As the issue, however, is clean milk, not
personal motive, it is important that educators and parents in all
communities benefit from the effective propaganda of both schools,
using what is agreed upon as the basis for local pure-milk crusades,
reserving that which is controversial for final settlement by research
over large fields that involve hundreds of thousands of tests.
[Illustration: A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND
SCHOOL FOR MOTHERS]
Pasteurization, municipal dairies, municipal milk shops, municipal
infant-milk depots, are the four chief remedies of the _doing things_
school. European experience is cited in support of each. We are told
that cow's milk, intended by nature for an infant cow with four
stomachs, is not suited, even when absolutely pure, to the human
infant's single stomach. Cow's milk should be modified, weakened,
diluted, to fit the digestive powers of the individual infant; hence
the municipal depot or milk dispensary that provides exactly the right
milk for each baby, prescribed by municipal physicians and nurses who
know. That the well-to-do and the just-past-infancy may have milk as
safe as babies receive at the depot, municipalization of farm and milk
shop is advocated. Some want the city to run only enough farms and milk
shops to set a standard for private farmers, as has been done in
Rochester. This is city ownership and operation for educational
purposes only. Finally, because raw milk even from clean dairies may
contain germs of typhoid, scarlet fever, or tuberculosis,
pasteurization is demanded to kill every germ. There are advocates of
pasteurization that deprecate the practice and deny that raw milk is
necessarily dangerous; they favor it for the time being until farms and
shops have acquired habits of cleanliness. Likewise many would prefer
private pasteurization or laws compelling pasteurization of all milk
offered for sale; but they despair of obtaining safe milk unless city
officials are held responsible for safety. Why wait to discuss
political theories about the proper sphere for government, when, by
acting, hundreds of thousands of lives can be saved annually? These
methods of _doing things_ will not add to the price of milk; it is, in
fact, probable that the reduction in the cost of caring for the sick
and for inspecting farms and shops will offset the net cost of depots,
farms, and dairies.
[Illustration: ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS]
[Illustration: ROCHESTER'S MODEL DAIRY FARM]
As to pasteurization, its cost is negligible, while the cost of
cleanliness is two, four, or ten cents a quart. Whether ideally clean
milk is safe or not, raw milk that is not clean is unfit for human
consumption. All cities should compel evidence of pasteurization as a
condition of sale. Large cities should have their own pasteurizing
plants, just as many cities now have their own vaccine farms and
antitoxin laboratories. Parents in small towns and in the country
should be taught to pasteurize all milk.
The _getting things done_ school admits the need for modified milk of
strength suited to the infant's stomach; affirms the danger of milk
that contains harmful germs; demands educational work by city, state,
and nation; confesses that talk about cleanliness will not make milk
safe. On the other hand, it denies that raw milk is necessarily
dangerous; that properly modified, clean, raw milk is any safer when
pasteurized; that talking about germ-proof milk insures germ
extinction. It maintains that pasteurization kills benign germs
essential to the life of milk, and that after benign germs are killed,
pasteurized milk, if exposed to infection, is more dangerous than raw
milk, for the rapid growth of harmful germs is no longer contested by
benign germs fighting for supremacy. While it is admitted that raw milk
produced under ideal conditions may become infected by some person
ignorant of his condition, and before detection may cause typhoid,
scarlet fever, or consumption, it has not been proved that such
instances are frequent or that the aggregate of harm done equals that
which pasteurized milk may do. Pasteurization does not remove chemical
impurities; boiling dirt does not render it harmless. The remedy for
germ-infected milk is to keep germs out of milk. The remedy for unclean
milk is cleanliness of cow, cow barn, cowyard, milker, milk can,
creamery, milk shop, bottle, nipple. If the sale of unclean milk is
prevented, farmers will, as a matter of course, supply clean milk. By
teaching farmers and milk retailers the economic advantages of
cleanliness they will cultivate habits that guarantee a clean milk
supply. By punishing railroads and milk companies that transport milk
at a temperature which encourages germ growth, and by dumping in the
gutter milk that is offered for sale above 50 degrees, the
refrigerating of milk will be made the rule. Purging magistrates'
courts of their leniency toward dealers in impure, dangerous milk is
better than purging milk of germs. Boiling milk receptacles will save
more babies than boiling milk. Teaching mothers about the care of
babies will bring better results than giving them a false sense of
safety, because only one of many dangers has been removed by
pasteurization. Educating consumers to demand clean milk and to
support aggressive work by health departments leaves fewer evils
unchecked than covering up uncleanliness by pasteurization.
[Illustration: NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF
SHOWING BABIES' PROGRESS]
[Illustration: PRODUCING WINTER CONDITIONS IN MIDSUMMER BY
PROPER REFRIGERATION FOR MILK IN FREIGHT CARS]
When doctors disagree what are we laymen to do? We can take an
intelligent interest in the inquiries that are now being made by city,
state, and national governments. Because everybody believes that clean
milk is safer than unclean milk, that milk at 50 degrees will not breed
harmful germs, we can demand milk inspection that will tell our health
officers and ourselves which dealers sell only clean milk at 50 degrees
and never more than 60 degrees, that never shows over 100,000 colonies
to the cubic centimeter. We can get our health departments to publish
the results of their scoring of dairies and milk shops in the papers,
as has been done in Montclair. We can tell our health officers that the
best results in fighting infant mortality are at Rochester, which city,
winter and summer, by inspection, correspondence, and punishment,
educates farmers and dealers in cleanliness, not only censuring when
dirty or careless, but explaining how to make more money by being
clean. Finally, mothers can be taught at home how to cleanse the
bottles, the nipples, all milk receptacles, and all things in rooms
where milk is kept. Absolutely clean milk of proper temperature _at the
shop_ may not safely be given to a baby in a dirty bottle. Infant milk
depots, pasteurization, the best medical and hospital care, breast
feeding itself, cannot prevent high baby mortality if mothers are not
clean. The most effective volunteer effort for pure milk is that which
first makes the health machinery do its part and then teaches, teaches,
teaches mothers and all who have to do with babies.
