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

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

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



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

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

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

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

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

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



CHAPTER XVII

AMERICAN REMEDIES: GETTING THINGS DONE

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

1. Study of the physical welfare of school children.

a. Examination of board of health records of children needing medical, dental, or ocular care, and better nourishment.

b. Home visitation of such children, in order to ascertain whether their need arises from deficient income or from other causes.

c. Effort to secure proper treatment, either from parents or from free clinics or other established agencies.

d. Effort to secure proper physical surroundings of children while at school—playgrounds, baths, etc.

2. Effort to secure establishment of such a system of school records and reports as will disclose automatically significant school facts,—e.g. regarding backward pupils, truancy, regularity of attendance, registered children not attending, sickness, physical defects, etc.

3. Effort to utilize available information regarding school needs so as to stimulate public interest and thus aid in securing adequate appropriations to meet school needs.

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

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

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

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

1. Physical defects found in public schools are, for the most part, such as frequently occur in wealthy families and do not of themselves presume as the cause insufficient income. Of 145 reported for malnutrition, 44 were from families having over $20 weekly.

2. Few of the defects can be corrected by nourishment alone; plenty of fresh air, outside nourishment at school, or extra nourishment at home will not entirely counteract the influences of bad ventilation and bad light in school buildings. Country children have adenoids, bad teeth, and malnutrition. Plenty of food will not prevent bad teeth and bad ventilation from causing adenoids, enlarged tonsils, and malnutrition.

3. Children whose parents have long lived in the United States need attention quite as much as the recent immigrant.

4. A large part of the defects reported could be produced by conditions due directly to neglect of teeth.

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

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

2. Physical deterioration, applied to America's school children, is a misnomer. No evidence whatever has been given that the percentage of children suffering from physical defects in 1907 is greater than the percentage of children suffering from such defects in 1857. On the contrary, the small proportion of defects that are not easily removable, as well as a vast amount of evidence from medical experience and vital statistics, indicates that, if a comparison were possible, the children of 1907 would be found to have sounder bodies and fewer defects than their predecessors of fifty years ago. If there is an exception to this statement, it is probably defects of vision, with regard to which school authorities and oculists seem to agree that confinement in school for longer hours and more constant application under unfavorable lighting conditions have caused a marked increase. Positive evidence as to tendencies will be easily obtained after thorough physical examination has been carried on for a generation.

3. The effect of massing facts as to physical defects of school children should not be to cause alarm, but to stimulate remedial and preventive measures, to invoke congratulations and aggressive optimism, not doleful pessimism and palliative measures born of despair.

4. The causes of physical defects are not confined to "marginal" incomes, but, while more apt to be present in families having small incomes, are found among all incomes wherever there exist bad ventilation, insufficient outdoor exercise, improper light, irregular eating, overeating, improper as well as insufficient food, lack of medical, dental, and ocular attention.

5. Whatever may be said of free meals at school as a means of insuring punctual attendance or better attention, they are inadequate to correct physical conditions that home and street environment produce.

6. To remove physical defects, causal conditions among all income classes should be treated, and not merely symptoms revealed at school by children of the so-called poor.

7. Parents can and will correct the greater part of the defects discovered by the physical examination of school children, if shown what steps to take. Where parents refuse to do what can be proved to be within their power, and where existing laws are nonenforced or inadequate, the segregation of children having physical defects in special classes might prove an effective stimulus to obstinate parents.

8. Where parents are unable to pay for medical, dental, and ocular care and proper nourishment, private philanthropy must either provide adequately or expect the state to step in and assume the duty.

9. Private dispensaries and hospitals must either arrange themselves to treat cases and to educate communities as to the importance of detecting and correcting physical defects, or must expect the state to provide hospital and dispensary care. Until private hospitals and dispensaries take steps to prevent people with adequate incomes from imposing upon them for free treatment, it is difficult to make out a case against free eyeglasses and free meals for school children.

10. Either private philanthropy or the state must take steps to procure more dental clinics and an educational policy on the part of the dental profession that will prevent the exploitation of the poor when dental care is needed.

