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TEXAS STATE LIBRARY
LEG. REF. DIV.

--------------- AUSTIN— « A S —
U. S. D E P A R T M E N T O F L A B O R

CHILDREN'S BUREAU
JULIA C. LATHROP, c t ie f

STANDARDS OF CHILD
WELFARE
A REPORT OF
THE CHILDREN’S BUREAU CONFERENCES
MAY AND JUNE. 1919

CONFERENCE SERIES NO. I
Bureau Publication No. 60

WASHINGTON
1919


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*

CONTENTS
PAGE

LETTER OF TRANSMITTAL........................................................................ ......... 7
GENERAL SUMMARY..................................... William L. Çhenery....................... 11

SECTION I
THE ECONOMIC AND SOCIAL BASIS FOR CHILD WELFARE
STANDARDS ................................ .............. .................... ............ • • ------ 21-77
Social Medicine .......................................... Dr. René S and............................. 23
The Financial Cost of Rearing a C hild.. .William F. Ogburn................. ... 26
The Economic^ of Child W elfare............. Dr. Royal Meeker.......................... 31
Family B u d g ets............................ . ...........Dean S. P. Breckinridge-----. . . . . 34
Cost of Living........... .................................Miss Florence N esbitt.................... 44
The Child’s Home......................................Mrs. Eva Whiting W hite............. 46
The Leisure of the Child.............. ...........L. H. Weir and Miss Abbie Condit 54
Standards for Children’s P lay................. Joseph Lee...................................... 63
Racial Factors .................................. ......... Professor Kelly Miller................. 66
Belgian Children in War Time................. Miss L. E. Carter........................... 71

SECTION II
CHILD LABOR............................................................. ............................... .
Legislative Prohibition of Employment........•. •• • ....................................
General S tan d ard s............... ..................... Owen R. Lovejoy.............
D iscussion.....................................................................................
Minimum Physical Standards................... Dr. Emma MacKay Appel
Defective Vision Among Chicago
Working Children................................ Dr. E. V. L. Brown..........
Dangerous Occupations .............................Dr. D. L. Edsall..........
Discussion ............. .................................................................i ..........
British Educational Standards................. Sir Cyril Jackson.............
D iscussion...........................................................................................
American Educational Standards............. Charles E. Chadsey..........
Discussion ............... .............................................................................
Legislative Regulation of Employment
State C o n tro l................................ . . .
Hours ..................... . . . . . ....................
Wage Principles
............. . . . . : .
Minimum W a g e ................................
Administrative Standards ............
Discussion, ........................................

3


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79-141
81-108
...

81
...85

...86
...91
...93
...96
...98
...102
...105
...108

109-131
Hon. Albert E. H ill...................... .109
Miss Agnes Nestor........................113
Professor F. S. Deibler......... . .116
Dr. Jessica B. Peixotto.................. 118
Miss Tracy Copp........................... 125
......................................... 131

CONTENTS

4

PAGE

Vocational Guidance and Placement..........................................
juvenile Placement in Great B rita in .... .Ronald C. Davison
Discussion ..................................................... ......................‘

132-141
....1 3 2
....1 3 7

SECTION HI
THE HEALTH OF CHILDREN AND MOTHERS
Maternity and Infancy
Standard Requirements for Obstetrical
0
4
................... Dr. J. Whitridge Williams
Discussion .. ^ ...................................... ‘ '“**' ’ ’ ” ’ ' ’ ’ " ’ ‘
The Control of Venereal Infection---------Dr. Philip C. Jeans.
D iscussion.....................
Dr. Charles V. Chapin
The Control of Midwifery
Discussion ................• • • • .................. . ’ ’
Essentials for Public Care of Maternity
Mrs. Eleanor Barton.........
and I n f a n c y ................... .................. *
Discussion ............................ .................
Dr. Radmila Milochevitch
Serbian Experience .......................... .......
Lazarevitch . . . .............
Dr. Henry P. Helmholz...
Urban Problems ...............................
*•
Maternity Centers in New York C ity .. . . Dr. R. W. Lobenstine. . . .
Discussion ..
Rural Problems
Discussion ..

Miss Elizabeth G. Fox,

The'Preschool Child................. ............
Health Centers for Preschool Children. Dr. Merrill E. Champion.
The Public Health N u rse...................... Dr. C.-E. A. Winslow---D iscussion................. .........................
French Experience ........— .................. ,Dr. Clothilde M ulon... . .
,Dr. S. Josephine B ak er..
Day Nursery Standards.................
Discussion ................. ..........................
Major Lewis Terman
Dental Clinics ........• ..............................
D iscussion...........................................
The School Child....................................
Nutrition Clinics ..........................
Discussion ................. ; ....................
Health Examinations and the
School Nurse....................... • • *•
The Nutrition of Adolescence...........
Chart.
Comparative Estimates
Physiological Needs for F ood...
The Need for Sex E ducation.. . . ---
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143-304
145-193
...145
...148
...149
...155
...157
...163
...167
...171
...173
,.176
,...1 7 9
....1 8 5
....1 8 6
....1 8 9
194-237
___194
....1 9 9
....2 0 5
....211

___219
___225
....2 3 4
....2 3 7
238-268

Dr. William R. P. Emerson...........238
____ ....2 4 4
. .Dr. Thomas D. W ood..................... 248
. .Dr. Graham Lusk........................... 256
of
..................... ............Faces page 261
. .Robert D. Leigh.............................262

5

CONTENTS

PAGE

European Experience

269-304

British Organization...................................Sir Arthur Newsholme....
Belgian Organization......... .................. .. .Dr. René Sand............
A Physical Classification of Children........Professor Fabio Frassetto
Plate I . . ........... ................— ............................................... .
Plate I I . . . . . . ................................... ................... ...........................

Plate i n ..................................... ...............................
Plate I V .............. ................................................................... .......... .
The International Red Cross and Child
Welfare ................................................. Livingston Farrand.......... .

,269
289
,292
299
300
301
302
303

SECTION IV
HILDREN m NEED OF SPECIAL CARE___

305-407

The Function of the State............................ ...............................

307-338

The Responsibility of the S tate...............Robert W. Kelso..
State Supervision of Agencies and
Institutions........................................ .C. V. Williams__
D iscussion.................................. t ...........................................
Child Welfare Work in Japan............... . .Takayuki Namaye

....3 0 7

Care of Dependent Children.........................................................
The Conclusions of the White House Con­
ference—Ten Years A fter................. Dr. Hastings H. H art.
Discussion ........................ . . . ...................... ............................
What Constitutes Sufficient Grounds for
the Removal of a Child from His
H om e........... .......................................Judge Victor P. Arnold
D iscussion................. ........................., ...........................................
Standards of Child Placing and Supervi­
sion ....................................................... Edmond J. Butler.........
Discussion ................. ........................................ „................ .
Child Caring Work in Rural Communities. Miss H. Ida Curry........

___313
....3 1 8 •
....3 2 1
339-367
339
344
.345
350
353
360
363

Care of Juvenile Delinquents.............................. .......................... ..............*368-390
Standards of Organization in Children’s
Courts ................................................ .Judge James Hoge R icks......... „ .368
Discussion ..................... ;........ ................................. ............'...................... 373
Standards of Probation Work................... Dr. Louis N. Robinson.................. 376
Discussion *............................................. ............................................
379
Medicopsychological Study of Delin­
quents ............................................. . Dr. William Healy and Augusta
F. Bronner
382
Discussion
388

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CONTENTS
\

PASS

391-407

Care of Mentally Handicapped Children
The Place of Mental Hygiene in the Child
Welfare Movement.............................. Dr. C. Macfie Campbell
A State Program for the Care of the Men­
tally Defective.................................. Dr. Walter E. Fernald
D iscussion.................................. ............

391
399
406

SECTION V
.409-427

STANDARDIZATION OF CHILD WEI

, The Method of Procedure...............
The Minnesota Child Welfare

. . . . Rev. William J. Kerby. . . . . . ....4 1 1
..Judge Franklin Chase Hoyt.___ 413
, C. C. Carstens........................ ....... 416
.. W. W. Hodson.................... ’• ....... 420

Discussion

v

SECTION VI
STANDARDS ..........................................................................................

..........429-444

............431
Com m ittees...................................
¿oq
Minimum Standards for Children Entering Employment...................................
Minimum Standards for the Public Protection of the Health
^

Minimum Standards for the Protection ofChildren in Need of Special Care. .440
.................. .445
I N D E X . . . . . - - ...................................*...............................................


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LETTER OF TRANSMITTAL
U. S. Department of Labor ,
Children ’s Bureau ,
Washington, D. C., Ju n e 15, 1919.

S ir:

H erew ith are subm itted the proceedings of a conference on C hild
W elfare S ta n d a rd s recently held u n d e r the auspices of th e C hildren’s
B ureau as th e conclusion of its C hildren’s Y ear program .
C h ild ren ’s Y ear, as th e second y ea r of th e w ar w as called in this
connection, grew o u t o f the studies m ad e b y th e C hildren’s B ureau of
child w elfare ab ro a d u n d er w ar conditions. It w as seen that, u n d er
circum stances of such difficulty as we happily can n o t conceive, th e civil­
ian p o p u latio n of E urope w ere achieving new laws for th e pro tectio n of
ch ildhood, new ideals for th e future dev elo p m en t of th e race. It w as
felt th a t th e second y ear of the w ar in th e U nited S tates ought to show
a p o p u la r sense of responsibility fo r child w elfare in som e deg ree com ­
m en su rate w ith o u r opportunities. H ence a p ro g ram was sta te d briefly
in th e F ifth A nnual R ep o rt of th e C hildren’s B ureau, which w as
a d o p te d b y th e W o m en ’s C om m ittee of th e C ouncil of N ational D e­
fense and, fo r th e p u rpose of carrying it forw ard, an organization of th e
g reat b o d ies o f w om en associated u n d e r th a t com m ittee w as effected b y
a specially created C hild W elfare D epartm ent, of w hich D r. Jessica B.
P eix o tto w as th e secretary.
W h en th e P resid en t w rote a letter ap p ro v in g C hildren’s Y ear, h e
co n clu d ed w ith th e follow ing statem ent:
“ 1 tru st th a t th e w ork m ay so successfully d evelop as to
set up certain irreducible m inim um stan d ard s fo r th e health,
education, an d w o rk of th e A m erican child.’’’
So th a t this conference was* a natu ral p a rt o f C hildren’s Y ear, a n d
b y m eans of a special allotm ent from th e P resid en t’s fund, an d w ith
y o u r ap p ro v al, it w as held. It w as felt th a t th e presence a t th e co n ­
ference o f guests w ho w ere engaged in th e practical p ro tectio n o f
children u n d e r w ar conditions in th e allied countries w ould b e an in­
v alu ab le stim ulus to this country.
7

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8

LETTER OF TRANSMITTAL

T h e follow ing guests from a b ro a d a tte n d e d th e conference a t your
invitation :
Sir A rth u r Newsholm e, late P rincipal M edical Officer of th e Local
G o v ern m en t B oard, E ngland.
Mrs. E leanor B arton, of th e W om en’s C o o p erativ e G uild, E ngland,
an organization of th e w ives of British w age earners.
M r. R o n ald C. D avison, D irector of th e Juvenile L ab o u r Exchanges
o f E ngland.
Sir C yril Jackson, B o ard of Education, E ngland.
D r. C lothilde M ulon, W ar D epartm ent, France, w ho has d o n e special
w ork in th e supervision of industrial creches during th e war.
Dr. R en é Sand, P rofessor of Social an d Industrial M edicine a t the
U niversity of Brussels, an d A dviser on M edical Inspection of th e M in­
istry of L abor.
Miss L. E. C arter, Principal of H igh School C, Brussels.
M r. Isad o r M aus, D irector o f th e D ivision of C hild P rotection, M inis­
try o f Justice, Belgium.
M r. T ak ay u k i N am aye, D ep artm en t of Interior, Jap a n , in charge of
refo rm ato ry an d relief w ork a n d the protection of children.
D r. R ad m ila M ilochevitch Lazarevitch, from Serbia, a physician an d
lead e r in social service activities.
Dr. F ab io F rassetto, P rofessor of A n th ro p o lo g y a t th e U niversity of
B ologna, Italy.
T h eir com ing to this country to a tte n d th e conference gave signal
p ro o f o f th e new in ternational sense of responsibility fo r child w elfare.
T h e generosity a n d graciousness w ith w hich each individual h as as­
sisted th e conference is gratefully recognized.
T his conference consisted n o t o f a single m eeting, b u t of à series of
regional conferences, eight in num ber, beginning w ith one in W ashing­
ton, M ay 5, 1919. Follow ing th e W ashington conference, m eetings
w ere h eld in N ew Y ork, C leveland, B oston, C hicago, D enver, M inne­
apolis, S an Francisco, a n d S eattle. In addition , certain of th e foreign
guests w ere speakers a t various national associations, such as th e S outh­
ern Sociological C ongress, th e N ational C onference of Social V(/ork,
th e N ational W o m en’s T ra d e U nion League.
Because of th e crow ded living conditions in W ashington, it w as
p racticab le to invite to th e W ashington conference only a sm all n u m b er
of A m erican ex p erts u pon th e different subjects considered, a n d th e dis­
cussions w ere of an inform al round-tab'le character. T h e atten d a n ce
a t th e regional conferences w as large an d representative.
N aturally som ew hat varying view s of m eth o d a n d ap p ro ach are p re ­
sented b y th e different authorities w hose contributions m ak e up this
volum e. O n th e g reat essentials of a child-w elfare policy for th e natio n
th e re is, how ever, m ark ed agreem ent. Public responsibility for th e

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LETTER OF TRANSMITTAL

9

grow ing generation, confidence in constructive m easures, insistence
up on g re ater uniform ity in laws, an d u pon th e necessity o f enlisting ab le
a n d d e v o te d citizens to carry on b o th public a n d p riv ate child-w elfare
activities, are all steadily em phasized. A t th e end of th e W ashington
conference th e ten tativ e child-w elfare sta n d a rd s which a p p e a r in this
boo k w ere ag reed upon. T h ey w ere p rin ted an d distributed for discus­
sion b y th e regional conferences an d a com m ittee w as nam ed to revise
them m th e light of criticism s a n d suggestions w hich m ight b e received
from th e la te r conferences an d from o th er interested citizens an d
associations.
T his com m ittee consists o f Dr. H astings H . H a rt, o f th e R ussell S age
F o u ndation, N ew Y ork C ity; Mrs. Ira C ouch W ood, o f C hicago, Directo * ^ E l i z a b e t h M cC orm ick M em orial F u n d ; Mr. O w en R. L ovejoy,
o f th e N ational C hild L ab o r C om m ittee, N ew Y ork C ity; Dr. H . L. K.
Shaw , o f th e S ta te D ep artm en t of H ealth of New Y ork,’ A lb an y ; an d
Mrs. H elen S um ner W oodbury, o f Chicago.
T h e B ureau invited th e h ead of the Rublic H ealth Service, D r. R u p ert
Blue, an d th e C om m issioner o f E ducation, D r. P. P. C laxton, to act w ith
it as a C om m ittee o f A rrangem ents.
\Y/-rf-1SS
A b b o tt w as tb e secretary o f th e conference, an d Mr.
W iiliam L. C henery has w ritten th e general sum m ary and, assisted by
Miss Ella A. M erritt, has p re p are d this volum e o f proceedings fo r p u b ­
lication.
R espectfully submitted*
Julia C. L athrop,
H on. W illiam B. ^X^ilson,
Secretary of Labor.


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Chief. |


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S T A N D A R D S O F C H IL D W E L F A R E

GENERAL SUMMARY
•

By WILLIAM L. CHENERY

N othing illum inates m ore searchingly th e ch aracter of a S ta te th an
th e m eth o d s it utilizes in th e upbringing of its young. T h e progress
w hich an y n atio n m akes, or fails to m ake, is faithfully reco rd e d in th e
h istory o f th e rearing of its children. T h e conditions u n d er which
infants are b ro u g h t into th e w orld, nourished, train e d a n d inducted into
th e responsibilities of m aturity com pose th e indisputable realities of
every social o rd er. T h e m an n er in which its children are n u rtu red is in
tru th p erh ap s th e best m easure of th e civilization of a race.
D uring m an y years, furtherm ore, know ledge has b een available th a t
am ong all m o d ern p eoples a large p ro p o rtio n of th e children b o m
w ere dying needlessly, an d th a t o th er large groups w ere vainly being
w asted b y unnecessarily dam aging circum stances. A recognition of
this has b een th e inspiration of th e large b o d y of am eliorative legislation
an d p riv ate effort characteristic of recent years. T h e war, m oreover,
by its m an ifo ld testing of th e sources of strength revealed suddenly
evils fo r which th e v ery continuance o f civilization h as d em an d e d
rem edy.
It w as accordingly for m any reasons desirable an d ap p ro p riate to en ­
d ea v o r a t this season to. state clearly w hat co n tem p o rary civilization
h as learn ed concerning the n u rtu re of children. C hief am ong these is
th e universal recognition of th e appalling price which w ar exacted of
th e young, an d th e consequent equally universal conviction th a t th e so­
ciety p reserv ed b y such sacrifice, in o rd e r to assure its ow n sound future
if for no m o re lofty m otive, m ust re a r all its children w ith a w isdom an d
a justice w hich h ith erto h av e now here b een attained.
It is, too,
peculiarly fitting a t th e en d of a p erio d during w hich th e b est w ork of
m en’s h an d s an d all the cunning of hum an science h av e b een d ev o ted to
d estruction th a t thought shouldsbe tu rn ed to restoration, to upbuilding,
to the d ev elo p m en t of a w ay of life w hich m ost effectually will heal th e
w ounds o f th e past. T h e m em ory of th e d re a d season through w hich
th e w o rld has struggled is a p o te n t inspiration to all to create a h ap p ier
future.
T h e C h ild ren ’s B ureau C onferences re p o rted in this volum e represent
p erh ap s th e m ost conspicuous single atte m p t y et m ad e to state w hat
co n tem p o rary civilization has learned concerning the w elfare of child­
h o o d . T h e P residential sanction u n d er which these conferences w ere
11

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12

STANDARDS OF CHILD WELFARE

sum m oned called fo r th e statem en t of “ certain irreducible m inim um
sta n d a rd s fo r th e health, education, an d w ork of th e A m erican child.
T h a t required com m on counsel of those in th e U nited S tates a n d in other
countries who b y reason of their experience a n d of their achievem ents
w ere qualified to form ulate such stan d ard s. T h e u n d ertaking a t­
trac ted th e co o p erativ e effort of public servants, of social service tech ­
nicians, of la b o r leaders, of publicists, of physicians, a n d of scientists in
m an y fields. A c tu a te d b y th e faith th a t th e scientific m eth o d is th e
m ost useful of th e tools possessed b y th e m o d ern w orld, th e organizers
of th e conferences b ro u g h t to g eth er m en an d w om en w hose sole p u r­
pose w as to ap p ly to th e service of th e A m erican child w h at has b een
p ro v e d to b e in co ntestably true. -N othing doctrinaire n o r anything u n ­
su p p o rted b y th e b u rd e n of scientific d a ta now available w as adm itted .
A w ide section of th e earth w as n aturally culled for advice. G uests
cam e from G re at Britain, C anada, France, Belgium, Italy, Serbia, an d
Ja p a n to th e conferences. A considerable n um ber of A m ericans dis­
tinguished in th eir various fields w ere invited to participate. A n en er­
getic e n d e av o r w as m ad e— w ithin th e practical lim its of such an ex­
p erim ent— to leave untouched no source of inform ation w hich m ight
conceivably b e of value to th e b e tte r pro tectio n of th e children of th e
U nited States. A v ery d irect effort w as p u t forth to ascertain w hat
the n atio n s w ith w hom th e U nited S tates w as associated in th e G re at
W a r h a d learn ed concerning th e safeguarding of childhood. T his
was d o n e because it w as know n th a t despite th e stress of w ar a splendid
ad v an ce in th e n u rtu re o f children h a d b een m a d e in E urope during th e
y ears im m ediately past.
A n im pressive b o d y of evidence assem bled b y th e C hildren s Bureau
of th e D ep artm en t of L abor, b y o th er divisions of the G overnm ent, b y
officials of o th er governm ents, as well as b y scientists, p riv ate organiza­
tions an d individuals, has long since ab u n d an tly in d icated m any of
th e perils surrounding childhood. Inform ation as to existing m enaces
a n d activities to reduce an d to end know n losses h av e natu rally fallen
into four classes. T h e w ork th ere fo re of th e conference w as div id ed
along those lines. T h e first springs of w aste are those a tte n d a n t upon
b irth an d th e early m onths of infancy. C onsequently, m en an d w om en
rep u ted to k now th e actual losses now suffered an d th e m o st effectual
m eans of elim inating these w ere b ro u g h t together. Since, furtherm ore,
th e safety of th e m o th er is th e key to th e w ell-being of the child, m a te r­
nity could n o t b e excluded from consideration. T h e pro tectio n of th e
h ealth of m o th ers a n d children thus b ecam e an initial to p ic of dis­
cussion. In this, leading A m erican authorities, to g eth er w ith represen­
tativ es of G re at Britain, France, Belgium, Serbia, an d Italy to o k p art.
T h e greatest, as w ell as th e m ost futile, from th e stan d p o in t of
co n tem p o rary m edical a n d econom ic science, of hum an losses is th e

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GENERAL SUMMARY

13

d eath of v ery young children. But fortunately the trag e d y of squand e re d in fan t life is preventable. E ngland especially during th e w ar has
d o n e m uch to lessen this w aste. Sir A rth u r Newsholm e, late chief m edi­
cal officer of th e Local G overnm ent B oard, as a d eleg ate from G reat
Britain, d escribed the m easures which are achieving this h a p p y result
in E ngland. M rs. E leanor B arton, an o th er British representative, set
fo rth th e p ro g ram p ro m o ted b y w orking-class w om en fo r the purpose
of assuring universal public provision for m aternity. Mrs. B arton
d escribed th e w ork of th e W om en’s C ooperative G uild in the securing
of g o v ernm ental aid fo r th e care an d protection of w om en during
childbirth. D r. R ené S and, P rofessor of Industrial M edicine a t the
U niversity o f’Brussels, explained th e m eth o d s through w hich Belgium,
d espite th e grim horrors of enem y invasion,' red u ced th e in fan t d ea th
ra te to a d eg ree u n ap p ro ach ed in th a t country b y th e re co rd s o f peace.
Sim ilarly D r. C lothilde M ulon, o f th e F rench ^Var D epartm ent, eluci­
d a te d th e devices utilized in P aris to accom plish a like result. P rofessor
F ab io Frassetto, of th e U niversity of B ologna, offered th e novel h y ­
pothesis of th e Italian anthropological school looking to w ard a fu n d a­
m en tal reduction of th e health disadvantages from w hich children suffer.
Dr. R ad m ila L azarevitch described the terrific losses en d u red b y S erbia
as a p a rt o f th e price of w ar, an d Miss L. E. C a rter pictured th e con­
sequences o f w ar’s hunger an d terro r on th e school children of
Brussels.
A m erican science w as b ro u g h t into counsel w ith th e contributions
from foreign lands. Dr. J. W hitridge W illiam s, of Jo h n s H o p k in s U ni­
versity, p ro p o sed certain sta n d a rd requirem ents fo r obstetrical care in
o rd e r to re n d e r as safe as possible b o th m o th er an d child. Dr. Philip C.
Jeans, of St. Louis, suggested general m easures to b e tak en to p re ­
v en t th e b light upon infant life d u e to venereal infections. D r. C harles
V . C hapin, of P rovidence, R h o d e Island, su p p o rted th e d ev elo p m en t of
p re n atal clinics, m aternity w ards, an d b e tte r obstetrical training as a
m eans of fu rth er protecting infancy an d m aternity. D r. H . F. H elm holz, o f E vanston, Illinois, ad v o c ated th e dev elo p m en t of b o th p ren atal
an d p o stn atal care of infants in o rd e r to low er present m orb id ity and
m o rtality rates. D r. R. W . Lobenstine, o f New Y ork City, outlined the
New Y ork p lan for th e establishm ent of m atern ity centers. Miss Eliza­
b eth G. Fox, o f th e A m erican R ed Cross, p ro p o sed th e creation of an
organization to give to rural m o th ers co m petent prenatal, natal, an d
p o stn atal care.
In th e discussion of th e health needs of th e child of preschool age
Dr. M errill E. C ham pion, of th e M assachusetts S ta te D ep artm en t of
H ealth, p ro p o sed th e establishm ent of health centers on a scale com ­
p arab le to th e public-school system as a m eans of preventing unneces­
sary sickness an d death. Dr, C.-E. A. W inslow, of Y ale U niversity,

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STANDARDS OF CHILD WELFARE

described the p a rt which public-health nursing should ta k e in th e re­
duction of th e national sum of juvenile disease. Dr. S. Josephine B aker,
of th e N ew Y o rk City H ealth D epartm ent, an d D r. C lothilde M ulon, of
the F rench W a r D epartm ent, discussed stan d ard s essential to th e right
co n d u ct of d a y nurseries, while P rofessor Lewis T erm an, of L eland
S tan fo rd Ju n io r U niversity, presen ted th e n eed for d en tal clinics. Tslutrition clinics to discover an d to correct th e m alnutrition from which
m any public-school children suffer w ere a d v o c ated b y Dr. W illiam
R. P. Em erson, of B oston. P rofessor G rah am Lusk, of C ornell U ni­
versity, discussed the nutrition of adolescence an d as an illustration o
th e im portance of this subject re p o rted u pon th e consequences of an
in ad eq u ate food supply am ong G erm an children during th e w ar. P ro ­
fessor Lusk stated th a t th e am ount of food n eed ed b y adolescent boys
exceeds th e requirem ent of ad u lt m en. D r. T h o m as D. W o o d of
C olum bia U niversity, stated th a t three-fourths of th e 2 2 ,0 0 0 ,0 0 0 school
children in th e U n ited S tates h av e health defects w hich are actually or
poten tially injurious to them as prospective citizens. D r. W o o d a d v o ­
cated a p ro g ram of regular h ealth inspection a n d exam ination in th e
public schools as a w ay of avoiding th e loss w hich results from negli­
gence of th e h ealth defects of the young. Mr. R o b ert D. Leigh, of the
U n ited S tates Public H ealth Service, d ea lt w ith th e n eed for sex ed u ca­
tion in th e p ro tection of th e h ealth of children.
• ,
A s a result of discussions a t th e W ashington conference definite
stan d ard s for th e protection of the health of m others an d of their
children w ere fo rm ulated an d referred to th e consideration of the
T h e tim e a t w hich children should en ter th e ranks of industry, th e
training which all should h av e prelim inary to em ploym ent, th e co n d i­
tions u n d e r w hich young people should assum e th e obligations an
th é b u rd en s o f m atu re citizenship, are elem ents of th e g reat pro b lem
of child la b o r w hich all m o d ern nations h av e found difficult. T h ro u g h ­
o u t th e industrial era, how ever, an increasing b o d y of p ertin e n t d a ta
h as b een accum ulated in this field an d accordingly it is now possible to
found stan d ard s on th e assured basis of ascertained fact.
T o th e C h ild ren ’s B ureau C onferences on this subject cam e lead ers of
A m erican thought. In these deliberations tw o British representatives
w ere ab le to p resen t th e particularly useful experience of G re a t B rit­
ain. Mr. R. C. D avison, Chief of th e Juvenile L ab o u r E xchanges of
G re at B ritain, re p o rted the progress to w ard a solution of th e g reat
p ro b lem w hich E ngland has m ad e b y m eans of a national control of
em ploym ent. Sir Cyril Jackson, spokesm an of th e British B oard of
E ducation, w as able to describe th e m eaning of th e educational revolu­
tion in G re at B ritain signalized b y th e passage of th e “ Fisher” E d u ­
cation A ct.

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A m erican w orkers p resen ted th e conclusions d eriv ed from their
observations of the em ploym ent of children in industry. Mr. O w en R.
L ove jo y of th e N ational C hild L ab o r C om m ittee stated th a t th e needs
of th e child him self m ust supplant all o th er interests in the form ulation
of s ta n d a rd s for th e p rotection of children against p rem atu re labor,
D r. E m m a M cK ay A ppel, of th e C hicago B oard of E ducation, d e ­
scribed th e m inim um physical stan d ard s required in “C hicago b efo re p e r­
m its to w ork are g ra n te d children. D r. E. V . L? B rown, of Chicago,
re p o rte d on th e w ork being d o n e to correct defective vision am ong
Chica’go w orking children. D ean D. L. Edsall, of th e H a rv a rd M edical
school, re p o rte d his conclusion th a t it is necessary to study n o t only the
n atu re of in d u stry b u t th e p articu lar fitness of th e individual child for
certain ty pes of em ploym ent before perm itting him to w ork. Mr.
C harles E. C hadsey, o f C hicago, urged th a t continuation schools p ro ­
viding instruction up to th e age of 2 1 years b e established.
T h e H o n . A lb e rt E. Hill, of Nashville, trac ed th e history of childlab o r legislation in Tennessee. Miss A gnes N estor, P resid en t of the
W o m en ’s T ra d e U nion L eague of Chicago, discussed th e question of
h o urs a n d p ro p o se d th a t m inors betw een sixteen a n d eighteen years
of age b e n o t p erm itted to w ork longer th an six hours a day. P ro fes­
sor F. S. D eibler, of N orthw estern University, suggested th a t advisory
com m ittees co m posed of school officials, representatives of industry an d
of lab o r exchanges w ith social w orkers m ight w ork out satisfactory
scales of w ages a t which children p ro p erly could en ter industry. Dr.
Jessica B. P eixotto, of th e U niversity of C alifornia, while advocating
school law s ra th e r than lab o r laws for the protection of children,
urg ed th a t m inors b e p aid th e m inim um w age aw ard ed w om en as soon
as th eir o u tp u t equals th a t of the o rd in ary adult. Miss T ra cy C opp, of
the W isconsin Industrial Com mission, described th e adm inistrative sys­
tem b y m eans o f which children in W isconsin are passed from school
to industry.
In th e end m inim um sta n d a rd s for th e g reater protection of A m erican
ch ild h o o d against the ch arted w rongs of prem atu re lab o r w ere d rafted ,
ap p ro v ed , an d com m ended to th e consideration of th e A m erican p e o ­
ple. T h e convincing w eight of testim ony w as to th e effect th a t the
lengthening of th e p eriod of actual childhood, an d a m o re intelligent
physical an d intellectual training for entrance into pro d u ctiv e em ploy­
m ent, offer this n ation th e o p p o rtu n ity for an u n p reced en ted increase
in natio n al strength.
T h e p ro tectio n of health affects all children, an d m easures to p re v en t
p re m a tu re em ploym ent concern th e g reat m ajority. B ut an o th er group,
those in d icated b y the p h rase “children in n eed of special care,” p re ­
sent a th ird w ell-defined an d urgent problem . T hese are th e d e p e n d ­
ents— th e poor, the incurably w eak, a n d th e delinquent. F o r them first

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STANDARDS OF CHILD WELFARE

effort a t refo rm began. T h eir plight inspired th e beginnings of the
th ild -w elfare m ovem ent.
Mr. R o b e rt W . Kelso, of th e M assachusetts S tate B oard of C hanty,
discussed th e obligation of th e state to w ard th e child w ith special needs.
M r. K elso stated th a t th e care of such children is a function of th e state
a n d th a t th e p riv ate agency perform ing this governm ental function
m ust conform to state standards. M r. C. V . W illiam s, of th e O hio
B o ard of S tate C h anties, a d v o c ated th e state supervision of public a n d
p riv ate agencies in o rd e r to guarantee th e m aintenance of p ro p e r
service. J u d g e V icto r P. A rnold, of th e C ook C ounty Juvenile C ourt,
outlined th e gro u n d s considered b y th e court sufficient to justify th e re­
m oval of children from their hom es. Mr. E d m o n d J. Butler, of th e
C atholic H o m e B ureau for D ep en d en t C hildren, New Y ork, pro p o sed
certain criteria to b e applied to foster hom es in w hich children are
p laced. H e a d v o c ated th e necessity of continued supervision o f chil­
d re n so placed . Miss H . Id a C urry, of th e S ta te C h an ties A id A ssocia­
tion, N ew Y ork, outlined a p lan of child-w elfare organization suited to
rural districts. J u d g e Jam es H o g e Ricks, of th e R ichm ond, V irginia,
Ju v enile C ourt, discussed th e organization of juvenile courts. H e
arg u ed th e ad v a n ta g es offered b y th e dev elo p m en t of these cm irts
along chancery lilies. D r. Louis N. R obinson, C hief P ro b atio n Officer
of th e M u n icip arC o u rt of P hiladelphia, asked for a g reater specializa­
tion in th e w o rk of p ro b a tio n officers, w ith a larg er experim entation in
m eth o d s of reform . D r. W illiam H ealy of th e Ju d g e B aker F o u n d a ­
tion B oston, tre a te d th e m edicopsychological stu d y of delinquency.
O nly b y th e use of such technical m ethods, D r. H ealy argued, 1» it p o s­
sible to av o id th e failures of o rd in ary efforts a t juvem e reform ation.
Dr. C. M acfie C am pbell, of th e Jo h n s H o p k in s H ospital, discussed th e
place of m en tal hygiene in th e child-w elfare m ovem ent. H e u rg ed a
g re ater co n sideration of th e im p o rtan t problem s of h ea lth involved in
th e p erso n ality of th e child. D r. W a lte r E. F ern ald , of th e M assa­
chusetts S chool fo r th e F eeble-M inded, set fo rth th e n eed for th e m en ­
tal exam ination of back w ard school children, th e establishm ent of
clinics an d of train ing classes, an d fo r o th er item s m a state p ro g ram fo r
th e care of th e m entally defective. D r. H astings H . H a rt, o f th e
Russell S age F o u n dation, tre a te d th e principles a d o p te d a t th e W hrte
H ouse C onference” in th e light of recen t experience. M r. T akayuki
N am aye, of th e Jap an ese D e p artm en t of Interior, p resen ted graphically
th e organization of child-w elfare w ork m Jap*».
_
In this territo ry A m erican experience h as b een rich. A t th e cl
o f his la st adm inistration a d e c a d e ago P resid en t R oosevelt sum m oned
th e “W h ite H o u se C onference,” which form ulated sta n d a rd s fo r th e
I n t e r n a t i o n a l trea tm e n t o f these children so m uch d ep e n d en t u p o n
society. T h e urgency of a progressively b e tte r ca re fo r th em while

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stim ulated b y p urely altruistic m otives is b u ttressed b y society’s n ee d to
p ro tec t itself against th e parasitic a n d th e crim inal— d ra fte d largely
from delin q u en t an d defective children w hose special necessities are
ignored b y th e state. T h e W hite H ouse C onference” sta n d a rd s w ere
reaffirm ed a t th e C hildren’s B ureau C onference, a n d b ro u g h t into
h arm o n y w ith th e know ledge w hich has been o b tain ed during th e p ast
decade.
C onsideration w as also given to th e p lace of legislation in crystalliz­
ing a n d m aking effective sta n d a rd s fo r child w elfare. M r. C. C. C arstens, o f th e M assachusetts Society fo r the P revention of C ruelty to
C hildren, d ea lt w ith th e need, for standardizing child-w elfare laws an d
discussed th e m eth o d s applicable. P residing Justice F ranklin C hase
H oyt, o f th e C hildren s C ourt of N ew Y ork City, stated th e necessity
fo r a codification o f children s law s from th e stan d p o in t o f New Y ork
experience. M r. W . W . H odson, of th e M innesota S ta te B oard of C on­
trol, d escribed in this connection th e w ork of the M innesota C hild W el­
fare Com m ission. A t th e sam e tim e th e n eed fo r w ell-organized chil­
d re n ’s codes co ordinating th e various phases of th e S ta te p ro tectio n of
child h o o d w as em phasized. T h e R ev. W illiam J. K erby, secretary of
th e N ational C onference of C atholic C harities, d rew atten tio n to the
need o f synthesizing sep arate lines of legislation into children’s codes
in o rd e r ad eq u ately to p ro tec t th e personality of th e child. P ractical
m eth o d s fo r developing such codes w ere presented.
P reced en t to th e selection o f an y single o p p o rtu n ity fo r th e b e tte r­
m en t o f th e conditions surrounding childhood is, m oreover, a considera­
tion o f th e social a n d econom ic situation o f th e people. F o r th e ex­
pression o f any sta n d a rd is m erely an am iable generalization unless th e
m aterial m eans fo r its application are available. A t th e v ery outset,
therefore, conference w as h a d concerning th e general basis upon
which th e structure o f progress m ight b e built. D r. R en é S and, o f the
U niversity o f Brussels, in this connection discussed “Social M edicine.”
Dr. S an d p o in ted out th e facts th a t “ th e hum an saving science has not
k e p t p ace w ith o th er sciences,” a n d th a t th e utilization o f know ledge
fo r th e p ro tectio n o f m an k in d h as lagged b eh in d th e actual ad v an ce of
th e science. H is p lea w as fo r a scientific organization o f society w ith a
d ev elo p m en t o f social m edicine to co v er th e field w hich now lies u n ­
occupied b etw een public hygiene, econom ics, social science an d p h ilan ­
thropy. ' In this w ay, D r. S an d argued, th e constructive dem ocracy
which m ust b e a scientific dem ocracy m ay b e m a d e real.
P ro fesso r W illiam F . O gbum , o f C olum bia U niversity, p re sen ted
d a ta show ing th e actual cost of rearing a child, b ased u p o n a stu d y of
b u d g ets collected fo r th e B ureau o f L a b o r Statistics o f th e D e p artm en t
of L ab o r an d fo r th e N ational W a r L a b o r B oard. Miss S. P. B reckin­
ridge, o f the U niversity o f C hicago, trea ted in detail th e gap betw een

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STANDARDS OF CHILD WELFARE

th e cost of living a t any defensible A m erican sta n d a rd an d the incom es
o b tain ed b y larg e sections of th e population. She recapitulated th e evil
n ational consequences as revealed b y infant m ortality rates an d other
such indices of social w aste w hich com e from this m aterial insufficiency.
She urg ed th e establishm ent of an econom ic m inim um below which, for
th e sake of th e nation, no fam ily should b e p erm itted to fall. Miss F lo r­
ence Nesbitt, institute instructor in dietetics for th e A m erican R ed Cross,
re p o rted th a t in places such as C hicago or C leveland, $ 1,500 is th e m ini­
m um cost of th e essentials fo r m aintaining an average fam ily o f five a t
w h at m ight b e called a norm al stan d ard . C om m issioner R oyal eeker
stated th a t the b u d g ets studied b y th e U nited S tates B ureau of L ab o r
Statistics disclosed the; fact th a t every increase in th e size of m any
fam ilies co m pelled th e sacrifice n o t only of th e com forts b u t of th e
necessities o f life “ to m eet th e m o st pressing n eed — th e n eed fo r fo o d ."
P ro fesso r K elly M iller, o f H o w ard U niversity, drew atten tio n to th e
special h an d icap of th e negro child because th e stress of econom ic
pressure falls heaviest u p o n th e b lack race.
M rs. E v a W hiting W hite described th e w ar housing p ro g ram o f the
F ed eral G o v ern m en t as it relates to th e p resen t needs of th e A m erican
child. M rs. W h ite u rg ed th a t th e dev elo p m en t o f a sound national
housing policy is prerequisite to th e attain m en t of hom es fit fo r th e u p ­
bringing of children. Mr. Jo sep h L ee an d Mr. L. H . W eir, of th e W a r
C am p C om m unity Service, in collaboration w ith Miss A b b ie C ondit,
of th e P lay g ro u n d an d R ecreation A ssociation of A m erica, presen ted
recreational schem es for organization of th e leisure of children.
Because th e practicability of progress is d eterm in ed b y th e m aterial
possessions o f th e people, the discussion of fam ily budgets, of th e cost
of child care, an d of the allied social factors involved, m akes explicit
th e obligation w hich m ust b e accepted if m o d ern sta n d a rd s for th e
n u rtu re of children are really to b e p u t into operation. T h e logic of
th e evidence ad d u c ed seem ed to indicate th a t a v ery larg e ratio of th e
fam ilies of th e U n ited S tates ob tain incom es to o sm all to m ak e possible
th e rearing o f children in th e m an n er w hich scientific a n d hum ane
considerations, as well as th e pro sp erity of th e nation, dem an d . T his
conclusion in itself is n o t w holly novel, b u t th e precise presen tatio n of
th e actual expen d itures necessary to a w holesom e upbringing o f th e
young is a distinct gain in social know ledge.
In th e follow ing pages ap p e a r th e principal p ap e rs re a d a t th e W ash ­
ington conference, an d a few of th e m o re significant contributions m ad e
in th e regional conferences. A ttach e d are liberal quotations from the
discussions w hich follow ed th e papers. T h ese show th e tre n d of th e
arg um ent th ro u g h w hich th e stan d ard s w ere form ulated. F inally th e
th ree g roups of m inim um stan d ard s ap p ear. T hese it should b e realized
are ten tativ e an d provisional an d in no sense m axim a. But th ey do

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rep resen t a serious effort to ap p ly to the service of childhood those p rin ­
ciples of w holesom e care so clearly indicated by science a n d com m on
experience. No longer can it b e said th at th e know ledge concerning
how to safeguard childhood is lacking. T h e d a ta are available. T hey
b e a r th e im prim atur of sane an d forceful thinking. O nly th e will to
achieve is now w anted. W ith th a t th e U nited S tates will b e able to
create a new era of safer, stronger, h ap p ier childhood, an era in which
the oncom ing generation is b e tte r equipped to carry on th e w ork of th e
republic.