[Illustration: NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT
SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS]
"Clean air, clean babies, clean milk," has been the slogan of Junior
Sea Breeze,--a school for mothers right in the heart of New York's
upper East Side. In the summer of 1907 twenty nurses went from house to
house telling 102,000 mothers how to keep the baby well. This was the
only district that had fewer baby deaths than for 1906. Had other parts
of the city shown the same gain, there would have been a saving of 1100
babies. The following winter a similar work was conducted by nurses
from the recently founded Caroline Rest, which has an educational fund
for instruction of mothers in the care of babies, especially babies not
yet born and just born. Heretofore the baby has been expected to cry
and to have summer complaint before anybody worried about the treatment
it received. If the baby lived through its second summer, it was
considered great good fortune. Junior Sea Breeze and Caroline Rest
start their educational work before the baby is sick, in fact, before
it is born. Their results have been so notable that several well-to-do
mothers declare that they wish they too might have a school.
Dispensaries and diet kitchens and more particularly maternity wards of
hospitals, family physicians, nurses, and midwives, should be required
to know how to teach mothers to feed babies regularly, the right
quantities, under conditions that insure cleanliness whether the breast
or the bottle is used. Perhaps some day no girl will be given a
graduating certificate, or a license for work, teaching, or marriage,
until she has demonstrated her ability to give some mother's baby
"clean air, clean body, clean milk."
FOOTNOTES:
[15] Libraries should obtain all reports on milk, Bureau of Animal
Industry, Washington, D.C.
CHAPTER XXVI
PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER
No profession, excepting possibly the ministry, is regarded with
greater deference than the medical profession. Our ancestors listened
with awe and obedience to the warnings and behests of the medicine man,
bloodletter, bonesetter, family doctor. In modern times doctors have
disagreed with each other often enough to warrant laymen in questioning
the infallibility of any individual healer or any sect, whether
homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day
most of us surround the medical profession or the healing art with an
atmosphere of necromancy. Even after we have given up faith in drugs or
after belief is denied in the reality of disease and pain, we revere
the calling that concerns itself, whether gratuitously or for pay, with
conquering bodily ills.
Self-laudation continues this hold of the medical profession upon the
lay imagination. One physician may challenge another's faults, ridicule
his remedies, call his antitoxin dangerous poison, but their common
profession he proudly styles "the most exalted form of altruism." Young
men and women beginning the study or the practice of medicine are
exhorted to continue its traditions of self-denial, and in their very
souls to place human welfare before personal or pecuniary advancement.
Newspapers repeat exhortation and laudation. We laymen pass on the
story that we know is not universally true,--physicians know,
physicians apply what they know without consciousness of error,
physicians must be implicitly trusted.
For a physician to give poison when he means to give food is worse, not
better, than for a layman to make the same mistake. Neither the moral
code nor the law of self-preservation enjoins a tuberculous mother to
take alcohol or to sleep in an unventilated room, even if an uninformed
physician prescribes it. Instruction in physiology and hygiene would be
futile if those who are educated as to the elementary facts of hygiene
and physiology must blindly follow blind physicians. A family doctor
who gives cod-liver oil for anæmia due to adenoids may do a child as
much harm as a nurse who drugs the baby to make it sleep. The physician
who refuses to tell the board of health when smallpox or typhoid fever
first breaks out takes human life just as truly as if he tore up the
tracks in front of an express train. This is another way of saying that
parents and teachers must fit themselves to know whether the family
physician and their community's physicians are efficient practitioners
and teachers. Every one can learn enough about the preventable causes
of sickness and depleted vitality to insist upon the ounce of education
and prevention that is better than a pound of cure.
For its sins of omission, as for its sins of commission, the medical
profession shares responsibility with laymen. For years leading
educators, business men, hospital directors, public officials, have
known that communicable diseases could be stamped out. The methods have
been demonstrated. There is absolutely no excuse to-day for epidemics
of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet
fever in the small towns of Minnesota, for uninterrupted epidemics of
tuberculosis everywhere. Had either laymen, physicians, or
school-teachers made proper use of the knowledge that has been in
text-books for a generation, this country would be saving thousands of
lives and millions of dollars every year. Our _doing_ and _getting
done_ have lagged behind our _knowing_.
The failure of physicians to "socialize" or "humanize" their knowledge
is due to two causes: (1) no one has been applying _result tests_ to
the profession as a whole and to the state in its capacity as doctor,
testing carefully the sickness rate, the death rate, and the expense
rate of preventable diseases; (2) physicians themselves have not needed
to know, either at college or in practice, the tax levied upon their
communities by preventable sickness. Public schools can do much to
secure result tests for individual physicians, for the profession as a
whole, and for boards of health. Schooling in preventive medicine, or,
better named, schooling in preventive hygiene, will fit physicians to
do their part in eradicating preventable disease.
Preventive hygiene is not an essential part of the training of American
physicians or nurses to-day. Not only are there no colleges of
preventive hygiene, but medical schools have not provided individual
courses. It is possible for a man to graduate with honors from our
leading medical colleges without knowing what "vital statistics" means.
Even boards of health, their duties and their educational
opportunities, are not understood by graduates; it is an accident if
the "social and economic aspects of medical practice," "statistical
fallacies," "hospital administration," "infant mortality," are familiar
terms. It is for this reason, rather than because physicians are
selfish, that indispensable and beneficent legislation is so generally
opposed by them when the prerogatives of their profession seem in
danger. Practically every important sanitary advance of the past
century has been fought at the outset by those whose life work should
have made them see the need. Physicians bitterly attacked compulsory
vaccination, medical inspection of schools, compulsory notification of
communicable diseases. What is perhaps more significant of the
physician's indifference to preventive hygiene is the fact that most of
the sanitary movements that have revolutionized hygienic conditions in
America owe their inception and their success to laymen, for example,
tenement-house reform, anti-child labor and anti-tuberculosis crusades,
welfare work in factories, campaigns for safety appliances, movement
for a national board of health, prison, almshouse, and insane-asylum
reform, schools for mothers, and milk committees. The first hospital
for infectious diseases, the first board of health, the first
out-of-door sea-air treatment of bone tuberculosis in the United
States, were the result of lay initiative.