11. The United States Bureau of Education is the only agency with authority and equipment adequate to secure from all sections of the country proper attention to the subject. Nothing in the world can prevent free meals, free eyeglasses, free medical care, free material relief at school, unless educational use is made by each community of the facts learned through physical examination to correct home, school, and street conditions that produce and aggravate physical defects. The national bureau can mass information in such a way as to convince budget makers in city, county, and state to vote gladly the funds necessary to promote the physical welfare of school children.



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



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

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



CHAPTER XVIII

COOePERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES

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

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



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

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





For School Children Compulsory education implies the ability of all families, even the poorest, to take advantage of school benefits. This means that children should be fed properly, clad comfortably, and healthfully housed. The New York Association for Improving the Condition of the Poor aims to cooeperate with school-teachers in every part of Manhattan and The Bronx to insure comfort and prevent suffering among school children, their parents, and younger brothers and sisters. On one day last winter we received appeals from school principals and teachers in behalf of twenty-nine families. Within six hours every family was visited, emergent aid in food and coal provided for many, and orders given for shoes and dresses and coats required by the children of school age. During the winter we gave not only clothing, groceries, food, and rent, but found work for older boys and parents, taught mothers to prepare food properly, and sent a visiting cleaner to make sick mothers comfortable and to get the children ready for school. In a word, we followed that need, the surface evidence of which comes to the attention of the teacher, back into the home and its conditions, aiding throughout the period when the family was unable to do justice by the school child. In many instances the home income was sufficient, but the home management inefficient. Probably such homes could be more effectively benefited through educational work emanating directly from the school. We can be reached by telephone (348, 349, and 1873 Gramercy) from 9 A.M. to 12 M. Letters or postal cards should be addressed to Mrs. H. Ingram, Superintendent, 105 East 22d Street. Reference slips will be gladly furnished upon application. The New York Association for Improving 1843 * the Condition of the Poor * 1905 Teachers of Manhattan and The Bronx Do you know of such children as these: 1. Convalescent children now out of school, who would be benefited by a stay at the seashore in May or June? 2. Children in school whose anaemic condition would be greatly improved by a week at Sea Breeze during July or August? 3. Small brothers and sisters (and tired mothers) who may need outings or special help? The New York Association for Improving the Condition of the Poor will act promptly. Write or telephone (348 Gramercy).

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

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

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

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

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

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

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

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



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



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



- Work for the Tuberculous 1. Tuberculosis classes 2. Reference to other agencies 3. Examination of children 4. Stimulation of suburbs - Psychiatric Work Work for Hygienic Conditions 1. For neurasthenics and 1. Individual instruction hysterics 2. Convalescent homes 2. For defectives 3. Industrial hygiene 3. For stammerers 4. Home hygiene 4. For epileptics / / / / / / / - - /SOCIAL WORK / M.G.H. / -/ - / / / / / / / / -/ - - References to Other Agencies / 1. Hospitals and sanatoriums / 2. Associated charities / 3. Societies for children / 4. District and visiting nurses / 5. Settlements / 6. Homes temporary or not / / 7. Employment agencies / / - - / -/ - Ward Work Work for 1. With cases soon to Cases of be discharged Varicose Ulcer 2. Cases needing friendly offices -/ - / -/ - Work for Assistance to M.G.H. Sexual Deviates - - Financial investigation Assistance to 1. Unmarried but Other Agencies (a) of Cases asking free pregnant treatment 2. Diseased 1. Steering cases (b) of Cases presumably 3. Exposed 2. Cooeperation able to pay a physician - - -

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

FOOTNOTES:

[10] The importance of recognizing the family as the unit of social treatment is presented in Edward T. Devine's Principles of Relief, and in Homer Folks's Care of Dependent, Defective, and Delinquent Children.



CHAPTER XIX

SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE

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

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

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

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



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



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

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

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

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

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



CHAPTER XX

PHYSICAL EXAMINATION FOR WORKING PAPERS

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

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

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

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

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

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





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

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

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



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

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



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

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

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



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



CHAPTER XXI

PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE

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

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



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

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

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

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





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

FOOTNOTES:

[11] See Dangerous Trades, compiled by Thomas Oliver; also list of reports by the United States Bureau of Labor.