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Section I
T h e Econom ic and Social Basis for
Child W elfa re Standards


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S O C IA L M EDICINE
By DR. RENE SAND
University of Brussels, Belgium

I should like to say a few w o rd s ab o u t the general principles on
which w e ought to lay th e foundations for th e law s concerning child
w elfare w e all wish to introduce, an d ab o u t th e best w ay to secure their
enforcem ent. I think you all agree th a t laws h av e to b e b ased on
science an d experience, m ore th a n on sentim ent o r p a rty lines. Y et
this h as b een v ery rarely th e case. Interests an d prejudice play an
im p o rtan t p art, I am afraid, in form ing public opinion. T h ere is n o t
m uch room left fo r science.
A t this m om ent, how ever, things look distinctly m ore hopeful. T h e
w ar h as tau g h t us to question all our m ethods, an d to ask for b e tte r
efficiency. Now, efficiency m eans a scientific organization, a n d co­
operation. T h o se tw o factors h av e really w on th e w ar. T h in k w hat
im p rovem ents our m unition factories, our arm y, th e life of th e nation
a t large, h a v e show n in th e last four years. T h e scientific a n d th e
co o p erativ e spirit h av e m ad e th e w hole difference a n d h av e achieved
w onders.
If we try to p e rv a d e oUr peace activities w ith those elem ents of
success, we strike a t two v ery p aradoxical facts. T h e first is th a t th e
hum an-saving science has n o t k e p t pace w ith th e o th er sciences. W e
h a v e g ath ered a few facts only ab o u t eugenics, ab o u t th e physiology
o f labor, ab o u t th e factors affecting th e grow th of children, all things
o f first-class im portance for our pro sp erity an d happiness. B ut sci­
ences like arch aeology (I do n o t w an t to attac k th e archaeologists; I
h av e a n u m b er of friends in th a t b ra n ch ) loom large in our m useum s
an d publications, a t least in E urope, although th ey can n o t b o ast th e
sam e usefulness. It seem s th a t instead of doing th e urgent jo b first,
m an k in d h as alw ays p re ferred to begin w ith th e less im p o rtan t task.
T h a t is alread y b a d enough. But here com es th e second p o in t:
th e utilization of science has n o t k e p t p ace w ith its advance. P rofessor
F red erick S. L ee has told us so in a recent book, in w hich h e shows
w h a t w e k now ab o u t the w orking of the hum an m achine, a n d th e
little use to which th a t know ledge has b een put. Y ou could tak e
o th e r exam ples; we know perfectly well how to eradicate m alaria
a n d yellow fever, y et these diseases still claim m any victims. W e
know, th a t w e could p rev en t h alf of th e d ea th s w hich occur every year,
23

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a n d y e t w e d o n o t p re v en t them . T h irty p er cent of o u r blind.infants
w ould see if only a few d ro p s o f an antiseptic solution w ere p u t in
th e eyes of every n ew born child.
T h e reason of all those deficiencies is th a t th e re is n o p ro g ram for
th e scientific organization of m ankind, n o agency to stu d y such a p ro ­
gram , n o teaching given on th e m atter. I th in k w e will n ev e r reach
th e p o in t w here we will really govern ourselves a n d m aster th e w orld,
until w e m ak e th e universities constructive. It is from these centers
th a t th e law s ought to originate, a n d n o t from th e political associations.
A university is n o t prim arily a place w here young m en p la y foot­
b all a n d learn G reek o r m athem atics; neither is it prim arily a school fo r
law yers o r physicians, n o r a place w here an ex p ert studies a t leisure, in
a co m fo rtab le environm ent, som e old A ssyrian inscription. T hese
activities are v ery v alu ab le a n d necessary. B ut w e m ust p u t forem ost
a higher an d m o re general p u rp o se; th e building up of civic a n d hum an
efficiency. T h e constructive university will n o t include m an y m ore
sciences th a n it d o es now , b u t it will teach th em from a n o th e r view point.
L et us take, fo r instance, public health. W e tell o u r u n d erg rad u a te s
h o w to p re v en t tuberculosis b y avoidance of contact, a w ell-balanced
diet, a co m fo rtab le hom e, an d rest. V e ry well. B ut w e d o n o t tell
th em h o w to p ro v id e th o se things. I w ould h av e public h ea lth tau g h t
in a w ay th a t w ould strike a t th e ro o t of th e question a n d proclaim ,
as S urgeon G en eral G orgas did,^ th a t th e g reatest public-health m eas­
u re y o u can in tro d uce is a m inim um w age law. I w ould h av e hygiene
stu d ied n o t only in th e la b o ra to ry ; I w ould ta k e th è u n d erg rad u a te s to
th e w orkingm an’s hom e a n d ask him a n d his w ife ab o u t th eir n eed#
a n d th e refo rm s th ey them selves suggest.
In short, I w ould go a step fu rth e r th a n p rev en tiv e m edicine, a n d
teach sociologie m edicine. T h e re is a field b etw een sociology, statis­
tics, biology, m edicine, hygiene, an d philanthropy, w hich is a k in d of
no m an ’s lan d . S om e p atro ls sta rt from th e biology b o rd e r, explore
a little stretch, a n d th e n com e back. T h e sam e occurs from all th e
b o rd ers. W h en tw o patrols, com ing from different b o rd ers, m eet
ea c h other, th ey som etim es fraternize; m o re often th ere is a big
scientific fight. 1 d o n o t m ind v ery m uch this k ind of fighting afte r
h aving seen th e o th er kind. T h e w orst featu re is th a t th e p atro ls sel­
d o m m eet, a n d so every b it 'o f know ledge w hich one b o rd e r gains
ab o u t no m an ’s lan d is lost fo r th e others. T h e re is no coordination
o f effort, no plan n ing together, n o team w ork.
I th in k this could b e av o id ed a n d a real n ee d b e m e t if w e sta rte d
fran k ly to organize th a t field u n d e r th e auspices of Sociologie M edicine.
Sociologie M edicine m eans th e m edical en d of social questions, o r
th e social en d o f m edical questions, as you p re fe r to p u t it. It w ould
h av e b ee n co n stitu ted long ago w ere it n o t fo r th e fact th a t it requires

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T H E ECONOMIC AND SOCIAL BASIS

45

teaching Biological, statistical, an d social m eth o d s to the physicians.
Now, biological m eth o d s th e actual o r future physician will accept
w ithout to o g re at trouble. T h ere will b e m o re resistance to statistical
m eth o d s; th ey n eed the use of higher m athem atics, an d fum bling ab o u t
in terrib le b o o k s like th e Census. B ut even that, th e b e tte r ty p e of
u n d erg rad u a te o r d o c to r will finally adm it, on account of th e scientific
stam p th a t statistics receive from m athem atics. W hen it com es, how ever, to sociological m ethods, th e average m edical m an revolts; sur­
veys, inquiries, social case w ork, all seem too hum ane to b e scientific.
A n d th en th ey m ix up w ith all sorts of social questions, nearly re la ted
to political questions. T h a t is a slippery field.
A n d y e t w e h av e g o t to plough this field, an d it will give us th e
richest crop th a t science has ever reaped, because th en w e will no
m o re guess, w e will know ab o u t the social questions. M arriage, child
w elfare, education, vocational guidance, labor, poverty, delinquency,
all those p ro b lem s h av e to b e tak en up b y sociologic m edicine. If
this new science is com prehensive enough, if it is recognized a n d d e ­
velo p ed , I h av e no d o u b t results will follow quickly.
A conference like this w here public officials, social w orkers, physi­
cians, sociologists, an d teachers m eet to g eth er is alread y a step tow ard
th e reclam ation of this com m on field. T h e school of industrial m ed i­
cine organized recently a t H a rv a rd is an o th er v ery valu ab le progression
in th a t direction.
W e co n stitu ted in Belgium in 1913 an association o f sociologic
m edicine w hich published a bulletin (B ulletin d e 1*A ssociation Beige
d e M edecine Sociale B ruxelles) a n d it w as progressing favorably.
Sociologic m edicine w as tau g h t in o u r universities to d o cto rs w ho
w an ted to tak e the public-health diplom a. B ut w ar has n ip p ed those
activities in th e bud. W e will h av e to tak e them up again, how ever,
as th ey will n o t only help to w ard m aking b e tte r laws, b u t also assist us
to w ard enforcing them in an easier an d m ore effective way. C on­
structive dem o cracy m eans scientific dem ocracy.


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T H E FIN A N C IA L C O ST O F R E A R IN G A C H ILD
By WILLIAM F. OGBURN
Bureau of Labor Statistics, U. S. Department of Labor

D uring m y p ast y ea r’s w o rk w ith th e N ational W a r L ah o r B oard
a n d th e U n ited S tates B ureau of L ab o r Statistics, I h av e received m any
inquiries concerning how m uch it costs to re a r a child. I am in a posi­
tion now to th ro w som e light on this q u estio n 'fro m d a ta collected b y
th e B ureau of L ab o r Statistics in all p a rts of th e country a n d particu­
larly from th e special m eth o d s em ployed in w orking up these d ata.
In P hiladelphia, for instance, tw o h u n d re d fam ily schedules w ere col­
lected from w orkingm en’s fam ilies w ith incom es betw een $ 8 0 0 an d
$ 2 ,0 0 0 , showing th e expenditures in detail for th e y ear 1918. T hese
d a ta w ere generalized into a series of equations in such a form as to
show, b y m erely substituting in th e equations th e size of th e fam ily an d
th e to tal y ea r’s ex penditure an d solving, th e average am ounts spent for
food, fo r clothing, fo r rent, for fuel an d light, for furniture a n d fur­
nishings, a n d fo r m iscellaneous expenses. O ne such equation is th e
follow ing: [ X J = 4 5 . 6 0 — 0 .0 1 0 3 X 3 -|- 3.132 X 2, in w hich X 3 is
th e to tal an n u al ex penditure in dollars, X 2 is th e size of th e family, X 4
is the p ercen tag e of th e to tal expenditure spient for food, an d [ ]
m eans th e average. F o r instance, if it is desired to know th e average
ex p en d itu re for fo od of a fam ily of th ree w ith a to ta l annual expendi­
tu re of $ 1 ,0 0 0 , w e substitute in th e equation 3 for X 2 a n d $ 1 ,0 0 0 for
X 3, a n d solving, w e find [ X J — 44.7. T his m eans th a t on th e average
4 4 .7 p e r cen t of th e to tal annual expenditure w ent for fo o d ; an d since
th e to tal an nual ex penditure w as $ 1,000, then th e am o u n t spent for
fo o d w as $ 4 4 7 . A n d so from this equation w e can find th e average
am o u n t sp en t fo r food b y a fam ily of an y size a n d w ith any incom e
(b etw een $ 8 0 0 a n d $ 2 ,0 0 0 ) .
N ot only can w e find th e average am ount spent for food for a fam ily
of a given size, b u t b y com paring th e am ount w ith th a t spent in a fam ily
having one ad d itio n al m em ber w e can ascertain how m uch is a d d e d to
th e fo o d b u d g e t for th e ex tra m em ber of th e family. T hus, w e can,
first, substitute fo r X 2 in this equation a fam ily of h u sb an d an d wife
(ju st m arried an d w ith no children) a n d learn th e am ount spent for
fo o d ; then, secondly, w e can substitute for X 2 th e sam e fam ily w ith a
child on e y ea r old, an d ascertain th e to tal am ount spent for food. T h e
difference b etw een th e first result an d th e second result will b e the
26

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T H E ECONOMIC AND SOCIAL BASIS

27

am o u n t a d d e d to th e food b u d g et for th e child from b irth to one y ear
old. W e,can , thirdly, substitute fo r X 2 th e fam ily w ith th e child tw o
years old an d th e result will b e th e am ount sp en t for fo o d fo r one y ear
b y a fam ily o f husb an d an d wife an d child from one to tw o y ears old.
By subtracting from this th ird result (co st o f food for h u sb an d a n d wife
an d child from one to tw o years o ld ) th e first result (c o st of fo o d for
h u sb an d an d wife w ith no ch ild ren ) w e can find th e am ount a d d e d
to th e fo o d b u d g et for a child from o n e to tw o y ears old. A s w e first
figured out th e am o u n t a d d e d to th e fo o d b u d g et for th e child from
b irth to one y ea r old, b y ad d in g th e am o u n t a d d e d to th e b u d g et for
the child from one y e a r to tw o years old, w e can tell how m uch is a d d e d
to th e fo o d b u d g et fo r a child from b irth to tw o years old. A n d so
b y rep eatin g this process we can ascertain*how m uch is a d d e d to th e
food b u d g et of a fam ily b y rearing a child up to sixteen years of age.
In o rd e r to m ake these successive substitutions, w e m ust h av e som e
unit to rep resent th e sizes of fam ilies w ith children o f different ages.
A fte r co n siderable research it w as th o u g h t justifiable to substitute for
th e size o f th e fam ily its equivalent in term s of a d u lt m ale units, using
a scale b ased on relative fo o d requirem ents m easured in calories.
T h ere are several such scales. T h e one alre ad y a d o p te d b y th e B ureau
of L ab o r Statistics w as used. A ccording to this scale, a m an equals
1.0,
a w om an equals 0.9, a child from b irth to th ree years inclusive
equals 0.15, a child from four to six years inclusive equals 0.4, a child
from seven to ten inclusive equals 0.75, a child from 11 to 14 inclusive
equals 0.9, a girl over 14 equals 0.9, an d a b o y o v er 14 equals 1.0. (A
discussion of th e representativeness of this scale an d also a full discus­
sion of th e form ation of th e equations is found in a forthcom ing bulletin
of th e B ureau of L ab o r Statistics of the U nited S tates D e p artm en t of
L a b o r.) T his scale enables one to express a fam ily w ith children of any
ages in a single num ber, which m ay b e substituted for X 2 in th e eq u a­
tions. W e can thus substitute in th e equation ju st discussed th e suc­
cessive sizes of th e fam ily until th e child is 16 y ears of age. T hus the
size of th e fam ily w hen th e boy is from 15 to 16 y ears old is 2.9 (hus* b an d equals 1.0, wife 0.9 a n d b o y 1.0 ).
In w orking o ut these am ounts spent fo r fo o d from th e a b o v e equa­
tion, it is necessary to substitute th e size o f th e to ta l annual expenditure
(w hich is usually ab o u t th e sam e as th e incom e) fo r X 3. W e can, o f
course, choose an incom e of any size, say $ 1 ,5 0 0 , an d find out how
m uch is a d d e d to th e food bill because o f rearing a child up to say 16
y ears o f age. B ut during these sixteen years, has th e incom e rem ained
th e sam e? If not, how m uch has it gone up? If th e incom e has gone
up, p ro b a b ly m ore has been spent on food th an w ould h av e been
sp en t if th e incom e h a d rem ained th e sam e. O f course if th e re h av e
been increases in w ages (o r increases in annual incom e) w e can m ake

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STANDARDS OF CHILD WELFARE

th e p ro p e r substitutions for X 3 a t th e p ro p e r tim es, i. e., stages in the
grow th of th e fam ily (X 2) , for a p articu lar family. B ut w e §re n o t so
m uch in terested in a p articu lar fam ily as in w h at takes place on th e
average. F o rtu n ately w e h av e found an o th er equation w hich gives
us this inform ation, [X 3] = 9 3 2 -j- 138 X 2. W e can tell from this
equation w h at th e averag e to ta l annual ex penditure is fo r a fam ily of
an y size, as d eterm in ed b y th e rep resen tativ e sam ple of fam ilies chosen
from P hiladelphia. T h u s for fam ilies of th ree (substituting 3 for X 2
an d solving) th e av erag e to tal annual ex penditure as d eterm in ed from
o ur sam ple of w orkingm en’s families is $ 1,346, a n d fo r fam ilies of four,
is $ 1,484. T h e larg er th e family, th e larg e r th e expenditure. A n in­
crease of th e size of th e fam ily b y one (in o u r equivalent a d u lt m ale
units) increases th e ex penditure b y $138. So from this equation w e
can determ in e th e ap p ro p riate X 3 to b e substituted for th e particu lar
size of fam ily (X 2) w e are discussing.
Follow ing th e p ro ced u re described in th e preceding four p a ra ­
graphs, w e find th a t w h at w e m ay term th e “ n et increase” of th e fam ily
b u d g et fo r food because of rearing a child to sixteen years, i. e., over
w hat th e fo o d w ould h av e cost if th ere h a d b een no child, w as $718.
T h e fo o d w hich th e child ate m ay h av e cost m ore th an this $ 718 of
“n et increase.” T h e husb an d a n d wife m ay h av e cut dow n on th e cost
of th eir food, o r th ey m ay h av e b o u g h t cheap er fo o d o r less (a n d p e r­
hap s in ad eq u a te) food. O r th ey m ay h av e m ad e econom ies in p u r­
chasing o r using food. T his “n e t increase,” then, w ould rep resen t n o t
th e full cost of food for the child, b u t only th a t p a rt of it which w as n o t
m et b y econom ies or b y lessened consum ption b y th e o th er m em bers of
the family.
F o r purposes o f com parison w ith this n e t increase, th e actual
cost of food fo r a child up to sixteen years m ay b e estim ated in the
follow ing w ay : T h e average cost of food p er a d u lt m ale p e r d a y for
th e families stu d ied in P hiladelphia w as $0.5 1. N ow from our equiva­
len t a d u lt m ale scale it is found th a t a b o y for th e first sixteen years of
his life eats as m uch as an ad u lt m ale w ould e a t in 9 .4 years. A t 5 T
cents p e r m an p e r d a y th e food for 9 .4 a d u lt m ales for one y e a r (l. e.,
a b o y fo r th e first sixteen years of life) w ould cost $ 1 ,7 5 0 . In o th er
w o rd s th e actual cost of th e child’s food, if it cost th e sam e as th e av e r­
age cost in P hiladelphia, w ould h av e been n o t $ 718 b u t $ 1 ,7 5 0 . T h e
difference is th e m easure of th e econom ies an d ad ju stm en ts m a d e in the
fam ily b u d g et for food over th e p erio d of the first 16 years of th e child s
life.
^
>
,
In a sim ilar m an n er w e can study expenditures for clothing, rent,
fuel an d light, furniture an d furnishings, an d m iscellaneous expenses.
T h e basic equations for these are th e follow ing:

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T H E ECONOMIC AND SOCIAL BASIS

[X5]f =

=
=
=
=
[X4] =
[Xi3 ]=
[XS] =
[X 6]
[X 7]
[X 8]
[X 9]

8.95
0.00569
21.59
0.00589
8.435 0.00218
2.004 + 0.00517
14.199 + 0.00703
45.60
0.0103
92.51 + 0.0235
932 + 138 X2
—

—

—

—

x3
x3
x3+
x3
x3
x3+
x3
—

—

—

—

—

0.249
0.0577
0.0172
1.447
1.297
3.132
15.71

x2
x2
x2
x2
x2
x2
x2

29

(clothing)
(rent)
(fuel and light)
(furniture)
(miscellaneous)
(food)
(deficit or surplus)

In these equations X 5 equals the p e r cent of to tal expenditure spent
fo r clothing; X 6, th e p e r cent for re n t; X 7, th e p e r cent for fuel a n d
light; X 8, th e p e r cent for furniture an d F irnishings; X 9, th e p e r cent for
m iscellaneous expense; X 4, th e p e r cent fo r fo o d ; X 13, th e annual
deficit ( — ) o r surplus (-}-) in dollars; X 3, th e total annual expendi­
tu re in d o llars; an d X 2, th e size of th e fam ily in units of th e ad u lt m ale.
F ro m th e foregoing list of equations th e n et increases of the b u d g et
fo r v arious classes of expenditure in rearing a child to sixteen years
h av e been co m puted. T h e am ounts are, respectively, fo r clothing,
$ 2 6 5 ; fo r rent, $ 8 0 ; for fuel an d light, $ 4 0 ; for m iscellaneous expenses,
$ 2 2 0 ; a n d fo r food, $720. A s rem ark ed previously, these are only
th e am ounts a d d e d to th e expenses because of the rearing of a child
to sixteen years, o v er an d ab o v e w h at th e fam ily w ould h av e spent
fo r them if th e re h a d b een no child to rear. It is m ost desirable to
find o u t w h at th e cost w as of actual expenditures on th e o th er com ­
m odities consum ed b y th e child as was estim ated in a previous p a ra ­
g rap h in reg ard to food. T his I h av e been unable to ascertain except
for clothing. T h e actual am ount spent on clothing for a b o y from birth
to sixteen y ears as com puted item b y item from fam ilies of th e w o rk ­
ing class w ith incom es aro u n d $ 1,500 an d w ith three children w as $525.
T his sum is to b e co n trasted w ith th e $265 which is th e am ount a d d e d
to th e clothing b u d g e t of th e fam ily for rearing a child to sixteen years
of age. E v id en tly th e husband an d wife econom ized on clothing in
o rd e r to clothe th e boy, a good deal m ore th an they w ould h av e d o n e
if th ere h a d been no child.
In conclusion, it will b e clear th a t this p a p e r does n o t concern th e
question of w h at a child ought to h av e in o rd e r to b e re are d properly.
T his is a m o st im p o rtan t question. A n d no d o u b t others will develop
it. T his p a p e r show s ra th e r w hat does h ap p e n to fam ily b u d g etary
costs w h ere children are b o rn a n d reared. It is a sad sto ry fo r those
fam ilies n e a r th e m inim um -of-subsistence level, as th e figures in th e
p reced in g p a rag ra p h s show. D oes, th e fa th e r’s w age go u p w hen a
child is born, an d another, an d an o th er? No, as th e fam ily grow s larger
an d older, th e fa th e r’s earnings d o n o t increase because of this fact.
W h a t d o es h ap p e n ? H o w are th e exigencies an d needs o f a grow ing
fam ily m e t? A n d particularly w hat h ap p en s to th e children, in th e
w ay o f com m odities purchased fo r them ? T h e d a ta of this p a p e r
th ro w co n siderable light on these points. In rearing a child from b irth

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STANDARDS OF CHILD WELFARE

to sixteen y ears o f age, $1,325 is o n th e average a d d e d to w h at th e
b u d g e ta ry costs for food, clothing, ren t, etc., w ould h av e b een if th e re
h a d b een no child. T his is th e n et increase in th e to tal expenditures
caused b y bringing up th e child. B ut th e actual cost of w hat th e child
consum es is far m ore. W e h av e seen th a t although th e n e t increase
o f th e b u d g et fo r fo o d an d clothing is only $ 985, th e actual cost of the
child’s fo o d an d clothing is $ 2 ,275. T h e difference betw een th e increase
in th e fam ily exp en ditures caused b y th e rearing of children an d the
actual cost of th e food an d clothing an d o th er item s consum ed b y them
ind icates th e ex ten t to w hich th e general fam ily stan d ard is low ered by
th eir presence. A t b ottom , it show s th e self-denial of th e father and
m other.


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T H E EC ONOM ICS O F C H IL D W E L F A R E
By DR. ROYAL MEEKER
Commissioner, Bureau of Labor Statistics, U. S. Department of Labor

I suppose th a t because I am an econom ist I am expected to p o in t out
th e relation betw een economics, the dism al science (so nam ed b y those
w ho know nothing ab o u t it) an d child w elfare, incidentally takihg up
the cudgels for th e dism al science.
W h eth er we discuss babies, baseball, bolshevism , or th e binom ial
theorem , w e finally com e up against th e fundam ental philosophy o f life
•-•th e m eaning of creation. W h a t is it all ab o u t? M any econom ic
discussions d eal w ith b abies chiefly as potential la b o r pow er. Now,
th a t is a ra th e r shocking id ea w hen first w e com e up against it in th a t
crude, b ru tal way. Shall w e nurture our b abies an d bring them to m a­
turity fo r th e p u rpose of creating the m ost efficient la b o r force? Shall
w e follow th e econom ic interpreters of history in ascribing all pow er
to the econom ic m otive in th e determ ination of hum an co nduct? Shall
w e follow th e efficiency m anagers an d th e scientific experts in laying
dow n th e principle th a t th e education o f the child m ust b e th e education
th a t will m ake him th e m ost efficient p ro d u c er so th a t w e m ay g et m ore
p ro d u ct, so th a t m ore babies m ay b e b ro u g h t into th e w orld, so th at
m o re w ork m ay be do n e to p ro d u ce m ore g o o d s so th a t m ore b abies
m ay be b ro u g h t into th e w orld, an d so on a d infinitum ?
T h a t is the w ay th e op p o n en ts of th e econom ic in terp re tatio n of his­
to ry an d th e o p p o nents o f scientific m anagem ent state th e case, an d , of
course, it im m ediately arouses every ounce o f opposition in all our
natu res an d we say, “ aw ay w ith such theories, aw ay w ith such d o c­
trines; w e will h av e none of them . W e will h av e th e education th a t will
bring th e child to its fullest developm ent.**
Now, w h at is th e fullest dev elo p m en t of th e child? Y ou see w e are
alre ad y up against th e philosophy of th e w hole thing. W h a t is it all
a^o tit? W h a t is ° Ur fundam ental philosophy of life? W ith o u t either
subscribing to o r opposing tho econom ic in terp retatio n of history it is
a t once ap p a re n t th at child w elfare is largely econom ic. If w e include
m th e definition o f th e econom ic m otive every desire th a t th e h u m a n 1
h ea rt feels, then th ere is no escape from th e econom ic in terp re tatio n o f
history. If w e w ant to give a narrow definition to it, how ever, an d
confine th e econom ic m otive to th e chasing of d ollars fo r th e p urpose
of satisfying o u r m o re im m ediate physical needs, if we h o ld th a t th ere
31

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STANDARDS OF CHiLD WELFARE

are ethical m otives and aesthetic motives and instinctive motives that
are m ore or less antithetical to' the economic motive, even so we are
bound to acknowledge th at child welfare is Very largely an economic
problem, because ethical teachings, aesthetic appeals, do not go very far
on an em pty stom ach; they do not go very far with the children living
under conditions of poverty and distress. W e m ust at least have an
economic background, even if we adm it without further argum ent that
economics do not include everything in the w orld and everything in
the universe.
W e h av e n o t p u t enough scientific stu d y into th e consideration of
w h at 4k in d o f upbringing children should b e given in o rd e r to enable
th em to reach th e fulfillm ent of th e purposes of creation. I tak e it th a t
th e C h ild ren ’s B ureau has b een established fo r a pu rp o se quite sim ilar
to th a t w hich b ro u g h t ab o u t th e establishm ent of tl\e B ureau of A nim al
H u sb an d ry . F o r m any, m an y years w e h av e given a g re at d eal of
th o u g h t to th e upbringing of hogs, cows, cattle, a n d horses. It is a v ery
im p o rtan t thing. I am n o t saying a w o rd against th e B ureau of A nim al
H u sb an d ry . I am glad it w as fo u n d ed w hen it was, an d I h o p e it will
k eep on doing th e excellent w ork it has b een doing. I think hogs, cows,
a n d h orses should b e given every encouragem ent to attain th eir fullest
self-realization.
O u r C h ild ren ’s B ureau is then, in a way, a B ureau of C hilh
H u sb an d ry . In extending its scope statistical studies are of vital im ­
portan ce. W ith o u t th e statistical investigations th a t th e C hildren’s
B ureau h as m a d e w e w ould n o t h av e a fraction of th e kn o w led g e th a t
we now h av e of th e n eed s fo r th e p ro p e r up-bringing of children. 1
m ight say incidentally th a t th e statistical w o rk of m y pw n b u reau has
co n trib u ted som ew hat to our know ledge of th a t subject. T ake, fo r ex­
am ple, th e cost-of-living statistics. T h ese tables for 22 cities ap p e are d
in the M o nthly R eview o f th e B ureau of L ab o r Statistics fo r May,
1919, a n d p re sen ted m any interesting phases. T a k e th e fact th a t the
larg er th e incom e th e larg er th e family. Q uite obviously th e exp lan a­
tion is th a t th e m o re children th ere are th e m ore w orkers. T h e in­
com e increases w ith th e n u m ber of incom e earners.
It is extrem ely interesting to study th e changes in th e p ercen tag e
distribution of expenditures w ith changes in th e size of th e family.
T h ey show th e influence of th e bab ies upo n expenditures. A w ife w hen
she first m arries, according to th e tabulations w o rk ed out, spends ab o u t
as m uch for clothes as th e husband, in th e w orkingm an’s fam ily. Som e
o f you m ay b e surprised to h e a r th a t th e w om an spends almost as m uch
as th e m an. T h e accepted notion is q u ite to th e contrary. B ut ju st as
soon as th e first b a b y com es h e r expenditure fo r clothes drops. W hen
th e n ex t b a b y conies, it d ro p s again; so eventually th e wife becom es
absolutely— I d o n o t like to say it b u t I d o n o t k now of an y o th er te rm

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T H E ECO N OM IC A N D SOCIAL BASIS

33

in w hich to express it— a dom estic slave. She is absolutely tied to th e
hom e, to th e house I m ean, n o t th e hom e. She has no clothes in w hich
she can a tte n d a m eeting like this to b e tau g h t ab o u t statistics an d all the
o th er things co nnected w ith child w elfare. She can n o t even go to
church unless she is willing to go in an outfit th a t do es n o t len d itself
to .display.
A s a m a tte r o f fact in m any incom es which I h av e studied I h av e
n o ted th a t w ith th e increase o f th e fam ily every item of expenditure,
except food, declines n o t sim ply in percentage b u t in absolute am ounts.
T his m eans, o f course, th a t com forts an d even necessities m ust b e sacri­
ficed to m eet th e m o st pressing n eed — th e need fo r food. O f course,
this is only in th e low er-incom e groups, b u t it certainly indicates th a t
som ething n eed s to b e d o n e to b rid g e this gap. It certainly indicates
th a t it is w o rth while thinking ab o u t this thing so carelessly an d com ­
placen tly called th e A m erican stan d ard of living.


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FA M IL Y B U D G ETS
By DEAN S. P. BRECKINRIDGE
U niv ersity of C hicago

T h ere are th ree item s which should b e included in any estim ate
of th e p ecuniary cost of child care. T hese are: th e cost of th e articles
n ee d ed fo r th e ch ild’s physical m aintenance; th e cost of th e m ainte­
nance of those persons necessary to th e child’s existence a n d care; and
th e cost of o th er persons w ho are necessary to th e situation of which
th e child is a p art. F o r such an estim ate of th e pecuniary cost, refer­
ence m ust b e m ade, of course, to an ascertained tim e a n d place.
T h e social w orkers of C hicago h av e m ad e it easy to answ er certain
questions w ith reference to th e m oney cost of child ca re in a fam ily
group in th a t city a t a given tim e, nam ely, in F ebruary, 1919. W ithin
th e p ast few w eeks representatives of th e various agencies dealing w ith
fam ilies in distress, u n d e r th e direction of Miss N esbitt,1 fo r som e tim e
th e distinguished dietitian of th e C ook C ounty Juvenile C ourt, h av e
b een w orking to form ulate ju st th a t statem en t; an d th e result of their
inquiry h as b ee n laid o r will b e laid b efo re th e responsible executives
of these agencies, w ith the suggestion th a t these estim ates b e reg ard e d
as a m inim um sta n d a rd below w hich n o fam ily for w hose life th e
agency is in an y w ay responsible b e allow ed to fall. In this attem p t,
as is th e usual practice, th e item s essential to th e co m fo rt an d w ell-being
of th e vario u s m em b ers of th e fam ily a re carefully designated b y th e
dietitian, w ith th e aid of th e o th er w orkers having to d o w ith fam ily
problem s.
'
j 1
i
In listing th e fo o d requirem ents, th e enum eration co rresp o n d s closely
w ith those m a d e b y others skilled in th e field of nutrition. T h e needs
of th e m o th er a n d children are estim ated in term s of th e n eed s of th e
a d u lt m an p e r day, taking th e 3 ,0 0 0 -3 ,5 0 0 calories as tUb energy basis
an d 75-100 gram s as th e p rotein requirem ent, w ith d u e notice of the
m ineral requirem ents. A s is com m only done, th e p ro p o rtio n allo tted
to th e w om en an d girls is sm aller th an th a t allo tte d to m en a n d boys;
b u t as has n o t alw ays b een done, th e fo o d requirem ents of th e o ld er
bo y s an d girls a re recognized as equal to th o se o f th e a d u lt o f th e
sam e sex.
,
In general, -the estim ate of food cost w as 43 cents p e r m an p e r day,
iF lo ren ce N esbitt, T h e C hicago S ta n d a rd B udget fo r D ep en d en t Fam ilies.
cago C ouncil of Social A gencies, B ulletin No. 5.

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T H E ECO N O M IC A N D SOCIAL BASIS

o r $ 3 .0 0 a w eek fo r th e m an, a n d $ 1 .6 0 a w eek fo r each child u n d e r
6, as th e y o unger child should h av e m o re expensive fo o d in sm aller
am ounts a n d th e o ld er çhild should h av e m o re fo o d o f th e cheaper
kinds.
T h e basis o f th e estim ate fo r clothing is careful inquiry am ong re a­
sonably- w ell-clothed fam ilies w here th e selection is know n to b e skilful
in th e n u m b er a n d kinds o f articles used. T h e estim ate is d ecen t an d
com fortable, in th a t allow ance is m ad e fo r night w ear a n d for changes
required b y th e alternating seasons. It is, how ever, fa r from lavish,
alth o u g h it p resupposes in d ep en d e n t enjoym ent ra th e r th an d e p e n d ­
ence u p o n ch aritable gifts o r com m on use.
A ssum ing th a t free m edical an d nursing service are available, a very
sm all estim ate is m ad e fo r expenditure re la ted to th e p ro tectio n of
h ealth .
S om ething is allow ed for th e recreation o f th e children o v er six b u t
n o t a t w ork a n d fo r th e school expenditures of those in school.
B y a d d in g to these estim ates a share o f th e necessary expenditures
fo r household supplies, w e can g e t totals w hich express th e m inim um
ex p en d itu re th o u g h t safe fo r a child m each of th e age an d sex groups
into w hich th e fam ily is classified.
COST P E R T E A R OF NECESSITIES FO R C H IL D R E N O F S PECIFIED AG ES AN D
EOR PARENTS.
(Calculated from figures given in budget referred to: not included in these estimates are
rent and insurance.)
Child
Child
Child Child
_child 0ver 14 _
under
3-5
6-9
10-12 ^-Child 1 3 -1 4 -^ ^ A t
3
Incl- In°lIncl.
Boy
Girl
Boy
Girl
Father Mother
r t w u i ® 3-39 $ 83.30 $ 96.20 y$109.20 $127.40 $114.40 $156.00 £124.80 $156.00 $¿24.80
Clothing ; . . . . . . 27.00 33.00
45.00
54.00
60.00
60.00
90.00 • 90.00 90.00
66 00
1ncreas e m h ousehold
p.“ ?®11“ . ' * * •*
Health (a) . . . .

3.00

E d u c tio n 11

........................

““

4-®9
3.00

4-50
3.00

4,50
3.00

4-50
3.00

4-5<)
3.00

4.50
3.00

4.50'
3.00

3-°°

f 00

300

3-°°

130(>

13-0D

(b)
3 00

(b)
"3 00

3.00 3.00

iaT0E s t im ^ < ; f n l ^ l u i 23-80 $175-50
* 199-70 $186.70 $266.50 $235.30
$252.00 $796^0
-f
health expenditures assume that public doctors and nurses will be used,
(b) Included in common expenditures.
.
'
Common expenditures:
Household supplies (for fam ily of t wo) . . . . . . . . . . . . . . .$48.00
P.

........... ................. ..................................

Education (newspapers, e tc .).................... ! . . ! ! ! . . ! " . ! ! ! .

78 00
9^00

B u t th ere is, m oreover, th e cost of th e fa th e r an d of th e m other.
T hese to tals fo r th e ra re family, know n to th e “investigator” as the
“n o rm al” fam ily of father, m other, a n d th ree to five children u n d er
fourteen, range from $ 8 4 2 .1 0 for th e fam ily w ith th ree quite young
children to $ 1 ,2 0 4 .3 0 fo r th e fam ily w ith five children scattered
through th e age groups b u t all u n d e r fourteen.
H ow ever, this estim ate says nothing o f insurance o r of rent. A c­
co rd in g to th e housing studies m a d e in C hicago during th e p ast fifteen
years, it w ould certainly n o t b e excessive to a d d from $ 7 .5 0 to $ 1 2 .5 0
a m o n th o r from $90 to $ 1 5 0 a y e a r for re n t to this estim ate, m aking
th e m inim um from $ 9 3 2 .1 0 to $ 1 ,3 5 4 .3 0 w ithout insurance a n d w ith­
o u t provision fo r the o ld er children’s b o oks an d m agazines, o r for

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STANDARDS O F C H IL D W E L F A R E

extras con n ected w ith o th er em ergencies th an those p ro v id ed for in
insurance arran g em ents— christenings, m arriages, etc. No allow ance
is included fo r ch aritable gifts o r contributions to th e church. O f these
estim ates, th e com m ittee says, “ th e sta n d a rd set is in th e judgm ent
of th e com m ittee th e low est one th a t will furnish conditions neces­
sary fo r satisfactory grow th an d d ev elo p m en t of children a n d norm al
a d u lt life, an d so in th e ju d g m en t of th e com m ittee no fam ily of
w h atev er nationality, p ast history, o r sta n d a rd s should b e allow ed
to fall b elo w it, if it is possible to p re v en t them from doing so.’*
T h e im p o rtan ce of this estim ate in th e C hicago situation m ay b e
illu strated b y th e difficulties u n d er w hich th e C ook C ounty Juvenile
C o u rt is operating, w hen u n d e r th e statu te th e highest am ount which
it can g ra n t to any one fam ily is $60 a m onth, o r $ 7 2 0 a year, an d then
only if th ere are six children, although fo r a fam ily in w hich th ere are
six children, even if th ey w ere all u n d e r three, th e allow ance w ithout
ren t an d insurance should b e $ 7 0 6 .8 0 , w ithout provision for th e
m other, o r $ 9 0 3 .6 0 if h e r fo o d a n d clothing w ere co u n ted in. If th ere
is an in cap acitated father, a contingency th e Juvenile C o u rt law defi­
nitely contem plates, th ere should, of course, b e provision fo r him , b u t
n o n e is m a d e u n d e r th e law.
In th e sam e way, th e S oldiers’ an d Sailors’ A llow ance provision, as
generous as th o se influential in securing th e a d o p tio n of this m eth o d of
caring fo r th e fam ilies of th e m en d a re d to suggest to C ongress, co n ­
tem p lates $30 a m o n th fo r th e m other, $15 from th e h u sb an d ’s pay
an d $15 from th e T reasury, an d allow ances for th e children of $10,
$ 7 .5 0 , an d $5, w ith $50 from th e T reasury, o r $65 alto g eth er ( o r $600
an d $ 7 8 0 an n ually) as th e u p p e r lim its of contributions.
T h re e po in ts should b e m ade, of course, in connection w ith these
estim ates:
1. T h e y are th e estim ates of p ersons w hose p o in t o f view is th a t
of hu m an w ell-being. T h ese persons are in daily co n tact w ith those
w hose p ecuniary resources fall far below even these slender allow ances.
T h ey are persons w ho, w hile trying to estim ate th e essential, are accus­
to m ed to think in term s of m inim a an d n o t of ad e q u ate o r generous o r
rev o lu tio n ary allow ances.
2. T h e estim ates are based, on th e one hand, on prices definitely
ascertain ed ; on th e other, on uses an d practices of careful intelligent
m anagers. In an y one of o u r com m unities, especially w ith th e shifting
an d m o v em en t of p o p u latio n th a t has b een b ro u g h t ab o u t b y th e w ar,
th ere w ould b e m any w om en w ho m ight b e highly skilled in household
arts o f v arious kinds y et n o t sufficiently fam iliar w ith th e conditions of
retail buying o r w ith th e requirem ents of th e season to tran slate the
incom e thus estim ated in such a w ay as to secure th e w ell-being p re ­
scribed.

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37

E stim ates sim ilar to th e one described h av e been m ad e in o th er
com m unities.1 Miss N esbitt cam e to C hicago afte r form ulating a
sim ilar b u d g et fo r C leveland agencies. In fact, the a rt of form ulating
th e b u d g et fo r th e fam ily in w hose beh alf responsibility is assum ed fo r
a consid erab le p erio d of tim e by the social agency, as fo r exam ple in
the case of the fam ily of a soldier o r sailor for w hom for som e reason the
G o v ern m en t allo tm ent an d allow ance provision is either n o t available
or inadequate, is now being well dev elo p ed an d is practiced b y m ost
case-w ork agencies. G o o d social case-w ork agencies m ust base their
w ork u p o n such estim ates, an d th e inadequacy of th e G overnm ent
allow ance has forced th e H om e Service Section of th e R ed C ross to
fram e sim ilar estim ates in o rd e r th a t th ey m ay n o t allow th e soldier’s
fam ily to suffer.
3.
T h o se who m ad e this estim ate h a d in m ind th e use of charitable
funds b y responsible social agencies, th e y w ere saying nothing of th e
w age bargain. T h ey w ere bringing pressure to b e a r in th e service of
th e w eak an d inarticulate an d n o t so m uch in behalf of the individual
u n d e r care as fo r the com m unity itself. B ut if their estim ates w ere
placed beside th e w age scales of m any of th e establishm ents in Chicago,
the discrepancy betw een the estim ated m inim um an d the actual incom e
w ould becom e apparent.
T h ere has alw ays been such a discrepancy. If we look b ac k upon
the> attem p ts to arrive a t such estim ates w e End, in 1 795, D avid
D avies2, a clergym an of th e C hurch of E ngland, gathering bu d g ets
an d illustrating from th e experience of his own parishioners th e c o n ­
nection betw een the inadequate w age p aid agricultural lab o rers in
E ngland an d th e dem oralizing effect of public o u td o o r relief. A t th a t
early d a te th e principle of th e m inim um w age w as urged b y th e liberal
W h itb re ad .3
T h e econom ists as well as th e statisticians an d the students of social
w ell-being h av e given atten tio n to the problem . In their discussions,
it has been assum ed th a t th e w age bargain entered into b y th e em ployer
an d th e em ployee, b o th acting u n d er the m otive of enlightened selfinterest, w ould b e such as w ould allow th e w orker to m aintain him ­
self as an efficient w orker an d to replace him self by an efficient
w orker, th a t is, w ould supply th e “cost of child care.” T h e estim ates
of the so-called necessaries for life, for com fort, o r for efficiency, h av e
recognized th e com plexity of (the problem b y including th e category of
conventional necessaries,” in which w ere grouped those indulgences,
*See W . J e tt L auck, C ost of L iving a n d th e W ar.
2T he C ase of th e L a b o u rers in H u sb a n d ry S tated an d C onsidered.
•Sam uel V^hitbread, 1 758-1815. See H am m ond, T h e V illage L ab o u rer, p s .
154 an d 179.