Dr. Hermann M. Biggs says that in America the greatest need of the
medical profession and of health administration is training that will
enable physicians and lay inspectors to use their knowledge of
preventive hygiene for the removal of living and working conditions
that cause preventable sickness. A physician without knowledge of
preventive hygiene is simply doing a "general repair" business.
For a few months in 1907 New York City had a highly efficient
commissioner of street cleaning, who, in spite of the unanimous
protests and appeals of the press, refused to give up the practice of
medicine. Hitherto the board of health of that city has been unable to
obtain the full time of its physicians because professional standards
give greater credit to the retail application of remedies than to the
wholesale application of preventives.
Statesmanship as well as professional ability is expected of physicians
in the leading European cities, more particularly of those connected
with health departments. There it is not felt that a medical degree is
of itself a qualification for sanitary or health work. After the
professional course, physicians must take courses in preventive hygiene
and in health administration. Medical courses include such subjects as
vital statistics, duties of medical officers of health, sanitary
legislation, state medicine.
The needless cost for one year of "catching" diseases in New York City
would endow in perpetuity all the schools and lectureships and journals
necessary to teach preventive hygiene in every section of this great
country. That city alone sacrifices twenty-eight thousand lives
annually to diseases that are officially called preventable. The yearly
burial cost of these victims of professional and community neglect is
more than a million dollars. When to the doctor bills, wages lost,
burial cost of those who die are added the total doctor bills, wages
lost, and other expenses of the sick who do not die, we find that one
city loses in dollars and cents more every year from communicable
diseases than is spent by the whole United States for hospitals and
boards of health.
Many diseases and much sickness are preventable that are not
communicable. Indigestion due to bad teeth is not itself communicable,
but it can be prevented. One's vitality may be sapped by irregular
eating or too little sleep; others will not catch the trouble, although
too often they imitate the harmful habits. Adenoids and defective
vision are preventable, but not contagious. Spinal curvature and flat
foot are unnecessary, but others cannot catch them. Preventive hygiene,
however, should teach the physician's duty to educate his patient and
his community regarding all controllable conditions that injure or
promote the health.
In the absence of special attention to preventive medicine new truth is
forced to fight its way, sometimes for generations, before it is
accepted by the medical profession. So strong are the traditions of
that profession and so difficult is it for the unconventional or
heterodox individual to retain the confidence of conservative patients,
that the forces of honorable medical practice tend to discourage
research and invention. The man who discovers a surgical appliance is
forced by the ethics of his profession either to commercialize it and
lose his professional standing, or to abide the convenience of his
colleagues and their learned organizations in testing it. Rather than
be branded a quack, charlatan, or crank, the physician keeps silent as
to convictions which do not conform to the text-books. Many a
life-saving, health-promoting discovery which ought to be taken up and
incorporated into general practice from one end of the country to the
other, and which should be made a part of the minimum standard of
medical practice and medical agreement, must wait twenty-five or fifty
years for recognition.
[Illustration: THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS
STILL AN OUTCAST IN SCORES OF HOSPITALS]
For want of a school of preventive medicine to emphasize universally
every new truth, the medical colleges are permitted to remain
twenty-five or fifty years behind absolutely demonstrated facts as to
medical truth and medical practice. In 1761 a German physician,
Avenbruger, after discovering that different sounds revealed diseased
tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815
Lëannec discovered that sound from the chest was more distinct through
a paper horn. On that principle the modern stethoscope is built. He
made an accurate diagnosis of tuberculosis, and while suffering from
that disease treated himself as a living clinical study. In 1857
Pasteur proved the presence of germs "without which no putrefaction, no
fermentation, no decay of tissue takes place." In 1884 Trudeau started
the first out-of-door care of pulmonary tuberculosis in America. In
1892 Biggs secured the compulsory notification of pulmonary
tuberculosis. In 1904 began our first out-of-door sea-air treatment for
bone tuberculosis. Yet there are thousands of physicians to-day who
sincerely believe that they are earning their fees, who, from houses
shut up like ovens, give advice to patients for treatment of
tuberculosis, who prescribe alcohol and drugs, who diagnose the disease
as malaria for fear patients will be scared, who oppose compulsory
registration, and who never look for the tuberculous origin of crippled
children. Just think of its being possible, in 1908, for a tuberculous
young man of thirty to pay five dollars a day to a sanatorium whose
chief reliance is six doses of drugs a day!
In 1766 America's first dentist came to the United States. By 1785
itinerant dentists had built up a lucrative practice. In 1825 a course
of lectures on dentistry was delivered before the medical class at the
University of Maryland. As early as 1742 treatises were written "Upon
Dentition and the Breeding of Teeth in Children." In 1803 the
possibility of correcting irregularities was pointed out, as was the
pernicious effect of tartar on the teeth in 1827. In 1838 attempts were
made to abolish, "in all common cases, the pernicious habit of tooth
drawing." In 1841 treatises were written on the importance of
regulating the teeth of children before the fourteenth year and on the
importance of preserving the first teeth. Yet in 1908 it is necessary
to write the chapter on Dental Sanitation. Few physicians, whether in
private practice or hospitals or just out of medical college, consider
it necessary to know the conditions of the mouth before prescribing
drugs for physical illness.
Osteopathy furnishes an up-to-date illustration. Discredited by the
medical profession, by medical journals and medical schools, it has in
fifteen years built up a practice of eight thousand men, having from
one to three years' training, including over one hundred physicians
with full medical training plus a course in osteopathy. There were
means of learning fifteen years ago what was truth and what was
quackery about the practice of osteopathy. By refusing to look for its
truth and by concentrating attention upon its quackery the medical
profession has lost fifteen years. Whereas the truth of osteopathy
should have been adopted by the medical colleges and a knowledge of its
possibilities and limitations required of every practicing physician, a
position has been reached where alleged quackery seems in several
important points to be discrediting the sincerity, the intelligence,
and the efficiency of orthodox medicine. No appeal to the natural can
be stronger, no justification of schools of preventive medicine more
complete, than the following paragraph from an osteopathic physician
who is among the small number who, having both the medical and
osteopathic degrees, see both the possibilities and limitations of
manual surgery and demand the inclusion of this new science in the
medical curriculum.
