Consumption Is chiefly caused by the Filthy Habit of SPITTING TAKE THIS CARD HOME And show it to your family, friends, and neighbors Consumption is a disease of the lungs, which is taken from others, and is not simply caused by colds, although a cold may make it easier to take the disease. The matter coughed up and sneezed out by consumptives is full of living germs or "tubercle bacilli" too small to be seen. These germs are the cause of consumption, and when they are breathed into the lungs they set up the disease. DON'T GET CONSUMPTION YOURSELF Keep as well as possible, for the healthier your body, the harder for the germs of consumption to gain a foothold. Every person should observe the following rules: DON'T live, study, or sleep in rooms where there is no fresh air. Fresh air and sunlight kill the consumption germs and other germs causing other diseases; therefore have as much of both in your room as possible. DON'T live in dusty air; keep rooms clean; get rid of dust by cleaning with damp cloths and mops. DON'T sweep with a dry broom. KEEP one window partly open in your bedroom at night, and air the room two or three times a day. DON'T eat with soiled hands. Wash them first. DON'T put hands or pencils in the mouth, or any candy or chewing gum other persons have used. DON'T keep soiled handkerchiefs in your pockets. TAKE a warm bath at least once a week. DON'T neglect a cold or a cough, but go to a doctor or dispensary.



- HOW TO GET WELL IF YOU HAVE CONSUMPTION If you or any one in your family have consumption, you must obey the following rules if you wish to get well: DON'T waste your money on patent medicines or advertised cures for consumption, but go to a doctor or dispensary (see last page). If you go in time, you can be cured; if you wait, it may be too late. DON'T drink whisky or other forms of liquor. 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 out in the fresh air and in the sunlight as much as possible. KEEP your windows open winter and summer, day and night. IF properly wrapped up you will not catch cold. GO to a sanatorium while you can and before it is too late. The careful and clean consumptive is not dangerous to those with whom he lives and works. Don't give consumption to others. Many grown people and children have consumption without knowing it, and can give it to others. Therefore every person, even if healthy, should observe the following rules: DON'T SPIT on the sidewalks, playgrounds, or on the floors or hallways of your home or school. It spreads disease, and is dangerous, indecent, and unlawful. WHEN YOU MUST SPIT, spit in the gutters or into a spittoon half filled with water. DON'T COUGH OR SNEEZE without holding a handkerchief or your hand over your mouth or nose. - $/

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

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

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

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

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

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

Would it help to punish employees for working in unhealthy places? The highest service that can be rendered industrial hygiene is to educate the industrial classes to recognize hygienic evils and to cooeperate 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 cooeperation of lay citizens rather than upon medical science or isolated individual effort. Without learning another fact about tuberculosis, we can stamp it out if we will but apply, and see that officers of health apply, lessons of cleanliness and natural living already known to us.



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





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.



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.



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.



- 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.



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.





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.



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.



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.



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?



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.



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.



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 cooeperation 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.





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. 1/4 in quart bottles 3/4 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 deg. F. or lower at dairy 45 deg. F. at creamery 45 deg. F. or less during transportation Not above 50 deg. 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 deg. for 30 minutes to 167 deg. for 20 minutes Cost per quart, estimated, 1/4 to 1/2 ct. Commercial, 165 deg. 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 cooeperate 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.



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.



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.





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.





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.



"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 anaemia 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.



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 Leannec 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.



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.