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STANDARDS O F C H IL D W E L F A R E

like th e pipe an d the new spaper, which th e w orkingm an w ould have
even if h e w ere th ereb y forced to d o w ithout th e articles thought b y the
econom ists to b e essential to his life, his w orkm anship, o r th e p erp etu a­
tion of the lab o r supply.1
W ith th e eighties cam e th e great effort of Mr. C harles B ooth8 to
p en e trate th e d ark est spots of L o n d o n ; an d follow ing on his great
inquiry into th e Life an d L ab o u r of th e P eople in L ondon, cam e
Mr. B. S eebohm R ow ntree’s8 attem p t to furnish an estim ate n o t only
of w h at th e d ep ressed classes receive a n d spend b u t an estim ate of
the incom e necessary in o rd e r th a t th e dietetic n eed s of th e household
should b e m et. His m inim um for food alone w as fixed for a m an in
Y o rk in th e y e a r 1899 a t th ree shillings a week, an d his w eekly incom e
for th e fam ily of five a t from 18s. to 26s. H is estim ates are review ed
a n d revised b y M r. Bowley4 on th e basis of a stu d y of the towns, N orth­
am p to n , W arrington, Stanley, an d R eading, a n d estim ated in 1913 a t
11s. I d . fo r m an an d wife, o r 17s. 4 d . for m an an d wife an d three
children u n d e r five years of age.
O r turning to th e inquiries pursued in th e U nited States, w e find,
besides th e estim ates of th e social w orkers, those form ulated on th e
basis of m inim um w age determ inations. T hese are rendered, how ever,
far less useful an d significant th an th ey m ight b e b y th e fact th a t in
general u n d er o ur C onstitutional lim itations, th e m inim um w age ideal ^
is th o u g h t applicable chiefly, if n o t exclusively, to w om en an d girls,
a n d so w e d o n o t h av e estim ates of m inim um fam ily incomes.
T he*idea of th e m o d ern relief-giving agency, th a t only b y ad eq u ate
reg u lar allow ance determ ined afte r investigation on th e basis of th e
special n eed s in th e individual case is th e responsibility of th e society
fulfilled, h as given rise n o t only to th e practice of b udgeting b u t called
fo r w ider studies of cost. T hese results m ay b e illustrated b y such
studies as C hapin’s S ta n d a rd s of Living in N ew Y o rk City, an inquiry
■ u n d ertak en b y th e New Y ork S tate C onference of C hanties, an d b y
M iss W inifred G ib b ’s M inim um C ost of Living in N ew Y o rk City,
JSee, fo r exam ple, A lfred M arshall’s discussion in P rin cip les of E conom ics,
V ol. I, Book II, chap. iv. See also J. S. Mill, P rin cip les of P olitical E conom y, Book
I chap, iii, section 5. “ B ut th e consum ption even of p ro d u ctiv e la b o u re rs is n o t all
of it p ro d u ctiv e consum ption. T h e re is u n p ro d u c tiv e co nsum ption b y p ro d u ctiv e
consum ers. W h a t th ey consum e in k eep in g up o r im proving th e ir h ealth , stren g th ,
an d th e capacities of w ork, o r in re a rin g o th e r p ro d u ctiv e la b o u re rs to succeed
them , is p ro d u ctiv e consum ption. But con su m p tio n o n p le a su re s o r luxuries,
w h e th e r b y th e idle o r by th e in d ustrious, since p ro d u c tio n is n e ith e r its o b je c t
n o r is in an y w ay ad v an ced by it, m u st be re c k o n e d u n p ro d u c tiv e ; w ith a re se rv a ­
tio n p e rh a p s of a ce rta in q u an tu m of en jo y m en t w h ich m ay be classed am o n g
necessaries, since an y th in g sh o rt of it w ould n o t b e co n sisten t w ith th e g re a te st
efficiency of lab o u r. T h a t alone is p ro d u ctiv e consum ption, w h ich goes to m am ta in an d in crease th e p ro d u ctiv e p o w ers of th e com m unity.”
2C h arles Booth, 1840 -1 9 1 7 .
3B. Seebohm R ow ntree, P overty.
4A. L. Bowley an d A. R. B u rn o tt-H u rst, Livelihood an d P overty.


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T H E ECO N OM IC A N D SOCIAL BASIS

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b ased on o b servation of fam ilies u n d er the care of the New Y ork
A ssociation for Im proving the C ondition of th e P oor.
A ll studies o f the first of these tw o groups follow substantially the
R o w n tree m eth o d of laying special stress on th e d ietitian’s estim ate of
th e physiological n eed s of the individual supplem ented b y th e practices
of som e public ag e n cy 1 which tran slate those needs into term s of prices
as found in the local com m unity. T o these estim ates of th e necessary
m inim um fo o d costs are a d d e d m uch less definite estim ates of th e costs
of shelter, clothing, th e protection of health, an d th e gratification' of
th e spiritual an d intellectual needs.
W h a te v er th e m eth o d of ap p ro ach o r th e basis of judgm ent, h o w ­
ever, one fact has em erged from these studies. T h e incom es earned
b y large n u m bers of our so-called in d ep en d en t w age-earning m en
h av e b een far below th è am o u n ts. estim ated b y students an d investi­
g ato rs as necessary to m eet the rational an d socially im p o rtan t needs.
C hapin concluded th a t th e task of m aking b o th ends m eet w as in 1907
too severe on all incom es u n d e r $800 “w ithout a low ering of th e stan d ­
ard s of living below th e norm al d em an d s of health, w orking efficiency,
an d social decency.” 2
Miss B yington3 estim ated in 1908 for H om estead, P ennsylvania,
th a t $ 1 5 .0 0 a week, o r $780 a year, w as necessary for health, while
$20 a week, o r $ 1 ,0 4 0 a year, was required for à reasonably A m erican
fam ily life. K ennedy4 in Chicago in 1914 found th at all fam ilies
earning less th an $600 en d ed the y ea r w ith a deficit, an d estim ates
th a t $80 0 w as th e least on which a fam ily of five could b e su p p o rted .
P rofessor Jessica P eixotto in O ctober, 1917, estim ated $ 1,320.5 A n d
so th e estim ates m ight b e m ultiplied.
In all the studies, th e deficiency of the w age level as m easured by
ratio n al estim ates of hum an needs has b een m a d e know n. D avies
show ed th a t reliance on the p o o r rates w as inevitable for th e g re at m ass
of his parishioners. E den thought th e deficiency m ight b e red u ced if
the w om en knew b e tte r how to spend. R ow ntree an d Bow ley re p o rt
ap p allin g p ercentages living either in p o v erty o r on th e b rin k of the
abyss. In th e U nited States, if w e recall th e suggested estim ates, we
find g re at num bers of th e w orkers falling below . T h e R ep o rt of th e
Im m igration Com m ission ap p o in ted b y C ongress m 1907 an d reporting iij 1910, contains a hideous m ass of testim ony to the inadequacy
1See, fo r exam ple, W om an a n d C hild W age E arn ers, V oi. X V I, B udgets of
Selected C o tto n Mill 'W orkers.
^R obert C. C h a p in ,'T h e S ta n d a rd of L iving A m ong W o rk in g m en ’s Fam ilies in
New Y ork C ity, p. 234.
3M arg aret F. B yington, H om estead, th e H ouseholds of a Mill T ow n, p. 105.
4Jo h n C. K ennedy, W ages a n d Fam ily B udgets in th e C hicago S to ck y ard s Dis­
trict, p. 79.
8W . Je tt L auck, C ost of Living a n d th e W ar, p. 131.

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40

STANDARDS O F C H IL D W E L F A R E

of th e incom es received by our foreign-born w orkers. G re at variations
exist am ong th e different nationalities, an d the different industries, but
n o t only such ancient offenders as th e textile industries th a t h av e alw ays
uriderpaid w om en an d children, b u t th e g reat m an-em ploying indus­
tries in th e new er sections of th e country, are show n to h av e h a d a w age
scale m aking im possible such life as is described an d p ro v id ed for in
the studies referred to above.
*
Sim ilar facts could b e a d d e d concerning our southern w hite millw orkers o r th e negro w age earners anyw here.
B ut th e question m ay b e put, if th ere is such a conflict betw een th e
estim ate placed on the ap p ro p riate cost of child life b y th e social inves­
tig ato r an d b y th e practices of m en as registered in th e w age bargain,
can w e b e certain th a t th e form er are correct? H ow can this claim b e
established? T h ere are several p ertin en t facts to b e noted. Som e of
th e m ost striking are those contained in the re p o rts on infant m ortality
recently published b y th e C hildren s Bureau.
F irst, as to the source of the incom e, it should b e ad m itte d th a t a
g rav e w rong has often b een do n e th e fam ily situation in th e investiga­
tions referred to above. T hose studies h av e considered com posite
incom es m ad e up of th e earnings of th e father, th e ^supplem entary earn ­
ings of th e m other, an d th e earnings of th e o ld er children. T h e C hil­
d re n 's B ureau m ad e a contribution of incom parable significance w hen
it called us to o u r senses an d po in ted out th a t the incom e to b e consid­
ered should b e th a t derived from th e earnings or th e activities of th e
father. O n this subject th e B ureau says convincingly:
“ T h e fa th e r’s earnings, it is believed, fu rn ish th e m ost reliable index to th e
econom ic statu s of th e fam ily b ecau se in m ost cases th e y a re n o t o nly th e chief su p ­
p o rt b u t also th e m ost stable a n d re g u la r elem en t in th e fam ily incom e. S upple­
m e n tary sources of incom e su ch as m o th er s a n d child ren s earn in g s a re likely
to be te m p o ra ry a n d fluctuating. A special o b jectio n to lu m p in g fa th e r s earn in g s
w ith th e earn in g s of th e m o th e r a n d ch ild ren is th a t th e gainful em ploym ent of th e
la tte r indicates a low econom ic sta tu s w h ich w ould te n d to be o b scu red w ere th e ir
earn in g s com bined.” 1

Second, as to th e am ount of th e incom e. T h e C hildren’s B ureau
h as given us som ething of a m easure of th e w aste resulting from th e
low incom e conditions to w hich reference has b een m ad e in th e w aste
of som ething no less precious th an infant life itself. A s th e incom e
of th e fath er goes dow n, th e d ea th ra te of th e bab ies goes up. In re ­
p o rt a fte r re p o rt th e correlation thus appears. F o r exam ple, from
a re p o rt on Johnstow n, P a., th e following figures m ay b e q u o te d :2
i n f a n t M ortality, R esults of a F ield S tu d y in M anchester, N. H ., B ased on B irths
in O n e Y ear, by B eatrice S heets D u n can a n d Em m a D uke, p. 40. U . S. C h ild ren s
B ureau Publication No. 20, In fan t M ortality S eries No. 6, W ash in g to n , 1917.
2Infant M ortality, R esults of a Field S tudy in Johnstow n, P a., Based on Births^ in
O n e C alen d ar Y ear, b y E m m a D uke, p . 45. U . S. C h ild ren ’s B ureau P ublication
No. 9, Infant M ortality S eries No. 3, W ash in g to n , 1915.

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T H E ECO N OM IC A N D SOCIAL BASIS

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" A g ro u p in g of babies a c c o rd in g to th e incom e o f th e fa th e r show s th e g reatest
incidence o f in fan t d eath s w h ere w ages a re low est, a n d th e sm allest incidence
w h ere th e y a re highest, in d icatin g clea rly th e relatio n b etw een low w ages a n d ill
h ealth a n d in fan t deaths.
"F o r all live babies b o rn in w edlock th e in fan t m o rta lity ra te is 130.7. It rises
to 255.7 w hen th e fa th e r e a rn s less th a n $521 a y e a r o r less th a n $1 0 a w eek, a n d
falls to 84 w hen he e a rn s $ 1 ,2 0 0 o r m o re o r if his e a rn in g s a re 'ample.* "

T his connection betw een low earnings of fa th e r an d high infant death
ra te persists if w e sep arate native from foreign born.
In considering th e b ab ies of n ative a n d of fo reig n m o th e rs se p a ra te ly . . .,
sim ilar v ariatio n s in m o rta lity rates acc o rd in g to e a rn in g s of fa th e r a re found!
alth o u g h th e fo reig n in fan t d e a th ra te is h ig h er in ea c h g roup. T h e fo reig n a re
less n u m ero u s b o th ac tu a lly a n d relatively in th e h ig h e r w age groups.
“ T h e fo reig n ers of a given w age g ro u p alm ost alw ays live in a p o o re r n e ig h ­
b o rh o o d th a n th e natives ea rn in g th e sam e am o u n t. T h e fo reig n ers go w h ere
th ey find th e ir ow n c o u n try m en , m ost of w hom a re p o o r, a n d h ence even those
w ho e a rn a fair w ag e find them selves, u n til th ey b ecom e A m ericanized, su r­
ro u n d ed b y p o o r conditions a n d an ig n o ra n t class o f p eo p le.” 1

F ro m M ontclair, N. J., th e follow ing testim ony w as ta k e n :2
" I t is obvious th a t even th e c a re given th e b ab y b y its m other, often m u st be
offset b y th e evils resu ltin g from a n incom e insufficient fo r th e fam ily’s needs, since
a low incom e freq u e n tly m ust involve u n d esirab le h o u sin g accom m odations, an
o v erw o rk ed m o th er, insufficient n o u rish m e n t fo r m o th e r a n d child, a n d lack of
co m p eten t m edical advice. . . . In M ontclair th e in fan t m o rtality ra te w as
ap p ro x im ately tw o a n d o n e-h alf tim es as h igh a m o n g fam ilies w h ere th e incom e
w as less th a n $12 a w eek as a m o n g fam ilies w h ere th e incom e w as $23 a w eek
o r m o re .”

F ro m M anchester, N. H ., th e follow ing evidence is o b tain ed :
"B abies b o rn in th e hom es o f unskilled w o rk ers w h ere earn in g s a re sm all face
g re a te r hazard s th a n those in m o re fo rtu n a te circum stances. W h en th e 1,564
live-born babies included in this stu d y a re g ro u p ed acco rd in g to fa th e r’s e a rn ­
ings, it is found th a t am o n g th e babies in th e low est-earnings gro u p in fan t d eath s
a re m o re th a n fo u r tim es as fre q u e n t as in th e h ig h est-ea rn in g s g ro u p .
* * *

*

¥

*

*

«

«

¥

¥

¥

¥

¥

¥

T h e in fan t m o rtality ra te show s a m ark ed a n d alm ost re g u la r decline as th e
fa th e r’s earn in g s becom e la rg e r. In th e g ro u p of babies w h ere th e fa th e r’s e a rn ­
ings a re less th a n $45 0 p e r a n n u m th e in fan t m o rtality ra te is 24 2 .9 , w hile in
th e n e x t group, w h ere th e fa th e rs e a rn from $45 0 to $ 549, th e fa te is 173.6.
It rises v ery slightly in th e n e x t class, $ 550 to $649, nam ely, to 1 74.5, a n d th e re ­
a fte r d ro p s steadily w ith e ach ad v an ce in econom ic statu s. T h e ra te , how ever,
i n f a n t M ortality, R esults of a Field S tudy in Johnstow n, P a., Based on B irths in
O ne C alen d ar Y ear, by E m m a D uke, p p . 46-47. U. S. C h ild ren ’s B ureau P ublication No. 9, In fan t M ortality Series No. 3, ^/asH iiigton, 1915.
_ 2In fan t M ortality, M ontclair, N. J., A S tudy of In fan t M o rtality in a S u b u rb an
S e S T B c f 4 P ' 9 ‘ U ' S’ C h ild ren ’s B ureau P u b licatio n No. I 1, In fan t M ortality


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STANDARDS OF CHILD WELFARE

42

doss n o t fall below 100 u n til th e f a t h e r s earn in g s re a c h $ 1 ,0 5 0 o r m o re. Babies
w hose fa th e rs e a rn $ 1 ,2 5 0 a n d over p e r a n n u m have a d e a th ra te of only 58.3. 1

O r from W a terb u ry , C onn. :
“ T h e in fan t m o rtality ra te fo r W a te rb u ry fo r b ab ies w hose fa th e rs e a rn ed
less th a n $450 d u rin g th e y e a r follow ing th e b irth of th e b ab y w as 153; th e ra te
very g rad u ally decreased in th e n e x t tw o incom e gro u p s, b u t it did n o t fall below
100 u n til th e gro u p $850 to $ 1 ,049 w as re a c h e d .’*2

A n d finally from B rockton, Mass. :
" T h é in fan t m o rtality ra te w as h ig h est (1 3 2 .2 ) fo r th e e a rn in g s g ro u p $650
to $ 8 4 9 , a n d low est fo r th e g ro u p $ 1 ,0 5 0 a n d o v e r ( 6 5 .5 ) .
C o n tra ry * to
th e findings fo r o th e r cities, th e m o rta lity ra te s fo r th e earn in g s g ro u p s u n d e r
$ 550 a n d $ 550 to $ 6 4 9 w ere co n sid erab ly lo w er th a n for th e g ro u p $ 650
to $ 8 4 9 . T w o exp lan a tio n s fo r th is p e c u lia r show ing m ay be ad v an ced : F irst,
th e g ro u p s a r e com parativ ely sm all, a n d co n seq u en tly m ay h av e b een co n sid er­
ably influenced b y exceptionally fav o rab le conditions in th e y e a r selected ; second,
th e earn in g s as re p o rte d in th e low est e arn in g s g ro u p do n o t alw ays reflect th e
fam ily’s sta n d a rd of living. T h e relativ ely h ig h p e rc e n ta g e of stillb irth s in th e
low est e a rn in g s g ro u p s m ay b e significant in c o n n ectio n w ith th e low m o rtality
ra tes.” 8

.

A n o th e r testim ony to th e soundness of these estim ates could b e
found, if w e d esired to learn th e truth, in th e records of th e juvenile
co urts a n d of o u r tru a n t schools. F rom the hom es of th e p o o r an d
th e ’’v ery poor,** from th e low, in ad eq u ate incom e groups, com e the
processions of children, boys an d girls, in w hose beh alf this C onference
is g athered.
A question m ay b e raised w ith reference to th e effect of th e w ar
on th e conditions described. O n this subject, others m ore closely con­
n ected w ith w ide inquiries into changes in price an d in w age levels will
speak. T h e testim ony of th e social agencies to w hich reference has
been m ad e is to th e effect th a t w age levels h av e n o t changed w ith rise
of prices. A g re at em ployer in a city in w hich an estim ate sim ilar to
th a t I h av e d escribed w as m ade, said th a t only one-fourth of his
em ployees earn ed enough to enjoy life a t th e level fixed b y th e social
w orkers.
Miss N esbitt is w illing to b e q u o ted on this subject in th e follow ing
w o rd s:4
^ In fa n t M ortality, R esults of a Field S tudy in M anchester, N. H ., Based o n B irths
in O ne Y ear, b y B eatrice S heets D u n can a n d Em m a D uke, p p . 38, 44. U . S. C hil­
d re n ’s B ureau P u blicatio n No. 20, In fan t M o rtality Series No. 6, W ash in g to n , 1917.
2In fan t M ortality, R esults of a Field S tu d y in W a te rb u ry , C onn., B ased on B irths
in O ne Y ear, b y E stelle B. H u n te r, p. 64. U . S. C h ild ren ’s B u reau P u b licatio n No.
29, In fan t M ortality Series Np. 7, W ash in g to n , 1918.
8In fan t M ortality, R esults o f a Field S tudy in B rockton, Mass., Based on B irths in
O ne Y ear, b y M ary V . D em psey, pp. 31-32. U . S. C h ild ren ’s B u reau P u b licatio n
No. 37, In fan t M ortality S eries No. 8, W ash in g to n , 191 9.
4D ictated by h e r in p riv a te interview , M ay 3, 1919.

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T H E ECO N OM IC A N D SOCIAL BASIS

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‘
*n c rease *** *he cost of living has, so fa r as m y o b serv atio n goes, b een
universal since th e b e g in n in g of th e w ar, a n d has risen in sm aller com m unities
alm o st as h igh as in th e cities. F o r example« th e cost o f stap le food m aterials,
including m ilk, a n d th e cost of clo th in g a re p ra c tic a lly th e sam e in th e sm aller
tow ns of n o rth e rn Illinois as in Chioago.
W h ere w o rk ers have b een eng ag ed in in d u stries d irectly affected b y th e
w ar, th e re has un q u estio n ab ly b een a larg e in crease in w ages. T his in crease is
b y no m eans universal. In com m unities w h ere th e re a re n o w a r industries, w ages
a re very little h ig h e r th a n b efo re th e w ar. In th e la rg e r cities, th e re a r e larg e
g ro u p s of w o rk ers w hose w age has n o t b een m aterially in cre a se d .”

F rom such facts as these, a few conclusions m ay b e d ra w n :
1* T h e com m unity can learn if it will w h at th e cost of child care is,
an d this know ledge will b e in th e possession n o t only of those w ho in
th e p ast h av e seem ed to profit from th e im perfect ad ju stm en t betw een
w age levels an d hum an needs, b u t of th e g re at m ass of th e w agew ork­
ers who will n o t m uch longer acquiesce in th a t m alad ju stm en t. T h ey
will h av e k n ow ledge from w hich th ey can conclude justly w hether
th e bill if d uly p resen ted can b e m et b y industry. T h e profits tak en
b y th e em p lo y er will b e co m p ared w ith th e gains secured b y th e
w orkers, a n d an am p ler share in life m ad e possible b y higher p a y as
well as larg e r shar(e of p ow er in th e future control of th e p ro d u c t of
in d u stry will b e dem an d ed .
2. W ith w id er know ledge a n d g re a te r exactness o f estim ate will
com e a w id er d em an d th a t w e ju d g e o u r com m on life b y our conduct
ra th e r th an b y o ur professions. A s th e C hicago com m ittee has said,
a level can b e fixed below w hich no one should b e allow ed to fall. T h e
fixing o f th a t m inim um an d th e giving to all th e o p p o rtu n ity to rem ain
on o r a b o v e th a t le v e l; th e fixing o f an ad e q u ate econom ic level m ainn tain ed ^ th e earning capacity of th e father, thus enabling th e m o th er
to specialize in th e exercise o f th e m atern al function; including in the
p ro g ram n ativ e born, b o th w hite an d black, an d foreign b o rn — this is a
possible goal fo r us to seek. H aving seen th e possibility, w e can “ do
no o th er th an seek it as a m a tte r of national honor. In fixing this
m inim um a n d in raising it as w e learn of o th er elem ents of cost n o t now
included m ay b e found a field fo r friendly rivalry. W hen once qu an ­
titativ e ad eq u acy has b een realized, qualitative value m ay receive
g re ater atten tio n a n d th e peculiar contributions of o u r variously en ­
d o w ed g roups m ay enrich an d beautify th e fabric of o u r natio n al life.
U ntil q u an titativ e adequacy has been attained, how ever, atten tio n to
v ariety a n d richness of life m ust b e in considerable m easure p o stp o n ed .
B ut b y so m uch th e m ore is b o th our present an d our future com m unity
life im poverished.
i


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C O ST O F L IV IN G
By MISS FLORENCE NESBITT
In stitu te In stru c to r in D ietetics, A m erican R ed C ro ss

It is practically im possible to avoid th e su bject o f fam ily incom e
w hen talking ab o u t child w elfare, because it lies so close to th e very
ro o t of all w ork for th e interests of th e child. If th e incom e of th e
fath er is n o t enough to cover th e necessities of life, do es n o t perm it
a m inim um norm al sta n d a rd of living, then either m o th er a n d children
are d riv en into industry, an d h om e life is n e g le c te d ; o r else th e sta n d ­
a rd is low ered, an d we h av e b a d housing, under-nourishm ent, a n d all
th e o th er hideous results of poverty. v
It is a difficult thing to give any absolutely, definite figures for an
incom e below w hich w e d o n o t d a re see fam ilies fall. T hese last few
years, since th e rise in cost o f living »has focused so m uch attention
upo n th e subject, have, how ever, given us increasing confidence th at
w e are ab le to m ak e a fairly accurate estim ate of this sort. W hen
ap p ro ach in g th e p ro b lem from different points of view, w e find th at
o ur results w hen trying to estim ate th e necessary cost of a norm al
stan d ard of living closely app ro x im ate each other. F o r exam ple, the
estim ate w hich th e B ureau of L ab o r b ased on a larg e volum e of
statistics as to w h at p eo p le really d o w ith th eir incom e, differs very
little from th e estim ates of those of us w ho sta rt from exactly the
opposite end, try ing to define th e elem ents of a norm al stan d ard , and
th en attem p tin g to discover th e cost of m aintaining such a stan d ard .
In C hicago, th ose w ho h av e b een w orking on th e p ro b lem recently
figure th a t it Costs ap proxim ately $ 1 ,5 0 0 a y e a r to b u y th e essentials
for m aintaining th e average fam ily of five— father, m o th er an d th ree
children— a t w h at w e m ight consider a norm al stan d ard . T h a t m eans,
of course, a m inim um w age of ab o u t five d ollars a d a y for th e w orking
m an.
L ast fall I m ad e an estim ate of th e m inim um cost of living for a
self-supporting fam ily in C leveland. T h e B ureau of L ab o r h a d at
th a t tim e ju st co m pleted their estim ate which placed th e cost of living
for ship build ers’ families a t som ething u n d e r $ 1 ,5 0 0 p e r year. M y
estim ate w as alm ost th e sam e. I asked tw o m anagers o f C leveland
factories how th a t c o m p a re d .w ith th e w ages of th eir m en. Each one
d e li v e r e d a t th e C hicago C hild W elfare R egional C o n feren ce, M ay 19, 1919.

44

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T H E ECO N OM IC A N D SOCIAL BASIS

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said th a t n o t m ore th an tw enty-five p e r cent of their p eople earned
as m uch as that.
W e are so in th e h ab it of thinking ab o u t th e ra th e r abnorm ally
high w ages som e p eo p le h av e received since th e beginning of th e war,
th a t w e ju m p to th e conclusion th a t the w hole b o d y of w age earners
are earning a g reat d eal m o re th an th ey are. W hen it really com es
dow n to figures, w e find th a t th ere are large groups of w orkers w ho
h av e b een affected very little b y these raises. In th e isolated com ­
m unities w here th e w ar industries h av e n o t p en e trated , th ere is no
increase in w ages th a t even begins to cope w ith th e increased cost of
living. If w e could raise w ages to m eet th e increase in th e cost of
living w e w ould b e on solid ground, b u t th ere has n ev e r b een a tim e
w hen th e o rd in ary w age of un train ed lab o r covered ad e q u ate living.
In 1914, w hen th e unskilled w age w as ab o u t tw o d ollars a day, it
to o k a t least $75 a m o n th to cover th e every-day requirem ents of d e ­
cent living.
So th ere seem only th ree w ays out of th e difficulty: T h e cost of
living m ust com e do w n ; or th ere m ust b e a nationalization of financial
responsibility w hich will relieve th e individual fam ily of a portion of
th e cost w hich th ey m ust now b e a r; or w ages m ust rise to co v er th e
cost of living; so th a t every child m ay h av e his ad e q u ate opportunity
fo r n orm al developm ent.


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T H E C H IL D ’S H O M E
By MRS. E V A W H ITIN G W H IT E
E lizabeth P eabody H ouse, Boston, M assachusetts

T his is a particularly o p p o rtu n e tim e in w hich to discuss th e question
o f th e ch ild ’s h om e because every citizen in th e U nited S tates is now a
sto ck h o ld er in certain housing p ro jec ts th a t strike a new n o te in tow n
an d city dw elling. F rom one end of th e country to th e other, speakers,
w riters, cham b ers o f com m erce, a n d public press are bringing hom e
to th e A m erican public th e significance of th e housing enterprises th at
w ere u n d erta k en in o rd e r to m eet th e em ergency n eed s of th e w ar
p erio d . It m ay b e said w ithout exaggeration th a t th e com m unities
d ev e lo p e d b y th e U nited S tates H ousing C o rp o ratio n an d th e E m er­
gency F leet C o rp o ratio n will stan d as typifying a recognition of a citi­
zen sh ip ,ro o ted in progressive fam ily sta n d a rd s an d d ee p en ed local ties.
A long th e A tlan tic C oast, an d along th e Pacific, b o rd e rin g th e G reat
Lakes, a n d in th e South, are areas w here for th e .first tim e, co m p ara­
tively speaking, th e w orkingm an has n o t b een disdained in bricks an d
m o rta r” ; w here artistry has en tered into th e structural plan<; a n d w here
th e housing p ro b lem has b een recognized n o t only as a question of the
house, b u t as co n cerned also w ith com m unity life in all its phases. It
has b een claim ed th a t w e can n o t b e said to h av e failed to build up
w holesom e industrial sections, because w e h av e n o t tried to build them .
H ereto fo re, w e h av e a d o p te d a system of suprem ely h ap h a zard grow th
an d d ev elo p m en t w hich has p erm itted real estate speculation to- such
an ex ten t th a t th ousands of lives h av e b een h an d icap p ed .
Now, how ever, w e h av e m a d e a beginning; w e h av e b ro u g h t com ­
p lete com m unities into being— com m unities of delightful single, d o u ­
ble, an d row houses, situated on attractively laid o u t streets a n d sur­
ro u n d ed b y g reen an d trees; houses th a t com bine com fort, conveni­
ence, a n d coziness. T hese houses in th e m ajo rity o f cases either sur­
ro u n d o r b o rd e r u p o n a square o r section w hich includes th e store dis­
trict, th e com m unity building w hich is m ean t to m eet social a n d recrea­
tion needs, th e m otion p icture house, a n d th e church sites. In term s
of ch ildhood, co m p are th e ad v an tag es of a b o y o r girl b ro u g h t up in
such! surroundings w ith those of a child living in n ea rb y industrial
sections. F o r exam ple, com pare a child living in B uckm an, P ennsyl­
vania, w hich is one of th e m ost attra ctiv e com m unities bu ilt b y th e

46

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47

E m ergency F leet C o rp o ratio n a few m iles out of C hester, Pennsylvania,
w ith a child living in certain sections of C hester.
If it is tru e th a t th e hom e is th e foundation of social im provem ent
(a n d th e evidence so far is overw helm ingly in favor of th e h o m e ),
an d if w e believe th a t th e m oral an d intellectual fibre o f th e n ex t g en ­
eration d ep e n d s u pon h om e conditions, then certainly th ere is b u t one
course o p en to th e sincere citizen, an d th a t is to d o everything hum anly
possible to m aintain th e th ree g re at gains in reg ard to housing th a t h av e
com e o u t o f th e w ar. T h e first concerns housing as a factor in indus­
trial efficiency. In o rd e r to m eet thg d em an d s of ou tp u t in m anufactur-.
ing w ar m aterial, “Big Business” d id everything possible in th e w ay
of facto ry m an agem ent a n d th e stu d y a n d regulation of factory p ro c­
esses. It w as seen, how ever, th a t o th er factors en tered into efficiency;
th a t in o rd e r to g et the m axim um o u tp u t fo r given energy g o o d housing
w as a necessity, so th a t m en m ight b e reinvigorated ra th e r th an en er­
v ated , ch eered ra th e r th an d ep ressed ; it w as seen also th a t w ith g ood
housing should go social organization; otherw ise neither th e m en n o r
th eir fam ilies w ere contented. T h e hom e in a com m unity setting b e ­
cam e of p rim e im portance.
T his fact should b e k e p t in th e fo refro n t of public thought. Until
industrial w o rkers in cities are p ro tec ted as to their living conditions,
an d until m anufacturing an d producing centers are established th a t
m ake life w o rth th e living, efforts in su p p o rt o f im proved industrial
m anagem ent, efforts to b e tte r fit m an to task becom e alm ost if n o t
quite an absurdity. T h a t vital force w hich com es from a sense o f p e r­
m anency a n d co m fort an d from a sense of th e security jof h om e ties is
th e p lus elem ent a n d th e m ost telling of industrial efficiency factors.
T h e w ar b ro u g h t this out. P eace m ust crystallize th e tru th of it in an
accep ted civic co d e such th a t n o t only shall p rotective housing law s
a p p e a r on ev ery city a n d state statu te book, b u t th e m ovem ent for
b e tte r housing shall sw eep b ey o n d pro tectiv e law to d em an d som e­
thing m o re th an a shelter, to d em an d a hom e. .
T h e second g re at gain of th e w ar in regard to housing has been the
recognition o f th e necessity of F ed eral aid. T h e G o v ern m en t m ust n o t
w ith d raw now . In a m a tte r so fundam ental as th a t of th e A m erican
sta n d a rd o f living th ere should b e F ed eral oversight of com m unity d e ­
v elo p m en t as well as m o n etary aid an d F ed eral initiative in th e stim u­
lation of com m unity housing enterprises. No m ore im p o rtan t m atters
are to face th e citizenship of th e U nited S tates in th e next few m onths
th a n th e establishm ent of a b u reau of housing in th e D ep artm en t of
L ab o r, a n d th e action o f C ongress on a bill w hich will b e presented, th e
o b ject o f w hich will be. to establish H om e L oan B anks so th a t m oney
m ay b e o b tain ed a t nom inal rates of interest b y th e individual h om e
builder. E veryone w ho believes in action an d not in passive good will

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STANDARDS O F C H IL D W E L F A R E

in such a v ital question as th a t of housing should get a copy of the
ten tativ e d ra ft of a bill designed to enable building a n d loan associa­
tions to increase their resources a n d aid m o re effectively in financing
construction w o rk in their respective localities. T his bill can b e o b ­
tain ed th ro u g h th e U nited S tates D e p artm en t of L abor, Inform ation
an d E d ucation Service.
F u rther, p riv ate organizations can do no b e tte r thing th an to back
up an ed u catio n al cam paign on th e question of th e h om e a n d th e
“O w n Y our O w n H om e M ovem ent.” T h e w ay fo r h om e owning
m ust b e cleared b y local safeguards of city planning, architectural d e ­
sign, consideration of cooperative buying as ap p lied to building m a­
terial, an d co partnership in th e operation of enterprises. E very social,
educational, an d fratern al society should h av e a series of m eetings on
h om e building an d hom e ow ning led b y experts an d run on th e forum
p lan of free discussion. T h ere should b e clear thinking a n d public ac­
tion b ased on an intelligent appreciation of all th a t is a t stake in regard
to th e conservation of hum an energy a n d th e preservation of life, p a r­
ticularly child life. T h e tim e is ripe for this. H ousing is com ing to its
\ own in th e public consciousness.
T h e th ird g re at gain th a t has com e from th e lessons of th e last tw o
y ears is a quickened sense of personal an d social ties. ^J^hen m en w ere
rem o v ed from th e fam ily circle, w hen th e netw ork of local ties w as
pierced, th a t fram ew ork w hich sustains us all a n d th e lack of w hich
leaves us b ew ildered a n d alone b ro u g h t an appreciation of d e ­
p en d en ce on com m unity forces. M ilitary training h a d its place. Mili­
tary strateg y h a d its place. E qually im portant, even in a state of war,
w as th e w eaving of civilian social relationships. Is n o t th e perm anency
of a dem ocracy largely d e p e n d e n t on th e closest possible develo p m en t
of relationships of g ood fellow ship; on th e th o u g h t exchange betw een
m an an d m an -and th e w elding to g eth er of h o m e an d hom e fo r th e p ro ­
tection an d encouragem ent of th e young? Surely hom es th a t see th em ­
selves in relationship to o th er hom es; th a t give of th eir b e st for good
schools; th a t insist on opportunities for w holesom e recreation; an d th a t
set a stan d ard of vital interest in com m unity affairs create a situation in
w hich th e generations th a t are com ing on ca n n o t b u t catch th e altruism
of citizenship b ased on action fo r th e com m on good, to say nothing of
th e assets of h ealth an d m ental pow er w hich p ro p e r living conditions
alw ays safeguard.
In spite of th e hopefulness of th e housing situation a t present,
p erm a n en t p ro tectio n for th e h om e will n o t b e gained b y thinking for
one m p m en t th a t som eone else will look afte r housing if w e d o not.
T h e forces th a t h a v e h eld b ac k housing legislation are so entrenched,
an d th e task seem s so intricate an d overw helm ing, th a t th e patient, p e r­
sistent, con stan t effort of all is n eeded. O n th e one h an d th e re is o p en

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V opposition to im proving conditions, an d on th e o th er a k ind of ap a th y
d u e to hopelessness. It is h ard to say which is th e worse. T h en th ere is
a curious k in d of contradiction which enters in. P ersons will affirm
m ost positively th a t o u r w idest circles of affairs— business enterprise,
m atters of g o v ern m en t— are n o t ends in them selves an d can b e con­
sidered as co n tributing to a given age o n ly in so fa r as th e individual
is benefited an d th e h om e circle p ro tec ted an d enriched. Y et, in th e
next b reath , these v ery peo p le will h ed g e a t facing squarely th e needs
of b e tte r housing because som eone will lose one o r tw o p e r cent interest;
or, because p re ced e n t w ould b e broken, they becom e suddenly co n ­
servative a t facing a tow n layout schem e, to forestall b a d conditions.
C ourage a n d d arin g are needed, b u t surely the thought of a h ap p ier
child h o o d fo r th o u san d s of children, to say nothing of th e pro sp ect of a
low er m o rb id ity an d d ea th rate, should furnish these. T h ere is nothing
m ysterious ab o u t g ood housing. T h e details of building so as to get
light an d air a n d to give privacy an d convenience, are in th e m ain
solved to a p o in t w here it is know n th a t a certain kind of hom e will
safeg u ard health. M inim um stan d ard s a t least h av e been w orked out
an d should b e a d o p te d an d enforced in every civilized com m unity.
T h e lo n g er th e bringing in of th e era of im proved housing is delayed,
th e m o re d o es society a n d th e state p a y the bill in th e bro k en dives of
m any a m an a n d w om an. A p arab le of th e tenem ents tells its ow n
story. “A little girl living in a court in an eastern city p lan ted a win­
dow b o x in all h o p e a t th e beginning of sum m er. S he nursed h e r see d ­
lings w ith g re at care a n d w as elated w hen th e first shoots ap p eared .
F ro m d a y to d a y she w atched h e r p lan ts an d vines grow, b u t w ith
each d a y th ey grew w eak er an d m ore sickly, w ithout sym m etry or
beauty. F in ally th ey d ied alto g eth er in th e v itiated atm osphere. Y et
th e child w as expected to d evelop into w om anhood u n d e r precisely
th e sam e co n d itions.”
T h e m o ral effect of b a d housing is n o t often as a p p a re n t as the
physical. It is said,, how ever, th a t tw o-thirds of th e delinquent chilcom e fro m hom es th a t no tow n o r city should perm it to exist.
O vercro w d in g ten d s to b re a k dow n nicety of m an n er a n d norm al re ­
straint. A young girl ca n n o t b e b lam ed for m eeting h e r friends in th e
d an ce hall, p ark, o r street, w hen hom e m eans .the kind o f tenem ent
th a t exists in n early all our cities an d tow ns. Leaving aside all th e
p ro b lem s o f tax atio n an d lan d values involved in discussing housing,
d a rk room s can b e elim inated; basem ent dw ellings fo rb id d e n ; a d e ­
q u ate w a te r supply insisted on; hom es can b e k e p t in rep air a n d free
from rubbish, an d in a sanitary condition. H e rd in g can b e stopped.
Now, th e b u ilding o f attra ctiv e houses an d th e develo p m en t of wellp lan n ed com m unities ca n n o t b e ad v o c ated w ithout taking into account
d o llars an d cents. T his lead s to a consideration of costs, rentals,

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STANDARDS O F C H IL D W E L F A R E

wages. A t th e p resen t tim e th e situation is acute because in nearly /
every section of th e country th ere is a shortage of hom es owing to the
fact th a t in th e m ain com m ercial building operations w ere h alted d u r­
ing th e w ar. A s a result, ren ts h av e risen according to th e old law of
supply an d d em an d , and, since prices of m aterials continue to b e high
an d uncertain, th e construction of hom es is still h eld up. T h e present
cost of m aterials, com bined w ith th e general uncertainty of th e financial
m ark et an d lo an rates a n d th e d e a rth of accom m odations m entioned
above, h as b ro u g h t ab o u t a situation w hich m akes governm ent aid
essential a t this time. A stan d ard ized fam ily b u d g et p rovides th a t
one-fifth only of a m an ’s incom e should go for rent. C learly this is
enough if a fam jly is n o t to b e stinted in th e w ay of food, p ro p e r clo th ­
ing, an d provision for th e education of th e children an d for safeguarding
old age. It is affirm ed th a t a t th e present rates of la b o r an d cost o f m a­
terial new ho m es ca n n o t b e constructed to ren t a t prices w ithin reach
of th e unskilled laborer.
C learly, then, as a m a tte r of public policy certain problem s should
b e im m ediately attack ed . F irst is a consideration of lessening th e tax
on h om es; second, th e elim ination o f speculation in building; third,
th e p ro tectio n of equities so th a t an investm ent will n o t b e lost as th e
result of d ep reciatio n o f values w hen a hom e district gives w ay to
business en terp rise; a n d fourth, th e tim e is ripe for definitely bringing
ab o u t th e decen tralization of industry so th a t increase of congestion
will b e sto p p ed . Industrial enterprises should n o t b e encouraged to
m ove into com m unities until plans are m ad e for housing th e peo p le
w ho will com e to m an them . O therw ise th e few gain a t th e expense of
th e m any. R en ts go up. T h o se w ho are p ro p e rty ow ners m ay gain.
T h o se w ho p a y re n t lose, an d th e com m unity brings u p o n itself very
grave d an g e r of so running up its expenses b y th e increase of d eg en era­
tive tendencies th a t th ere is an inestim able resultant loss. A s to fam ily
life, an y o n e fam iliar w ith industrial com m unities know s of instance after
instance w here a norm al fam ily forced b y th e lack of housing facilities
to live u n d e r b a d conditions has becom e subnorm al. T h e fa th e r b e ­
com es ill. Loss of w ages results. D eath m ay follow. T h e m o th er
m ay b e fo rced to w ork. T h e children are b ro u g h t up u n d e r conditions
which are n o t such as to give them a fair chance. C onversely th ere is
th e fam ily th a t h as lived u n d e r b a d tenem ent conditions w ith a history
• of illness an d loss of am bition th a t afte r m oving into a ten em en t w ith
sunshine a n d neatness com es ^to its ow n a n d swings into self-respect an d
prosperity. Now, if houses can n o t b e constructed fo r th e unskilled,
th en let us m e e t th e n e e d 'fo r th e skilled, an d b y increasing accom m oda­
tions tak e th e inflation o u t of second an d th ird an d fourth ra te p ro p ­
erty an d th ereb y p erm it th e fam ily to raise its stan d ard s an d to b etter
its living conditions.