The physical method of treating disease presents a tremendous and
significant departure from the empiricism of medicine and the
experimentation of dietetics, the restricted fields of
electricity, suggestion, water cures, and massage. The patient as
an individual is not treated; the disease as a disease is not
treated; the symptoms are not treated; but the entire physical
organism, with its many parts and diverse functions, is
exhaustively examined until each and every abnormal condition,
whether of structure or of function, causing disease and
maintaining symptoms, is found and administered to with the skill
of a definite art, based upon the data of an exact science.
Likewise the truths underlying Christian Science have been disdained by
medical schools and medical experts, just as its spiritual truth has
been disdained by religious leaders, until it has grown to such
strength that laymen are almost forced to question the sincerity and
the efficacy of the conventional in religion as well as medicine. In
May, 1907, the Emmanuel Church in Boston organized a clinic for the
purpose of utilizing for neurasthenics particularly both the spiritual
and the physical truths underlying religion and the various branches of
medical science. Daily papers and magazines are giving a great deal of
space to this experiment in "psychotherapy," which is discussed in the
chapter on Mental Hygiene. Schools and chairs in preventive hygiene
would soon give to the medical profession a point of view that would
welcome every new truth, such as the alliance of religion and medicine,
and estimate its full worth promptly. Truth seeking would be not only
encouraged but made a condition of professional standing.
Just what attitude any particular physician takes can be learned by the
teacher or parents whose children he treats. If he pooh-poohs or
resents board of health regulations as to isolation of scarlet-fever
patients, he is a dangerous man, no matter how noble his personal
character. If he says cross-eyes will straighten, weak eyes will
strengthen, or nose-stopping adenoids "absorb," he is bound to do harm.
If he says tuberculosis is incurable, noncommunicable, hereditary, or
curable by drugs, or if he tries to cure cancer by osteopathy, he can
do more injury than an insane criminal. If he fails to teach a mother
how to bathe, feed, and clothe the baby, how to ventilate a room for
the sick or the well, he is an expensive luxury for family or for
school, and belongs to an age that knew neither school nor preventive
hygiene. If he takes no interest in health administration; if he
overlooks unclean milk or unclean streets, open sewers, and unsanitary
school buildings, street cars, churches, and theaters; if he does not
help the health board, the public hospitals, the schools, the factory,
and tenement departments enforce sanitary laws, he is derelict as a
citizen and as a member of an "exalted profession." If he sees only
the patients he himself treats or one particular malady, he is derelict
as a teacher, no matter how charming his personality or how skilled in
his specialty. If a school physician is slovenly in his work, if he
spends fifteen minutes when he is paid for an hour, should the
efficient school-teacher conceal the fact from her superiors because he
is a physician? If private hospitals misrepresent facts or compromise
with political evils for the sake of a gift of public money, their
offense is more heinous because of their exalted purpose. The test of a
physician's worth to his patients and to his community is not what he
is or what he has learned, and not what his profession might be, but
what happens to patient and to community. Human welfare demands that
the medical profession be judged by what it does, not by what it might
do if it made the best possible use of its knowledge or its
opportunity.
[Illustration: TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS
FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN
Caroline Rest Educational Fund was given to show the value of
such teaching]
A dispensary that treats more patients than it can care for properly is
no better than a street-car company that chronically provides too few
seats and too many straps. Unless physicians test themselves and their
profession by results, we shall be compelled to "municipalize the
medical man." Preventable sickness costs too much, causes too much
wretchedness, and hampers too many modern educational and industrial
activities to be neglected. If the medical profession does not fit
itself to serve general interests, then cities, counties, and states
will take to themselves the cure as well as the prevention of
communicable and other preventable sickness. Human life and public
health are more precious than the medical profession, more important
even than theories and traditions against public interference in
private matters. The unreasoning opposition of medical men to
government protection of health, their concentration on cure, and their
tardy emphasis on prevention have forced many communities to stumble
into the evil practices mentioned in Chapter XVI. Incidentally, the
best physicians have learned that the prosperity of their profession
increases with every increase in the general standard of living. It is
the man in the ten-room house not the man in one room who supports
physicians in luxury. It is the healthy man and the healthy community
that value efficient medical service.
Many American cities maintain dispensaries and hospitals for the poor.
Whether they will go to the logical conclusion of engaging physicians
to give free treatment to all regardless of income depends largely upon
what the next generation of private physicians do. The state already
says when a physician's training fits him to practice. It will soon
expect him to pass rigid examinations in the social and economic
aspects of his profession,--its educational opportunity, vital
statistics, sick and death rates. Will it need to municipalize him in
order to protect itself?
Obviously the teacher or parent should not begin cooperation with
physicians by lecturing them or by assuming that they are selfish and
unwilling to teach. The best first step is to ask questions that they
should be able to answer:
What causes cholera morbus or summer complaint? When does milk
harm the baby? How can unclean milk be made safe? Whose fault is
it that the milk is sold unclean and too warm? What agencies help
sick babies? What is the health board doing to teach mothers?
Or, if a school physician, the teacher can ask:
Why not remove these adenoids? What causes them? When will they
disappear by absorption? What harm can they do in the meantime?
How long would an operation take? Would it hurt very much? What
would be the immediate effects? Why not act at once? What
provisions are there in town for such operations? Why have the
physicians paid so little attention to breathing troubles? What
could your state do to interest physicians in school hygiene? Will
the school physician talk to a mothers' meeting? What agencies
will give outings to sick children? What dispensaries are
accessible? Who is the proper person to organize a public health
league?
Physicians love to teach. If teachers and parents will love to learn
and will ask the right questions, all physicians can be converted into
hygiene missionaries, heralds of a statesmanship that guarantees health
rights to all.