CHAPTER XXII

HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY

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

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

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

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



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



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

1. Throw the bedding over the foot of the bed.

2. Close the window that has been open during the night.

3. Drink a glass of water.

4. Bathe the face, neck, crotch, chest, armpits (finishing if not beginning with cold water), and particularly the eyes, ears, and nose. If time and conveniences permit, bathe all over.

5. Cleanse the finger nails.

6. Cleanse the teeth, especially the places that are out of sight and hard to reach.

7. Breakfast punctually at a regular hour. Eat lightly and only what agrees with you. If you read a morning paper, be interested in news items that have to do with personal and community vitality.

8. Visit the toilet; if impracticable at home, have a regular time at business.

9. Have several minutes in the open air, preferably walking.

10. Be punctual at work.

11. As your right by contract, insist upon a supply of fresh air for your workroom with the same emphasis you use in demanding sufficient heat in zero weather.

12. Eat punctually at noon intermission; enjoy your meal and its after effects.

13. Breathe air out of doors a few minutes, preferably walking.

14. Resume business punctually.

15. Stop work regularly.

16. Take out-of-door exercise—indoor only when fresh air is possible—that you enjoy and that agrees with you.

17. Be regular, temperate, and leisurely in eating the evening meal; eat nothing that disagrees with you.

18. Spend the evening profitably and pleasantly and in ways compatible with the foregoing habits.

19. Retire regularly at a fixed hour, making up for irregularity by an earlier hour next night.

20, 21, 22. Repeat 4, 6, 8.

23. Turn underclothes wrong side out for ventilation.

24. Open windows.

25. Relax mind and body and go to sleep.

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

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

1. Bathing less frequently than once a week is almost as dangerous to health as it is to attractiveness.

2. Distaste for unclean linen or undergarments and for acts or foods that interfere with vitality should become instinctive.

3. Excesses in eating or playing should be automatically corrected the next day and the next. Parties we shall continue to have. It will be some time before reasonable hours and reasonable refreshments will prevail. Meanwhile it is probably better for an individual to sacrifice somewhat his own vitality for the sake of the union, the class, or the church. While trying to improve group habits, one can acquire the habit of not eating three meals in one, of eating less next day, of sleeping longer next night, of being particularly careful to have plenty of outdoor air.

4. Visits to the dentist twice a year at least, and whenever a cavity appears, even if only a week after the dentist has failed to find one; whenever the gums begin to recede; and whenever anything seems to be wrong with the teeth.

5. Periodic physical examination by a physician.

6. Examination by a competent physician whenever any disorder cannot be satisfactorily explained by violation of the daily routine or by interruption of business or domestic routine.

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



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



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



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

FOOTNOTES:

[12] Serviceable guides to personal habits of health are Aristocracy of Health by Mary Foote Henderson, and Efficient Life by Dr. Luther H. Gulick.



CHAPTER XXIII

INDUSTRIAL HYGIENE

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

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

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

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



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

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

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

We are told that employees should assume the management of welfare work.

Should they install sanitary conveniences? Of course not.

Would they know the need of a wash room in a factory if they never had had one? No.

Should they manage lunch rooms? A few employers have attempted unsuccessfully to turn over the management of the lunch rooms to the employees, the result being that one self-sacrificing subofficial in each concern would find the burden entirely on his shoulders before working hours, during working hours, and after working hours. Employees cannot attend committee meetings during working hours, and they are unwilling to do so afterwards, for they generally have outside engagements. Furthermore, the employees know nothing about the restaurant business. If they did, they would probably be engaged in it instead of in their different trades. All experiments along this line of which we have heard have failed. The so-called "democratic idea," purely a fad, never has been successfully operated.

Many employers would introduce welfare work into their establishments were it not for the time and trouble needed for its organization. The employment of a welfare director removes this obstacle. Successful prosecution of welfare work requires concentration of responsibility. All of its branches must be under the supervision of one person, or efforts in different directions may conflict, or special and perhaps pressing needs may escape attention. Pressure of daily business routine usually relegates welfare work to the last consideration, but the average employer is interested in his men and is willing to improve their condition if only their needs are brought to his attention.