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T h e tim e is ripe in A m erica fo r the d ev elo p m en t o f cooperative
enterprise. New Y ork is becom ing interested in th e co o p erativ e a p a rt­
m en t house. T h e copartnership housing p lan w hich has b een d e ­
v elo p ed in E ngland should b e studied an d experim ented w ith here.
If* as in E ngland, th e G ov ern m en t should loan p a rt of th e ca p ital'sto ck
the possibility of developing such a com m unity w ould b e m aterially in­
creased. U n d e r th e co-partnership schem e houses a re let a t o rd in ary
ren tals to persons w ho ow n a certain n u m b er of shares. D ividends on
capital are lim ited to five p e r cent. Profits rem aining a fte r th e p a y ­
m en t o f th e cu rrent expenses, interest, a n d am ortization charges on
m ortgages an d loans, a n d div id en d s on capital, are d iv id ed am ong th e
copartnership ten an ts in p ro p o rtio n to th e shares p aid in. H ouses are
leased on 9 9 -y ear leases as a rule, so th a t a m an is n o t necessarily h eld
to o ne spot, as h e can dispose of his shares o f stock. V acancies h av e
b een ra re in E ngland as it is to th e ad v a n ta g e of all th e sh areholders
to d o w h at th ey can to ren t p ro p e rty so as to m aintain th e b alan ce of
profits. U pkeep a n d rep air costs h av e been less th an in th e case of
th e av erag e run o f p ro p e rty fo r th e sam e reason; a n d losses from n o n ­
p ay m en t o f re n t are b ro u g h t dow n to a m inim um because a m an ’s
shares are tak en in case ren t is n o t paid. B etter accom m odations can
b e o b tain ed fo r less m oney. T h e com m unity safeguards itself an d
co ntrols its n eig hborhood enterprises. T h ere is freed o m from loss if a
person m oves. T h e “unearned increm ent” accrues to th e tenants.
^
could b e freed from th e dead en in g effects o f re n t w ithout
value received, one of th e g reat econom ic b u rd e n s w ould b e rem oved
an d the insidious circle of b a d housing, loss o f energy a n d am bition, in­
effectiveness a t w ork, a n d th e “w h at’s-the-use” a ttitu d e a t h o m e w ould
b e b ro k en into. Instead th ere w ould b e th e self-respecting house­
h o ld er; th e alert cooperative citizen; th e p a re n t w ho rad iates h o p e and
sees b efo re his children n o t an existence of dull gray, b u t a future of
satisfaction in taking p a rt in th e activities o f their time.
If th e question of ren t can b e ad ju sted our n ex t consideration is th a t
of th e ap p o rtio n m en t of the rest o f th e fam ily incom e. C hildren m ust
h av e g o o d food. T h ey m ust b e well dressed. T h ey m ust h av e the
o p p o rtu n ity o f training for special talents. C ost o f living a t th e present
tim e is high. W ages are n o t keeping pace in m an y occupations. Even
in o rd in ary tim es th e m o th er has a com plicated task in d eed in w orking
out h e r fam ily b u d g et an d in running h e r household so as to live within
th a t b u d g e t an d m aintain th e health o f h e r fam ily a n d p ro v id e fo r their
n ee d ed change o f th o u g h t through recreation. Exactly as th e h o m e m ust
b e p ro tec ted b y elim inating b a d housing so th e necessities o f life m ust
b e b ro u g h t w ithin range of o u r citizenship. S u perneeds can ta k e care
o f them selves. Increased p roduction of foodstuffs; m o re econom ical
distribution; th e cooperative store; th e com m unity kitchen; training

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STANDARDS JOF C H IL D W E L F A R E

in the a rt of h o m e m anagem ent— all these challenge our genius an d
enterprise. F o r th e sake of the A m erican child our entire range of
public activity should b e gauged b y th e w ay in which basic n eed s are
m et an d b y th e w ay in w hich la b o r is assured an o p p o rtu n ity for w ork
an d an incom e such th a t th ere shall b e a m argin of saving fo r security.
In co rp o rated in th e ideals of th e race is th e ideal o f hom e. Into the
ideal of th e h o m e en ter all those factors of hom e-m aking on th e p a rt
of m o th ers a n d fathers which Create a b ack g ro u n d th a t enables chil­
d re n to grow up tru e to them selves, stim ulates them to ca rry on th e
w o rk of th e w orld, an d leads them into th e w o n d ers of life. T h e hom e
is still th e g re at educational institution. E very d o llar sp en t on school­
ing is u n d ercu t b y b a d environm ental conditions created b y the h o ^ k
an d is m ultiplied m any tim es o v er b y the right k ind of h om e standards.
N ot only should hom es b e well constructed a n d healthful, b u t beau ty
should en ter in. T h e fam ily circle should carry w ithin itself th e m anysided social obligations of person to person th a t establish in a child
grow ing up u n d er such influences th a t involuntary response to th e obli­
gations m et in th e n atu ral relationships of life w hich m eans high-m inded­
ness, courtesy, a n d appreciation of self in relation to others. T h e p h y si­
cal aspect of th e h om e is only one phase of o u r subject. T h e m an ag e­
m en t of th e h o m e an d th e creation of th e indefinable atm osphere
w hich m eans th e real h om e is th e second factor. H o m e m anagem ent
is a science. M oreover, a h ea rth sto n e becom es truly»a h ea rth sto n e only
as a result of d eep religious sense, ethical outlook, an d cultural a p p re ­
ciation. C en tral in educational p ro ced u re should b e hom e training for
b o th b o y s an d girls, an d no system of public education is stan d ard iz ed
th a t d o es n o t offer extension courses in o rd e r th a t housew ives m ay
tak e a d v a n ta g e of th e b est th o u g h t as to expenditure, household tasks,
an d child care. O u r schools should b e im b ed d ed in th e h o m e life of
th eir com m unities. P are n ts an d teachers should k now one another,
should ap p reciate th eir d ep en d en ce on one another, an d should w ork
as one in th e educational enterprise, if every b o y a n d -g irl w ho is
g ra d u ated from o ur schools an d higher institutions of learning saw
clearly th e effect of so-called politics on th e hom e a n d th e result of
business exploitation w hen fathers an d m o th ers are sacrificed to in­
dustrial com petition, th ere w ould b e far less n eed fo r repressive legisla­
tion. If o u r young peo p le w ere train ed in th e principle of thrift, m oney
w ould give g reater values. If they th o u g h t through to th e things th a t
really co u n t fo r h appiness a n d well-being, which, a fte r all, in spite of
th e g re at v ariety of m o d ern activities, are v ery few, g re ater personal
poise w ould result, as well as g reater response to those fundam ental
d irect relationships th a t h av e th eir basis in th e fam ily circle a n d th e
loyalties of friendship. It is a m a tte r for m ost serious consideration
th a t w ith all th e gains th a t h av e b een m ad e so m any com m unities still

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T H E ECO N OM IC A N D SOCIAL BASIS

53

d o little to p re p a re their young peo p le to m eet th e responsibilities of th e
h om e an d th e rearing of children.
A s trustees of th e w elfare of our children, our citizens are n o t living
up to A m erican ideals unless th ey m ake e^ery effort to secure for each
b o y an d girl th e right to a w e lb o rd ere d hom e, th e b est of schooling,
free playtim e, a n d th e privilege of taking p a rt in th e w ork o f th e w orld
cn a basis o f equitable industrial adjustm ent.


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T H E LEISU R E O F T H E C H ILD
By L. H . W EIR

War

C am p C om m unity Service, W ash in g to n ,

D.

C.

an d
MISS ABBIE C ON DIT
P lay g ro u n d a n d R ecreatio n A ssociation of A m erica

I shall p resen t to you a statem en t of th e m inim um stan d ard s which
th e N ational P lay g round an d R ecreation A ssociation of A m erica feels
are necessary to p ro v id e p ro p e rly fo r th e leisure of th e childen in
A m erican com m unities. T his is discussed alm ost entirely from the
p o in t of view of public provision, nothing being said of m inim um
sta n d a rd s th a t should b e p ro v id ed through p riv ate agencies.
T h e facts w hich h av e b.ecome significant as a result of th e war,
show ing th a t a th ird of th e d ra fte d m en w ere rejected because of'
physical unfitness, h av e from th e purely physical p oint o f view m ad e
it necessary for A m erica to ask herself th e question: “H o w far is th e
n atio n responsible fo r this condition? H as A m erica failed to p ro v id e
its m en in child h o od w ith th e essentials for h e a lth ? ” R ep o rts which
h av e com e from G re at B ritain an d F rance an d o th er foreign countries,
as well a s from A m erica, p ro v e th a t when, as a result of w ar pressure,
less em phasis w as laid on p ro p e r recreational activities, th ere w as a
g re at increase in juvenile delinquency a n d an alarm ing grow th in crim e
on&the p a rt o f th e youthful population of th e countries, as well as a
decrease in physical fitness.
T h a t th ere is a very definite connection betw een recreation an d
health, an d b etw een recreation an d juvenile,delinquency, is an incon­
tro v ertib le fact. In m any sections of cities in w hich p laygrounds h av e
b een established it has b een d em o n strate d through tests a n d exam ina­
tions th a t in a surprisingly short tim e a higher deg ree o f health an d
increased physical efficiency h av e resulted. T h e records of th e police
co urts in such districts p o in t to a distinct falling off in th e n u m b er of
boys arrested for m isdem eanors. T h e rem ark ab le progress of th e
recreation m ovem ent in A m erica, show ing an ex penditure of m illions
of d o llars b y m unicipalities, ap p ro p riated n o t because o f a theory,
b u t because it has b een d em o n strated to these cities th a t b e tte r health
a n d b e tte r citizenship will result if th e energy of children is directed
in th e p ro p e r channels; the passage of com pulsory laws for physical
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T H E ECO N OM IC A N D SOCIAL BASIS

education in a n um ber of cities providing for a certain am o u n t of
d irected physical exercise an d p lay each d a y as a p a rt of th e school
curriculum ; a n d th e fact th a t F rance an d E ngland h av e passed national
physical education law s——these are all significant of the im p o rtan t place
w hich recreation has com e to occupy in th e life of th e child, an d th e
recognition w hich has been given it.
STANDARDS O F PH Y SIC A L EFFICIENCY

If it is true, as authorities are agreed, th a t th e child m ust h av e o p ­
p o rtu n ity fo r w holesom e recreation if h e is to develop along norm al
lines a n d becom e physically efficient, w hat are th e m inim um sta n d a rd s
o f recreatio n w hich m ust b e m aintained?
O rganized recreation as a necessary p a rt of th e child’s d ev elo p m en t
is so new a conception as com pared w ith th e health, education, a n d
w ork sta n d a rd s applied to child life th a t practically no effort has
h ith erto b een m ad e to establish m inim um sta n d a rd s for th e leisuretim e activities o f th e child. A possible exception to this lies in th e
step tak en b y th e P layground an d R ecreation A ssociation of A m erica,
which th ro u g h a com m ittee of experts, has a d o p te d tests for boys an d
girls rep resen tin g th e m inim um physical sta n d a rd s w hich boys an d
girls sh ould reach if they are to b e physically fit. T h e tests fo r boys \
are briefly o utlined as follow s:
T h e A th letic B adge T est for boys:
F irst T est— 12 years of age.
P ull up (C hinning) . . . . . . . . . . . . . . . . .
S tan d in g b ro a d j u m p .......... ..
.^
6 0 -y ard d ash
..........

. . . . . . 4 tim es
. . . . 5 ft. 9 in.
. 8 3-5 seconds

S econd T est— 1 3 years of age an d over.
Pull up (C hinning) . ............................... . . .
S ta n d a rd b ro a d j u m p ...................................
6 0 -y ard d ash . . . ......................................... ..
O r 10 0 -y a rd d a s h ...........................................

. . . . .
... 6
. . .'.8
...14

, T h ird T est— high school boys.
Pull up (C h in n ing) ........................................
R unning high ju m p ..........................................
2 2 0 -y ard r u n ...............

.......... .9 tim es
. . . . 4 ft.. 4 in.
. . .2 8 seconds

6 tim es
ft. 6 in.
seconds
seconds

NECESSITY O F PL A Y A ND PH Y SIC A L TRAINING

In o rd e r to attain these standards, which h av e been d em o n strate d
to rep resen t m inim um stan d ard s, a child should h av e physical tra in ­
ing a n d gam es in th e school, an d in ad d itio n an o p p o rtu n ity fo r
w holesom e d irected o u td o o r p la y in his leisure time. D r. H e n ry S.
Cuttis, on e o f A m erica’s forem ost authorities on p lay g ro u n d s a n d
recreation, has said :
T h e first requisite of any ad e q u ate system is


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th a t it m ust furnish p lay to every child every day. T his needs no
discussion. 'We all realize th a t o u td o o r air a n d exercise are essential
to th e physical, social, a n d intellectual w elfare of children. T hey
can n o t b e really w ell an d grow up into vigorous m en an d w om en
unless th ey are g etting an h o u r o r tw o of such activity every day.
D r. C urtis fu rth er suggests th a t p lay is th e first form of education,
an d should h av e its larg est p lace in th e early y ears of life, since th ere
is n o la te r tim e w hen physical achievem ent m eans so m uch to th e child
as it d o es in th e p erio d b efo re tw elve years of age. H is experience
lead s him to feel th a t th ere should b e tw o or th re e hours a d a y of
o rganized gam es d uring th e first few years of th e elem entary school,
a n d this should dim inish w ith advancing years to a m inim um of one
h o u r a d a y “w hich is ab o u t as little as ad u lts can g et along w ith an d
m aintain v igorous h ea lth .”
T h e m ajo rity of com pulsory physical education S ta te law s p ro ­
viding fo r com pulsory physical education w hich h av e b een passed in
A m erica stip u late th a t tw enty m inutes a d a y shall b e th e m inim um
tim e d e v o te d to physical training. In a n u m b er of th e law s it is
definitely stated th a t this shall b e th e m inim um an d th a t a longer
p erio d is desirable. A large p ercentage of th e physical unfitness dis­
closed b y th e d ra ft m ight h av e b een p re v en ted if th e m en h a d h ad
p ro p e r physical education in their youth. A t least ^ 30 p e r cent of
physical unfitness, according to Dr. Eugene L ym an Fisk, M edical
D irector, Life E xtension Institute, is d u e to p o o r general physical con­
dition, rem ed iab le b y p ro p e r nutrition, physical training a n d personal
hygiene.
ORGANIZED PLAY

E veryone is agreed, how ever, th a t th e child s physical exercise
ca n n o t b e lim ited to physical training in th e schools. T h e re m ust b e
p ro v id ed for him in his free tim e th e o p p o rtu n ity for w ell-directed
p lay w hich will supplem ent physical training in th e schools, a n d at
th e sam e tim e give a guidance to his energy th a t m akes fo r citizen­
ship. A larg e n u m b er of considerations m ust en ter into an y discus­
sion of th e m inim um requirem ents of organized play, an d a set of
stan d ard s which will h o ld fo r one com m unity m ay b e ill a d a p te d to
com m unities an d conditions of an o th er city. If a child is to h av e
play, how ever, th ere are certain requisites w hich are essential in an y
com m unity. O f these a p lace to p lay is p erh ap s th e first consideration.
P la y S p ace

In d eterm ining a sta n d a rd for th e am o u n t of play space necessary,
th e follow ing factors m ust b e co nsidered:
1.
D istribution of P laygrounds.—-The distribution of p laygrounds
h as m uch to d o w ith their utilization. F o r exam ple, tw o acres of


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gro u n d d iv id ed in. four p arts an d d istributed in congested districts
of a large city w ould d o m an y tim es m ore g o o d fo r sm all children
th an the sam e tw o acres on th e outskirts o f a city tw elve m iles from
w here th e children are. Local conditions m ust determ in e how p lay ­
grounds are to b e d istributed if they are to m eet distinct needs. T h e
po p u latio n of a. city, its juvenile population, spaces available, th eir
suitability, a n d th e distance children m ust go are am ong th e d eterm in ­
ing factors.
A s a result o f A stu d y m a d e b y H en ry V . H u b b a rd , A ssistant P ro ­
fessor of L an d scape A rchitecture a t H a rv a rd U niversity, it h as b een
p o in ted o u t th a t children u n d e r six 6ught n o t to b e obliged to go m ore
th an one-fourth of a m ile to their playground, a n d these playgrounds
should b e lo cated in such a m an n er as to m ak e it unnecessary for
children to cross c a r tracks. T h e average effective radius for children
from six to tw elve years of age is ab o u t one-half mile, a n d fo r children
from tw elve to seventeen w ho ca n n o t afford carfare, three-quarters
of a m ile. B oys will go a longer distance th an this to reach a baseball
field. E xperiences differ in th e various cities regarding th e distances
w hich children will go, b u t th e averag e effective radii stated of onequ arter, one-half, a n d th ree -q u arte r m iles are conservative an d re p re­
sent th e m inim um o f service w hich a city sh o u ld offer in th e distribution
of its playgrounds.
2. Size o f P lo t.— T h e only solution fo r a m inim um playground
is its m axim um use, b y having th e g round used each h o u r b y different
g ro u p s a n d b y p u ttin g th e em phasis on gam es requiring little space.
O n e acre u sed six tim es a d a y is equal to six acres used once. If
th e re are as m an y as six h u n d re d children it will n o t b e possible for
a p lay g ro u n d to b e m uch sm aller th an an acre. M any authorities
feel th a t th ere o u g h t n o t to b e m o re th a n th re e h u n d re d children
using a p lay g ro u n d of an acre. A n acre is th e m inim um size fo r a
school p lay g ro u n d according to D r. Curtis* estim ate. F o r m ore th an
500 children, ab o u t 40 square feet p e r child should b e a d d e d to an
acre p lay g ro u n d .
T o give th e child th e ideal expression a n d o p p o rtu n ity it w ould be
necessary to h av e for baseball, football, hockey, an d skating, four
acres; fo r tennis, tw o acres; fo r in d o o r baseball, one acre; for basket
ball, o n e-fourth acre; fo r volley ball, one-half acre; fo r running track,
ju m ping pits, a n d sim ilar apparatus, one-fourth acre. T his m akes eight
acres of p lay g ro u n d fo r a thousand pupils, b u t all these activities could
b e carried on in five acres b y playing less football a n d tennis.
3. A g e of C hildren.— O n this d ep e n d s th e use which will b e m ad e
of th e play g ro u n d. It is possible to h an d le m ore children p e r acre
w hen th ey are u n d er ten years of age. L ittle children will use swings,
sand boxes, teeters, an d sim ilar devices, which, if correctly placed,

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d o n o t occupy m uch space. T h e gam es of children up to ten y ea rs
of age are largely group gam es, n o t th e real team gam es w hich require
m o re space.
4. N um ber of C hildren Likely to U se P lay g ro u n d a t O n e T im e.—
T h ere is alw ays a rising an d falling tid e o f children on th e play g ro u n d
during th e day. In judging th e am o u n t o f p lay space necessary, th e
am o u n t of th e "heaviest lo a d " m ust b e considered, b u t adm inistrative
devices can som etim es b e used to distribute th e load.
F ro m th e
p lay g ro u n d stan d p oint, this is th e big co n trib u tio n .o f th e G a ry p lan
of organizing.
v'
.
5. D ensity of P opu latio n p q r A cre an d D ensity R ange.— T h e
n u m b er of children using a p lay g ro u n d a t an y o n e tim e is m uch
sm aller th a n th e n u m b er of children w ho are serv ed b y th e p lay ­
ground, a n d th e n um ber of children benefited m ay be, therefore, tw o
to six tim es th e av erag e daily atten d an ce. A neig h b o rh o o d m ay b e
ad eq u ately p ro v id e d w ith play g ro u n d space even if it d o es n o t h av e
enough to care for all th e children of th e n eig h b o rh o o d a t one tim e.
M r. R o w lan d H aynes, form erly field secretary of th e P layground
a n d R ecreation A ssociation of A m erica, from his stu d y of recreation
in a n u m b er of cities, b ecam e convinced th a t w here th e density of
p o p u latio n exceeded 35 o r 50 to th e acre, 80 p e r cent of th e children
w ould b e playing aw ay from hom e, because sufficient space w as n o t
p ro v id e d aro u n d th eir ow n hom es.
F ro m M inneapolis com es th e statem en t th a t th ere should b e one
acre o f little children’s playgrounds for each 15,000 p o p u latio n ; one
acre d e v o te d to th e uses of th e neig h b o rh o o d cen ter fo r every 5 ,0 0 0
p o p u latio n ; a n d one acre for grounds fo r special sp o rts fo r each
10,000 p o p u latio n . T his statem en t affirms th a t th e play g ro u n d for
little children should b e a t least one acre in area; a p lay field from
tw o to ten acres; a n eig h b o rh o o d cen ter from tw o to fo u r acres; a n d
a g ro u n d fo r special sports from tw o to ten acres.
6. G ro u p s S erv ed .— W hile th e n u m b er of children in a neigh­
b o rh o o d w ho n ee d a p lay g ro u n d varies according to th e density o f
p o p u latio n a n d th e density range, th e size of th e group w ho n e e d an d
will use th e p lay g ro u n d d ep e n d s on o th er conditions, such as th e hom e
h ab its of th e children, th e length of tim e th e p lay g ro u n d h as b een
in use, an d th e am o u n t of confidence w hich th e p lay g ro u n d lead ers
h av e inspired in th e residents of th e neighborhood.
E q u ip m en t

T h e equipm ent p ro v id e d on a play g ro u n d varies greatly w ith th e
am o u n t o f m o n ey available. W h e re funds are lim ited, wise p lay ­
g ro u n d officials will expend th em fo r leadership ra th e r th a n fo r a large
am ou n t o f m aterial equipm ent. T h e re are, how ever, certain kin d s


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o f ap p a ratu s which, according to m inim um stan d ard s, should Be
included in an y p layground. T h ese include a sand box, swings, slides,
a n d an a d e q u ate supply of gam e equipm ent, such as b ask e t ball,
volley ball, b ase ball, b ea n bags, an d sim ilar supplies. Such supplies
are considered b y m any play g ro u n d w orkers to b e m ore im p o rtan t
th an fixed ap p aratus. A s th e value of teeters an d giant strides is
d eb atab le, th ey m ay b e om itted from th e consideration o f m inim um
sta n d a rd s along th e line of equipm ent. B oys’ o u td o o r gym nasium
equipm ent, like m an y o th er kinds of apparatus, w hile desirable, is
n o t essential.
Som e so rt ,of shelter, how ever inexpensive, should b e p ro v id ed on
a playground, as should toilet facilities an d drinking w ater.
L ead ersh ip

T h e provision of space to play an d a m inim um am ount of ap p a ratu s
d o es n o t co m p lete th e responsibility of th e city to w ard its children.
If th e utilization o f th e p lay facilities is to b e m a d e a fa cto r in child
life th ere m ust b e p lay leadership to insure such use o f th e ap p a ra tu s
as will m ak e th e child d eriv e th e g reatest benefit from it, to teach
the child to p lay th e gam es th a t will m ean m o st in his developm ent,
an d to give th e right direction to instincts which, if u ndirected, m ay
lead th e child to th e juvenile court. Innum erable instances o f splen­
d id ly eq u ip p ed p lay g ro u n d s little used because th e y lack th e vital
elem ent of leadership, w hile n ea rb y alleys an d streets w ere cro w d ed
w ith children, h av e d em o n strate d b ey o n d d o u b t th e p rim ary im p o rt­
ance o f leadership.
In an y consideration of m inim um sta n d a rd s it is im p o rtan t to d e ­
term ine w h at is th e largest n u m ber of children w hich o n e p lay le a d e r
can care fo r p ro p erly. T his d ep e n d s to a large extent, according to
Mr. E rnst H erm ann, w ho h as h a d m any years experience in p lay ­
g ro u n d w ork, on th e am ount o f self-governm ent which can b e d e ­
v elo p ed am ong th e children. T his w hole question of th e n u m b er o f
lead ers n ee d ed fo r a definite n u m b er o f children, h e m aintains, is a
m atter o f teaching an d developing self-m anagem ent b y gradual, p e r­
sistent, an d nev er-ending organization. T h e basis o f such organiza­
tion m ust b e th e form ation o f th e children into groups o r gangs o f
from eight to tw elve m em bers, w ith a gang lead e r self-selected an d
self-propagating, as in th e old n eig h b o rh o o d ty p e o f gang. T h e
cleverest d irec to r can d irect continuously only th e n u m b er o f children
he can perso n ally entertain. T his n u m b er ca n n o t exceed sixty chil­
d ren fo r a certain length o f tim e. If, how ever, th e le a d e r can im bue
each sm all g roup w ith th e m eaning of real leadership a n d real sp o rts­
m anship, h e can in a y ea r’s tim e supervise from 5 0 0 to 6 0 0 children.
Mr< H erm an n estim ates th a t w ith ad e q u ate space, layout, an d equip
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m ent, an d w ith an organization of self-m anagem ent, th e n um ber of
individuals u n d e r each le a d e r can b e m ultiplied from six to te n tim es
w ithin a year.
.
T h e re are few leaders, how ever, qualified to d ev elo p such a form
of organization, w hich represents m o re id eal conditions th a n usually
exist on a playgrouncl. T h e experim entation w hich such a p la n in ­
v olves w ould in th e g re at m ajo rity of instances p ro b a b ly result in
loss of tim e a n d in a failure to p ro v id e even th e m inim um am o u n t of
leadership necessary. U n d e r th e right leadership it m ight b e w o rk e d
out successfully.
In co n trast to th is opinion it is interesting to n o te the. statem en t of
an o th er authority, Mr. G eo rg e E. Johnson, o f H a rv a rd U niversity, w ho
m aintains th a t u n d e r th e m o st fav o rab le conditions th e re is a m uch
sm aller lim it to th e teacher’s capacity to h an d le children successfully
th an M r. H erm an n ’s outline sets. M any ty p es of play, as, fo r exam ple,
dram atic, n ee d m uch m o re intim ate leadership th a n can b e given by
one perso n to 500 o r 600 children a t th e sam e tim e, th o u g h organiza­
tion a n d grouping can greatly ex ten d th e le a d e r s capacity. M r. Jo h n ­
son gives as th e m axim um n um ber for real leadership th e follow ing:
■INDOORS-----Ages.
0-2
4-6
7-9

10-12

13-15

W ith
E quipm ent.

W ith o u t
E quipm ent.

iu

30
, 30
40
40

20
20
25
25

-OUTDOORSW ith
E quipm ent.

10

W ith o u t
E quipm ent.

30
40
40
40

T h e re are certain requirem ents in leadership w hich affect even th e
A m ong these are the follow ing:
1. T h e p o o re r th e stationary an d m o v ab le equipm ent, a n d th e less
effective th e organization of th e space a n d equipm ent, th e m o re lead ers
will b e required a n d th e m o re vivid an d inspiring m ust b e th e personal
leadership p ro v id ed.
2. E v ery p la y center m ust h a v e a d irec to r in ch arg e o f th e entire
ground. A s a m inim um sta n d a rd , no d irecto r should b e expected
single-handed to d irect th e activities o f m o re th a n 75 children, unless
such a system of organization as has b een suggested can b e d eveloped.
W h ere th ere are several h u n d re d children on th e p lay g ro u n d it is ab so ­
lutely im possible fo r one directo r to h an d le th e situation even o n a
m inim um efficiency basis, a n d assistants, o r such specialists as athletic
directo rs o r physical training directors, m ust b e p ro v id ed .
3. In an y system w here m ore th an one p lay g ro u n d is in v o lv ed th e re
m ust b e in ad d itio n tP th e.d irecto rs of th e individual g ro u n d s a recrea­
tion superintendent, supervisor, o r secretary, w hose ta sk it is to h av e
general oversight of th e w ork, to b e responsible fo r its developm ent,

minimum ¡standard.


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coordination, an d enlargem ent, an d for seeing th a t play facilities an d
activities are p ro v id ed th e child during the entire year. N o w ork can
b e carried on effectively w ithout such a responsible head.
4.
T h ere m ust b e a governing b ody, either a recreation com m ission,
departm en t, o r b o ard , to h av e general charge of th e w ork; o r if local
conditions m ak e it ad visable to h av e th e w ork conducted b y an existing
d ep a rtm en t of the m unicipality, it should b e adm inistered b y th e school
b o ard , p a rk b o ard , d ep a rtm en t of public w orks, or som e o th er m unici­
p al d ep artm en t. T h e w ork should b e sup p o rted b y m unicipal funds.
K ind of P lay a n d Its D u ratio n

D irected p la y w hich stim ulates th e child into diversified activities of
v arying deg rees of physical an d nervous intensity m ust b e h an d led w ith
g re at caution, an d even u n d er these conditions no tw o children will
b e equally benefited. T h e spontaneous p lay of children up to nine
y ears of age w ith an occasional short period of directed play is p ro b a b ly
th e b est k in d of play. Indoors th e p eriods m ust h av e frequent inter­
m issions o f free play. D uring o rd in ary school recesses th e average
child should h av e from ten to fifteen m inutes of vigorous play. A cco rd ­
ing to M r. G eo rg e E. Johnson, this p erio d of p lay should n o t b e less
th an h alf an hour.
A ctiv e gam es w hich d em an d severe physical a n d nervous applica­
tion m ust b e v ery short indeed, an d vigorous an d quiet gam es should
b e altern ated . A fte r th e child becom es nine years of age, p eriods of
active p lay n atu rally grow longer. B ut th ere should still b e m ore o r
less reg u lar interm issions. T eam gam es should b e stim ulated am ong
children o v er ten years of age, an d special em phasis should b e laid on
th e d ev e lo p m e n t of team gam es am ong girls. Each child should b e
given th e o p p o rtu n ity to b e a m em ber of som e team .
CONCLUSIONS

A n y decision regarding m inim um stan d ard s fo r th e leisure tim e activ­
ities o f th e child m ust necessarily b e conditioned by th e age of th e chil­
dren, local conditions as they relate to p lay space available, th e density
o f po p u latio n , layout a n d equipm ent of playground, th e system o f ed u ­
cation in th e com m unity, an d m any o th er considerations w hich w ould .
im m ediately suggest them selves. A few ten tativ e a n d v ery general
conclusions m ay b e draw n regarding som e of th e irreducible m inim um
s ta n d a rd s w hich should p revail:
1.
Irreducible m inim um stan d ard s fo r th e leisure tim e of children
require th a t th ere should b e no less th an tw o hours of organized p lay
fo r every child outside of school hours every d a y th ro u g h o u t th e entire
year. T h e m unicipality should b e responsible fo r the establishm ent
o f p lay g ro u n d s an d p lay centers financed from public funds raised b y
taxation.

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2. W hile it is n o t essential fo r a city to p ro v id e play g ro u n d space
on th e accep ted basis o f th e m inim um stan d ard s of th irty square feet
p e r child, sufficient to en ab le all th e children of a city to p lay u n d er
leadership a t one tim e, th ere m ust b e o p p o rtu n ity furnished w hereby
all children shall p lay u n d e r leadership a t certain p erio d s of n o t less
th an tw o hours. In com m unities in w hich th e G ary p lan o r som e m o d i­
fication of it form s th e basis of th e educational system , such p lay will
b e a p a rt o f th e regular school curriculum .
3. T h e re should b e a p layground w ithin an effective radius of oneq u arte r o f a m ile fo r children u n d e r six years, one-half of a m ile for
children o v er six, a n d baseball fields w ithin th e radius of one mile.
T h e size of th e p lay g ro u n d should b e d eterm in ed b y th e density of
p o pulation, n u m b er of children to b e served, th e activities conducted,
an d eq u ipm ent p ro v id ed . A n acre for 500 children is th e sm allest
possible space w hich should b e p ro v id e d ; w hen th e sam e playground
m ust b e used for little children a n d for o ld er boys an d girls, th e space
should, b e div id ed . F o r th e m ost p a rt n o a ttem p t should b e m ad e to
p lay gam es requiring a g re at d eal of space on this general ground, b u t
o p p o rtu n ity fo r such gam es should b e p ro v id e d in an athletic field con­
taining ab o u t six acres, an d p roviding for baseball, football, tennis,
an d sim ilar activities.
4. T h e m inim um tim e for p la y an d physical education in schools
should b e 30 m inutes p e r day.
5. W h ere lack of funds m akes it necessary to choose betw een a
larg e am o u n t of equipm ent an d ad e q u ate leadership, th e funds should
go into th e salaries of train ed leaders.
6. E very p lay g ro u n d m ust h av e one d irector m general charge of
the g round. T h ere should b e sufficient leadership so th a t each p lay
lead e r will h av e n o t m o re th an 75 children u n d er his im m ediate d irec­
tion a t one tim e. M inim um sta n d a rd s m ust p erm it of constructive play
an d rep resen t som ething m o re th a n an a ttem p t to keep children from
injuring them selves on Apparatus. T h ere should b e a supervisor o r
su p erin ten d en t in charge of th e w ork during th e entire year, u n d e r a
governing b o a rd of control.
•
7. M inim um equipm ent should include swings, a sand box, slides,
an d possibly teeters, a giant stride, an d o u td o o r gym nasium equipm ent.
W h ere equipm ent is lim ited th ere m ust b e increased em phasis on le a d ­
ership an d a liberal quantity of such gam e supplies as b ask et balls, b ase­
balls, b ea n bags, etc. T h ese supplies are even m o re im p o rtan t th an
fixed ap p aratu s. E ach p lay g ro u n d should h av e som e k ind of a shelter,
toilet facilities, an d drinking w ater.
8. A ctive play should b e carefully directed, a n d quiet a n d vigorous
gam es should alternate. E very child w ho is old enough should h av e
an o p p o rtu n ity to engage in team gam es, an d g reat em phasis should
b e laid on team gam es for girls.

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S T A N D A R D S F O R C H IL D R E N ’S P L A Y
By JOSEPH LEE
P resident, W a r C am p C om m unity Service, W ash in g to n , D. C.

P lay fo r grow n people is recreation— th e renew al of life. F o r chil­
d ren it is grow th, th e gaining of life. T h e p ro b lem of ch ild ren 's p lay
th erefo re is th e p ro b lem of w heth er they shall grow up* a t all, an d full
o p p o rtu n ity fo r children s p lay is th e first thing dem ocracy will p ro v id e
w hen it shall h av e truly b een established. . T o state a com plete set of
m inim um requirem ents w ould tak e a long time, b u t I w an t to p o in t o u t
som e of th em th a t are in d an g e r of being overlooked.
I. T h e first requirem ent fo r th e p la y of th e little child is a m other.
T o him his m o th er is a t once instigator, audience, playm ate, playground,
an d ap p aratu s. If his ow n m o th er is d ead, he m ust h av e an o th er to
tak e h e r place. T h ere are p len ty of w om en spiritually dying fo r lack
o f children a n d children spiritually dying for lack of m others. T h e
tw o m ust b e b ro u g h t together! A m o th er is of course of no use to th e
child w hen h e is locked up in a room an d she is w orking in a factory.
By h aving a m o th er I m ean having one w ho has tim e to p lay a m o th e r's
p art.
B* T h e n ex t requirem ent o f th e child’s p lay is a hom e, a place
w here h e can h av e his ow n things to p lay with, his ow n p lace to k eep
them , an d som eone to share w ith him a n d to b e interested in w h at
h e does. M ore th a n h a lf of our child w reckage is d u e to b ro k en hom es,
a n d th e disaster to their p la y life is in g re at p a rt to blam e.
BI. A n o th e r essential to th e child from a v ery early age is a childcom m unity w ith established p lay traditions, gam es suitable to his
age th a t are im m em orial (th e y n eed n o t b e m o re than th ree m onths
old to possess this la tte r a ttrib u te ), gam es th a t are tak en fo r g ra n te d
as w h at every fellow do es a n d th a t afford a v ariety for different seasons
an d different tem p eram en ts a n d talents. T h ere m ay b e a p lay lead e r
behind _the g roup a n d its tradition, b u t th e group is th e living
m edium fo r th e child. A m ong th e plays in vogue fo r childen o v er
eleven years o f age should b e th e g re at team gam es.
IV.
E very child should h av e th e equivalent o f a tool house, a
w oodshed, an d an attic in his life, w heth er p ro v id ed b y th e hom e, th e
school, o r som e n e a r n eig hborhood institution. H e m ust, a p a rt from
an y system atic teaching, h av e things to ham m er an d cut an d m elt an d
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STANDARDS O F C H IL D W E L F A R E

p u t together, to burn, color, an d otherw ise d eal w ith as his soul leads
him . H e m ust h av e all th e tools, paints, m aterials, an d suggestive
o b jects th a t h av e th e pow er to satisfy him an d to lead him on.
V . E very child should go through a p erio d o f having pets— any­
thing from w hite m ice to horses will do.
V I. E very child should b e encouraged to m ak e collections of
stones o r b o n es o r leaves o r som e such objects, an d should b e shielded
from th e k in d of n atu re stu d y w hich is to th e love of beasts a n d flowers
w h at th e stu d y of anato m y is to social life.
V II. E very child m ust grow up in th e presence of th e arts. H e
m ust h av e painting m aterials an d see peo p le painting ab o u t him
sketching an d carving a n d expressing their ideas in form an d color.
H e m ust h av e a chance to d o these things him self, to see pictures
incidentally, n o t having them too m uch explained o r talk ed about,
b u t finding them , as a m a tte r of course, p a rt of his experience. T h e
a r t teaching in th e schools m ust, from th e first an d always, include
m aking pictures from his ow n m ind an d im agination.
H e m ust b e b ro u g h t up in th e presence of m usic an d of th e fam iliar
use of song an d of m usical instrum ents— n o t forced to play th e piano
until so sterilized on th a t side th a t h e will n ev er listen again to a
so n ata if h e can h elp it, b u t given a chance to learn on som e instrum ent
an d sufficient training to see w heth er th a t is really for him a form of
utterance.
H e m ust h e a r read in g aloud an d tak e p a rt in it, n o t in th e inane
an d stultifying m eth o d o f reading som ething to th e teacher w hich she
alre ad y know s b y h e a rt an d d o es n o t w ant to hear, b u t o f bringing
in things th a t h e has re a d a n d Wants others to h e a r because h e likes
them , o r hearing things, th a t others h av e found w orth listening to.
F o r these p u rposes th ere should b e in every neighborhood, w hether
in th e school o r lib rary o r otherw ise, a house of th e Muses, o r rather,
tw o houses, o ne fo r m usic a n d one for th e o th er arts. T h e latter
should b e full of bo o k s an d pictures an d tables an d w indow seats to
go off an d re ad at, w ith p erh ap s a little stage. T h e form er should
also b e beautiful a n d h av e pictures an d a g ard en b esides its music
room s.
T h e id ea th a t children should b e tau g h t to b e useful m ust b e supple­
m en ted b y th e idea, equally im portant, th a t they should b e p re p a re d to
live.
V III.
T h a t children should h av e all th e o u td o o r p la y th a t they can
h o ld is to o obvious an d now to o well know n to n eed restating. F o r
children u n d er six th ere m ust b e a b ack y a rd w ith a san d b o x an d o th er
things to p lay w ith a n d a little general p lay g ro u n d in th e block.
F o r th ose from six to ten th ere m ust b e a sufficient playground, p ro p ­
erly eq u ip p ed an d w ith th e right leadership, w ithin a quarter o f a m ile,

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T H E ECONOM IC A N D SOCIAL BASIS

usually, connected w ith th e school; an d for the rest below seventeen
th e effective radius is h alf a mile. T h e playgrounds an d playhouses
m ust b e m ad e beautiful. T h ere m ust b e full o p p ortunity for skating,
coasting, an d skiing in w inter w here th e clim ate m akes it possible, an d
for b ath in g an d b o atin g in th e sum m er.
IX.
E very child m ust h av e a g arden in his hom e, o r tw o m onths
a y ea r of co u n try life. In fact, he ought to have th e latter anyw ay,
an d will h av e to arran g e it w ith his m o th er or his aunt o r p a rtn e r to
look afte r his h om e g ard en w hen h e is away.
T h ese are som e of th e things we shall p ro v id e when we learn to
tak e either dem ocracy o r education seriously.-

1


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R A C IA L FA C T O R S
By PR O FESSO R KELLY MILLER
H o w ard U niversity, W ashington, D. C.