LICENSING THE PRACTITIONER
Three parties are interested in setting a high standard for physicians,
dentists, druggists, nurses, and veterinary surgeons--the profession
itself, the schools that educate, and the general public on whom the
arts are practiced. The schools and the practitioners are, for the most
part, primarily interested in protecting a monopoly of skill. Their
interest in restrictive legislation is analogous to that of the labor
union which limits the number of apprentices. This trade unionism among
professional colleges and professional graduates of these colleges has
gradually developed a higher and higher standard that results in
greater protection to the public. The first step is generally to demand
that all persons entering a profession after a given date shall prove
to the state their ability to "practice" without injury to clients. It
is almost impossible to get such laws through unless the original law
exempts all persons by whatever name, who are practicing the art in
question at the time the law is passed. Whether we are speaking of
medicine, law, dentistry, accountancy, osteopathy, or barbering, this
has been the history of compulsory restriction and of state
examinations.
As with regard to most other legislation, the enforcement of the law
lags behind its definition. Moreover nothing is done after a man has
passed a certain examination to see that he remains fit and safe to
treat the public. Because no supervision is provided except on the day
of examination, it is possible for men and women to fill their brains
for a week or two weeks with the information necessary to pass what
coaches and tutors have learned will, in all probability, be asked.
Forever after, the public is left to protect itself. Out of this
condition have arisen the evil, unethical, and unprofessional practices
represented particularly by painless dentists, by ignorant or dishonest
physicians, and by osteopaths and careless nurses.
The machinery for preventing these evils is discussed in Chapter XXIX.
Suffice it here to present to parents and teachers the need for
examination in advance of certification that will show whether or not
those who make a livelihood by caring for others' health are equipped
to mitigate rather than aggravate evils, and for further tests by which
the public can learn from time to time which, among those professional
men who are protected by the public against competition, continue to be
safe. Finally, if, as will be clearly seen, it is desirable that what
we call professional ethics persist and that self-advertisement be
discouraged, society must, for its own protection, adopt some other
means than epithets to correct the evils of self-advertisement and
quackery. Even though we admit the responsibility of each citizen when
he goes to the house of a private practitioner who has made no other
effort to lure him thither than to place a card in the window, it must
be seen that we cannot hold responsible for their choice men and women
who receive through newspapers, magazines, or circulars convincing
notices that Dr. So-and-So or the Integrity Company or the Peerless
Dental Parlor will place at their disposal, at prices within their
reach, skill and devotion absolutely beyond their reach at the office
of an efficient private practitioner. Some way must be found by which
departments of health will currently impose tests of methods and
results upon physicians, opticians, pharmacists, manufacturers of
medicine, and dentists.
As laymen become more intelligent regarding their own bodies and
healthy living, it grows harder and harder for quacks and incompetents
to mislead and exploit them. Better than any possible outside safeguard
is hygienic living. Fortunately, we can all learn the simple tests of
environment and of living necessary to the selection of physicians,
dentists, and opticians, or other "architects of health" whose
efficiency and integrity are beyond question.
PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
CHAPTER XXVII
DEPARTMENTS OF SCHOOL HYGIENE
The term "school hygiene" generally suggests no other school than the
public school. State laws say nothing about compulsory hygiene in
military academies, ladies' seminaries, or other preparatory and
finishing schools. Yet when one thinks of it, one must conclude that
the right to health and to healthful school environment cannot
equitably be confined to the children whose tuition is given at public
expense. There is a better way to check "swollen" fortunes than by
ruining the health of "fortune's children." The waste and danger of
slow-minded, noticeably inefficient children are no less when parents
are rich than when parents are poor. There is no justification for
neglecting the health of children in parochial schools, in private
schools for the well-to-do or rich, or in commercial schools for the
ambitious youth of lower income strata. Nor has the commercial,
parochial, private school, or college, any clearer right than the
public school to injure or to fail to promote pupils' health. So far as
school hygiene is advisable, so far as it is right to make hygiene
compulsory, its personal and social benefits should be shared by
children of school age without regard to income, and its laws should be
enforced by all teachers, principals, and officers that have to do
with school. In presenting a programme for school hygiene this chapter
refers to the hygiene taught, the hygiene practiced, the hygiene not
taught, and the hygiene not practiced in buildings and on grounds where
children and youth are at school, whether these children are in
kindergarten or high school, in reformatory or military academy, in
charitable school, or in finishing and preparing center for society's
juniors.
The question of the local, state, and national machinery by which
proper standards of school hygiene shall be made effective will be
taken up after we have considered individual steps in a comprehensive
programme for school hygiene.
1. _Thorough physical examination of all candidates for teachers'
positions and periodic reëxamination of accepted teachers._
Teachers would be grateful to be told in time their own physical needs
and the relations of their vitality to the vitality of their pupils.
Are your teachers examined? Do they know the laws of health and the
signs of child health? Are they permitted to continue in schoolrooms
after tuberculosis is discovered? Are normal graduates given physical
tests before being permitted to teach and before being permitted to
give four years to preparation for teaching?
2. _Thorough physical examination of every single child in every single
school upon entering and periodically during school life._
We believe a vast number of things that "ain't so" about the health of
country children as compared with city children, of private-school
children as compared with public-school children. Where do we find more
degenerate men, physically and morally, than in so-called "American
settlements," where, for generations, children have had all outdoors to
play in, except when in homes and schoolhouses that are seldom cleansed
and seldom ventilated? Open mouths and closed minds clog the "little
red schoolhouse"; there headaches do not suggest eye strain; there
deafness and running ears are frankly attributed to scarlet fever which
everybody must have with all the other "catching" diseases, the earlier
the better; there colds begin in December and run until March, to the
serious injury of attendance and promotion records; there bone
tuberculosis is called "knee trouble" or "spine trouble in the family";
there boys like my little friend Fred count the bottles of cod-liver
oil they take to cure adenoids that could be removed in two minutes.
The index to community life and community living conditions should be
read in the country, not only for the country's sake, but also for the
sake of the city whose milk and water, poisoned in the country, cause
thousands of deaths annually, besides annual sick bills exceeding many
times over the Russell Sage and Carnegie Foundations, which we rightly
call munificent. Reading the index of private schools and colleges is
important for their children and youth, but still more important for
the community upon which unbridled passion, inability to work or to
spend properly, inconsequential thinking, mediæval ideals of caste,
etc., can inflict greater injuries than can typhoid fever or cholera.