In th e m idst of th e living truth, statistical facts are m ere d ea d
form ulas. Mr. Secretary, w hen you an d y o u r train ed staff of statis­
ticians get to H eaven, as of course you will, I trust you will p u t them
to th e task of determ ining how m uch m ilk an d honey are necessary
to m aintain an ad u lt saint fo r ten thousand years. A n d afte r you have
m ad e y o u r calculation rem em ber th a t it requires just as m uch to m ain­
tain a b lack saint as it does to m aintain a w hite one.
E very child b o rn into the w orld is entitled to a fair chance in th e
race of life. A ssertion a n d exertion of the individual’s best possibil­
ities are th e b irth rig h t of childhood. A ll m en are endow ed b y their
C rea to r w ith th e inalienable rights of life, liberty, an d th e pursuit of
happiness. Society, b y creating harsh conditions an d a benum bing
environm ent, m ay frustrate th e fruition of these rights, an d deny the
enjo y m en t thereof, b u t it cannot tak e aw ay the inherent claim thereto^
T h ey are reaffirm ed b y N ature every tim e a new b a b e is born.
D em ocracy is the w atchw ord of the hour. T h ere is no creed o r
caste in th e cradle. N ature gives each individual a fair start, though
society m ay d en y him a fair chance. T h e K ingdom of H eaven, as
p o rtra y e d b y its F ounder, represents the ideal of hum an relationship:
“Suffer little children to com e unto m e an d forbid them not, for of
such is th e K ingdom of H e av en .” Surely th ere is no discrim ination
of race o r co lo r in this benediction of childhood. G reat, indeed, is th e
cd ndem nation o f th a t social o rd e r w hose suppressive regim e denies this
b enediction to th e least of these little ones.
T h ere is no N egro pro b lem as such. T h e N egro to d a y represents
the acute p hase of th e universal hum an problem . T h e speciality of
his need s calls for a special p ro g ram of treatm ent. A ll th e topics listed
on th e p ro g ram of these several sessions ap p ly to th e N egro child as
well as to an y other. A n d just as th e afflicted m em b er of th é b o d y
m akes th e w hole system im m ediately conscious of its suffering, so th e
N egro in his social distress focuses th e atten tio n of th e w hole upo n
his acute situation until his condition has becom e norm al.
It is a wise provision of N ature th a t w hen one m em ber suffers th e
w hole b o d y suffers w ith it. If this w ere n o t so, the sound m em bers,
secure in* their im m unity from relative affliction, w ould p a y no heed


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T H E ECO N OM IC A ND SOCIAL BASIS

67

or solicitous reg ard to th e distressed m em ber, how ever sore m ight b e
its suffering an d affliction. But th e nervous organization of th e b o d y is
so k nit to g eth er th a t pain in one m em ber afflicts th e w hole system .
Thus, th e afflicted p a rt transm its its feeling to th e central station,
which, in turn, pulsates it to th e h ealthy m em bers as a distress call
for succor an d relief. T his sym pathetic response is instantaneous.
T h e N egro is a p a rt of the b o d y politic.
T h e N egro child is b o rn into an environm ent of econom ic a n d social
depression w hich is calculated to crush th e just aspiration o f hum anity.
T h e stress of econom ic pressure falls heaviest upon th e black race, an d
is felt m ost acutely b y th e black child. Insufficiency o f n u rtu re blights
th e w hole n atu re of th e grow ing child. T h e N egro has com e up
th rough th e inheritance of slavery w here th e child through som e g ood
h ap w as supposed to m atu re his physical capacities as th e anim als do.
T h e cultivation of th e intellectual, m oral, an d social qualities w hich fit
one for a d em ocratic o rd e r found little encouragem ent in a regim e
which exploited th e b lack child m erely for his anim al a n d m echanical
pow ers. A h alf century of p artial freedom w ith im perfect provision
an d facilities is h a rd ly sufficient to overcom e th e heav y han d icap of
these traditions. T h e N egro still loiters a t th e o u ter edge of industry
an d constitutes th e left-over m an in our econom ic calculations. H e is
th e last considered for app o in tm en t an d th e first for discharge. T h e
h a rd exactions of a livelihood m ake such heavy d em an d s u p o n fa th e r
an d m o th er th a t insufficient tim e an d strength are left for th e p ro p e r
care an d rearing of the offspring. T h e N egro w om an m ust becom e a
w age earn er to supplem ent the m eagrtf incom e w hich th e m an is able
to earn. T h e child is th e ultim ate sufferer, an d b ears th e b ru n t of it all.
T h ere is a m istaken conception in th e w orld to th e effect th a t th e
Negro can m aintain a stan d ard of life on a low er level of w age com ­
pensation th an the w hite m an. T his is an econom ic a n d racial fallacy.
T h e N egro bu y s in th e sam e m ark et an d pays th e sam e o r higher prices
for like com m odities, an d w herever his incom e is low er th an th a t of
th e w hite his sta n d a rd of life m ust b e correspondingly depressed. W e
are speaking of standardizing children. Y ou can h av e only one sta n d ­
ard ; tjhere is only one ethical stan d ard , th ere is only one scientific sta n d ­
ard, th ere is only one econom ic stan d ard , th ere is only one political
stan d ard . Y ou ca n n o t h av e tw o yardsticks, you can n o t h av e tw o m ul­
tiplication tables, one applied to one race an d one to th e other.
So w herever th e N egro is being depressed below th e level of econom ic
w ell-being, th e life of th e race is depressed correspondingly. T h e
w orld w ar h as incidentally b ro u g h t enlarged econom ic o p p o rtu n ity to
the Negro. L et it b e h o p ed th a t this tem p o ra ry ad v a n ta g e will b e m ad e
p erm an en t so th a t the hom e life of this race m ay b e correspondingly
uplifted.

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STANDARDS OF C H IL D W E L F A R E

W h a t chance h as th e child of th e alley, b e re ft of p aren tal care, whose
physical, intellectual, an d m oral n atu re is stunted an d starv ed by
pinched an d im poverished surroundings?
S hut in b y the m urky
horizon of this gloom y environm ent, how can h e b e expected to becom e
a co m p eten t cow orker in th e new o rd e r of things which is being
ushered in? T h e lavishing of w ealth b ey o n d reasonable requirem ents
u p o n th e children o f th e fortunate few is p o o r com pensation for the
soul im poverishm ent of those innocent children u pon w hom ,,society
places so h eav y a load. T h e m ost pathetic picture from w hich our
b o asted civilization w ould hide its face is th e helplessness an d h o p e ­
lessness of the black child farthest dow n.
But 1 w ould n o t m ake the picture too gloom y. N ot every Negro
child is subject to th e sam e degree of disadvantage. T h ere is a rapidly
increasing elem ent of th e race w hich is pushing up to a higher level of
decency, decorum , an d dignity of life, an d is providing for its chil­
d ren th e ad v an tag es an d opportunities w hich are their ju st due. U n­
fortunately, like th e corresponding class am ong th e whites, this elem ent
is n o t prolific in offspring. T h e N egro race, like th e w hite race, is
still b reed in g from th e b ottom .
E ncouragem ent com es from th e fact th a t society’s c ru d e s t regula­
tion can n o t w holly d efeat th e purposes of N ature, or ta k e aw ay th e
b irth rig h t even of th e N egro child. F rederick Douglass, th e slave
child, v ied w ith th e dogs for th e scraps th a t fell from his m aster’s tab le;
an d y e t F red erick Douglas, th e m an, vied w ith the noblest of the
lan d in th e em b odim ent an d appreciation of the higher hum an values.
B ooker T . W ashington an d P aul L aurence D u n b ar b ro k e th e invidious
b a r of a d eg rad ed childhood an d rose to a high level of public honor
an d esteem . W h a t w as accom plished so conspicuously b y the few
illustrious individuals is being m ultiplied b y thousands in lesser m easure
in all p a rts of th e land.
T h e gospel of w ealth is paradoxical. T h e G o o d B ook tells us
th a t “ th e love of m oney is th e ro o t of all evil’’ ; b u t experience teaches
us th a t th e lack of m oney is th e source of m ost social ills. P o v erty leads
to m o st of th e evils th a t hum an flesh is heir to. Vice, crime, an d
d eg rad atio n are its natu ral offspring. T h e child of a d eg rad in g envi­
ro n m en t m ay possibly escape d eg rad atio n of character, b u t th e risk is
to o g reat fo r enlightened society to hazard. T h e child w ith capacity
for decency w ho becom es d eg rad ed , th e child w ith capacity for know l­
ed g e w ho grow s up in ignorance, th e child w ith capacity for virtue who
becom es vicious, represent a hum an trag e d y the aw ful responsibility
fo r which society m ust shoulder.
T h e cure of p o v erty m ay n o t elim inate all social evils; b u t social
evils can n o t b e elim inated while p o v erty prevails. T h e political tu r­
moil of th e w orld, is, a t b ottom , econom ic. T h e w orld is convinced

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T H E ECO N O M IC A N D SOCIAL BASIS

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th a t the right political o rd e r can n o t b e m aintained until p o v erty has
b een banished. T h e N egro will b e am ong th e last elem ents of society
to feel the relief from this aw ful load. T h e children of th e race should
n o t b e m ad e to w ait upon this slow am eliorative process.
E d u catio n is the only practicable partial rem edy. T h e p ro p e r in ­
tellectual, m oral, social, an d vocational training will go far to correct
th e evils w hich u n fo rtu n ate social conditions im pose u p o n th e Negro
child. E d u cate th e child in th e w ay he should go, an d h e will b e likely
to lift him self to a higher level, it w ould b e a m ockery in d eed if this
g re at sacrifice to m ake th e w orld safe for dem ocracy should fail to
m ake d em ocracy safe for the child, even the child farthest dow n.
T h ere is b u t one practical p ro g ram u pon w hich all right-m inded an d
patrio tic A m ericans can agree, an d th a t is the im m ediate relief a n d
uplift of th e N egro child.
T h e S ta te has assum ed th e responsibility for education. T h e p e r­
form ance of th e S tate should b e 100 p e r cent efficient. It is a disgrace
to a soverign S tate to h av e any one of its functions im perfectly p e r­
form ed. T h e function of education in m any of our S tates is h ard ly
ten p er cen t efficient. E very child should receive ad e q u ate educational
ad v antages. T h e G o v ern m en t owes this d u ty to th e child, especially
th e N egro child w hose race has been so loyal to the G overnm ent in the
h o u r of its peril. T h e m o st effective service th a t can b e ren d ere d th e
child h o o d of this race m ay b e do n e b y persuading th e G o v ern m en t of
th e U nited S tates to furnish national aid for education in th e places
w here th ere is need.
A t th e annual m eeting of th e D ep artm en t of S uperintendents o f th e
N ational E ducation A ssociation a t A tlan tic C ity in F ebruary, 1918,
a resolution was unanim ously a d o p te d to th e effect th a t th e N ational
G o v ern m en t should re n d er aid to education in those S tates w hich
stan d in need of it. H e re is a p lan w hich all can ap p ro v e w hich will
go farth er th an an y o th er practicable provision to lift th e N egro child
up to th e desired stan d ard .
Som e say th a t th e N egro p ro b lem is in so lu b le; b u t the A m erican
p eo p le h av e n ev er seriously tried to solve th e race problem . If th e
F ed eral G o v ern m ent will educate every child according to his n eed s
this will b e the first im p o rtan t step in this direction.
T h e N egro child sits in th e shadow of p o v erty an d ignorance. H is
social environm ent benum bs his higher pow ers an d faculties. H e looks
a t th e proclaim ed new o rd e r of things an d longs to en ter into its sun­
shine an d joy. But, alas, conditions forbid. T h e new freedom which
the w orld w ar has just fought for w ith countless cost of b lo o d an d
treasure will p ro v e to b e b u t v anity an d vexation of spirit if the least
of these is d en ied his G od-given birth rig h t to en ter into this proclaim ed
new order.


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W h en I co nsider th e sad lot of the N egro child I can n o t refrain from
indulgence in th e ancient lam en tatio n : “Oh, th a t m y h ead w ere
w aters an d m ine eyes a fountain of tears, th a t I m ight w eep d a y an d
night for th e slain of th e children of m y p eo p le.”


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B ELG IA N C H IL D R E N IN W A R TIM E
By MISS L. E. CARTER, Brussels, Belgium

I u n d erstan d you are interested in the destiny of th e little country,
Belgium. P erh ap s th e little countries serve as links betw een th e g reat
nations in the g re at international w ork we are looking forw ard to, so
th a t I v en tu re to give special details concerning w hat has b een d o n e in
m y country for child w elfare.
I w ould consider tw o periods, one ending on A ugust 4, 1914, an d
th e o th er one com prising th e follow ing four years.
T h e first p erio d com prises eighty-eight y ears of independence. T h e
jubilee of fifty years of in dependence w as celebrated in 1880. T hen
in 1905 w e celeb rated w ith joy th e seventy-fifth y ea r of liberty, an d
w e w ere looking forw ard to the celebration of a h u n d re d years of in d e­
pendence. A lre ad y som e of our large factories w ere prep arin g for
the celebration.
L ong b efo re th e application of th e law of com pulsory education,
which to o k effect in 1914, an d which obliges children in Belgium to
go to school until th e age of fourteen, we h a d m any prosperous schools
all o v er th e country— S ta te schools a n d o th er schools w orking in co­
o p eration w ith th e S tate— an d a g reat n um ber o f parochial schools.
W e are trying y e a r afte r y ear to bring those schools into b e tte r and
b e tte r condition.
A m ong these schools those of B russels w ere th e best. I h av e
b ro u g h t w ith m e th e annual school re p o rt fo r Brussels fo r 1913, th e
last th a t w as p rin ted, because during th e w ar we w ould n o t h av e o u r
m atters p rin ted . T h ey w ere censored b y th e G erm an authorities, so
w e w ere w ithout an y printing. T h e re p o rt will show you th a t we
h a d tw en ty -th ree elem entary schools fo r boys an d girls, b u t separated.
W e h av e n o t in Belgium y o u r system of coeducation. W e h a d busi­
ness schools fo r girls a n d m anual schools for boys. T h ere w ere three
special schools fo r dom estic science entirely equipped, a n d our ele­
m en tary pupils w ent periodically to those schools w hich w ere especially
ad a p te d for th e teaching of dom estic econom y. W e also h a d th ree
high schools for boys, th ree high schools fo r girls, one norm al p rim ary
school fo r b oys an d one for girls. W e h a d considered, too, th e
question o f d efective children an d d ea lt with it as b est w e could.
In 1913 th e law for th e protection of children w as ap p lied to d e ­
linquent child ren ; special tribunals w ere ap p o in ted an d v ery good
results cam e from th at organization.
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W ith re g ard to physical training, our children h av e a t least h alf an
h o u r a d ay *in exercise, either gym nastic or play gam es. B efore the
w ar w e served m eals in the schools. W e called th e several organiza­
tions “th e cup of m ilk,” “ th e cup of coffee.'* T h ere w as an o th er one,
“ the m outhful of b re a d ,” because w e h a d m any p o o r children w ho h ad
n o t enough fo o d a t hom e. W e also p ro v id ed th e children w ith clothes;
an d th e girls in the high schools in their lessons on needlew ork sewed
on clothing necessary for little b ro th ers an d sisters.
O n e of th e things of which Brussels was v ery p ro u d w as a national
collection of th e principal landscapes an d of the principal scenery of
the country which h a d b een given to th e schools. T h e schools h ad
copies of beautiful pictures th a t h a d b een m ad e b y our best artists.
M any of th e places represented h av e b een to a great extent destroyed.
Besides th e d a y schools we h a d evening classes in all our schools for
th e children w ho h ad left school too early an d for those w ho w an ted to
progress fu rth er in their studies.
M edical inspection is organized as com pletely as possible in our
schools w ith th e help of d o cto rs an d of nurses. W e send th e delicate
children into the country ; w e h a d five country hom es fo r th a t purpose
— now one h as disap p eared entirely. Besides these country hom es
th ere w as a p riv ate institution called th e O pen A ir A ssociation which
h a d co u n try houses w here our children could b e sent.
E verything lo oked hopeful, although w e think th a t we h av e still
m uch to do. A n d am ong the m any things th a t w e m ust create are,
of course, m o re p laygrounds fo r our children.
w ould like also
to see established the principle of coeducation, an d a b e tte r u n d e r­
standing pf vocational guidance. O ur libraries are quite sm all and
our aim is to establish som e children’s libraries on th e m odel of A m eri­
can libraries. W e w an t also, if possible, if it is n o t against th e interest
of th e family, to persu ad e children to go to school until th ey are a t least
sixteen.
T h e beginning of th e second period is m ark ed b y th e invasion of
Belgium b y th e G erm ans. Y ou know th a t m any of o u r tow ns dis­
ap p e are d entirely, schools, churches, everything. F actories an d w o rk ­
shops w ere closed. T h ere was no w ork, no possibility for child labor.
T h ere are w orkshops for apprenticeships, b u t all o v er th e country
m any of these w ere destroyed. O thers w ere tak en b y th e G erm ans
an d used fo r o th er purposes.
B russels being th e capital an d especially b eing guided b y Mr.
A d o lp h M ax, w ho is I believe internationally n o te d for his integrity
an d his sense of justice an d courage, was p ro tected . A ll except three
of o ur m an y schools (th re e th a t w ere used b y th e G erm ans) rem ained
open. But th ey h a d to fight against difficulties of m any kinds. A n d

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am ong these difficulties was th e fact th a t in the severe cold 6f the
w inter our pupils h a d no fire a t all, an d in those large buildings m ad e
principally of stone the cold w as very, v ery severe indeed.
I w an t to dw ell on these difficulties an d on th e result o f them b e ­
cause th ere w as n o t only th e w ant of coal, b u t th ere w as also (in spite
of the help given b y A m erica) th e w an t of food. Dr. S and sum m ed
up th e result of the difficulties against which we h a d to fight b y saying
th a t o u r school children are one full y ear below norm al in their d e ­
velopm ent. O u r boys h av e lost th ree p o u n d s in w eight an d our girls
fo u r pounds.
O n e of th e dreadful' things for our children w as th e environm ent in
w hich th ey w ere placed. I h av e read in an A m erican b o o k on child
w elfare th a t “in m any respects environm ent is the dom inating factor
o f hum an d ev elopm ent, an d this applies especially to th e p erio d of
childhood. T h e physiology of children proves them to b e extrem ely
plastic in b o d y , an d psychology has re n d ere d a sim ilar conclusion in
respect to m ental qualities.” A s to the observations concerning m ental
life, this is a fact. W hile our children ought to b e b ro u g h t up in an
atm o sp h ere of truth, while our p aren ts ought to teach them the cour­
age of speaking th e tru th always, during th e w ar p aren ts h a d th e pain­
ful d u ty a t tim es to teach thei^ ch ild ren to say lies, an d to teach them
th e courage of speaking them out in spite of th reats an d of b a d
treatm en t. I know a sw eet m other, of th e m ost noble character, re­
fined, rich, w ho w an ted to do som ething for h e r country. H e r boys
w ere still to o y oung to serve. She saw the wives of w orkm en now
gone to w ar in distress because they h a d no new s a t all from their
h u sban d s o r from their sons. W ith the help of m any others she o r­
ganized a system of correspondence, w hich was quite fo rb id d en b y th e
G erm ans. H e r little boys help ed her, w ith o th er persons. T hese
b oys m et th e letter carriers on their w ay to school an d b ro u g h t b ack
th e letters h id d en am ong their school b o oks an d copy books. T his
lad y to ld m e m an y a tim e how distressed she w as because she h a d to
m ak e up h e r stories w ith h e r children so as n o t to b etra y the p erso n s
w ho w ere helping h er in this system of correspondence. T h e system
w o rked o u t fo r tw o years. T h en things w ere found out. S he w as
tried, an d she d efen d ed herself. O ne of m y friends w ho has been
w orking in th e R ed C ross in P aris w ent dow n to th e place w here the
ju d g m en t to o k place in th e h o p e of sustaining th e courage of o u r friend,
an d w hen she cam e b ac k she to ld m e th a t she w as n o t in n eed of
co u rage; th a t she spoke so splendidly th a t th e h earts of h e r judges
w ere m o v ed to tears.
W ell, this n o b le w om an h a d b een obliged, as h a d m any others, to
teach h er children to tell lies. O ur children w ant an atm osphere of
calm, of confidence of life. O ur children in Belgium T or nearly five


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y e a rs ‘h av e lived in an environm ent of fear, agitation, w orry, an d
h atred . A n d though th e causes of fe ar are dying away, w orry an d
h atre d are still th ere a t w ork. T h e fe ar an d h a tre d w ere felt even
b y little babies. I rem em ber this instance. In a tram car w ere several
persons. T h ere en tered a w om an w ho h a d a b a b y in h e r arms. She
sat on on e side of th e car. O n th e o th er side of th e ca r w as a G erm an
officer alone. N o body sat dow n n ex t to him . T h e fath er of th e child
h a d rem ained on th e p latform . A s soon as th e child, w ho could
h ard ly speak, saw th e G erm an, h e gave signs of g reat uneasiness, of
agitation, an d h e w as re ad y to cry. T h e fa th e r w as obliged to com e
in th e car to calm th e child, an d tu rn ed his face to th e w indow so he
w ould n o t see the G erm an officer. In som e such cases m others and
fath ers h av e b een arrested an d considered as responsible fo r their
children. In this case th e officer lo oked grieved an d w alked out of
th e car o nto th e platform .
I could tell you m any o th er tales. T h in k of th e m any children w ho
w ent to b e d w ith their little parcels re ad y in case th ey should h av e
to escape during th e night. W h a t sweet, restful slum ber could these
children g et?
Instead th ere w ere h eavy d ream s an d h o rrid night­
m ares o f rap in e an d m urder. Imagine^ phildren escaping w ith their
m o th ers an d having to tram p som etim es during days an d nights. I
h av e b een to ld of children w ho came* to our hospital an d w ho died
n o t of any special illness b u t really of fright, of horror. T h ere w as no
spectacle m o re aw ful th an th e eyes of those p o o r little children ex­
pressing th e greatest fear. T h e m others them selves w ere so desp erate
a n d so sp en t in grief th a t th ey w ere n o t able to weep. F ancy these
scenes rep eated a t every m om ent, every day, an d acting on the deli­
cate n ervous system of a child.
O ne of m y pupils, one of o u r b rig h test girls, a v ery clever girl, a t
eighteen, b ro k e d ow n entirely. She belo n g ed to a w ell-to-do family.
She w as n o t in n eed of b e tte r food, b u t she h a d b een w orrying about
h e r fa th e r w ho w as an officer in th e arm y, w orrying ab o u t h er m other
w ho w as ill from th e fact of n ev er having a letter from th e father, and
w orrying from having to tak e th e responsibility of th e household. She
lost in a v ery sh o rt tim e tw enty pounds. M any d o cto rs saw her, an d
th ey d eclared h e r organs w ere in g ood condition, b u t th a t h e r nervous
system h a d b een so strained she h a d given way. O ne em otion a child
m ay bear, b u t m an y em otions, n o t so. It w as n o t possible for h er
young nervous system to b e a r it. U n d e r norm al conditions one of
these shocks w ould h av e b een sufficient to b re a k dow n o r to injure
fo rev er th e n ervous system of a child. Now, think th a t our little
children suffered from these shocks constantly during five years.
A t h om e th ey h a d th e love of their m others, b u t they b re ath ed
the h o t atm o sp h ere of care an d sorrow , caused alw ays b y th e sam e


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ECO N OM IC A N D SOCIAL BASIS

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reason— the fath er was aw ay o r th e son h a d gone to sea trying to
reach th e front, o r som etim es it w as th e w an t of m oney. A n d even if
o ur p o o r children w ere well lo o k ed afte r a n d if every service w as
o rganized to give th em th e fo o d they w anted, th e p eo p le of th e m id d le
classes, obsessed b y a feeling of dignity, w ould receive no help. O ne
o f m y pupils h a d fainted several tim es during th e school hours, an d
w e knew th a t she fainted on account of w eakness. I w rote to th e
m o th er as discreetly as I could, asking h er if I could help her. She
replied expressing h er thanks an d saying th a t she an d h e r h u sb an d
h a d som e savings, an d th a t they w ould b e ab le to h o ld out until th e
w ar w as over, w h atev er the length of th e w ar should be.
W h a t th e child n eed s is joy, n o t an existence am ong these terrib le
things, seeing th e m o th er grieving d a y afte r day. C hildren w ere
glad to escape som etim es from hom e an d go to school w here a t least
th ey fo und com panions of their ow n age. B ut even school was n o t
w h at it ought to be. In general, teachers d id th eir duties splendidly,
an d I am v ery p ro u d b f th e fact th a t we w ere ab le to keep th e schools
open during these long years. B ut th ere w as th e w an t of liveliness th a t
a certain w eakness can n o t provide. T h ere is alw ays a touch of d re ari­
ness; an d th e pupil feels th a t som ething is w anting. T h e physical
w eakness of the staff as well as th a t of th e children could b e m easured
every day. Som e teachers used to tell m e— an d I u n d ersto o d w hat
they h a d said because I h a d passed through th e sam e experience—
how th eir h ead s ached, an d th ey explained, “W e feel as if th e envelope
of o ur n erves has b een w asted aw ay, an d as if every m ovem ent we
m ake is felt.”
N ow these children w hom we h a d in o u r school an d in th e o th er
schools w ere h elp ed in every way, b u t th ey becam e w eaker an d
w eaker. T h ey ought to h av e h a d a change of air. T h ey ought to
h av e h ad p ro p e r food. T h ere w as th e possibility of sending a certain
n u m b er of the children to our country hom es, b u t th ere w ere n o t
enough country hom es, an d even children of w ell-to-do fam ilies could
n o t b e sent to th e country to p riv ate hom es because in those priv ate
hom es th ere w as no food to b e had. In 1918 w e w ere given fifteen
places in these country home^. In o rd in ary tim es our children w ould
n ev er h av e accepted such an invitation, b u t here it w as a v ery h a rd
task fo r th e h ead s of the schools to choose fifteen am ong th e m ass of
four o r five h u n d re d children, all needing a change of air. I received
m an y letters which I could scarcely answ er from those country hom es
w here th e children w ere going. T h ey w ent to sleep on m attresses m ad e
of hides. T h ey h ad no potatoes, no butter, no vegetables, no fruit,
b u t they w ere sent th ere to escape from a prison, w hich th e tow n was,
an d to g et th e fresh air of the country.
I com m ent again on th e fact th a t though w e w ere helped, th e food

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given to ©ur children w as n o t sufficient. In schools w here the children
p aid high fees, w e h ad to organize visits of distribution of th e little
cakes which w ere m ade, an d w e h a d to give also soup. I will outline
an o th er incident. E rnest Solvay, having reached th e age of 80 years
an d belonging to th e com m ittee w hich h a d done m uch to help, these
children expressed their appreciation b y m aking him an offering; and
E rnest Solvay, to th an k them , sent to each child a h a rd biscuit which
in n orm al tim es they w ould n o t h av e eaten, an d a piece of chocolate
th e size of m y finger. W hen th e children saw th e biscuit a n d th e little
b it of chocolate, it w as really painful to us, th e elders. B ut w hen I
w ent aro u n d in th e classes to see w hat h a d b een d o n e w ith th e piece of
chocolate, I found th a t all th e children h a d k e p t th e piece of chocolate
w ith the exception of one little b o y w ho h a d tasted it— it w as so te m p t­
ing, or else they h a d given a little piece to th e teacher, an d they
carried it hom e to their "parents. T h e teachers received the sam e little
piece a few d ay s after, an d I received mine. I carried m ine hom e an d
d iv id ed it w ith solem nity betw een the four persons w ho com posed m y
household.
T h e result of th e debility a n d w eakness of our children w as very
a p p a re n t in th e higher classes. T h e possibility of personal w ork d e ­
creased. T h e pupils u n d ersto o d th e m essage th a t w as given to them ,
b u t th ey w ere quite u nable to d o as well their personal tasks a t hom e,
an d th e dom estic lessons a n d the exercises th a t n eed ed skill h a d to
b e left aside.
B ut play, this w as th e m ost pitiful sight. W e saw little children
stopping in their play. T h ey did n o t u n d erstan d w hat h a d h ap p en ed .
T h ey w ere to o w eak to go on, an d m any a child h a d d ro p s of p ersp ira­
tion running dow n his face. M any w ere th e cases of fits of faintness,
an d v ery frequently som e of the senior girls w ho in ten d ed to go to th e
university h a d to d ro p their studies; they h ad n o t strength to go on.
Several w ere th e cases of d eath s th a t m ight h av e b een p re v en ted if
the young p eo p le h a d h a d w h at was necessary for them .
I d o n o t exaggerate in th e least. F o r th e p ast few days I h av e
been living in a kind of earthly p arad ise; I can n o t forget an d 1 will n o t
forget th at o ur little children an d our peo p le h av e lived a n d are still
living-in a k ind of purgatory. If I have dw elt on these subjects it is
because I think— although I am n o t giving a scientific explanation—
th a t th e facts are fundam ental necessities to help us to discover law s;
an d I h av e dw elt on these results as one dw ells on th e ch aracter of
a disease in th e h o p e of un d erstan d in g b e tte r th e necessities of th e
situation— as one studies abnorm al conditions to u n d ersta n d b e tte r
w hat is required u n d e r norm al conditions. T h e privation during the
w ar of th e elem ents necessary to th e child’s w elfare an d th e w ay in
w hich these privations h av e acted on th e bo d ies an d souls of our chil
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d ren, show m o re th an ev er th e necessity of giving th em w h at they
n eed — p u re air, g o o d food, exercise, liberty, joy.
I com e to a n o th e r conclusion. T h e children of Belgium h av e suf­
fered as all th e children in th e affected countries h av e suffered, an d
you, m y bro th ers, you h av e h ea rd th e cry of th e children. Y ou h av e
answ ered th e touching appeal, b u t m ore is to b e done. T h ese aw ful
results, m o re terrib le than can b e recounted, are th e consequences of
war. A n d if w a r is to teach us w h at is th e m eaning of life, y e t I w ould
like th a t such a lesson should neverm ore b e taught. I should like
o th er m ean s to b e found to com e to such conclusions as this th a t w e are
discovering, th a t w e should live in a m ore dem ocratic way. N ations
p erh ap s are going to d isap p ear b efo re th e international m ovem ent. I
am n o t speaking as a scientific person w ould speak, n o r h av e I m ad e
use o f an y statistics. B ut I believe th a t in th e general w ork of h u ­
m anity each m ust b ring w h at h e can bring.
I co n clu d e b y giving you a m essage which w as given to m y school.
W e h a d a visit from tw o A m erican ladies w hich pleased us v ery much,
a n d b efo re going these ladies asked if o u r pupils w ould ta k e this
p led g e w ith th em :
M ay we, th e w om en of A m erica an d th e w om en
o f B elgium an d th e w om en all o v er th e w orld, unite our efforts an d
en d e av o r w ith all our h e a rt an d soul to carry out th e w ork of recon­
struction an d of p eace.” A n d 1 will a d d only one w o rd : “F o r the
sake of our ch ild ren.”


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Section II
Child Labor
(T h e m inim um stan d ard s in reg ard to th e em ­
p loym ent of children a d o p te d b y the W ashington
C onference will b e found on pages 4 3 3 -4 3 5 .)


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LEGISLATIVE PROHIBITION OF EMPLOYMENT
G E N E R A L ST A N D A R D S
By OW EN R. LOV EJOY
S ecretary , N ational C hild L ab o r C om m ittee

H ith erto w e h av e m o re o r less unconsciously em ployed th e sliding
scale in relation to child-labor standards. W e p u t prohibition of night
.work in one S tate, which h a d an extrem ely low all-round stan d ard , on
very m uch th e sam e plan e of achievem ent as establishing an eight
instead of a ten -h our d a y in an o th er S tate, which h a d relatively high
stan d ard s. T h a t is, it has been natural to w o rk w ith alm ost equal
enthusiasm fo r high sta n d a rd s in S tates w here th e d em an d for them
w as strong an d for m uch low er stan d ard s w here th e d e m a n d w as less
o r w here it w as lacking. T h en w hen those sta n d a rd s w ere established
we w o rked fo r still higher ones. W e used th e sliding scale in acco rd ­
ance w ith th e age-old th eo ry of d em an d an d supply. T his th eo ry
in econom ics is fallacious. It is tim e to discard it in social w ork. It
is tim e to co nsider solely th e individual, for w h at is right for th e in d i­
vidual is right fo r industry an d society an d th e w orld a t large.
A rg u m en ts h av e been used to p ro v e th a t child la b o r is n o t eco­
nom ical; th a t it is fatal to la b o r because it low ers w ages; th a t it is not
in h arm o n y w ith efficiency fo r th e m an u factu rer; th a t it is n o t co n ­
ducive to th e ed ucation o r to th e physical h ea lth a n d v igor of th e
nation. N ow it is tim e to talk of th e child, an d in turning to th e child
it is ev id en t th a t really v ery little account h as b ee n tak en of him . W e
know th a t w o rk can n o t b e g ood for his health, b u t w e d o n o t know
scientifically how b a d it is for him, n o r w h at are th e effects of different
kinds of w o rk u p on his developm ent, n o r a t w h at age it is, physically
speaking, perm issible fo r him to en ter in d u stry in general.
A few S tates require b y law a physical exam ination of children w hen
they leav e school a n d ap p ly for w ork perm its, b u t th e fact th a t these
children h av e n o t b een subject to system atic physical exam inations
during th eir school life m akes this exam ination of alm ost negligible
value. F u rth erm o re, up to d a te n o t a single one o f th e 48 com m on­
w ealths requires system atic physical exam ination of ch ild ren betw een
14 a n d 16 y ears of age w ho are a t w ork. A m erica has n o t even h ad
th e intellectual curiosity to try to find out w hat industry do es to h er
children.
F u rtherm ore, though certain studies h av e been m ad e of child nature,
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of child psychology, an d o f adolescence, w e really d o n o t know w hat
th e child n eed s m entally a n d spiritually. I think it is tim e w e ap p lied
ourselves to this task. W e know th a t n early h alf th e children w ho
leave school in o rd e r to go to w ork d o so because th ey are tired of
school, because th ey dislike th e teacher, “ d id n o t g et on,” o r p re fer
to w ork. W h y d o es this com m on phenom enon o f re v o lt against school
ap p e a r so regularly a t th e age of 1 3 o r 14 ? Is it th e fault of th e child
o r of th e school? A re we w illing frankly to face th e fact th a t th e
elab o rate a n d form al school system built up b y us adults on b eh a lf of
ch ild ren is n o t acceptable to th e beneficiaries? T h a t p erh a p s th ey
could p o in t a w ay to its im provem ent? W h a t in sh o rt are th e n eed s
of ch ildren? It is ev id en t th a t in o rd e r to fix our stan d ard s, this ques­
tion m u st first b e answ ered. B ut until th e studies can b e m a d e — -and
th ey n ev er can b e finished, fo r as science ad v an ces new light will co n ­
tinually b e th ro w n u p o n one o f its m o st interesting a n d baffling p ro b ­
lem s— certain m inim um legislative requirem ents should b e set up, to
b e established as soon as possible in th e m ore ad v a n ced com m unities,
an d to b e ap p ro ach ed for th e present as a lim it in S tates w hose citizens
d em an d less protection.
A reaso n ab le m inim um age fo r entrance into in d u stry w ould b e 16
years. T his should ap p ly to all com m on w ork, such as th a t offered b y
factories, mills, canneries, offices, stores, laundries, restaurants, an d to
all th e m iscellaneous occupations en tered b y children. It should b e a
flat m inim um , th a t is, fo r all gainful occupations w ith th e o n e exception
of agriculture. Eighteen y ears should b e th e m inim um ag e fo r w ork
in m ines an d o th e r especially dangerous industries, a n d 21 th e age for
m orally d an g ero us w ork such as falls to th e lo t of n ight m essengers in
o u r cities. T h ere should b e p eriodic exam ination of all w orking chil­
d re n to see th a t th ey are n o t being b ro k e n dow n in health, a n d m eans
should b e a d o p te d fo r th eir transfer, if advisable, to less harm ful in­
dustries o r th eir rem oval from industry altogether. Such an exam ina­
tion, m a d e n o t less th an once a year, w ould in a short tim e show just
w h at are the, industries a n d o p erations which induce excessive fatigue,
p red isp o se to disease, o r lead to stunted grow th.
A s to h o u rs of em ploym ent th e regulations recently p ro p o se d b y
th e C om m ission on International L ab o r Legislation for insertion in th e
P eace T re a ty a n d a d o p te d b y th e P eace C onference in Paris, A pril
28, 1919, offer a suggestive basis. T h e Sixth A rticle p ro p o ses “ the
ab olitio n o f child la b o r a n d th e im position of such lim itations on th e
la b o r o f y oung persons as shall p erm it th e continuation o f th eir e d u ­
cation an d assure th eir p ro p e r physical d ev elo p m en t.“ T h e term
“ ab o lition o f child la b o r” is so indefinite th a t unless light w ere throw n
u p o n it b y o th e r p o rtio n s o f th e statem ent, it w ould h av e little m ore
effect than similar d eclarations in o u r ow n national political p a rty

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platform s. F o rtunately, how ever, th e com m ission speaks w ith a defi­
niteness th a t leaves no room for doubt. T h e F o u rth A rticle p ro ­
poses “th e ad o p tio n of an eight-hour d a y o r a 4 8 -hour w eek as the
sta n d a rd to b e aim ed a t w here it has n o t a lre a d y b een o b tain ed .”
T his lim itation of hours d o es n o t relate to child labor, which, according
to A rticle Six, is to b e entirely abolished. T his eight-hour d a y a n d 48h o u r w eek refers to la b o r in general— to th e p ro tectio n o f m en a n d
w om en— to th ose o f m atu re physical developm ent.
T h e co ro llary is obvious, an d it has alre ad y been recognized u n d er
existing co n d itions b y th e a d o p tio n o f an eight-hour d a y fo r children
in S tates w here th e lim itations of hours fo r m en an d w om en w ere 10, 11,
o r 12 hours, o r w here, perhaps, no lim itation existed. T h e principle
underlying this discrim ination in th e interest of children assum es th a t
th e grow ing, d eveloping child subjected to industry should h av e th e
b u rd e n laid on g ra d u ally ra th e r th an all a t once, an d th a t if m en an d
w om en n eed p rotection, children n eed m o re protection. But now we
face a n ew condition, fo r certainly A m erica w ith its n atu ral resources
a n d a b u n d a n ce o f en terp rise ca n n o t afFord to stan d on a low er plane
th an th e o n e p ro p o se d in this international lab o r com pact. If an eighth o u r d a y m easures a desirable social lim itation fo r th e la b o r of m en
a n d w om en, th en an eight-hour d a y is to o long fo r th e la b o r o f chil­
dren. F o r th e first tw o years a t least— nam ely from 16 to 18 years o f
a Se— no child engaged in o rd in ary industrial processes should b e
em ployed to exceed six hours a day. T h erefo re w e should pro p o se
as th e m axim um industrial b u rd e n th a t restriction of hours to six p e r
d a y a n d p ro h ib ition o f night w ork u n d e r 18 y ears o f ag e should of
course form p a rt o f th e program .
O bviously this p ro g ram ca n n o t b e p u t into im m ediate effect so long
as excessive industrial b u rd e n s are laid on th e shoulders of halfstarv e d m others, an d so long as o u r schools persist in “ teaching” in­
stead o f edu cating our children. It w ould b e ab su rd to force law ­
m aking a h e ad of sta n d a rd s th a t public opinion can m aintain. But
these sta n d a rd s a re suggested as th e ones th a t in o u r educational and
legislative w o rk should u n d o u b ted ly b e our object. H ow soon we
m ay h o p e to a p p ro ach them u n d e r existing conditions I leave to our
statistical experts. Since 1890 o u r p o pulation has increased 60 p e r
cent an d o u r n et annual p ro d u ctio n o f w ealth has increased 700 p e r
cent. O bviously, therefore, if p eo p le w ere ab le to exist in 1890 th ey
should b e ab le to exist oh a v ery m uch high er p lan e an d a m o re com ­
fo rtab le p lan e in 191 8 ; a n d during this p erio d w e h av e p ro d u c ed
m illionaires m o re prolifically th an anything else except paupers.
A lth o u g h ap p ro x im ately three-fourths of our w orking children are
em ployed in agriculture, this is one o f th e m ost difficult of all occupa­
tions to regulate. F arm w ork is u n d o u b ted ly harm ful w hen accom 
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p an ied b y exploitation as- in th e C o lo rad o b ee t fields an d th e S outhern
co tto n fields, an d y et w ork ab o u t th e hom e farm on a v ariety of occu­
pations, o r w ork for a neighbor, m ay b e highly healthful an d instruc­
tive. T h e m ost serious objection to this form of w o rk is th a t it alm ost
in variably ten d s to keep th e child out of school fo r m o re o r less of the
sh o rt p erio d th a t rural schools are in session. T h e child gradually
falls b eh in d his n orm al grade, one year, tw o years, o r th ree years. H e
is b o th ash am ed a n d b o re d a t being forced to stu d y w ith younger
children on m atters th a t are too elem entary to hold his attention.
R etard a tio n lead s to fu rth e r re ta rd atio n an d to early d ro p p in g out
altogether.
T h e tro u b le suggests th e cure. W hile it m ight b e unfair an d w ould
u n d o u b ted ly b e quite im possible to enforce a law directed against th e
em ploym ent of children on farm s, w e can raise th e educational sta n d ­
a rd in rural com m unities, a n d w e m ust d o so a t once if w e wish to
retain o u r rural p o pulation an d our agricultural soundness. T h e con­
d ition of o ur rural com m unities n o t only affects our social a n d civic
institutions; it strikes a t th e v ery foundation of econom ic prosperity.
T en p e r cen t o f th e rural p o pulation can n o t re a d an agricultural
bulletin, a farm jo urnal, a th rift appeal, a new spaper, th e C onstitution,
o r th eir B ibles; answ er an incom e ta x questionnaire; o r keep business
accounts. S ecretary L an e says: “W e spent m illions of dollafs in
p resenting to th e co u n try th e reasons w hy w e w ere a t w ar, a n d m ore
th a n ten p e r cent of th e m oney th a t w as spent w as spent fruitlessly,
because th e p eo p le w ho g o t th e literature, w ho got th e speeches, who
g o t th e appeals, co uld n o t u n d ersta n d one w o rd th a t w as w ritten.”
O n e th in g th a t draw s o u r boys to th e city is th e call of life an d
h um an intercourse a n d b e tte r facilities for know ledge. If w e can in
som e m an n er en d o w o u r co u n try schools w ith vitality, m an th em w ith
teachers earning a n d getting living wages, introduce th e spirit of com ­
m unity effort, an d give scope fo r th e instinct of w orkm anship, an d if
w e can th en create an d enforce ad e q u ate com pulsory education laws,
w e shall h a v e elim inated th e w orst evil of children’s em ploym ent in
agriculture. W e shall a t th e sam e tim e b e building up an educationally
eq u ip p ed a n d consciously effective agricultural an d land-m inded
population.
C o n tin u atio n schools a n d law s com pelling em ployers to allow tim e
fo r atte n d a n c e b y th eir em ployees u n d e r 18 years of age should b e
th e reverse side o f o u r child-labor laws. B ut it is v ery difficult to
confine oneself to legislative prohibitions w hen th e w hole tre n d of
ch ild -lab o r effort an d education w ork in this co untry is in th e direction
of construction ra th e r th a n prohibition. O u r enforced laws, how ever
good, h o w ev er effective in keeping children out of industry a n d in
school, will avail v ery little unless w e p ro v id e a b e tte r substitute than