The physical record of each child should be kept from date of entrance
to date of leaving school, showing condition at successive
examinations, absence because of illness, etc.
3. _Thorough physical examination of children when leaving school, or
when passing compulsory school age, as a condition to "working papers"
and to "coming out."_
To give working papers to children seriously handicapped by physical
defects is to buy future industrial trouble, hospital and poorhouse
bills. A boy with adenoids, a girl with eye trouble, should not be
permitted to begin the fight for self-support without at least being
clearly shown that the correction of these defects will increase their
earning power. At present a schoolgirl with incipient tuberculosis, or
predisposed to that disease, can get working papers, go to a hammock or
tobacco factory, work long hours, breathe bushels of dust, deplete her
vitality, spread tuberculosis among her co-workers and home associates,
infect a tenement,--and all this without any help or advice or any
protection from society until she is too sick to work and her physician
notifies the health department that she is a danger center. We may
disagree about society's right to control a child's act after the
defects are discovered, but who will question society's duty to tell
that child and her parents the truth about her physical needs before it
accepts her labor or permits her to "enter society"?
4. _Supervision by physicians of hygiene practiced in schoolrooms and
on playgrounds._
Superintendent Maxwell, of New York City, and other educational leaders
urge teachers to do their utmost to learn the physical conditions and
home environment of the individual child, and to fit school treatment
to the individual possibilities and handicaps. But experience proves
conclusively that try as they will, teachers and principals have
neither the special knowledge nor the time to acquire the special
knowledge requisite to use the facts disclosed by the physical
examination of school children. Physicians and nurses are needed, not
so much for treating children, as for teaching children, parents,
teachers, family and dispensary physicians.
Private schools have visiting physicians who may be consulted; they
need physicians to supervise, with power to examine or to require
certificates of examination. The Committee on the Physical Welfare of
School Children found that when a visitor was detailed for that purpose
it was easy to secure the coöperation of parents, teachers, family
physicians, dispensaries, school boards, and charitable societies. The
Hawthorne Club's school secretary has been similarly successful in
Boston, as have those of Hartley House, Greenwich House, and the Public
Education Association in New York.
5. _Restriction of study hours at school and at home to limits
compatible with health._
Whether the hours of study at school and at home are excessive cannot
be learned from treatises on pedagogics or physiology. Because children
differ in vitality as in ability to learn, the maximum limit for study
hours should be determined by the individual child's physical
condition. When the Japanese went to war with Russia the highest
authority in the field was the army surgeon. To this fact was largely
due the astonishingly small amount of sickness and the high fighting
capacity and endurance of the Japanese, working under unfavorable
conditions. No board of school superintendents or board of directors,
no state superintendent of schools or college professor, has the right
to compel or to allow study hours beyond the maximum compatible with
the individual student's physical condition and endurance. The
physician responsible for school hygiene should have an absolute veto
upon any educational policy, method, or environment demonstrably
detrimental to children's vitality.
6. _Establishment of a "follow-up" plan to insure action by parents to
correct physical defects and to attend to physical needs._
The advantages of _getting things done_ over _doing things_ have been
repeatedly emphasized. In smaller cities and in rural districts it is
particularly important for schools to get things done better by
existing local agencies, such as churches, health and street-cleaning
departments, hospitals, clinics, medical and sanitary societies, trade
unions, young people's societies, and women's clubs. Where parents who
have been followed up and taught, obstinately or ignorantly refuse to
attend to their children's needs, the segregation of the physically
defective or needy will encourage the coöperation of children
themselves in persuading parents to act intelligently for the child's
sake. No child wants to remain "queer" or "dopey" or behind his peers.
The city superintendent of schools for New York City has asked for laws
compelling parents to permit operations and punishing them for
neglecting to take steps, within their power, to remove physical
defects discovered at school.
[Illustration: TEACHING A MOTHER TO CARE FOR ONE CHILD INSURES
BETTER CARE FOR ALL HER CHILDREN]
7. _Physiological age should influence school classification and school
curriculum._ On this subject the studies of Dr. C. Ward Crampton,
referred to in the chapter on Vitality Tests, are invaluable and as
convincing as they are revolutionary. Scientists accept his proof that
our present high school curriculum is ill adapted to a large proportion
of children; the "physiologically too young" drop out; only the
physiologically mature succeed. The two physiological ages should be
given different work. Children whose bodies yearn for pictures,
muscular and sense expression, should be given a chance in school for
normal development. Analysis should wait for action. Organized play and
physical training antedated physical examination in our schools. Like
the curriculum they often disregard physiological age, doing harm
instead of good. Facts as to physical condition and physiological
development would enable us to utilize the momentum of these two to
broaden school hygiene and to insure proper physical supervision. Only
good would result from adopting Leipsic's plan of having school
children examined without clothing, in the presence of parents if
parents desire. Expensive? Not so expensive as high school "mortality"
due to maladjusted curriculums that force the great majority of boys
and girls to drop out before graduation and ruin the health of a large
fraction of those who remain.
8. _Construction of school building and of curriculum so that, when
properly conducted, they shall neither produce nor aggravate physical
defects._
When the state for its own protection compels a child to go to school,
it pledges itself not to injure itself by injuring the child. Thousands
of children are now being subjected to conditions in school far more
injurious than the factory and shop conditions against which the
national and state child labor committees have aroused universal
indignation. Two illuminating studies of school buildings in New York
City were made last year by the Committee on the Physical Welfare of
School Children, and later by the Board of Education. Similar studies
should be made of every schoolroom. Whereas our discussions of
buildings and curriculum have hitherto proceeded largely from abstract
principles of light, ventilation, heating, and pedagogics, these two
reports deal with rooms, equipment, courses of study, and school habits
as they are, with obvious detrimental effects on child victims.
Numerous questions that it is practicable to answer are given in
Chapter XIV.
What and when to build can be better determined after we have learned
the what and the where of present equipment.