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work, a n d a b e tte r school system a n d curriculum th an th e one in vogue.
A n d here we return to th e question of children s needs. L et us b y all
"means w ork fo r th e m inim um stan d ard s w hich com m on sense an d our
industrial experience justify, b u t let us a t once begin th e cam paign
fo r the scientific determ ination of th e physical effects of w ork, through
regular physical exam ination of school an d w orking children. L et us
by all m eans encourage educational experim ents, especially those
which seek in som e w ay to satisfy the craving of youth an d adolescence
fo r real w ork, fo r learning through doing, an d for w age-earning. If
w e can finally elim inate the tw o evils of being taught on th e one h an d
an d being ex ploited on th e other, we shall h av e touched th e h ea rt of
th e problem . It is possible th a t this m ay b e d o n e b y bringing w ork
into the schools o r taking th e schools out into th e w orld of a d u lt en­
d ea v o r an d lab o r; b y substituting for o u r industrial training, education
th rou g h responsibility an d initiative in different kinds o f h a n d an d
b rain w ork. Such experim ents will inevitably lead to a b e tte r u n d er­
stan d in g o f child n atu re a n d to an in terp retatio n of its unexpressed
dem ands.
DISCUSSION
M r. G eorge G. C hatfield, o f th e B ureau of A tte n d a n c e of th e N ew Y ork
C ity B oard of E ducatio n , em phasized th e necessity fo r la rg e r p u b lic ex p en d itu res
in o rd e r to p ay fo r th e len g th en ed school p erio d pro p o sed .
H on. P. P. C laxton, U. S. C om m issioner of E ducation, discussed th e significance
of calling this conferen ce a t a tim e w hen th e p eo p le of th e w o rld a re deeply
in terested in problem s p e rta in in g to th e w elfare of childhood.
‘‘T h e re a re tw o reaso n s fo r it,” said Mr. C laxton. “ F irst, th e re is g re a t d a n g er
now because of th e v ery g re a t losses' in life an d m oney, a n d g re a t d estru ctio n
of p ro p e rty , th a t m an y h ard sh ip s m ay fall on ch ild ren th a t o th erw ise w ould not.
A n am o u n t equal to o n e -th ird of all th e w ealth of th e w o rld in 19 14 h as been used
up. T h e loss of life has b een v ery g re a t a n d m an y fam ilies have b e e n left w ith
children w ith o u t fa th e rs; m o th e rs left to su p p o rt th e ir fam ilies; a n d fre q u e n tly
th e children left in even w o rse condition..
T h e re is a n o th e r g re a t reaso n . N ever b efo re h as it b een so im p o rta n t as
now th a t hu m an ity should b e considered, th a t no child should g row to m anhood
o r w om anhood w ith o u t th e ed u catio n n e cessary to p re p a re it fo r citizenship in
th e new dem ocracy of th e w orld, fo r m a k in g a good, h o n e st living, a n d fo r a t­
tain in g th e full sta tu re of m an h o o d a n d of w om anhood. T h e w o rld h as p aid a
g re a t p rice fo r freedom a n d fo r dem o cracy , b u t th e re can be no freed o m so long
as children a re slaves. A n d Pestalozzi, th e g re a t Swiss e d u c a to r of a c e n tu ry ago,
w as rig h t w hen he said th a t th e re can be no freedom w ith o u t th e ed u catio n of
m an. D em ocracy can n o t be safe in th e han d s of a p eo p le a la rg e n u m b e r of
w hom have been stu n te d in childhood a n d have failed in th e m en tal a n d m o ral
a n d p hysical developm ent n e cessary fo r th e du ties a n d responsibilities o f d em o­
cra tic citizenship.”


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MINIMUM P H Y S IC A L S T A N D A R D S
By DR. EMMA M ACKAY A PP E L
C hicago B oard o f E d u catio n

M edical inspection w as first in tro d u ced into th e schools fo r the
pu rp o se of prev enting th e sp read of infectious diseases. L ater, in ­
vestigations w ere m ad e of th e physical defects having d irect bearing
upo n a child’s progress in school. Inspection w ith these o b jects in
view continues to b e th e chief function of th e school physicians in m any
cities, w hile in o th ers th e m edical w o rk has progressed, an d general
physical exam inations are m ad e yearly w ith a view to im proving th e
physical w ell-being of th e child.
W ith th e a d v e n t in Illinois o f th e child-labor law requiring th a t
children going to w ork b e exam ined b y a physician, th e physical con­
dition o f th e child has tak en on a new aspect. M edical inspection is
carried a step fu rther— to com plete physical exam ination a n d super­
vision, in an effort to co rrect all physical defects a n d to establish a
p ro p e r n u tritio n al balance, as well as to inquire into th e m ental status
of th e child. M easures fo r th e p rom otion of th e h ea lth of th e in­
dustrial child m ust b e p rev en tiv e as well as rem edial.
T h e im p o rtan t factors entering into th e sta n d a rd of requirem ents of
physical fitness fo r industry are:
F irst— T h e child m ust b e physically able to p erfo rm th e w ork re­
quired o f him , w orking an eight-hour day.
S econd— T h e child m u st b e ab le to p erfo rm the p articu lar w ork
co n tem p lated w ithout injury to himself.
T h ird — T h e child m ust b e free from an y condition w hich m ight b e
harm ful to his cow orkers.
T h e placing of th e physically fit child in industry, th e o p p ortunity
of im proving th e physically unfit, an d th e placem ent of th e h an d i­
c a p p ed child in suitable w orking conditions, h av e b een th e v ery jm
teresting w ork of the m edical exam iners of th e b o a rd of education
since th e Illinois C hild L ab o r L aw w ent into effect in July, 1917. It
h as b een th eir aim to direct, suggest, advise, consult, a n d p rovide
m eans fo r treatm en t, to th e end th a t every child, insofar as is possible,
shall b e in p erfect physical condition b y th e tim e h e is sixteen years
of age.
,
T h e m eth o d s of p ro ced u re in th e physical exam ination used in the
C hicago certificate-issuance office are as follow s:

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(a ) A routine m eth o d o f conducting a n d recording physical ex­
am inations is alw ays ad h e re d to. T h e tim e required fo r each exam ­
ination is from th ree to ten m inutes.
( b ) A b rief history of th e child is o b tain ed covering p ast diseases,
p resen t condition, a n d sym ptom s if indicating p resen t illness. T h e
child is questioned in reg ard to hernia, as to. o p erations perform ed,
an d as to m aturity.
(c ) T h e child is then w eighed an d m easured. A ten tativ e m ini­
m um sta n d a rd o f four feet eight inches in height an d eighty p o u n d s in
w eight fo r a fo urteen y e a r old child was a t first ad o p ted , b u t it has
been low ered to four feet seven inches an d seventy-five pounds. T his
stan d ard , while som ew hat below th e norm al for a fourteen y e a r old
child, h as p ro v e d to b e a very w orkable stan d ard an d th e low est one
consistent w ith no rm al health. O ccasionally exceptions are m a d e in
fav o r of th e undersized child w ho has np defects an d w hose w eight is
n orm al o r ab o v e norm al fo r his height.
( d ) A careful physical exam ination is th en m ade. G ait, posture,
speech, th e co lo r a n d tex tu re of the skin, th e condition of th e eyes an d
eyelids, th e nose, m outh, an d th ro a t are ob serv ed ; exam ination of the
chest, h eart, a n d extrem ities is carefully m ade. A ll defects are ca re­
fully n o ted an d recorded.
,
(e ) Suggestions are m a d e for th e correction o f faulty gait an d
posture, an d children having defects in speech are referred to the
schools a n d clinics fo r treatm ent. A ll skin lesions m ust b e tre a te d an d
cured b efo re a certificate is issued.
(f ) W h en d efects in vision are found, th e child is sent to a recog­
nized m edical d ispensary fo r reexam ination an d correction.
An
exam ination b y an oculist is insisted upon— no organ is m o re vital,
an d n o n e requires m o re careful an d skillful atten tio n th an th e eye.
U pon th e results of its tre a tm e n t d e p e n d n o t only th e child’s vision,
b u t to a g re at ex tent his general h ealth as well as his industrial value.
A ll glasses o b tain ed from an optician m ust b e checked b y an oculist
b efo re th e certificate is issued, an d all diseases of the eye an d eyelids
m ust b e tre a te d b y an oculist.
,
(g ) W h en defects in hearing occur, a reexam ination b y an ear
specialist is required, also an exam ination of th e nose an d th ro at.
M any children w ho do n o t respond to trea tm e n t are given certificates
for suitable w o rk ; others are sent to th e schools fo r th e d e a f for further
training. I realize th a t v ery little atten tio n has been given to our d ea f
children, b u t I recall the case of a v ery bright, clear-eyed, w ell-nourished
b o y w ho en tered m y office w ith a queer hesitating rem a rk : “ Y ou d o n ’t
rem em b er m e, D o c to r? ’’ I reached fo r his reco rd to refresh m y
m em ory an d re a d : “ H o ld — absolute deafness, large a n d infected
tonsils an d adenoids, u n der-nourished; referred to school fo r d e a f an d


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C entral F ree D ispensary.” I asked him in a v ery low voice— which he
h ea rd perfectly-—w hat h a d h ap p en ed . “ I w en t to th e school th e lad y
sent m e td, h a d m y tonsils an d ad en o id s out, an d now I h e a r all right
an d h av e gained tw elve p o u n d s.” A t least one child h a d b een helped.
(h ) N ext in im portance to th e eye are th e teeth, an d here w e m eet
o ur g re atest difficulty. In m an y issuance offices certificates are delayed
until all d en tal w ork has b een com pleted. In C hicago w e require the
pro p h y lactic w o rk an d a n o te from a d en tal clinic o r p riv ate dentist
stating th a t th e child is receiving d en tal care. A ll cases of p y orrhea
a n d alv eo lar abscesses are d elay ed for treatm ent. H ow ever, upon
second an d th ird exam inations w e frequently find th a t trea tm e n t has
b een neglected. In this case w e again d elay th e certificate a n d a fresh
sta rt is m ade.
(i) T h e m outh a n d th ro a t are exam ined, an d certificates are d e ­
lay ed fo r trea tm e n t o r rem oval of th e ad en o id w henever th ere is evi­
d ence o f#a serious interference in breath in g o r deafness. W e delay
certificates fo r one ty p e of tonsil only, th at is, th e hy p ertro p h ied
cryptic, a n d infected tonsil, com plicated b y cervical o r axillary
ad e n o p a th y o r cardiac findings. T h e child’s general physical co n ­
d ition is also co n sidered in this connection.
( j ) In case of th e sim ple goitre of adolescence w e advise th e child
against h eav y lifting o r strain of any kind. C ertificates are delayed,
how ever, w h ere th e th y ro id enlargem ent is accom panied b y sym ptom s
of hyperthyroidism , an d sanitarium care is p ro v id ed w henever possible.
(k ) T h e exam ination of th e lungs an d g lan d u lar system is m ad e in
detail, careful atten tio n being p aid to the child’s general condition,
w eight, d eg ree of anem ia, etc. if th ere a re findings indicating a
possible incipient tuberculosis, either pulm onary o r glandular, the
child is referred to th e M unicipal T uberculosis D ispensary for observa­
tion an d treatm ent. A ll children w ho h av e b een p atien ts a t either the
T uberculosis D ispensary o r Sanitarium , o r in w hose fam ily th ere is an
o p en case of tuberculosis, are required to bring a letter from th e dis­
p en sary stating th a t they are free from tubercular infection an d th at
th e^ will b e k e p t u n d e r observation, reporting a t the dispensary at
least once in tw o m onths. , A ll pulm onary lesions, either acute or
chronic, are required to h av e trea tm e n t until definite im provem ent is
shown.
( l) Follow ing m a jo r surgical operations v ery careful exam inations
are m ade, an d w hen necessary abdom inal su pporters o r corrective
ap p a ra tu s are p ro v id ed .
(m ) C hildren having cardiac lesions of-a serious n atu re w ith sym p­
tom s of decom pensation, are n o t given certificates. T h ey are advised
o f th eir condition an d referred to their fam ily physicians o r to a dis­
pensary. S anitarium care has been o b tain ed for m any of them . T he


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m ild card iac case is g ra n te d a certificate p ro v id ed p ro p e r w ork can
b e secured. T h e placing of a h e a rt case is m ost difficult. F inding th e
p ro p e r position w here th ere will b e no lifting of h eavy packages, w here
the child is n o t required to leave hom e v ery early in th e m orning, or
w here th e n oon h o u r is n o t too short, as w ell as persuading th e child
to m ake th e necessary, change, often against th e w ishes of his parents
an d his em ployer, calls for b o th tim e an d patience. T h e children all
w ork u n d er supervision, reporting a t stated intervals for reexam ination
an d advice. T h ey are follow ed up in th eir em ploym ent b y th e social
service d e p a rtm e n t o f one of our large m edical dispensaries, w here a
special industrial h e a rt clinic has been established. Special lab o ra to ry
exam inations, such as urinalyses, b lo o d counts, a n d W asserm ann tests,
are required w hen indicated.
(n )
C ertificates are g ra n te d n o t only to children w ho are h a n d i­
cap p ed b y card iac disease, b u t also to those w ho are crippled o r d e ­
form ed, to th e deaf, dum b, an d nearly blind, as well as to children w ith
varying deg rees of spinal curvature, s&me of them requiring m echan­
ical appliances to co rrect their deform ities. T hese cases are all gone
o v er v e ry carefully to m ake certain th ere are no active processes, Xray pictures are tak en w hen necessary, a suitable kind of em ploym ent is
found, an d th ey are p erm itted to w ork u n d er supervision.
U n d er th e law of th e S ta te o f Illinois a child is required to have
finished th e fifth g ra d e in o rd e r to o btain a certificate. W e h av e found
m any re ta rd e d an d subnorm al children. T hese defective children
constitute a special pro b lem a n d quite an unsolved one. W h enever
indicated, m en tal tests are m ade, a n d a few children h av e b een found
to b e low -grade m orons. O thers show a m o d era te degree of feeble­
m indedness, an d m any are b o rd erlin e cases. T hese children com e
from th e p o o rest social environm ents. T h ey are re ta rd e d in school
an d are frequently advised b y th e teach er to leave an d go to w ork.
Som e are delinquents, others stupid, dull, an d u n stead y in em ploym ent.
T h e greatest difficulty is experienced b y th e vocational bureau in finding positions for these re ta rd e d children. T h ey are frequently dis­
ch arg ed fo r carelessness or irresponsibility. T h ey change positions for
trifling reasons o r just because they are tire d of w ork. E verything
possible is d o n e for th em b y our office to p u t th em in as perfect physical
condition as possible. W e insist upon antisyphilitic treatm ent.
T his group of children, to g eth er w ith th e undersized an d u n d e r­
w eight group, a re a t th e p resen t tim e being forced out of industry—
first, because of th e returning soldier* an d second, because of the
F ed eral C hild L ab o r Law, w hich is forcing th e b e tte r industries to
em ploy only th e child o v er sixteen y ears o f age.
T h e follow ing figures, o b tained from th e em ploym ent certificate
d ep artm en t of the b o ard of education, show th e physical defects found

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by the m edical exam iners in exam ining children applying for em ploy­
m ent certificates in C hicago during the four m onths ending A pril 30,
1919:
T o tal n u m b er exam inations (b o th first a n d s u b s e q u e n t)....................
N um ber physical defects fo u n d . ............................................................ .. .

10,066
1,110

Follow ing is a classification of the physical defects found:
T ype of D efect
N um ber Cases
Nose an d th ro a t findings (a c u te a n d c h ro n ic ) . . . . 235
D efective te e th .................... .............. ,
^
. 181
D efective vision. .........................................................
298
Skin affections, pediculosis, e t c .............
83
M alnutrition, underside a n d u n d e rw e ig h t.................. 121
C ard iac fin d in g s .......................
100
O th e r d e fe c ts............... ................................................... .. ,
92
T otal

P e r C ent

21.2
16.3
26.8
7.5
10.9
9.0
8.3

1,1 10

100.0

im p o rtan t as are th e physical stan d ard s fo r th e w orking child, of
even g re ater im portance is th e ty p e of m edical exam iners. T hey
should b e th oroughly train ed physical diagnosticians— 'graduates of
recognized m edical schools. T h ey m ust h av e a definite know ledge of
industrial conditions, m ust b e ab le to ju d g e of th e ability of th e p a r­
ticular child to do th e w ork required of him, an d should also u n d e r­
stan d the d em an d s of th e different industries em ploying children.
A b o v e all, th ey should b e intensely interested in th e w elfare of the
w orking child.
N O TE

/

A t a la te r session of th e co n feren ce D r. A p p el suggested th a t a p e rm a n e n t
com m ittee be ap p o in ted by th e c h airm an (M iss G race A b b o tt of th e C h ild re n ’s
B u reau ) to fo rm ulate definite stan d ard s of n o rm al developm ent a n d so u n d h ealth
fo r use of physicians in exam ining w o rk in g children. A m otion to th is effect
w as carried unanim ously.


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D E F E C T IV E V ISIO N A M O N G C H IC A G O W O R K IN G C H IL D R E N
By DR. E. V . L. BROW N
P ro fesso r of O ph th alm o lo g y , U n iversity of Illinois C ollege of M edicine

D uring th e p ast y ear th e V ocational B oard of th e C hicago public
schools h as sent som e 1,340 boys an d girls of 14 an d 15 years of age
to m y clinic fo r exam ination of their eyes, prelim inary to th e issuance
of a w o rk certificate u n d e r th e new Illinois child-labor law. T hese
children w ere a p a rt of those discovered b y th e general physical ex­
am ination given a t th e issuing office to b e suffering from som e defect of
vision. A s th e g roup of these children sent to m y clinic w ere selected
a t ran d o m , th e results, I feel, indicate w h at will p ro b a b ly b e found on
the av erag e in an y such larg e group of 14 an d 15 y ear old children
w ith d efective vision w ho ap p ly for w ork certificates in any good-sized
A m erican city w ith a m ixed population.
A vtab u latio n of th e results of our exam inations is n o t w ithout interest
a t this tim e, because it is th e first of such surveys.
T h ese exam inations w ere con d u cted b y m e personally, an d w ere
checked in d ep en d en tly b y th e assistant refractionist of m y clinic, Miss
M arg aret A. H eath. T h ey w ere m ad e afte r fifst one, then th e other
eye h a d b een p u t a t rest b y th ree days’ use of atro p in sulphate one p e r
cent solution. T his w as instilled four tim es each d a y b efo re th e child
retu rn ed to th e clinic for th e second exam ination.
F ro m th e w elfare stan d p o in t it is a m a tte r of gratification th a t th e
averag e case o f defective vision, as revealed b y our tests, can b e im ­
p ro v ed to th e ex tent indicated, nam ely: 3.5 “visual ten th s.” 2 T his is
show n b y th e accom panying table.
C O R R EC TIO N O F D EFEC TIV E VISION IN C H IC A G O W O RK IN G CHILDREN
29 children w ho cam e w ith less th a n 1/1 0 n o rm al vision w ere im proved to 4/1 0.
7 5 children w ho cam e w ith
1 /1 0 n o rm al vision w ere im proved to 5 /1 0 .
127 children w ho cam e w ith .
2/1 0 n o rm al vision w ere im proved to 7/1 0.
139 children w ho cam e w ith
3/1 0 n o rm al vision w ere im proved to 8/1 0.
I 60 children w ho cam e w ith
4 /1 0 n o rm al vision w ere im p ro v ed to 10/1 0.
I 56 children w ho cam e w ith
5/1 0 n o rm al vision w ere im proved to 8 / 10.
226 children w ho cam e w ith
6/1 0 n o rm al vision w e re im proved to 10/1 0.
I 34 children w ho cam e w ith
8/1 0 n o rm al vision w ere im proved to 1 1/ 10.
95 children w ho cam e w ith
1 0 /1 0 n o rm al vision w e re im proved to 2 0 /1 0.
83 ch ild ren w ho cam e w ith
1 2 /1 0 n o rm al vision w ere im proved to 13/1 0.
100 children w ho cam e w ith
1 5 /1 0 n o rm al vision w ere n o t to be im proved.
13 children w ho cam e w ith
2 0 /1 0 n o rm al vision w ere n o t to b e im proved.
A verage im provem ent p e r case. . ........................................................... 3.5 visual ten th s.
^D eliv ered a t th e C hicago C hild W elfare R egional C onference, M ay 19, 1919.
2A n o rm al eye read s 1 0 /1 0 , o r 10 “ visual te n th s.” A n eye w ith only o n e -te n th
( 1 / 1 0 ) vision is said to have one “ visual te n th ” ; a n eye w ith tw o -ten th s vision is
said to have tw o “ visual te n th s,” etc.
,

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In plain English, this m eans th a t the child who can read the largest
letter on th e test card a t tw enty feet (a n d w ho should read it a t tw o
h u n d re d feet) can b e fitted w ith glasses enabling him to re a d letters at
tw enty feet which th e norm al child can read a t from fifty to sixty feet.
T his definitely tak es th e child out of th e m edico-legally “ b lin d ” class
an d places him in th e group which sees quite adequately. T h e average
w orking m an or w om an w ith only this 2 0 /5 0 vision seldom wishes for
b e tte r vision (ex cep t for the m o v ie s).
T h e last four lines of th e tab le illustrate cases w here th e child’s vision
was fo und to b e norm al in one eye, b u t "exam ination of th e fellow eye
show ed m ark ed ly p o o r vision. T h e p o o r eye w as first b ro u g h t to as
nearly n orm al as possible. T h en an exam ination of the ap p aren tly n o r­
m al eye w as m ad e in o rd e r to relieve the strain u n d er which it w as very
p ro b a b ly w orking. T his exam ination often revealed th a t further im ­
p ro v em en t could b e obtained, as for instance, from 1 0 /1 0 to 2 0 /1 0 .
F ro m th e stan d p o in t of the eye d o cto r I can only urge the value an d
im p o rtan ce of exam inations of this type for all children w ho are com ­
p elled fo r one reason or an o th er to go to w ork.


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D A N G E R O U S O C C U PA T IO N S
By DR. D. L. EDSALL
D ean, H a rv a rd M edical School

It is obvious th a t children are m ore subject to th e dangers of acci­
d en ts th an adults. E veryone know s that. It is equally plain to anyone
who has studied the question th a t children are far m ore p ro n e than
ad u lts to influences of o th er dan g ers th a t occur in occupations; for
instance poisons, a n d especially poisons th a t affect th e nervous system ;
substances th a t disturb th e gastrointestinal tra c t; an d to a large extent
substances th a t affect th e skin. It is obvious also th a t children, besides
being inherently m ore subject to th e effects of such things, are heedless
an d ig n o ran t as co m p ared w ith th e average adult, an d therefore require
v ery m uch m o re p rotection th an th e average adult.
T hese dan g ers are recognized w here suitable law s exist, an d in som e
places law s covering these points are fairly successfully developed.
I th in k th a t one can p ro p e rly d em an d th e entire prohibition of the use
of child lab o r in any processes in which th ere is d an g e r of exposure to
poisonous substances, o r serious d an g e r of exposure to substances th a t
are harm ful to the skin, o r particularly to the eyes; an d also in any
processes w here th ere is d an g er of exposure to irritating dust. C hil­
dren, an d those in th e earlier years im m ediately follow ing childhood,
are peculiarly p ro n e to develop a laten t tuberculosis, an d th ey m ust
th erefo re b e p ro tec ted from dangers th a t are likely to excite tu b er­
culosis, which is the g reat d an g er b ey o n d all o th er m edical dangers.
C hildren are also peculiarly p ro n e to th e effects of general physical
strain, an d to th e effect of postural strains— a fact som etim es o v er­
looked in regulations. Som e of th e m ost ex trao rd in ary deform ities
I h av e ev er seen in children h av e b een d u e to th e fact th a t their w ork
c a u sed an unusual strain of som e kind. I h av e in m ind a young boy
w hose w ork caused pressure on th e left side of th e chest; h e h ad th e
m ost ex trao rd in ary chest deform ity I h av e ever seen, due solely to his
w ork. H e w as n o t ill in any o th er way. Such w ork should b e p ro ­
hibited fo r children, because th e b ony structure of th e child is extrem ely
flexible as co m p ared to th a t of th e adult, an d h e is highly subject to
effects of strain.
O ne of th e m ost im p o rtan t things in considering children in relation
to industry is w h at peo p le n o t accustom ed to details of industrial proc- ■
esses do n o t alw ays ap p reh en d ; nam ely, th a t you m ay suspect all you
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STANDARDS O F C H IL D W E L F A R E

wish ab o u t an industry, b u t you know nothing ab o u t its effect on
h ealth until you know the detailed processes th a t th e individual m ay
h av e to m eet. Y ou never know w hether a thing is going to b e harm ful
or healthful until you h av e w atched the actual process, a n d th e sub­
stances used in it. •A n d th a t can only b e d o n e b y precise, definite,
an d d etailed k n ow ledge of each process. M aking up a co d e of p ro ­
h ibited occupations necessarily involves precise inform ation as to the
particu lar processes in particular trades. T h a t is an e lab o rate m atter.
A ll th e things I m entioned can b e d em an d e d -p ro p e rly as prohibitive
regulations, an d are alre ad y carried out in som e of th e p a rts of the
w orld w here th e b est regulations now exist. B ut even if you h av e
y o u r law it has to b e adm inistered, an d u n fo rtu n ately these law s are
n o t v ery satisfactorily adm inistered in m ost places.
B eyond th a t I think it is alw ays essential to h av e all such statutes
d raw n so th a t n o t only shall certain recognized an d acknow ledged
d an g ers b e p ro h ibited, b u t the person or b o d y having th e adm inistra­
tion of th e law shall h av e th e p ow er which exists in certain of the
S tates of this country an d in E ngland— nam ely, th e p ow er o f a d d in g to
th e desig n ated processess such others as through new investigations
a p p e a r from tim e to tim e to b e p ro p e rly subject to the sam e regulations.
Such new pro h ib itions should alw ays b e subject to hearing on the
p a rt o f th e in terested persons. In this w ay one can cover th e m a tte r
far b e tte r th an b y having new statutes passed every tim e a new thing
which is dan g ero us com es along.
I think th e n u m b er of children in this country who are actually sub­
ject to w h at w e Can specifically say are serious occupational hazard s
p e r se is com p aratively small. It is highly im p o rtan t to keep th e child
from being exposed to them , b u t if w e lim it our interest in dangerous
occupations to things th a t are, p e r se, actual dangers to th e child, we
h av e tak en up th e v ery m inor side of this p ro b lem an d h av e left out
w hat is b y far th e m a jo r side. I h av e seen v ery few children w ho have
been d am ag ed b y th e fact th a t the process th ey w ere w orking at
belon g ed essentially in th e class of highly dangerous occupations. I
have seen m an y a child w ho has been v ery g reatly injured b y th e fact
that, having som e sm all o r large physical defect, h e h a d gone into
an occupation entirely unsuitable fo r him . T his is a v ery com plex
problem . T h e fact th a t a g reat m any children are in ju red by occu­
p atio n is show n for exam ple b y such figures as those o f T eleky, w ho
studied children in V ienna. It w as quite astounding to see the results.
T h e figures show ed th a t in the fourteenth y ea r out of 100 children there
occurred on th e average 22 illnesses in the course of th e y ea r th a t put
them to b ed . T h ey w ent to w ork a t fourteen. T h e next y ea r those
illnesses w ere practically doubled, up to 41, an d th ey stayed aro u n d 39,
40, an d 41 fo r th e following th ree years. So th a t in th e early years

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of th eir going to work, evidently w ork in som e w ay practically doubled
the m o rb id ity of childhood. T his w as u n d o u b ted ly d u e to various
causes— to th e fact th a t th e g reat m ajority of these children w ent to
w ork too early; th a t in all probability they w ent to w ork a t tasks th at
w ere too h ard for them ; an d to o th er sim ilar factors. B ut I have no
d o u b t th a t a large factor in th e increase in m o rbidity was th a t a great
m any of those children entered upon w ork they ought n o t to have
u n d ertak en w hen they could pro p erly have been p u t to w ork a t other
things.
T h e thing w e m ust seek for the benefit of th e individual, an d for the
benefit of society a t large, is n o t to keep m o d erately defective chil­
dren out of w ork w hen th ey get to th e age w here they should w ork,
b u t to see to it th a t they d o th e right kind of w ork. T h ere is a far
g reater n u m b er of children of this kind th an we realize. T h e Society
for the S tu d y an d C ontrol of H e art Diseases, for exam ple, m akes the
statem en t th a t th ere are a t any tim e in New Y ork C ity alone as m any
as 2 0 ,0 0 0 school children w ho h av e organic h ea rt disease, an d who
need special atten tio n in reg ard to the occupations they undertake.
T h ey are cap ab le of being productive m em bers of society w ith fairly
goo d health, on th e one hand, o r of becom ing cripples, o r being killed
off, on th e o th er hand.
A s to th e individual, n o t only in his econom ic capacity as a p ro d u cer
b u t in his h appiness an d in his goo d health, it is b e tte r fo r him if
h e can w ork th a t h e should w ork. H e stays in health if w orking
a t th e right k ind o f w ork. T h a t has been show n clearly in relation to
the heart, fo r instance. It has been show n th a t m any persons with
h ea rt disease do b e tte r a t w ork th an w hen allow ed to loaf. T u b e r­
culosis is a far g re ater problem , particularly laten t tuberculosis. T h e
n u m b er of persons th a t h av e th e kind of tuberculosis discoverable by
physical exam ination is only a fraction of the n um ber th a t h av e
p o ten tial tuberculosis. M any of those th a t h av e potential tuberculosis
go to w ork a t weaving, o r grinding m etals, o r blacksm ithing, o r som e
o th er occupation for w hich they are n o t suited, ju st because their
fath ers o r o th er m em bers of their fam ily h av e gone into th a t w ork.
M any such persons h av e a history of tuberculosis in th e fam ily b u t w ere
supposed to b e well them selves. Som etim es they h av e been exam ined
b efo re going to w ork, b u t they h av e a b a d fam ily history an d a b a d
exposure, a n d w here they tak e up a b a d occupation, in a few m onths
they dev elo p a dangerous form of tuberculosis.
M atters of th is k ind constitute a vastly bigger pro b lem th an th e spe­
cific h azard s of industry. Legislative prohibition can h av e co m p ara­
tively little effect in reg ard to them . It is far m ore an educational
m atter, an d th e p erio d w hen education is of value is b efo re the children
enter industry. T w o persons have a strategic position in reg ard to this

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m atter— the school physician an d th e fam ily physician. T h e school
physicians do n o t all of them do as careful w ork as Dr. A ppel, an d
do n o t all of them tak e th e sam e kind of interest. 1 heive run across
com p arativ ely few of them who know anything ab o u t industry o r who
p ay m uch atten tio n to it. T h e educational authorities also are in
various strategic positions an d should b e generally ed u cated them ­
selves in reg ard to this m atter. O n th e o th er han d , m edical p ro ­
fessors an d d o cto rs should b e educated quite differently from w hat
they h av e b een in reg ard to it. M edical education has b een largely,
an d still rem ains largely in m ost m edical schools, education for the
care of th e individually sick. M edicine itself has th e potential capacity
of being quite as m uch th e preventive care of the com m unity a t large,
an d physicians m ust b e ed u cated in th a t line.
If those tw o things are persistently do n e w e m ay b y those m eans
accom plish m o re th an if w e d ev o ted ourselves only to th e pro b lem of
actual dan g ero u s hazards.
A n o th e r thing th a t can do a g reat deal is the education of industrial
m anagers. I h av e been deep ly gratified to see in this country in the
last few y ears a greatly increased com prehension on th e p a rt of in­
dustrial m an ag em ent of th e econom ic im portance of health. It is
calculated th a t th e tu rn o v er costs a p lan t from $35 to $200, acco rd ­
ing to th e ch aracter of w ork, each tim e one m an leaves an d an o th er
takes his place. I saw figures in one p la n t w here th e tu rn o v er for
several y ears p a st h a d b een alm ost tw enty thousand persons. T h e
tu rn o v er in th a t p la n t costs ab o u t one m illion dollars a y ea r^ —the loss
in training the individual, th e loss in destro y ed m aterial, an d the loss in
unskilled w ork, is enorm ous. T h e tu rn o v er of a child costs as well
as th e tu rn o v er of an adult.
W e can d o a little b y legislative prohibition. W e can d o a great deal
m o re b y attack in g th e pro b lem through the school, thro u g h school p h y ­
sicians, th rough m edical schools an d physicians, through hospitals,
an d th ro u g h th e service d ep artm en ts of the trades. If th e child can
b e fitted to his occupation before h e enters industry a n d before he
m ust go th rough th a t v ery serious econom ic loss of changing from one
occupation to an other, th e econom ic saving an d th e saving of life and
h ealth will b e extrem ely large.
DISCUSSION
In th e succeeding discussion, D r. G eorge P. B arth, D irector, School H ygiene
B ureau, M ilw aukee, em phasized th e im p o rtan ce of safeg u ard in g th e physical co n ­
dition of th e child w hen he leaves school to go to w ork. T h e need fo r h ealth su p e r­
vision, he stated, w as show n by a n intensive study of th e causes of th e absence of
ch ild ren from school m ade in M ilw aukee in b e b ru a ry , 1917. O f th e to ta l of
147,258 half days lost b y ch ild ren d u rin g th a t m onth, 9 8 ,2 6 0 , o r 67 p e r cent,


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C H IL D LABOR— LEG ISLA TIV E P R O H IB IT IO N

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w ere due to diagnosed a n d ex p lain ed illness of th e child. D r. B arth also spoke
of th e fact th a t w h ere w o rk in g ch ild ren a re re q u ire d to a tte n d co n tin u atio n
schools a n excellent o p p o rtu n ity is offered to find o u t w h e th e r th e child is
fitted fo r th e job a t w h ich h e is w o rk in g a n d th e effect of th e jo b u p o n his
physical w ell being.
Mr. R. C. D avison, C hief of th e Juvenile L ab o u r E x ch an g e, E ngland, spoke
as follow s: “ In o u r w o rk in th e M inistry of L a b o u r in dealing w ith juvenile
em ploym ent w e have som e re la tio n w ith th e certify in g fa c to ry su rg eo n s w ho a re
ap p o in ted to exam ine c h ild ren . It is th e d u ty o f th e fa c to ry su rg eo n s u n d er
th e F a cto ry a n d W o rk sh o p s A c t o f 1907 to ex am ine ev ery child o r y o u n g
p erso n u n d e r th e age o f 16 w ith in seven days o f th e com m encem ent o f w o rk in
facto ries a n d w o rk sh o p s w h e re c e rta in p ro cesses a re c a rrie d on.
“ T h e long list of th e tra d e s a n d p ro cesses to w h ich th a t a c t ap p lies covers m ost
of th e im p o rta n t m an u fa c tu rin g p rocesses. T h e w o rk e r in th o se p ro cesses u n d e r
th e age of 16 m ust also b e reex am in ed ev ery tim e h e ch an g es his em ploym ent.
U n d er o u r p re s e n t ed u catio n al system , th a t is, u n til M r. F ish er’s new a c t com es
into force, th e re is still th e h alf-tim e system u n d e r w h ich ch ild ren o f 12 a n d
13 m ay w o rk half tim e in th e fa c to ry a n d go to school h a lf tim e. T h o se halftim ers a re supposed all of th em to be exam ined a t th e tim e w h en th e y becom e
available fo r full-tim e em ploym ent. T h a t gives a n o p p o rtu n ity fo r m en tal
exam ination an d advice as to tre a tm e n t. A b o u t 4 0 0 ,0 0 0 ex am in atio n s covering
th e w hole field a re re q u ire d to be m ade an n u ally . T h is figure I am a fra id is
som e y ears old a n d it is p ro b a b ly la rg e r d u rin g re c e n t y ears.
“ T h e w o rk th a t I am p a rtic u la rly asso ciated w ith is th e estab lish m en t o f ju v e ­
nile advisory com m ittees in co n n ectio n w ith em p lo y m en t exchanges, a n d th e
p o in t of co n tac t th a t w e h av e w ith th e c e rtify in g fa c to ry su rg eo n s is in dealing
w ith th e difficult cases th a t th ey com e acro ss in th e ir exam inations, a n d in try in g
to find som e form of suitable em plo y m en t fo r th e re je c te d cases. W e have also
been able th ro u g h th e juv en ile em p lo y m en t ex ch an g es to pro v id e th e certify in g
facto ry surgeons w ith special in fo rm atio n a b o u t ch ild ren w ho go into fac to rie s a n d
to pass on to th em copies of th e school m edical officer’s re p o rts. It is stro n g ly
u rg ed b y m any peo p le th a t in fu tu re th e w hole w o rk of th e fa c to ry su rg eo n s
should b e han d ed over to th e school m edical officers.
“W h ere th e certifying fa c to ry su rg eo n s find th a t a child is u n su ited to th e job
into w hich h’e h as gone of his ow n acco rd , th e n it is fo r th e ju v en ile advisory
com m ittee a n d th e juven ile em p lo y m en t ex ch an g e to tr y to find som e o c c u p a ­
tion, if o ccu p atio n is necessary, in w h ich th e child w ill n o t b e h a rm e d a n d will
n o t suffer. T h e p lacin g of ch ild ren w ho a re really su fferin g fro m som e in h e re n t
defect, b u t w ho a re capab le of em ploym ent, is n o t, in c e rta in p a rts o f th e c o u n try ,
c arried on b y th e juven ile em plo y m en t exch an g es a t all n o r b y th e ju v en ile a d ­
visory com m ittees, b u t th ese cases a re h an d ed o v er to v o lu n ta ry b odies know n as
th e A ssociations fo r th e C are of P hysical a n d M ental D efectives. T h e y h av e a
g ra n t from th e G overnm en t to aid th em in th e ir w ork, a n d w e leave to th em th e
ca re of th e defective ch ild ren .”


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B R ITISH E D U C A T IO N A L S T A N D A R D S
By SIR CYRIL JA CKSO N
B oard of E ducation, E ngland

I rem em ber nearly 35 years ago w hen first I w ent to live in E ast
L ondon, th e first jo b I w as given w as to try to help a m iserable family.
T h ere w ere six children of a w idow , th e eldest of w hom h a d ju st passed
his sta n d a rd in school an d g o t exem pt. H e was th e first w age earn er
w ho w as going to look afte r th a t family. H e w as an extraordinarily
b rig h t b o y o r h e w ould n o t h av e passed th e sta n d a rd a t tw elve years
old. N aturally a b o y of tw elve years old in E ast L ondon, in a p o o r
family, in one of th e w orst slum s o f th e place, d id n o t h av e all the
qualifications w hich a re necessary for th e b a ttle of life, an d a few
m o n th s later I w as visiting him in jail. N ow from th a t m o m en t I h av e
sought an d w o rk ed to abolish any educational sta n d a rd th a t allow s
an y b rig h t b o y to get o u t of school b efo re th e m inim um age. A n d th e
Fisher A c t h as abolished for th e w hole nation an y such educational
stan d ard .
In L o n d o n w e h av e long h a d fourteen years as th e age a t which
children m ay leav e school for w ork. U n d e r th e new act fourteen will
b e th e m inim um age th roughout th e w hole country, th e rural area, o r
w h erev er it m ay be, w here th e age in th e p ast has b ee n thirteen an d
in som e cases even tw elve. T h at, I consider, is one of th e great
m easures of th e F isher A c t of last year. B ut we h av e gone even bey o n d
th a t in th e Fisher A ct. A s you know w e in E ngland h a v e h a d nearly
five y ears o f w ar. O u r children h av e b een tak en o u t of th e schools
b efo re th eir tim e. O u r b oys a n d girls h av e b een p u t to w ork, very
necessary w ork, fo r th e country. A n d p erh ap s it w as a b o ld step for
th e M inistry of E ducation, a t th e v ery m om ent w hen child lab o r was
a t its highest prem ium , to b ring in a sw eeping act fo rb id d in g in future
an y child u n d e r fourteen tq w ork, a n d abolishing a t one sweep all the
h alf tim e w hich h a d b een considered necessary in th e textile factories
in L ancastershire since tim e im m em orial. So, as I say, u n d e r this bill
child lab o r is not, even in war, going to b e exploited in th e future.
I suppose you know in th e textiles in L ancastershire tw elve to fo u r­
teen h as b een considered the* norm al age fo r h alf tim e instruction of
children because it w as considered th a t for h alf th e tim e th ey ought
to b e learning th e m anipulation of th e textile tra d e s a n d th e m achines.
O f course it w as perfectly ridiculous to suppose th a t these children of
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tw elve to fo urteen either w ere really necessary to th e industry o r w ere
learning tex tile m anipulation. T h ey w ere m ostly m a d e to run erran d s
for th e a d u lt w orkers, although each h a d his task assigned to him in
th e w orkshop. B ut th e parents, I am afraid, w ere th e p eo p le w ho
w ere th e m o st difficult to m ove in this question of half tim e. T h e
p resen t chief insp ector o f th e B o ard of E ducation to ld m e n o t long
ago th a t w hen h e w as a L ancastershire inspector one of th e p aren ts
kno ck ed a t his d o o r one m orning to know w hy T om m y h a d n o t b een let
off school. H e said: “H o w old is h e ? ” ' Tw elve.
W hen w as h e
tw elv e?” “T h e d a y b efo re y esterd ay .” H e said: “W ell, h as h e b ee n
in his ex a m in a tio n ?” “ No, th e re has n o t b een one.
W ell, h e
exclaim ed, “w e ca n n o t h o ld an exam ination th e d a y afte r every child s
b irth d a y th ro u g h o u t L ancastershire.” T h e p a re n t said: I h a v e lost
one lass w ith o u t getting anything o u t of her, a n d I d o n t w ant to lose
th e la d .” T h a t w as th e principle on w hich th a t p a re n t w as d em anding
his son’s w o rking th e d a y afte r h e b ecam e tw elve years old. ■
T h a t is abso lu tely sw ept aw ay u n d e r th e F isher A ct, b u t th e ac t goes
even fqrther, because b ey o n d this raising o f th e m inim um ag e to
fourteen, w hich is, y o u know , low enough, it h as a perm issive p ro ­
vision w hich allow s an y local au th o rity to m ak e th e low est age fifteen,
eith er fo r all th e ch ildren in th a t area o r for p a rt of th e children in th a t
area, acco rd in g eith er to th eir tra d e s o r conditions o r to th e m eans
o f th eir paren ts, as th e local au th o rity m ay decide. I h o p e th a t in th e
larg er a n d m o re p rogressive places w e shall a t once go fo rw ard an d
m ak e th a t by-law raising th e age to fifteen. In L o n d o n th e ag e has
b een fo u rteen now fo r a d o zen o r m o re years, b u t th ere is n o reason
w hy w e should n o t go forw ard a n d m ak e it fifteen a t once. It w as
said th a t no b o y in th e country could learn to m anage cow s a n d horses
unless h e b eg an a t tw elve. I expect h e will learn all th e b e tte r if h e
h as h a d a little lo n ger education a n d show s a little m o re intelligence,
an d I h o p e th a t w e shall v ery shortly m ak e th e general ag e fifteen o r
sixteen.
T h e p re sen t act gives us still fu rth er th e continuation school, a l­
th ough n o t w ith quite th e sam e h ours as in O ntario. T h e F isher A c t
p rescribes th a t all th e young peo p le in th e co untry up to 18 years
o f age m ust a tte n d continuation school for 320 hours a year. T h a t
provision, how ever, will n o t com e into effect im m ediately. F o r th e
first few y ears th e age will b e sixteen,, b u t' a t th e en d o f seven years
18 is to b e th e lim it th ro u g h o u t th e w hole country, an d in seven years
m uch m ay h ap p en . W e m ay raise th e required atten d a n ce to 4 0 0 o r
500 h o u rs b e fo re th e seven y ears pass. I think 320 h o u rs o r eight
hours w eekly fo r 40 w eeks is a sm all enough estim ate.
I suppose th a t o u r industrial conditions a re n o t v ery unlike yours.
E very one has h ea rd a g reat deal o f m o d ern conditions o f labor, a n d it

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is obvious th a t th e m o d e m conditions o f la b o r w hich ap p ly to our
facto ry w o rk a re n o t th e sam e as they w ere w hen th e w orkm en w ere
ab le to tak e an interest in th e ir w ork because th ey m a d e som ething
w ith th eir ow n h ands. N ow th e w orkm an is only th e hum an p a rt of
a v a st m achine, doin g som e sm all o peration of industry. A ll this
m eans th a t w e h a v e tp give a g re ater interest outside th e factory.
W h a t w e a re d o in g in E ngland 1 h av e no d o u b t you are doing here.
W e a re ap p ro ach in g v e ry rap id ly a national basis o f hours. M ost o f
th e b ig tra d e s of th e co u n try are now filin g their hours a t 4 4 o r 48 hours
a w eek. I.th in k w e shall v e ry shortly h av e an eight-hour d a y an d
possibly a sh o rter n u m b er o f hours as th e regular natio n al system , as
it is now in A ustralia.
B ut if th a t is so it is all th e m o re im p o rtan t th a t th e w orking m en
an d th e w o rk in g w om en shall know how to use th eir leisure, th a t they
shall h av e ed u cation to enable th em to use th eir leisure, a n d th a t th ey
shall h av e a t th eir disposal further schools which th ey can a tte n d
so th a t th ey m ay b ecom e citizens in th e tru e sense of th e term .
O n e o f th e m o st h opeful signs, I think, of th e progress of E ngland
is th e latest ap p o in tm en t to one of o u r o ldest universities, C am bridge.
T h e latest p ro fesso r of Italian is a m an w ho w en t to th e bench a t tw elve
y ears of age an d w o rk ed as a basket-m aker, a n d w ho h as tau g h t him ­
self n o t only Italian b u t five o th er languages, an d is now an ad m itte d
au th o rity on Italian history a n d Italian literature. I believe th a t is a
tru e d em o cratization o f an o ld university. B ut in o rd e r th a t it m ay n o t
b e o nly th e exceptional b o y w ho can d o th a t b u t th a t all o u r lad s
an d girls m ay h a v e an o p p o rtu n ity of im proving th eir education, w e
m u st surely see to it th a t such a m inim um educational s ta n d a rd exists
th a t ev e ry b o d y is ab le to g et up to th e top.
T h e re are, o f course, m an y o th e r provisions of th e F isher A c t which
are v ery interesting to us. T h e m ain interest to us is, of course, its
natio n al aspect— th e fact th a t n o local authority in th e future will b e
ab le to fall b elow th e m inim um w hich has b een laid dow n b y the
F ish er A ct. W e shall h av e g re at difficulty, o f course, in getting
acco m m o d atio n s an d m o re th a n all in getting teachers. Y ou h av e n o t
suffered as w e h av e suffered in th a t respect. W e h av e h a d to stop
building for n early five years, a n d our schools arp sadly in arrears.
Y ou h av e n o t lost so m an y teachers as w e have. T h e flow er of our
m en teach ers w en t to th e front, a n d som e o f th em will n o t return. W e
shall th ere fo re h av e to com e forw ard w ith o u r new A c t an d d o th e b est
w e can to m ak e th e flesh for th e bones p ro v id ed for us b y th a t A ct.
T h e A c t itself has given us all a v ery g reat d eal of hope.
* A fu rth er provision o f th e F isher A c t w hich I m ight touch u pon is
th a t relating to th e physical health of th e children. W e in E ngland
h a v e h a d fo r som e y ears p a st considerable m edical inspection— prac
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tically in all th e schools. W e h av e m edical inspection an d v ery con­
sid erab le m edical tre a tm e n t of th e children. B ut th a t is sto p p ed w hen
th e child h as left school, except fo r th e exam ination in factories by
th e certifying facto ry surgeon. N ow u n d er th e F isher A c t th e re is
a v ery im p o rtan t provision w hich enables th e school m edical authority,
w ho will see th e b o y a n d girl, of course, in th e continuation school,
to go into th e question o f th eir h ea lth an d inspect them , a n d if th e
em ploym ent is such th a t it is stunting th eir grow th o r is u n h ealth y for
them , th e school authorities m ay pro h ib it such em ploym ent. T h at, I
feel, is an ad v an ce fo r th e S ta te because n ev e r b efo re h av e w e really
g one from th e ed ucational stan d p o in t to prohibiting em ploym ent o n th e
g ro unds o f health.
T h ere are o th er things in th e act on th e sam e line. F o r exam ple, we
are allow ed in th e future to p a y fo r a n d to establish h o lid ay cam ps
o r an y o th e r k in d of clubs o r physical recreation fo r these young
p eo p le up to 18 y ears o f age w hich m ay b e considered necessary for
th eir physical d ev elopm ent. I think, too, all o f us w ho h av e w atched
th e rejection o f m en w ho h av e com e fo rw ard fo r service, as w e h av e
in E ngland, because of their low physical developm ent, d u e to their
early going into industry a n d to th e unh ealth y conditions of so m any
w orkshops, ap p reciate th a t these provisions are extrem ely im p o rtan t
to us.
O u r P rem ier, referring to th e classification o f o u r soldiers— which,
as y o u know , begins a t A a n d w orks dow n to C— p o in ted o u t to us
n o t long ago th a t you ca n n o t m ake an A-1 n atio n out of C -3 citizens.
A n d it is th a t w hich w e h av e now to tak e in han d , ju st as I think we
m ust tak e in h a n d th e intellectual ad v a n ce o f o u r citizens if th e old
B ritish n atio n is to keep its h ea d a b o v e w a te r a t all. W e shall h av e
keen com petition w ith A m erica in th e future. W e w a n t it. It will do
us all good. B ut w e shall certainly h av e to “ buck u p ” if w e are to h old
o u r h ea d s up. I h av e b een looking, in N ew Y o rk a n d here, a t som e
o f th e h igher schools^ a n d especially in N ew Y o rk I tried to see som e
co n tinuation schools an d som e vocational schools. 1 am n o t one of
th ose w ho th in k th a t o u r continuation schools m ust b e m ainly v o ca­
tional. I th in k w e should run a g re at risk if w e w ere to say too m uch
a b o u t th e vo catid nal ch a rac te r of th e schools. A s a sop to th e em ­
p lo y er b efo re atten d a n ce w as com pulsory w e m ight h av e d o n e it, b u t
now th a t w e are com pelling th e em ployers to send th e child anyhow ,
I th in k w e will b e justified in saying th a t w e w ho control education
m ust d ecid e w h at th e b o y h as to learn ; a n d surely it is m o re im p o rta n t
in th e future th a t th e citizens o f an y natio n should h av e a general
edu catio n a n d som e hum an education th an it is th a t w e should fit
th em a t a v ery early age fo r som e p articu lar industrial occupation.
I th in k th ere is no d o u b t th a t w e h av e in th e pursuit o f vocational

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education b een to o a p t to consider too little th e w hole m an, a n d I
am hoping th a t if w e give sufficiently g o o d education in o u r 320 hours
th e em ployers m ay p erh ap s give th e vocational education in th e rest
o f th e tim e. I d o n o t think th e b oys are going to b e n early as vital to
th e em ployers w hen th ey h av e to b e tak en o u t of th e shops a certain
n u m b er o f h o urs a week. It is w ithin th e possibilities th a t boys will
n o t b e quite so easy to em ploy, a n d will n o t find a jo b quite so
easy to g et in th e future, w hen the em ployer h as to ta k e th e tro u b le
to h av e tw o b o y s to a jo b o r to let them ou t certain h alf d ay s a Week
to go to school. T h a t will b e from m y p o in t o f view a success, because
I do n o t think th a t even w hen we h av e lim ited th e age to 15 y ears for
full-tim e em ploym ent, o r w hen w e h av e got p art-tim e em ploym ent to
18, w e h a v e .d o n e o u r d u ty b y th e hum an b o y a n d b y th e h u m an girl.
DISCUSSION
Miss Ju lia C . L ath ro p (C hief, C h ild ren ’s B u re a u ) : I do n o t th in k a n y E nglish
a u th o rity can possibly realize th e eag ern ess w ith w h ich w e have w a tch ed th e
p ro g ress of th e F ish er Bill th ro u g h P arliam en t, b e c au se w e saw a t once th a t som e­
body in E ngland had h ad th e co u rag e to do a th in g w h ich n o b o d y in A m erica had
been bold en o u g h to do, w h ich w as to try to cu t, b y a n in d ire c t a tta c k , th e ro o t
o f ru ra l child labo r. W e w ould like to g e t a sim ilar schem e in th is c o u n try ,
M r. C h airm an , a n d w ith th e c o o p eratio n o r b y th e a ctiv ity of y o u r division of th,e
G ov ern m en t (th e B u reau o f E d u c a tio n ) to see aid given by th e F ed e ra l G o v ern ­
m en t to S tate a u th o ritie s fo r e lem en tary edu catio n , w h ich w ould be so un iv ersal
th a t in this c o u n try also w e w o u ld a t once d estro y ru ra l child la b o r by a n in d irect
a tta c k . I w ould like to kn o w how m u ch o pposition from th e lan d o w ners of E n g ­
lan d w as experienced in g ettin g this m easu re th ro u g h .
S ir C yril Jack so n : I th in k th e re w as no o pposition, sim ply b ecau se w e w ere
in th e m iddle of a g re a t w ar, a n d w e tru ste d Mr. F ish er. If w e h ad h ad tim e to
th in k a b o u t it I th in k no doubt th e farm ers w ould have opp o sed it v e ry vigorously.
H on. P . P . C lax to n (U . S. C om m issioner o f E d u c a tio n ) : H ow m an y days does
this law re q u ire of school a tte n d a n c e up to fo u rte e n ? Is it 2 2 5 ?
S ir C y ril Jack so n :
M r. C lax to n t

O h, no.

Full tim e.

W ell, th a t is 2 25?

S ir C yril Jack so n :

240, I should th in k .

M r. C lax to n : I w ish you w ould ta k e n o te o f th a t. In th e U n ited S tates it is
usually 180 days o r less— 1-80 fo r o u r cities, a n d an a v e ra g e o f 140 fo r ru ra l
com m unities. T h e F ish e r A c t does no t, how ever, p re v e n t ch ild ren fro m w o rk in g
w hen th ey a re n o t in school on th e ir fa th e rs’ ow n farm s, does it?
S ir C yril Jack so n : W e have lim itation of h o u rs in th e a c t. C h ild ren over
12 y e a rs of age m ay w o rk o n e h o u r b e fo re 9 a . m ., if th e y do n o t w b rk a fte r
6 p. m ., I th in k it is.
Miss L a th ro p : Is it tru e th a t th is a c t is recognized a s a m e a su re w h ich is
absolutely as m u ch a la b o r m easu re as it is a n ed u catio n al m easu re? W as it


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p u t th ro u g h u n d e r th e delusion th a t it w as p u re ly to te a c h children- to re a d an d
w rite b e tte r, o r w as it recognized th a t it w as going to revolutionize child lab o r
in E ngland?
Sir C yril Jack so n : W e all k new th a t it w as going to m ak e a trem en d o u s
difference in lab o r, becau se th e fact th a t th ese co n tin u atio n schools w ould tak e
half tim e aw ay from th e facto ries w as a d irect ch allenge to th e em ployer? It
has been, I think, acce p te d by th e em p lo y er as such a n d a g re e d to. I am a very
old friend of Mr. F isher, a n d I ta lk e d o v er th e bill w ith him b efo re it w en t to th e
H ouse. I also talk ed w ith c e rta in ch am b e rs of com m erce, a n d on th e w hole I
th in k th e em ployers recognized th a t u n d e r m o d ern conditions it w a i n ecessary
fo r them to allow th e child ren to h av e tim e off fo r school. T h e re fo re I th in k it
is tru e to say th a t it is recognized as a lab o r bill as w ell as a n e d u catio n al bill,
an d th a t from th e child-labor p o in t of view it w as w elcom ed by everybody.
M r. C lax to n : I w ould like to ask Miss L a th ro p a
of F ed eral aid to th e S tates fo r ed u catio n in th e ru r a l
w ould you couple som e re q u ire m e n t in re g a rd to
w ould n o t b e effective e x cep t fo r th e h o u rs th a t th e

question. W ith th e giving
com m unities a n d elsew here,
child lab o r?
O th erw ise it
ch ild ren w e re in school.

Miss L a th ro p : I w ould alw ays in th e m a tte r of special subsidies ta k e a leaf
from a n E nglish book. T h e y a re th e o nly p eo p le sp eak in g th e E nglish lang u ag e,
g ra n tin g th a t th e y include th e ir ow n colonies, w ho know how to give a subsidy.
W e h an d o u t m oney a n d ru n aw ay. T h e y h a n d o u t m oney a n d stay by. T h ey
say: “ Y ou can have this m oney if you do y o u r d u ty acco rd in g to th e stan d ard s
ag re e d u p o n b etw een th e F ed eral G o v ern m en t a n d th e local a u th o rity .
Is n o t
th a t tru e ?
S ir C yril Jack so n :

T h a t is tru e .

Miss L a th ro p : It w ould be a d isaster if w e b e g a n this effo rt to stan d ard ize
ed u cation by g ettin g rid of child lab o r w ith o u t settin g up new sta n d a rd s of ed u ­
cational effectiveness. T h e g re a t a d v an ta g e fo r us m a discussion o f th is E nglish
m easure is th a t it show s us a w ay to stan d ard ize ed u catio n in th e in te re st of th e
fu tu re a n d a t th e sam e tim e to g et rid of th e o n e th in g w e h av e n e v e r d a red
a tta c k — ru ra l child labor.
O ne reaso n I have said th is is b ecau se I have seen in o n e c o u n try in th is w orld,
a n d u n d e r th e A m erican flag, schools so w ell m an ag e d th a t th e ch ild ren clam ored
to go to them . E ight y e a rs ago I saw th e schools in th e P hilippines, a n d found
th ey did n o t d are have a co m p u lso ry ed u catio n law th e re b e c au se th e y h a d n o t
en pugh schools to ta k e c a re of all th e children, a n d th a t thte ch ild ren w ere eag er
to go to th e schools b ecau se th e schools w ere a g reeab le a n d ta u g h t th em to do
all sorts of th in g s th ey h ad n o t know n how to do b efo re. T h e schools w ere
steadily lifting u p th e sta n d a rd of life. C hild ren w ere ta u g h t to co o k ; th ey Were
ta u g h t to raise p o u ltry fo r eggs a n d food in stead of fo r cock fighting; in a h u n d re d
w ays directly co n trib u to ry to th e h ap p in ess of life th ey w ere b ein g ed ucated.
M r. C lax to n : W ill ta k in g th e ch ild ren off th e farm s u n til th e y a re 12 o r 14
years of age, ex cep t fo r th is h o u r a day, seriously in te rfe re w ith a g ric u ltu ra l p ro ­
duction in E ngland?
Sir C yril Jack so n :

I do n o t see w h y it should.

I w as som e tim e in A u stralia

ks head of th e E ducatio n D ep a rtm e n t, a n d w e h a d th e re a v e ry la rg e a g ric u ltu ra l
po p u latio n . I h ad a fre e r h a n d th e re th a n I have h a d in E ngland, a n d I raised th e
age to fo u rteen fo r everybody a t o n ce d irectly I got th e re . T h e o nly allow ance


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I m ade fo r th e fa rm e rs w as th a t th ey m ight have a n ex em ption fo r children
d u rin g h arv est tim e, b u t I do n o t rem e m b e r th a t w e ev er h ad a n y applications.
T h e difficulty of com ing to th e c e n tra l d e p a rtm e n t w as e n o u g h to d eter them
from asking fo r th e ex em ption. I do n o t th in k th a t a g ric u ltu re suffered in th e
least degree.
«Mr. Claxton: I am quite su re th a t in th is c o u n try w ith o u r m o d ern m ethods of
farm in g w e could p ro d u c e all w e do a n d m ig h t p ro d u c e m u ch m o re if children
w ere n o t re q u ired to w o rk th e ir lives aw ay on th e farm . T h e re is o n e o th e r th in g
a b o u t it th a t it is w o rth w hile considering, th a t th e re a re som e th in g s th a t can be
done on th e soil, on th e farm , a b o u t th e hom e, th a t h av e ju s t as g re a t a n e d u ca­
tional value as a n y th in g a te a c h e r can say to th e p u p il in th e schoolhouse. W o rk
has ed u catio n al value if it is p ro p e rly d irected a n d in th e rig h t m easure, a n d
if it is done intelligently. I th in k w e shall realize th a t th e w hole m a tte r is n o t
m erely one of pro h ib itio n , n o t m erely o n e o f n eg atio n , b u t one o f positive d irection
in th e rig h t w ay.
Robert C. Deming (C o n n e c tic u t S tate B oard of E d u catio n ) :
ask as to th e effect of this law u p o n s tre e t trad in g .

I w ould like to

Sir Cyril Jack so n : W e have lo n g h a d by-law s ag ain st ch ild ren w o rk in g a t
stre e t trad es. In L ondon, I th in k , th e m inim um a g e is 14 fo r boys a n d 16 fo r
girls. T h e new a c t does n o t m ak e a n y ex cep tio n th e re in fav o r of child ren of
school age. It only forbids a n y child tra d in g on th e stre e ts below th e a g e of 14.
T h a t has b een th e by-law in L ondon fo r a long tim e. Now it is a n a tio n a l law
a n d w ill h ave to b e enforced, b u t w e shall still have th e rig h t th a t w e h a d befo re
to raise th e age to' 16 y e a rs if w e w ish to in c e rta in localities.
Mr. Claxton: Do you c o n tem p late u sing th e system of h alf tim e in a lte rn a te
w eeks, so th a t tw o boys o r tw o girls m ay hold th e sam e jo b — th a t is, so it m ay
be possible fo r all th e ch ild ren to have a good half-tim e school a tte n d a n c e th ro u g h
th e p e rio d of adolescen ce u p to 18?
Sir Cyril Jack so n : I have seen a n d n o ticed th a t system in force in th e schools
in N ew Y ork, a n d w e shall, o f course, b e only too glad to get th a t so rt of hint.
Mr. Claxton: H ave you done a n y th in g of th a t kind?
Sir Cyril Jack so n : W e have n o t done it b y legislation. W e have done it by
p ractice. W e have h ad boys in L ondon w ho have been doing silversm ithing w o rk
on half tim e in th e a rtc ra ft schools a n d h alf tim e in th e shops.
Mr. Claxton:
work?

But n o n e w h e re th ey have th e privilege of g en eral v o cational

Sir Cyril Jackson:


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No, I do n o t th in k w e have h ad th a t y e t; I h ope w e m ay.

A M ER IC A N E D U C A T IO N A L S T A N D A R D S 1
By CH A R LES E. CHADSEY
F o rm er S u p e rin te n d e n t o f Schools, C hicago

I am m uch im pressed w ith th e necessity of having a higher sta n d a rd
th an exists a t th e p resen t tim e in Illinois, w here w e allow a fourteeny ear-old b o y o r girl to go out of th e C hicago schools as soon as he
o r she h as co m p leted th e fifth grade. It is well fo r us to h av e cer­
tain ideals. I d o n o t w an t those ideals to b e so high th ey can never b e
realized, b u t I d o w an t th em high enough to give us som ething definite
to w ork for. It seem s to m e th a t it is n o t u n reasonable to say th a t
here in this S ta te no child shall h av e his form al education com e to an
en d until h e is sixteen y ears o f age, w h eth er h e h as finished th e eighth
g ra d e o r th e university.
I think fu rth e r th a t w e are n o t d o in g th e right thing for our young
p eo p le u n d e r tw enty-one, w ho h a v e reached th e age a t w hich th e law
perm its th em to go to w ork, if w e allow th em to sep arate them selves
entirely from school opportunities, unless th ey h av e com pleted high
school. F o r th a t larg e group th e re should b e continuation schools,
offering th e w o rk b est fitted to th e individual needs.
So I h av e th ese tw o ideals to set b efo re us. A few years from now
I m ay h av e a higher ideal, b u t I think these sta n d a rd s are reasonable:
first, th a t education shall b e th e chief an d only occupation of all chil­
d re n up to th e age o f sixteen, because no child can h av e g o tten too
m uch ed u cation during th a t p e rio d ; a n d secondly, th a t those young
p eo p le w ho h a v e n o t finished high school a t least, an d w ho are a t
w o rk b etw een th e ages o f sixteen a n d tw enty-one, shall h av e an o p p o r­
t u n i ty - y e s , shall b e com pelled b y S ta te law — to go on w ith th eir ed u ­
cation, th a t ed u cation being re la ted definitely an d especially to th e
w o rk th ey a re doing. U n d e r th o se conditions, I think w e can say the
condition o f child h ood in our S ta te w ould b e trem endously im proved,
an d ev entually th e citizenship of o u r co u n try w ould reach a perceptibly
h ig h er sta n d a rd th a n it h a s reach ed a t th e p resen t time.
Now, d u rin g th a t in terv al betw een th e p resen t tim e an d th e tim e
w hen such an ideal m ay h av e b een b ro u g h t about, w h at should w e d o ?
I th in k w e should alw ays b e taking th e n ex t step. In Illinois w e h av e
re g ard e d as th e p erfect condition o u r law th a t no child shall leave
d e li v e r e d a t th e C h icago C hild W elfare R egional C o n feren ce, M ay 19, 1919.

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school until h e is fourteen a n d has finished th e fifth grade, no continua­
tion w o rk b eing compulsory* In this w e d o n o t co m p are favorably w ith
certain o th e r S tates in th e U nited States. O ur law is n o t as g o o d as
th a t o f M ichigan o r Ohio, o r as th e law s o f a n um ber of o th er States.
It w ould b e quite sim ple fo r us to tak e one step forw ard a n d say
th a t th e com pulsory education law shall b e changed so th a t no indi­
v id u al shall receive a p erm it to w ork until h e is fifteen years of age
an d h as finished th e sixth grade. L et us p u t this into effect fo r a y ear
a n d g et ad ju sted to those conditions, a n d a y e a r from th a t tim e let us
tak e an o th er step, perh ap s m aking th e com pletion of the seventh g ra d e
com pulsory; th en th e eighth g ra d e ; th en p erh ap s extending th e age
fo r leaving school to sixteen years. It m ay b e w iser to sp read this o v e r
a n u m b er o f y ears if th ere is a necessary econom ic a n d business re a d ­
ju stm en t to new conditions.
I d o n o t recognize, as som e seem to im ply, th a t th e g re at obstacles
in th e w ay o f higher stan d ard s fo r com pulsory education a n d child
lab o r are fo u n d in th e schools. I think they are found ra th e r am ong
those v ery sincere social w orkers w ho see in an extension of these
laws th e d an g e r of a sufficient decrease in th e incom e o f deserving
families to m ak e them d ep en d en t, w here th ey are now ind ep en d en t.
I h av e discussed this question scores of tim es w ith social w orkers of th e
highest stan d ard , of w hose sincerity th ere can b e no question. It is
tru e th a t th ere are m any hom es w here the w ages of th e child m ark
th e difference b etw een dep en d en ce an d independence. It is tru e th a t
it w ould b e u n fo rtu n a te to d o anything which w ould increase the
n u m b er o f th o se w ho m ay becom e to som e extent pauperized. W e
h av e a com plicated problem . < B ut a t th e sam e tim e w e m ust rem em ber
th a t it is m o re im p o rtan t to conserve th e rights of th e child th a n to
p e rp e tu a te th e rights of som e person w ho will d eterio rate from sem i­
pauperization.
H ow ever, I see no reason for such a result. W e should recognize
th e rights of these children, an d w here th ere is financial necessity, p ro ­
v id e scholarships w hich will m easure th e difference betw een th e earning
p o w er o f th e fam ily w ith th e assistance of the child, a n d th e earning
p o w er o f th e fam ily w ithout such assistance. I see no m ore reason w hy
th a t should b e pauperization th an th e m o th er’s pension law s which
are in o p eratio n in m any States. It is justice, n o t pauperization.
I rem em b er a few years ago w hen I w as in C olorado th a t I received
a lette r from th e then m ay o r of th e city, urging m e in th e strongest
language o f w hich h e w as capable th a t a certain child, eleven years
of age, should b e given a perm it to w o rk because th e m o th e r w as a
w idow . T h a t m ay o r th o u g h t h e w as doing a kindly thing. H e thought
I w as d o in g a ra th e r unjust thing in n o t giving a p erm it to a child
eleven years old. T h a t is som ething I cannot conceive as being possible


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C H IL D LABOR— LEG ISLA TIV E P R O H IB IT IO N

107

a t th e p re sen t tim e. B ut w e all k now o f S tates w here p erh ap s the
m ajo rity o f th e p eo p le believe th a t th ere is nothing u n reasonable in
allow ing a tw elve-year-old child to leave school an d go to w ork.
W e h a v e com e to assum e in a n u m ber of S tates th a t u n d e r certain
conditions a fourteen-year-old child should b e allow ed to w o rk ; th a t
failure to p erm it him to d o so brings ab o u t an injustice to a fam ily,
a n d th a t a com p lete w ithdraw al of all o f th a t k ind of la b o r m ig h t h av e
certain d etrim en tal effects u p o n d ie industry a n d com m erce of th e
com m unity. T h a t is n o t so. A com m unity can ad ju st itself to th e
id ea th a t th e entire tim e of young p eople lz n e e d e d fo r education up
to th e age o f sixteen exactly as easily as it h as ad ju sted itself to th e
id ea th a t fo u rteen is a p ro p e r stan d ard . It is v ery easy fo r industry
an d com m erce to a d ju st them selves. It is usually v ery easy fo r th e
econom ics o f th e h om e to ad ju st itself, a n d in th e com paratively few
cases w here th e re m ust b e relief it is quite possible for th e child to b e
tak en care of b y a p riv ate organization, o r preferably, in m y judgm ent,
b y th e S ta te itself.
I m en tio n ed as m y id eal th a t young p eo p le u n d e r 21 years o f age,
w ho have- n o t finished high school a t least, shall b e com pelled to
a tte n d co n tin u atio n schools, especially designed to m eet th e ir needs.
P erh ap s th e first step in th e w ay of com pulsory continuous education
m ay b e to h a v e continuation schools only fo r th a t com paratively
lim ited g ro u p of b o y s an d girls w ho are w orking u n d e r perm its, a t
p resen t those from fourteen to sixteen years of age; b u t le t us extend
th a t co m pulsory co ntinuation school education w ith th e requirem ent of
a p erm it to eighteen years instead of sixteen. L et u s see th a t no child
shall leav e th e public schools until h e is eighteen y ears of age unless
h e h as received a p erm it. A n d th en let us see to it th a t w e h av e com ­
pulsory co n tin u atio n schools fo r th a t group of individuals w ho are
thus released from school to w ork.
H e re w e h av e a p racticab le plan. P erh ap s it should n o t com e into
o p eratio n to o ra p id ly ; possibly continuation school education m ay
b e m a d e com pulsory first for th o se fifteen y ears of age; th e n ex t y ear
for th o se sixteen y ears of ag e; th e n ex t year, seventeen; b u t w ithin
a reaso n ab le tim e le t us h a v e such a law actually on our statu te b o oks
an d actually in force. T h e n I believe w e can say th a t w e h av e accom ­
plished som ething definitely w o rth while, an d th a t w e will h av e p laced
our S ta te am o n g th e m o st a d v a n ced as to th e b ro ad -m in d ed n ess w ith
which its citizens lo o k u p o n this great p ro b lem of conserving th e lives
of o u r children, so th a t w hen they cease to b e children th ey will b e
fitted as effectively as possible for life.


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STANDARDS OF CHILD WELFARE
DISCUSSION

Miss G race A b b o tt (o f th e C hild ren s B u reau ) re a d th e m inim um stan d ard s
ad o p ted by th e W ash in g to n C o n feren ce w ith refe re n c e to child la b o r a n d education. She ad d ed :
I w ish, a s a citizen a n d v o te r of C hicago, th a t Illinois sta n d a rd s w ere so h ig h
th a t th ese stan d ard s m e a n t n o th in g to you. P erso n ally , I will say th a t Illinois is
fa r fro m leading in child-labor legislation; th e re is a v e ry definite necessity for
all of us to go to w o rk . A n d I w a n t to g u a ra n te e to M r. C hadsey h e re a n d now,
as a social w o rk e r fo r m a n y y e a rs in C hicago, th a t social w o rk e rs w ill n o t hinder
b u t help him in acco m p lish in g th is p ro g ra m ; th a t ev ery o n e o f th em , w h e th e r
w o rk in g w ith a relief ag e n c y o r n o t, w ill assum e w h a te v e r ad d itio n al b u rd e n is
involved in raisin g th e sta n d a rd fo r th e ed u catio n of ch ild ren . ’T h e y a re n o t
w o rth y of th e nam e o f social w o rk e r unless o n e o f th e ir p rin c ip a l jo b s is seeing
th a t th a t th in g is accom plished. I am su re th e re is no one h e re w ho is n o t read y
a n d w illing to jo in w ith th e school a u th o ritie s in elevating a t o n ce th e re q u ire ­
m ents of ed u catio n of th e ch ild ren o f C hicago, o f Illinois, a n d o f th e N atio n .”


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LEGISLATIVE REGULATION OF EMPLOYMENT
STA TE CONTROL
By T H E H ON . ALBERT E. H ILL
F o rm e r L ieu ten an t G o v ern o r o f T en n essee an d S p e a k e r of th e S ta te S en ate

In the discussion of th e legislative regulation of th e em ploym ent of
children I shall tak e for g ra n te d it is a foregone conclusion th a t the
follow ing h av e been established as m inim um stan d ard s of child-labor
laws:
( a ) T h a t th e em ploym ent of children u n d e r sixteen years of ag e is
"prohibited in an y mill, factory, w orkshop, laundry, teleg rap h o r tele­
p h o n e office, o r in th e distribution o r transm ission of m erchandise or
m essages, o r in an y form of em ploym ent th a t interferes w ith regular
atten d a n ce a t school.
( b ) T h a t no m inor shall b e em ployed fo r m ore th an eight hours
p e r d ay n o r m o re th an forty-eight h ours p e r week.
(c ) T h a t no m inor shall b e em ployed b efo re 7 a. m. n o r la te r th an
6 p. m.
( d ) T h a t no m inor shall b e em ployed in an y occupation w here
th ere is m o re th a n th e o rd in ary h az ard to hum an life.
W ith these sta n d a rd s agreed upon, I shall briefly com m ent upon
a few of them .
In th e eight-hour d a y for children th e re should b e a b re a k in the
d a y — a p erio d o f real recreation. No child should b e em ployed in
any concern th a t do es n o t furnish a clean, w holesom e p lace fo r th e
child to eat his lunch, stretch him self, a n d w ash his face a n d hands.
T h e 7 a. m. to 6 p. m . lim it fo r m inors w ould p ro h ib it th em from
carrying ro u tes o f m orning papers. T his should b e done. It is w ork
th a t is of serious d etrim en t to th e child physically, m orally, an d from
an ed u catio n al standpoint, a s an y public-school teach er can testify.
Boys do in g this w o rk m ust arise n o t la te r th an 3 o r 4 o ’clock in th e
m orning, a n d usually sta rt o u t w ithout b re ak fa st a n d p o o rly p ro tec ted
against th e w eather. T h e y h an g aro u n d in groups, in all sorts of places,
w aiting fo r p a p e rs to b e given out. T h ey com e b ac k from th eir routes
hungry, tired , an d sleepy; it is th en alm ost school tim e, so th e re is no
tim e fo r rest; a n d th ey are physically a n d m entally unfitted fo r school
atten d an ce. T h is w ork, like th e street trades, should b e left fo r adults.
T h en com es th e perplexing question o f a m inim um w age. C ertainly
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a child em ployed eight hours a d ay for six days a w eek ought to b e
earning a living— th a t is, h e should b e fully self-supporting. H is w age
should furnish him housing, food, a n d clothing, an d leave a little m ar­
gin fo r recreation an d em ergencies. A sm aller w age w ould b e a social
crim e. W h a t this w age should b e m ust b e w o rk ed out b y ex p erts an d
accep ted b y us.
W e should tak e into consideration, how ever, th a t it w ould b e h ard ly
fair to enforce this w age w here a child is em ployed only p a rt tim e, as
w hen h e w orks only afte r school hours o r during vacation, o r a t an
em ploym ent w here h e is clearly serving an apprenticeship w hereby he
will learn a useful skilled tra d e b y w hich h e can m ak e a living for
him self a n d fam ily whfen h e reaches m anhood. If all la b o r w ere o r­
ganized, this p ro b lem Would solve' itself, o r a t least each organized
tra d e w ould solve th e p ro b lem for its trad e, an d then see th a t its re­
quirem ents w ere enforced. B ut all lab o r is n o t organized, a n d we
m ust d ea l w ith conditions as w e find them .
T h ere is also th e subject of th e adm inistration of ch ild -lab o r laws,
fo r th e ad m in istration of a law is as im p o rtan t as th e provisions of the
law itself. A law o f m inim um sta n d a rd s adm inistered in an intelligent
m an n er a n d rigidly enforced, will accom plish b e tte r results th an an
ideal law p o o rly adm inistered. It is one thing to g et a law passed an d
an o th er to h av e it enforced. In each S ta te it is necessary to h av e a d e ­
p artm e n t o f factory inspection, charged w ith th e d u ty of carrying out
these laws. F acto ry inspectors should b e m en of practical experience,
in full sy m p ath y w ith th e laws. E very concern em ploying m inors
should b e com pelled, u n d er h eav y penalties fo r failure, to file w ith th e
facto ry in sp ecto r m on th ly re p o rts show ing fo r every m in o r em ployed,
th e nam e, age, nam e of parents, n atu re of w ork, hours em ployed, an d
w age received.
T h e re are certain o th e r law s so necessary in th e p ro p e r enforcem ent
of ch ild -lab o r law s th a t they m ay well b e called com panion laws.
A m o n g such law s is a v ital statistics law. U nless th e S ta te is required
to k eep a reco rd of births, th e factory inspector is com pelled to rely on
th e w o rd o f th e em ployer o r th e p a re n t as to th e age of a child, an d
experience h as tau g h t th a t this causes th e g re atest confusion.
L aw s requiring atten d a n ce a t school fo r th e full school term are
also necessary to p re v en t child labor. C om pulsory school-attendance
laws, b ack ed up b y free tex t books, are, in fact, g re at p reventives of the
child -lab o r evil.
M others’ pension law s are also closely re la ted to child-labor laws.
W ith o u t d o u b t th e p o o r w idow has b ee n m a d e th e excuse fo r child
lab o r m o re often th an she has b een th e cause, b u t she is a cause often
enough to m ak e it essential th a t th e S ta te should m ake provision fo r the
m o th er o f a fam ily of children left w ithout support. T hese children be
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com e th e w ard s of th e S tate. T h ey can b e cared fo r m uch m ore eco­
nom ically a t h om e th an in institutions. ■If th e S tate will p ro v id e m o th ­
ers’ pensions to m eet this n eed it will save for future use one of its
greatest assets, th e lives an d w ell-being of its future citizens.
T h e only connection th a t I h av e h a d w ith child-w elfare w ork has
b een n early tw enty-five years’ experience as a m em ber of a legislature
th a t has h a d this question up for tw enty-five years. In th a t S ta te w hen
we started o u t w e could n o t g et any support, b u t w e m a d e a stan d ard ,
an d w e h av e progressed until to d a y w e h av e alm ost reach ed th a t
stan d ard .
T h e law o f 1911 p ro h ib ited th e em ploym ent of an y child u n d e r 14
y ears of age in an y mill, factory, w orkshop, laundry, teleg rap h o r tele­
p h o n e office, in th e distribution o r transm ission of m erchandise o r m es­
sages, o r in any business w hich in terfered w ith the child’s atten d a n ce
a t school during an y p a rt of th e school term . U n d e r th e sam e law
children u n d e r sixteen years of age w ere p ro h ib ited from em ploym ent
on d an g ero u s m achinery, an d children u n d e r eighteen years of age
w ere fo rb id d e n em ploym ent as m essengers for teleg rap h o r m essenger
com panies b etw een 10 p. m. an d 5 a. m.
In 1915 a law w as passed excluding canneries from th e operation
of th e 1911 law, b u t again in 1917 canneries w ere b y law b ro u g h t
u n d er th e regulation.
In 1917 th e 1911 law w as further am en d e d so as to require a w o rk ­
ing certificate issued b y th e county su perintendent of schools b efo re
an y child betw een 14 an d 16 m ight b e em ployed.
T h e h o u rs of w ork fo r m inors u n d e r sixteen years w ere first regu­
lated b y law in 1907, to w it: T h a t afte r Jan u a ry 1, 1908, no child
u n d e r 16 y ears of age should b e em ployed longer th an 62 hours in one
w eek; afte r Jan u a ry 1, 1909, n o t longer th an 61 hours, an d a fte r J a n ­
u ary 1, 1910, n o t lo n g er th an 60 hours. In 1913 a law w as passed
reducing th e h o u rs to 58 p e r w eek an d 10J/2 p e r day. B y an o th er
act of th e sam e year, it w as p ro v id e d th a t no child u n d e r 16 years
should b e em ployed betw een 6 p. m. an d 6 a. m. A n am en d m en t
passed in 1915 red u ced th e w eekly hours fo r such m inors to 5 7. T h e
law of 1917 finally am en d e d form er law s so th a t no child u n d e r 16
y ears of ag e m ay b e em ployed betw een 7 p. m . a n d 6 a. m ., n o r m ore
th an 8 h o u rs p e r d a y o r six days p e r week. So th e 8 -hour sta n d a rd
w as reared , covering a p erio d of ab o u t seven years.
T h e C om pulsory School A tten d an c e L aw w as passed in 1913, re­
quiring th a t all children betw een 8 an d 14 y ears of age shall atten d
school fo r 80 consecutive day s each year, or, in th e larg er cities, for the
full term .
In 1915 th e M others’ P ension L aw was first passed authorizing the
ex p en d itu re of $ 4 ,0 0 0 b y the county courts in certain larger counties.