In passing it is worth while to note that in large cities teachers are
frequently forced to choose between bad ventilation and street noises.
From Boston comes the suggestion that we avoid noises and evils of
congestion by building schoolhouses for city children on the outskirts
in the midst of fields, transporting, and, if necessary, feeding
children at public expense. While it is true that the public funds now
spent in attempting to cure physical and moral ills would purchase
ample country reservations, the practical next step seems to be to
provide ample play space and breathing space within the city for every
school building already erected, and without fail for all buildings to
be erected hereafter.
9. _Hygiene should be so taught that children will cultivate habits of
health and see clearly the relation of health and vitality to present
happiness and future efficiency._ Social rather than personal, public
rather than private, health needs emphasis. Children can be shown how
their health affects their neighbor; why money spent for health boards
is a better investment than money given to corrupt politicians; that
the cost of accepting Thanksgiving turkey or a park picnic from a
political leader who encourages inefficient government is sickness,
misery, deficient schooling, lifelong handicap; that children and
adults have health rights in school and factory, on street and
playground, which the law will protect if only they know when these
rights are infringed.
10. _Central supervision of school hygiene._ In private and public,
boarding and day, country and city, reformatory and military,
commercial and high schools, the index--physical welfare of school
children--should be read and interpreted. Headquarters should learn
whether or not physical examinations are made and whether harmful
conditions are corrected. So far as public schools are concerned,
"headquarters" means for cities the fact center that informs city
superintendent or school board; for rural schools, it means the county
superintendent's office. Whether city or county headquarters have the
facts and act accordingly should be known by state superintendents.
Whether state superintendents are demanding the facts and educating the
county and city headquarters of their states should be known to the
national commissioner of education and by him published for all the
world. Some people think the state health board should be responsible,
others the state educational authority. The important thing is to make
some one officer responsible. Methods can be easily worked out if the
need is conceded. Legislatures will gladly confer the powers necessary
to reading the index of all public schools.
As for parochial and private schools, they may resent for a time public
supervision of their hygiene teaching and practice. However, the case
could be so presented that they would ask for it, because it would help
not only their pupils and society but the schools themselves. No
religious belief or private investment can afford to admit that it
disregards child health; state supervision would require nothing more
than evidence of adequate school hygiene.
11. _Information gained at school regarding conditions prejudicial to
community health should be published and made the basis of an
aggressive campaign for the enforcement of sanitary laws._ Ten thousand
uses can be made of the information gained at school, ten thousand
forces can be made to do educational work, but only a few kinds of work
can be done effectively at school. Franklin Ford has said: "You can
relate school to all life, but you cannot bring all life under the
school roof." As Chapters XVI-XVIII make clear, to socialize the point
of view of dispensaries and hospitals is more effective than to put
clinics in school buildings. To _do for_ or _give to_ people who can
help themselves is to _give up_ and _do up_ power of self-help.
Machinery that must some day exist for the execution of this programme
will be approximately the following:
I. NATIONAL MACHINERY
1. Clearing house for facts regarding school hygiene as taught and
practiced in all schools under the Stars and Stripes; this to be a
part of the National Bureau of Education.
2. Scientific research to be conducted by the National Bureau of
Education or by the future National Board of Health.
II. STATE MACHINERY
1. Clearing house for facts regarding school hygiene taught and
practiced in all schools within state limits; this to be
maintained by the state educational authorities.
2. Agents to make special inquiries as to practice and teaching of
school hygiene.
3. Agents to inspect and to instruct county superintendents,
county physicians, teachers, normal schools, etc.
4. A bureau of experts--architect, sanitarian, teacher--whose
approval must be obtained before any school building can be
erected. (A plan which brought excellent results when applied by
state boards to charitable institutions, hospitals for the insane,
etc.)
5. Standard making by normal schools, state universities,
hospitals, or other educational and correctional institutes under
direct state management.
III. COUNTY MACHINERY
1. Clearing house for facts regarding school hygiene taught and
practiced in all schools within county limits; this to be
maintained by the county superintendent of schools.
2. Physician and nurse to organize inspection and instruction for
rural schools, to give lessons and make demonstrations at county
institutes, to show teachers how to interest physicians, dentists,
health officers, and parents in the physical welfare of school
children.
IV. TOWN AND TOWNSHIP MACHINERY
1. Teachers intelligent as to physical needs, as to sanitation of
buildings, etc.
2. An examining physician, to be salaried where the population
justifies; elsewhere to work as a volunteer in coöperation with
teacher and with county physician.
3. Physical history of each child from date of entrance to date of
leaving school, to be kept up to date by teacher.
V. CITY MACHINERY
1. A division to be known as the Department of School Hygiene,
headed by an officer who gives his entire time to that department.
2. A subcommittee of the Board of Education.
3. Clearing house for facts regarding school hygiene taught and
practiced in all schools within city limits.
4. Specialists to examine applicants for teaching positions, and
to reëxamine teachers to determine fitness for continuance, for
promotion, and for special assignments.
5. A bureau for inspection and control of all hygiene of school
buildings, old and new, with power to compel repairs or to reject
plans that do not make adequate sanitary provision.
6. Similar supervision of curriculum and of study hours
prescribed.
7. A bureau for the inspection and control of curriculum, required
home study, exercise, physical training, etc., so far as relates
to the health of pupils, and to the physical ability of children
to be in certain grades or to be promoted. This will decide the
duration of lessons, frequency of intermissions, sequence of
subjects, time and method of recess throughout the various grades.
8. Supervision of indoor and outdoor playgrounds, roof gardens,
indoor and outdoor gymnasiums, swimming pools, etc.
9. Supervision of instruction in school hygiene.
10. A staff of inspectors for communicable diseases of pupils and
teachers, to be subject to the board of education or the board of
health.
11. A staff of examiners adequate to examine all children and
teachers at least once a year for defects of eye, ear, teeth,
nose, throat, lungs, spine, bones, glands, etc., and for weight
and height to be under the control of the board of education or
the board of health. The expense would not be as great as the
penalty paid for omitting such examination.
12. A staff of nurses to assist medical examiners to give children
practical demonstrations in cleanliness, to teach mothers the care
of children both at their homes and in mothers' meetings, to
enlist the coöperation of family physician and neighborhood
facilities, such as hospitals, dispensaries and relief agencies,
magistrates' courts and probation officers,--all to be under the
control of the board of education or the board of health.
Whether inspectors, examiners, and nurses shall be directed by the
board of education or the board of health is a question that it is
impossible to decide without knowledge of local conditions. So far as
state and county organizations are concerned, it is clear that whatever
the boards of health may do, it will be necessary for state and county
superintendents of education to equip themselves with the machinery
above recommended. In cities it is quite clear that a board of
education should be responsible for all of the machinery suggested,
excepting the three divisions that have to do with work hitherto
considered as protection against transmissible diseases, namely,
inspection, examination, district visiting. In Cleveland these are
school duties. In New York they are duties of the health department.
Boston has school nurses and health department physicians. The state
law of Massachusetts provides that where health boards do not examine
school children, school boards may spend money for the purpose.
As to inspection for transmissible diseases, it seems quite clear that
health boards should not delegate their authority or responsibility to
any other body, for they alone are accountable to their communities for
protection against contagion. It is clear, too, that in the interest of
community health, departments of health are justified in pointing out
in advance of contagion those children most likely to become a menace.
Similar grounds of public interest justify the health boards in sending
nurses and physicians to the home as a means of getting things done.
Dr. Biggs feels that responsibility for the physical welfare of school
children will strengthen health work in all cities, and, given proper
interest on the part of school officials, should make possible
universal coöperation in a constructive programme. On the other hand,
he believes that division of responsibility between school and health
boards will weaken both in their appeals for funds and for support of a
constructive programme. I have heard principals and superintendents
maintain also that the moral effect of a visit to the school by a
representative of the health board vested with powers of that board was
much greater than a visit by a representative of the school board. They
further allege that a physician coming from the outside is more apt to
see things that need correction and less apt to accept excuses than an
inspector who feels that he belongs to the same working group as the
school-teacher. Because the follow-up work in the homes incident to
successful use of knowledge gained at school involves so many sanitary
remedies, it is theoretically better organization to hold the health
authority responsible.
CHAPTER XXVIII
PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY
Many of the elements of the machinery outlined in the preceding chapter
already exist in New York City. All of them brought together, either by
amalgamation or by proper coördination, would present a very strong
front. Unfortunately, however, there is not only unsatisfactory team
work, but the efficiency of individual parts is seriously questioned by
the heads of the health and school departments.
The inspection for contagious diseases, the examination for physical
defects, the follow-up work by nurses and physicians, are in charge of
the department of health. Physical training and athletics for
elementary and high schools, winter recreation centers, and vacation
playgrounds are under directors and assistants employed by the board of
education. Heretofore inadequate powers and inadequate assistance for
training or for research have been given to the physical director.
The city superintendent of schools, in his report for the year 1907,
presented to the board of education in January, 1908, declares that the
"present arrangements have been inadequate.... In only 248
schools--less than half the total number--were any examinations for
possible diseases made. In these 248 schools not more than one third of
the pupils were examined. It is only a few months since any
examinations for physical defects were made outside of the boroughs of
Manhattan and The Bronx, and then only on account of the New York
Committee on the Physical Welfare of School Children."
As is so often the case, it is difficult to decide the merits of a
method that has not been efficiently executed. The department of health
has not hitherto done its best in its school relations. The
commissioner of health, in a public interview, expresses resentment at
the strictures by the school authorities. Yet in 1907 he permitted to
accumulate an unexpended balance of $33,000 specifically voted for
school inspectors, and repeatedly tried to have this amount transferred
to other purposes. The interest of the Bureau of Municipal Research in
municipal budgets that tell for what purposes money is voted and then
prevent transfers without full publicity, preserved this particular
fund. Moreover, the discussion that prevented its diversion from
physical examinations strengthened the health department's interest in
this important responsibility. Neither physicians nor nurses have been
adequately supervised. Instead of seeing that defects were removed, the
department of health sent out postal cards like the following:
[Illustration: (Notice Example)]
+-----------------------------------------------------------------------+
| "This Notice Does NOT Exclude This Child From School" |
| |
| DEPARTMENT OF HEALTH |
| THE CITY OF NEW YORK |
| |
| _Oct. 2, 190_6_ |
| |
| The parent or guardian of ___________________________________________ |
| of____________________________________attending P.S.__51___________ |
| is hereby informed that a physical examination of this child seems to |
| show an abnormal condition of the ___________________________________ |
| ___Eyes, Nose, Throat and Teeth______________________________________ |
| _____________________________________________________________________ |
| Remarks__Is Anaemic__________________________________________________ |
| _____________________________________________________________________ |
| |
| Take this child to your family physician for treatment and advice. |
| Take this card with you to the family physician. |
| |
| THOMAS DARLINGTON, M.D., |
| Commissioner of Health. |
| |
| HERMANN M. BIGGS, M.D., |
| General Medical Officer |
+-----------------------------------------------------------------------+
From 118,000 such notices sent out only 9600 replies were received, of
which only one in twenty stated that attention had actually been given
the needy child. The department had been satisfied with evidence that
family physicians had advised parents properly, as in the case of the
child above reported:
[Illustration: (Card example)]
+----------------------------------------------------------------------+
| TAKE THIS CARD TO YOUR PHYSICIAN |
| |
| The Physician in charge is requested to fill out and |
| forward this postal after he has examined this child. |
| |
| I have this day examined ___________________________________________ |
| of P.S. __51______________ and find the following condition: |
| |
| __As reported, Also enlarged (unclear) glands_______________________ |
| and advised as follows:__operation for adenoids and tonsils_________ |
| _____Dental treatment at Cornell. Fresh air ________________________ |
| _____outing at Sea Breeze Eyes wait.________________________________ |
| |
| Respectfully yours, |
| _______P.L. OB___________ |
| Date __Oct. 9, 1906______ _________________________ |
| |
+----------------------------------------------------------------------+