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In 1917 th e am ount w as increased to $8,000. T h e only counties
availing them selves of this privilege are S helby an d K nox. So you see
we are progressing very slowly in reg ard to m others’ pensions.
In controlling th e lab o r of children T ennessee is well to th e fro n t
except in th ree particulars. It has no law controlling street trades, no
law requiring physical exam inations a n d no law fixing a m inim um wage.
T h ese are co n sidered essential b y students of child-labor conditions.


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HOURS
By MISS AGNES NESTOR
Presid en t, W om en’s T ra d e U nion L eague, C hicago

W e feel to d a y th a t w e h av e com e to a real p o in t of d ep a rtu re from
old stan d ard s. T hose w e drew up a few years ago, p erh ap s five o r ten
years ago, are no longer considered sta n d a rd s for today. T h e stan d ­
a rd s w hich w ere set up in th e child-labor law w ere various safeguards
th a t w e all felt w ere w ell w orth w hile a n d necessary. W e all felt very
p ro u d o f th em a few years ago, b u t I th in k w e feel to d a y th a t w e
m ust d e p a rt from them a n d go on to w h at m ay b e considered b y som e
groups, I assum e, as v ery radical.
A s w e go o v er th e law s in th e various S tates w e feel w ithout particu­
lar exam ination th a t w e h av e fairly g o o d laws, th a t w e h av e v ari­
ous safeg u ard s throw n aro u n d th e children a t th e ages they are p e r­
m itted to w ork. A s w e go d ow n th e list o f S tates w e find th e m axi­
m um w orking h o urs1 for children u n d e r sixteen y ears in nineteen S tates
an d th e D istrict o f C olum bia to b e eight h o u rs a d a y an d forty-eight
h o u rs a w eek, a n d in eleven ad d itio n al S tates th e sam e hours b u t w ith
certain exem ptions; in ten S tates2 a m axim um w orking d a y of nine to
ten h o u rs b u t n o t m ore th an fifty-eight hours a w eek; a n d in seven
S tates ten h o u rs o r m o re a d a y w ith sixty ho urs a week.
A fte r th e age of 16, children are p erm itted in m any S tates to w ork
ten hours, in som e S tates even longer. In Indiana, w hich is one of our
im p o rtan t industrial States, th ere is no regulation of th e hours for w om en. T h u s afte r children reach th e age of 16— an d girls of 16
are children— th ey can w o rk 12, 14, in fact any n u m b er of hours th a t
th e em p lo y er m ay choose. O ur safeguards are left off a t th a t very
te n d e r age.
I w as g lad to h e a r M r. L ovejoy suggest raising th e age to 18 an d
lim iting th e h o u rs of w o rk of children betw een th e ages of 1 6 a n d 18
to six h o urs a day. I am glad to subscribe to th a t sta n d a rd because
w e h a v e to face this question as a h ea lth question— w e m ust face th e
fact th a t th e child m ust go through life. A re w e going to p erm it him
to w o rk such long hours a n d u n d e r conditions so injurious as to h an d i­
cap him fo r th e rest of his life? I feel th a t I can ta lk critically of the
various S tates, o f th e legislation th e y h av e now a n d th e safeguards
which n eith er y ou n o r I feel are adequate, because in m y ow n S tate I
1 T h ese h o u rs do n o t alw ays a p p ly to ch ild ren a t w o rk in all occu p atio n s.
2 In o ne of these S tates th e law ap p lies only to ch ild ren u n d e r M .

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feel th a t w e are fa r b ehind in th e m a tte r of pro tectiv e legislation. In
Illinois w e p erm it our girls o v er 16 to w ork ten hours a d ay a n d six
days a week. W orse th a n that, w e p erm it night w ork. W e h av e no
prohibition of night w o rk a t all except for th e children betw een th e
ages of 14 a n d 16. W e are n o t sufficiently stirred o r alarm ed b y th e
conditions w e are perm itting. W e m ust h av e an educational cam ­
paign to p resen t certain facts; y et w hen We p resen t these facts to o u r
legislators w e seem unable to m ak e them feel th a t w e are doing m ore
th an ju st talk, as th ey say, sentim ent to them .
D r. S an d spoke ab o u t basing th e cam paign on science a n d experi­
ence. T w o y ears ago in Illinois we w ere agitating fo r an eight-hour
law fo r w om en, a law w e h a d b een trying to get for m an y years. O ur
legislators felt th a t w e d id n o t h av e sufficient evidence to p resen t to
them . T h ey felt th a t w e ought to h av e a scientific investigation m ade,
th a t w e ou g h t to h av e experts study th e question so th a t w e could com e
b efo re th em la te r w ith testim ony to convince them th a t o u r co n ten ­
tions w ere tru e; to su p p o rt them w ith sufficient facts an d b ase our
d em an d s fo r this legislation on such a report.
T h ere w as a com m ission ap p o in ted ab o u t tw o years ago, u p o n which
I h a d the privilege of serving. It w as m a d e up of tw o representatives
o f em ployers, tw o representatives of w om en w orkers, a n d th ree physi­
cians. O f course, th ey d o n o t consider seriously w h at th e w om en
w orkers say— th ey say w e are n o t scientific— b u t we w ere feeling quite
ch eered b y th e th o u g h t th a t w hen th e testim ony of th e th ree physicians
on this com m ission w as b ro u g h t in som e atten tio n w ould b e p aid to it.
T his com m ission h a d a lim ited tim e to w ork an d a lim ited a p p ro p ria ­
tion. It w as n o t ap p o in ted until January, 1917, an d d id n o t g et dow n
to w ork until ab o u t A pril, a n d h a d to m ake a re p o rt b y D ecem ber.
B ut even in th a t tim e th ere w ere a num ber of v ery interesting studies
m ade. T h a t re p o rt w as su b m itted to the G o v e rn o r th e first of
D ecem ber.
„ E x p erts to ld us th a t to m ake a stu d y of fatigue you m ust m easure
fatigue b y o u tp u t; so w e m ad e studies of output. W e w ere ab le to find
certain factories an d p articu lar industries w here hours h a d b een changed
a n d to m ak e co m p arative studies. W e sent out charts to em ployers;
we exam ined th e card s in th e factory inspector’s office; w e sent out
questionnaires ; w e g o t the testim ony of industrial physicians. W e g o t
inform ation from as m any sources as possible. W e found th a t long
hours are n o t justified b y output. W e found, fo r instance, in one stu d y
covering a p erio d o f four years, th a t b y reducing a 5 4 -h o u r w eek to a
4 8 -h o u r w eek th é total o u tp u t w as increased tw o p e r cent an d the
hourly o u tp u t w as increased seven p e r cent. I n a n o th e r in d u stry th e
sam e red uction o f hours in a p erio d o f nine m onths increased th e total
o u tp u t 3.9 p e r cent an d th e hourly o u tp u t 11.8 p e r cent. In still an o th er

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industry, covering a y ea r an d a half, w ith th e sam e decrease in hours,
th e to tal o u tp u t increased 1 3.4 p e r cent an d th e hourly increase was
31.5 p e r cent. W e found in studying seasonal trad e s th a t it d id n o t
p ay to h av e long hours o v er th e season. T h e sh o rter length week,
while it elim inated th e big spurt a t th e beginning, te n d e d to w ard a
stead y p ro d u ctio n th ro u g h o u t th e entire season. A 6 6 -h o u r w eek
raised th e o u tp u t a t th e beginning of th e season, b u t b ro u g h t it dow n
a t th e en d so th a t th e to tal o u tp u t d id n o t justify th e long hours.
If th e em ployer w ould look a t this m atter from an econom ic sta n d ­
p o in t it w ould b e to his advantage. W e ourselves h av e a bigger ques­
tion to consider, th e health of the child.
W e p resen ted this re p o rt to th e Illinois legislature. S om e o f th e
m em bers a re d istu rb ed because w e h av e n o t com e in w ith a scientific
classification o f industries. B ut every one adm its th a t in factory w ork
w here speeding-up takes place th ere is a g re at strain w hich necessitates
regulation. W o rk in th e stores, w hich is considered a light occupation,
w e know includes th e strain o f standing steadily an d th e pressure of
th e public. T h e fatigue a t th e en d o f th e d a y is as g reat as factory
fatigue. So it is w hen you go to o th er occupations. W e believed w e
w ere justified in asking th a t th e lim itation of an eight-hour d a y b e set on
all th e occupations th a t w e h av e included u n d e r o u r p resen t law until
som e o th e r stu d y o r o th er evidence is b ro u g h t b efo re th e legislature to
ju stify a d ifferent regulation.
W e stu d ied th e question further. W e w ere eager to k now w h at
effect th e long w orking h ours of th e m o th er h a d u p o n th e h ealth of
th e child. W e m a d e studies a t som e of th e w elfare stations in Chicago,
w here th e C h ild ren’s B ureau in its C hildren’s Y ear C am paign w as w eigh­
ing th e children, getting inform ation, an d giving advice to th e m others.
O u t o f 1 10 b ab ies registered a t one branch, 67 w ere found in g ood
co n dition a n d 43 in p o o r condition. A m ong th e 67 w ell babies th ere
w ere only 3 w hose m o th ers w ere w orking m o th ers; am ong th e 43
undern o u rish ed th ere w ere 10 w hose m o th ers w ere w orking. W e find,
no m a tte r w here w e go, th a t if long h ours exist th ey affect th e health
o f th e w om en an d eventually th e health of th e children, a n d thus th e
h ealth o f th e future race.
I am g lad to subscribe to an d suggest as a sta n d a rd fo r to d a y th a t
no child should b e p erm itted to w ork u n d e r th e age of 16, th a t no
child b etw een 16 an d 18 years of age should b e p erm itted to w ork
m o re th an six h o urs a day, an d th a t no w om an o v er 18 should b e p e r­
m itted to w o rk m o re th an eight hours a d a y / I should like to see th e
eight-hour d a y universal th ro u g h o u t th e country. W e ought a t this con­
ference to p u t forw ard ad v an ce standards, sta n d a rd s th a t all people,
n o t o nly of o u r co u n try b u t o f all th e countries o f th e w orld, are p re ­
p ared to m eet today.

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W A G E P R IN C IP L E S 1
By PR O FESSO R F. S. DEIBLER
N o rth w estern U niversity

I h av e b een ask ed to speak on th e principles underlying w age sta n d ­
ard s of w orking children. I d o n o t know th a t th e principles d eterm in­
ing th e w age of th e.w o rk in g child are essentially different from th e
principles which should d eterm ine th e w ages th a t any individual w orker
should receive. T h e re is n o subject in th e h eld of econom ics concern­
ing which it is so difficult to lay dow n principles on w hich one can stan d
w ith p erfect assurance as th a t o f wages. It is one thing to lay dow n
general principles governing general conditions; it is quite an o th er
thing to say w h at a p articu lar w age shall be.
T h e re are, how ever, certain general principles th a t should a t least
n arro w th e g ro u n d fo r dispute. T w o general principles co n ten d for
suprem acy in all w age m atters. O ne, know n as th e P roductivity
Principle” is th a t b efo re a w age can b e paid, a p ro d u c t m ust b e p ro ­
duced. In o th er w ords, w ages m ust com e o u t o f p ro d u ct. W hile
th ere m ay b e differences o f opinion as to how m uch of th e p ro d u c t
shall go to la b o r a n d how m uch to profits of capital, unless, as Sec­
re ta ry W ilson says, th ere is som ething to divide th ere is n o t m uch use
in hav in g a dispute. T his is only an o th er w ay of expressing th e id ea
th a t econom ists p u t in m o re form al term s. A long w ith th a t as a
principle of determ ining wages, th ere is th e principle of th e living
w age— th e m inim um cost of w h a t is necessary to m aintain th e individ­
ual in physical efficiency. T h e re is n o t only th e question of w hether
a concern can p a y th e w ages, b u t th ere is also th e question o f w heth er
th e individual can live on th e wage.
U n fo rtu n ately so fa r as th e application of these principles is co n ­
cerned, they o p erate som ew hat differently w hen w e are dealing w ith
m aterial go o d s from w h a t th e y d o w hen w e are dealing w ith labor.
O rdinarily, in the case of m aterial goods, if th e price does n o t cover the
cost o f p roduction, th e g o ods will no longer b e pro d u ced . B ut u n fo rtu ­
n ately w e alre ad y h av e a supply of labor, an d w e'w ill continue to h av e a
supply, even th ough th e cost of m aintaining it in a state of physical
efficiency is in ad eq u ate; even though th a t cost in th e form o f w ages is
n o t sufficient to m aintain lab o rers in a state of physical efficiency.
Excessively low w ages will result in a grad u al d eterio ratio n of th e
ch aracter of th e la b o r supply an d will result eventually in a depreciation
of th e p ro d u ctiv ity of industry.
d e li v e r e d a t th e C hicago C hild ^X^elfare R eg io n al C o n feren ce, M ay 19, 1919.

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F u n d am en tally these tw o principles— th a t of th e living wage, an d
th e pro d u ctiv ity theory, o r th e principle o f w h at th e p ro d u c t will afford
— ap p ly as m uch in th e case of th e ’em ploym ent of children as they
d o in th e case of adults. It is tru e th a t som e industries will b e carried
on fo r a tim e during w hich th e returns from th e p ro d u c t are n o t a d e ­
q u ate to cover th e cost, th a t is, during a p rom otional p erio d , while a
m ark e t is being found. B ut b ey o n d th a t tim e th e in d u stry will n o t con­
tinue unless th e returns cover th e cost o f production. So in som e cases,
fo r those entering industry th ere m ay be, fo r a certain p erio d a t least,
a kin d of training w hich is in th e n atu re o f prom otion. A p p re n tic e­
ship, w here it really m eans learning a trad e , has som ething of th a t
character. M oreover, em ployers say th a t it tak es a p erio d of tim e
for th e individual to becom e w orth his com pensation; to a certain
extent, n o d o u b t, this is true.
I find a t th e p resen t tim e th a t th e re is a v ery encouraging sym ptom
to b e found in th e discussions o f em ploym ent m anagers— how far it is
a real sign o f d ev elo p m en t it is too early to say. T h ere is an increas­
ing sentim ent in fav o r of insisting on a careful jo b analysis of all the
w ork in a shop a n d th e arran g em en t o f these jo b s in such a w ay th at
th ere is a definite chance for everyone w ho com es into th e factory o r
into th e in d u stry to h av e an o p p o rtu n ity for prom otion. If th a t form
o f h an d lin g in d u stry continues a n d becom es a p e rm a n en t p a rt of the
co n d u ct o f industry, those w ho a re entering, say, from th e schools,
do in a m easure sta rt to w ork a t a profession. T h ey h av e Something
definitely ah e ad of them . It is som ew hat in th e n atu re of an a p p re n ­
ticeship, n o t th e o ld apprenticeship in w hich a single tra d e is learned
b u t one in w hich th e industry is learned." U n d e r those conditions th e
w age a t th e sta rt m ight p erh ap s b e even less th a n th e keep o f the
individual, if th e jo b actually lead s to a p erm a n en t position giving
ad e q u ate return. T h a t is a possibility. T h e re are o th er jobs, how ever,
th a t n ev er lead anyw here in particular, th e child being h ired because
his w age is low er th an th a t of an adult. In case of th a t k in d of a jo b
I see n o justification fo r less th an a living w age. A n industry th a t
pays less is p ro b a b ly a parasitic industry an d should n o t b e in existence.
H o w are th e principle o f cost an d th e principle of p ro d u c t going to
function? In som e places th e p ro d u c t m ay b e ad e q u ate to p a y th e
b o y o r girl a larg e w age; b u t certainly no larg e r w age will ever b e
p aid th an is necessary to g et th e w orker. H o w can th e functioning
of these principles b e directed ? I see no o th e r m eth o d th an one sim ilar
to th a t o f collective action. It m ay b e th a t a m eth o d can b e w orked
o u t th ro u g h ad v isory com m ittees com posed o f school officials, lab o r
exchanges, rep resentatives o f industry, a n d social w orkers. Such
com m ittees m ig h t w ork o u t a satisfactory scale o f w ages u n d e r w hich
children leaving school m ight en ter industry on a satisfactory basis.
T his seem s to m e th e m ost practical w ay of solving th e problem .

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MINIMUM W A G E
By DR. JESSICA B. PE IX O T T O
P ro fesso r of Social E conom ics, U niv ersity of C alifornia

In this co m p an y th ere is no n eed to urge th e m erits of m inim um w age
legislation. H ere a t least, th e case for such legislation has b een finally
w on. In all circles, it is gaining ground.
F o r a century, facts slowly accum ulated a n d assem bled h av e show n
th a t a large p ro p o rtio n of w orking p eo p le w ere being p aid w ages th a t
d em o n strab ly co uld n o t give them a b a re subsistence. A s conse­
quence, fo r m o re th a n a generation th e industries paying such wages,
th e so-called sw eated industries, h av e b een th e focus fo r a rising tid e
o f p rotest. F ew persons in a m o d ern com m unity w ould n o t shudderingly p ro test th e w om an w ho stitched an d stitched an d starved, b u t
equally few realize th e h a rd fight necessary to elim inate th e ty p e; few
trace th e connection betw een legislation fo r a m inim um w age a n d th a t
process o f elim ination.
F o r m inim um w age legislation has m a d e its w ay in opposition to
w ell-established opinion. U nquestioning acceptance of th e specula­
tiv e psychology th a t inspired individualistic doctrines led o rth o d o x
econom ists to insist th a t th e op eratio n of econom ic forces alone could
determ in e th e w ages of labor. A n y o th er m eth o d , th ey declared, w ould
in th e long run w o rk to th e d isad v an ta g e of th e la b o re r an d all o th er
elem ents in society. E ven collective bargaining has fought an uphill
b attle n o t y e t w on. M inim um w age legislatiorf w as fo r a long tim e a l­
to g eth er p rev en ted . N ot until a w ave of new conviction sw ept o v er th e
civilized w orld, n o t until it cam e to b e fairly w ell-established thinking
th a t low w ages are an injury to the w orker a n d especially to th e rising
generation, a n d th a t th e closest interrelation exists betw een a living
w age a n d th e health, th e strength, th e skill, a n d th e intelligence of the
w orking p o p u latio n,— n o t until th en d id th e m ovem ent for a d e a d lift
in w ages th ro u g h legal enactm ent get any headw ay. D reariest fact of
all, n o t until business interests cam e to see th a t w ell-fed la b o r spelled
intelligent la b o r a n d thus la b o r th a t paid, d id effective opposition to
th e passage of such law s cease. T hen, in spite of th e econom ist, b e ­
cause of th e d re a d o f physical d eterio ratio n th a t agitation a n d investi­
gation h a d aroused, a n d because of a recent “ business” principle th a t
“ cheap la b o r is d e a r la b o r,” m inim um w age legislation began. T hough

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th e em phasis, speed, an d clearness vary, the leading nations are now all
legislating on th e principle th a t ho ld s destitution socially d isad v an ­
tageous a n d th erefo re intolerable a n d declares it a social safety device
to secure fo r all w orkers, from industry, n o t from philanthropy, th e
m eans to buy a m inim um of food, shelter, an d clothing.
T his public legalized interest in th e cash nexus betw een em ployer
an d em ployee b eg an in 1894, w hen th e New Z ea lan d Industrial an d
C onciliation A c t w as passed a fte r considerable agitation an d investiga­
tion. In spite o f a continuing opposition, b y 1915 all th e A ustralian
S tates h a d m inim um w age law s th a t h av e g radually b een ex ten d ed to
ap p ly to all industries. G re at B ritain to o k th e first step in this direc­
tion w hen th e T ra d e B oards A c t w as passed in 1909 a n d p u t into o p ­
eration in 1910. T his act authorized fo u r tra d e b o a rd s to fix m inim um
rates in fo u r tra d e s especially subject to sw eating. T hough all seem to
h av e b een m o re in terested in hom e w o rk an d earnings of h om e w orkers
th an in facto ry w orkers an d their wages, F rance, Belgium, an d G erm any
h av e also tak en steps to w ard legal control of th e w ages of fem ale
w orkers. T h e S tates of C an ad a h av e interesting m inim um w age law s
actively enforced.
M assachusetts p assed th e first m inim um w age law in th e U nited
S tates in 1912. In 1913, C alifornia, C olorado, M innesota, N ebraska,
O regon, U tah, W ashington, an d W isconsin enacted law s touching w age­
fixing. In 1915, A rkansas an d K ansas; in 1917, A rizona; an d in 1918,
the D istrict o f C olum bia follow ed. Thus, tw elve States a n d th e D istrict
of C olum bia now h av e law s th a t aim prim arily to fix th e m inim um w age
which m ay b e p aid to w om en b u t w hich also tak e into account th e
w ages of m inors an d in som e cases also regulate th e conditions u n d e r
which th ey m ay w ork. A rizona, A rkansas, U tah, an d C olorado h av e
b een practically inactive since passing their law s a n d N ebraska lacks
ap p ro p riatio n fo r enforcem ent.
W isconsin a n d M innesota h av e
scarcely b egun active enforcem ent. Thus, a t best, five States, M assa­
chusetts, O regon, W ashington, C alifornia, K ansas, an d th e D istrict o f
C olum bia, are actually enforcing m inim um w age laws. T h e active
S tates are M assachusetts an d th e Pacific C o ast States, W ashington,
O regon, a n d C alifornia.
In all of th e S tates except A rizona, th e law covers all industries.
O nly th e A rizo n a law lim its p ro te c tio n to certain industries. T h e Dis­
trict of C olum bia specifically om its dom estic service. N one of these
com m issions in an y S ta te h a v e y e t used th eir full legal pow ers. Each
.com m ission is p ro ceed in g slowly, industry b y industry, covering first
those industries p ro v en m ost m enacing to th e life an d to th e happiness
of th e w orkers. A ll th e law s cover fem ales of every age a n d m inor
boys. A rizona a n d A rkansas d o n o t specifically set m inors ap a rt. T h e
o th er S tates m ak e four classes for aw ards— ad u lt experienced w om en,


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a d u lt inexperienced w om en, experienced m inors, an d inexperienced
m inors.
T h e w o rk o f young persons in industry is characterized b y abuses
w ith w hich m o st o f us are all to o fam iliar: low w ages o r no w ages;
long hours, n ig h t w ork; th e apprenticeship p erio d unduly p ro lo n g ed ;
appren tices disch arged a t th e end of th e learning p e rio d ; to o m any
appren tices; young w orkers entering th e tra d e s w ith no vocational
guidance.
v
T h e m inim um w age law s u n d e r discussion aim to co rrect som e o r all
o f thèse abuses. In general, it m ay b e said th a t all th e S tates are
m eeting som e o f th e evils, b u t th a t no n e are m eeting all o f th e evils.
O bviously all p rofess to co rrect th e abuses of low w ages o r no wages.
In C alifornia a t least, th e com m ission is also given special p ow er to
stan d ard ize h o u rs an d conditions of w o rk ; it can regulate night w ork
an d th e length o f th e w orking d a y an d can set th e length of th e learning
p erio d so th a t it shall n o t b e u n d u ly prolonged. It can also control th e
ed ucational quality o f th e apprenticeship, b u t thus far has n o t d o n e so.
California, M assachusetts, W ashington, an d K ansas limit th e p ro p o rtio n
o f app ren tices w ho m ay b e em ployed in any one business. C alifornia
h as a ra th e r futile ruling th a t no m ore th an 33 1-3 p e r cent shall b e of
this class; W ash in gton an d M assachusetts lim it this group to 25 p e r
cen t of th e force; K ansas lim its it to 20 p e r cent.
A w a rd s fo r m inors are m a d e a t th e sam e tim e th a t all o th e r aw ards
are m ade. In all these States, except W isconsin, w here th e ag e is fixed
a t tw enty-one, m inors are persons u n d e r eighteen. A rizo n a m akes its
aw ard on th e flat ra te basis. T h e $ 10 a w eek ra te fixed as th e m inim um
b y th e A c t o f 1917 applies as has b een said to all w orkers in all in­
dustries. U n fo rtu n ately th e A rizona law is n o t being enforced.
T w o o th er states, U tah an d A rkansas, fix rates on som ething like a
flat ra te basis. U tah h a s a g ra d u ated scale according to age an d ex­
p erien ce: $0.75 p e r d a y fo r all w orkers u n d e r eighteen; $ 0.90 fo r a d u lt
learn ers; an d $1.25 fo r experienced w orkers. A rkansas fixed a flat
ra te in 1915 o f $ 1 .0 0 a d a y fo r th e first six m onths; th ere after for
w om en an d m inors th e ra te is $1.25. A fte r investigation a n d public
hearing th e com m ission m ay raise th e rate. In 1919, in sp ite o f rising
prices, this low ra te is unchanged.
In all the o th er States, m inim um rates fo r apprentices a n d learners
are regularly b elow th e “ cost of living” rates fo r adults. T h ey are
also g ra d u ated according to age an d according to industry an d are o r­
d in arily increased a t regular intervals to th e en d of a p erio d w hose
length is fixed from tim e to tim e b y th e m inim um w age boards. It
m ight excuse th o u gh n o t justify low wages, w ere educational o p p o r­
tunities legally p ro v id e d to offset low pay. B ut I h av e found in th e
law s n o rulings reg ard in g educational opportunity. W hen apprentice-


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ship w as a status, th e law a n d th e co n tract d ictated n u rtu re a n d training fo r those in d en tu red o r otherw ise b o und. T h e ad v a n ta g e of th e
m aster d ictated th e sam e thing. M odern apprenticeship, how ever, is
ordinarily a farce. It has no real likeness to m edieval apprenticeship
w here th e m aster “ obligated him self to teach th e ap p ren tice a tra d e ”
until h e could m ak e a m asterp iece., T h e educational opportunities p ro ­
v id ed b y m ost m ercantile a n d m anufacturing p lan ts trav esty th e nam e.
“A p p renticeship” can n o t now b e a r com parison w ith m edieval usage.
T herefore, if a tw o o r th ree y e a r apprenticeship p erio d is allow ed, as it
w as until this y ea r in W ashington an d still is in C alifornia a n d M assa­
chusetts, com m issions th a t m ake such rulings m ust either b e influenced
b y th e interests of business o r b e paying unthinking hom age to outw orn
traditions.
M inim um w age law s should consider th e w ork perform ed, irrespec­
tive of th e age of th e w orker. T o m ak e painstaking “ ap p ren tice” ex­
ceptions fo r m inors is m erely concession to an outw orn custom a n d to
shortsighted business enterprise. T hese exceptions m a d e fo r m inors
are disad v an tag eo us to th e a d u lt w orker an d to th e com m unity. G ra n t­
ing m inors less th a n a subsistence w age is likely to p ro tec t them from th e
w orst abuses only; th e abuse o f low w ages continues unchecked.
T h e m inim um w age set for w om en b y an y one S tate is now here as
y et a w age th a t perm its them to live well. It is still only a ra te that, as
W a lte r L ippm an says, “gives ju st enough to secure existence am id
d ru d g ery in g ray b o ard in g houses a n d cheap restau ran ts.” T h e Pacific
C o ast rulings o f A pril, 1919, announced a m inim um of $ 1 3 .5 0 as
against $ 10 previously p a id ; in th e D istrict of C olum bia th e ra te is
$ 1 5 .5 0 fo r th e printing trades. E ncouraging as these figures are w hen
view ed retrospectively, th ey m ean little actual adv an ce in real wages.
W h en eq u ated w ith a rising scale of prices in 1919, it is plain th e sub­
sistence sta n d a rd of 1913 has m erely b ee n m aintained. Since the
stan d ard w hich sets th e m inim um w age of w om en is such th a t th e w age
covers little m o re th an physical necessities, obviously w age rates for
m inors th a t are uniform ly below this sum are in no real sense living
wages. In existing rulings, th e p a y of young persons of sixteen to
eighteen is regularly one-fourth to one-third below th e b a re subsistence
level set fo r w om en. C ustom ary? Yes! S atisfactory? No!
It m ay b e o b jected th a t raising their w ages w ould p ro b a b ly exclude
m inors from industry. T his is a desideratum , n o t an objection. A ny
wage, high o r low, ten d s to te m p t m inors to leave th e schools to o soon.
T h e n atio n n eed s its children in school long enough to p re p a re fo r th e
d em an d s o f dem ocratic social order. A th eo ry of education sent th e
child into industry. O n e h u n d re d an d fifty y ears ago it w as th o u g h t
w holly d esirable th a t children should b e a t w ork as early an d as long
as possible. W e w ho g ath er here to -d ay in connection w ith these


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p ro b lem s of child la b o r are as eag er to g et them o u t of w ork. It w ould
b e a p o etic justice, Would it not, if a th eo ry o f education tak es them
o u t o f th a t d eterio ratin g discipline to w hich a th eo ry of education con­
signed them . In th e U nited S tates— for th a t m a tte r in all c iv iliz a tio n nothing b u t ignorance o r p en u ry sends children to w age w ork. U pper
class sta n d a rd s h av e long follow ed th e practice of p ro lo n g ed schooling.
In th e so-called m id d le classes, p a re n t an d child are alike am bitious for
it an d m ak e sacrifices to give it to their children. In a dem ocracy,
u p p e r class sta n d a rd s so p en e trate th a t all th e **A m ericanized” h av e
one sta n d a rd of living though perforce different planes of living. It
is so b er fact th a t all A m ericans w ould give th eir children pro lo n g ed
p re p ara tio n fo r life if incom e perm itted, a n d th a t even now all A m eri­
cans, h ow ever sm all their incom e, strive to give it to th eir children.
T h e free public school an d th e university are forever w hetting an am ­
bition fo r k n o w ledge th a t to d a y is felt b y little less th a n th e w hole
p o pulation.
T o rule th a t m inors m ust b e p aid as a d u lt w orkers are paid, ac co rd ­
ing to experience o r inexperience, w ould doubtless low er th e d em an d
fo r young w orkers because business could n o t long afford an y b u t
train ed an d intelligent help. T hus th e child w ould b e k e p t in school
w ith a d d e d incentive to get a little technical education, w hile a t the
sam e tim e his p aren ts’ d em an d for a living w age w ould b e p ro p o r­
tionally sh arpened. Experience an d investigation h av e becom e basis
fo r a public opinion th a t in th e U nited S tates favors th e elim ination
from all industry, an d especially from dangerous occupations, o f all
m inors until th eir eighteenth year.
A s th ey relate to m inors, these m inim um w age laws, these a d v e n ­
tures into th e no-m an s lan d of w age-rate fixing, are the latest com ers
in th e g roup of regulations designed to p ro tec t children from the
w astes of th e industrial process. T h e child-labor law s w hich p reced ed
them aim ed fu n d am entally to rem ove young children from industry.
T h ey to u ch ed b u t slightly th e destiny of the adolescent children. In
m ost civilized countries m any m inors are still a t w age w ork. W e find
them in larg er o r sm aller p ro p o rtio n in industry, w here they receive
m o n ey wages, o r in agricultural or dom estic service, w here they receive
th e b e tte r p a rt o f th eir p a y in kind. C haracteristically, th e y o ung person
in in d u stry goes th ere from a w age-earner’s h om e to supplem ent fam ily
earnings. T h e child o f p h ilan th ro p y as well as th e child o f its own
p aren ts will b e found a t w age w ork afte r fourteen. T hough dom estic
o r farm service is know n to b e th e service th e least prom ising, th e w orst
paid, an d th e m ost u n p ro tected o f an y class o f w ork, y e t th e 1910
census tells us th a t one an d one-half m illion of th e children betw een th e
ages of ten an d fifteen years are listed as farm laborers, an d even
th ough th e m ajo rity of these are re p o rted as “w orking a t h o m e,” they

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a re still doing a w o rk th a t lim its th eir o p p o rtu n ity to p re p a re for
life. T h e can t ab o u t young children a t fourteen “ saved from th e
city’s strain” b y being sent to th e country to w ork survives in despite
of findings. A stu d y in a rural section of N orth C arolina m ad e b y the
C hildren’s B ureau in 1916 show ed tw o-thirds of th e w hite a n d threefourths of th e negro children betw een 5 a n d 15 y ears of age doing
chores a n d w orking long, h o t hours in th e co tto n fields, o v er a third
of th em u n d e r te n years of age. F arm w ork an d house w ork then
seem to co m p ete w ith p o o r school curriculum an d p o o r atten d a n ce
law s in d ev eloping illiterates a n d incapables to b e u n d erp aid m inors.
W ith all th e facts review ed, it w ould seem fair to say th a t m inim um
w age com m issions h av e as y et failed to tak e a consistent stan d in legis­
lating fo r m inors. C reated to w ork out w ages on a cost of living basis,
th ey still— even in th e Pacific C oast S tates an d in th e D istrict of C olum ­
bia a n d desp ite th e intention of th e acts in all b u t M assachusetts— allow
business interests ( “ the financial condition of th e occupation” as it
is p h rased in M assachusetts) to k eep aw ards below subsistence levels.
A p p a ren tly eith er th e courage o r th e pow er is still lacking to say frankly
through law en actm ent th a t m en w ho ca n n o t run th eir business w ithout
cutting w ages b elow a recognized living cost shall n o t cloak th eir ow n
inefficiency b y using up young p eo p le’s lives.
M inim um w age legislation fo r m inors is u n d o u b ted ly m aking som e
progress. A n excessive n u m ber of apprentices is no longer p erm itted ,
an d the p erio d of apprenticeship begins to h av e limits. Som e w age
as against no w age a t all is now available for inexperienced w orkers.
Finally, th e w hole question o f apprenticeship has b een raised to an is­
sue th a t is b eing m e t progressively though slowly.
T h ro u g h these laws, m inors a t w o rk are p ro tec ted in som e seven
com m onw ealths from th e m ost ag g rav ated form s of exploitation, a n d in
th e Pacific C o ast S tates from th e m o st u n fo rtu n ate conditions o f w ork.
But th e apprenticeship p erio d is still too long; th e w hole field of agricul­
tural la b o r a n d dom estic service has n o t y et b een b ro u g h t w ithin th e
law ; a true; ed ucational opportunity during th e apprenticeship p erio d
h as n o t y e t b een legally p rovided. T h erefo re th e current legislation
b y countenancing th e practice of low er w age to m inors continues a
situation disad v antageous to th e ad u lt w orker a n d to th e com m unity.
Since th e w age aw ard to ad u lts b y these com m issions is a sub­
sistence w age a n d nothing m ore, to p ay less to an y w orker is to co n ­
tinue an evil p ractice o f subsidizing industry out of th e h ealth of th e
nation an d encouraging th e em ploym ent of the u ntrained. M inors a re
b est p ro tec ted b y school law s ra th e r th an b y la b o r laws. Legislation
for com pulsory school atten d a n ce; fo r p ro lo n g ed schooling; fo r co n ­
tinuation schools; for juvenile la b o r exchanges th a t p ro v id e th e m a ­
chinery to register the desire for w ork, an d th e cu rren t d em an d fo r

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w orkers, a n d give vocational guidance; a n d finally, legislation fo r a
m inim um w age for the b re a d w inner of a fam ily group, so th a t m o th er
an d children shall n o t b e obliged, despite th e p ro v en disadvantage, to
supplem ent th e earnings of th e fath er— these things will d o fa r m ore
to p ro tec t m inors th an m inim um w age legislation.
T h erefo re I subm it these sta n d a rd s of legislation for young persons.
A s im m ediate steps, m inors are best p ro te c te d b y law s for com pulsory
school atten d an ce, fo r continuation schools, vocational guidance an d
th e like:. M inim um w age legislation should tak e cognizance of only tw o
classes, th e experienced a n d th e inexperienced w orkers. G iven th e
sim ple initial w o rk in m ost industries, a six months* p erio d of learning
is all-sufficient. In th e few em ploym ents w here th e w ork is exception­
ally h a rd to learn, a b o n a fide apprenticeship p erio d m ay b e p ro v id ed
for, b u t as soon as th e o u tp u t of th e m inor equals th e o rd in ary o u tp u t of
th e ad ult, th e m inor should receive th e m inim um w age p ro v id ed b y th e
aw ard .


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A D M IN IS T R A T IV E S T A N D A R D S
By MISS TR A C Y C O P P
W isconsin In d u strial Com m ission

A few y ears ago th e ad v an ced em ployer w as th e m an w ho h a d
established the eight-hour w orking d ay an d p ro v id ed for d ec en t w ages
a n d g o o d w orking conditions. B ut to d a y an em ployer to b e a d ­
v an ced m ust h av e established som e accep tab le p lan of jo in t control
in his shop. A few years ago w e said th a t a child w ho h a d lived four­
teen y ears an d w ho h a d certain m inim um educational qualifications
w as legally qualified to e n te r industry. T o d ay , how ever, all th a t can
b e said of perm itting children to go to w o rk a t th e age of fourteen is
th a t it is b e tte r th a n perm itting th em to d o so a t an earlier age.
W e h av e seen in W isconsin th e o peration o f a g o o d law . W e h av e
seen in d u stry organized to m eet it. W e h av e seen th e d ev elo p m en t of
special agencies to ta k e care of th e unusual child. W e h a v e seen the
procession of children w ho com e into th e p erm it office fo r th eir first
w orking perm its an d fo r th e reissued p erm its fo r each new jo b . W e
b eliev e th a t w hen th e tim e com es— a n d I am n o t sure th a t it is n o t here
now — to im prove our child-labor law, it should b e im p ro v ed b y raising
th e ag e a t w hich children m ay en ter industry, an d b y raising th e ed u ca­
tio n al qualifications for such entrance.
In W isconsin th e responsibility fo r th e enforcem ent of all legislation
affecting th e relation b etw een m an agem ent a n d la b o r is given 'to th e
industrial com m ission. In th e city of M ilw aukee (w hich is h alf of th e
S tate so fa r as th e em ploym ent of children is co n cern ed ) th e industrial
com m ission issues th e la b o r perm its. Itvhas b ee n m y privilege to have,
as supervisor, au th o rity in th a t d e p a rtm e n t fo r th e last seven m onths.
I h a v e p re p a re d fo r you a practical outline o f o u r office procedure,
o ur m eth o d s of enforcem ent, th eir relation to th e continuation school,
to th e inspection service, a n d to th e o th er d ep a rtm en ts of th e com ­
mission.
T h e W isconsin law requires all children betw een th e ages o f 14 an d
1 7 w ho are em ployed, o th e r th a n in agricultural pursuits, to secure
la b o r perm its. Issuing la b o r p erm its fo r children has m an y signifi­
c a n t aspects o th er th a n th e ir legal entrance into industry. F o r in­
stance, th e p erm it rep resen ts a change in educational experience for
th e child. U posn its issuance fie leaves th e regular school an d enters
th e continuation school on an eight-hour-a-w eek basis, w hich tim e is
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STANDARDS O F C H IL D W E L F A R E

tak en o u t of his w orking hours. T h e perm it also represents, for the
bo y s especially, an o p p o rtu n ity for a p ro g ram o f apprenticeship, which
begins a t th e age o f 16. T h e apprenticeship co n tract tak es th e place
o f th e la b o r p erm it fo r children betw een 16 a n d 1 7 years of age, b u t
th e continuation school education continues a t least to th e eighteenth
year.
T h e p erm it should m ean th a t a child has h a d th e ad v a n ta g e of com ­
p e te n t counsel an d advice in relating his tendencies an d abilities to th e
jo b op p o rtu n ities in th e locality. T h e perm it also m eans to th e child
th a t h e shall b e follow ed into th e factory b y th e S ta te inspection serv­
ice fo r th e p u rp o se of enforcing th e hours of lab o r a n d th e pro h ib ited
em ploym ents clauses o f th e child-labor law, an d th a t substantial vio­
lations of th e law a t least shall b e corrected.
T h e p erm it h as an a d d e d an d serious significance to th e em ployer.
I t m ean s m o re th an sim ply a m eans of classifying young p eo p le into
gro u p s fo r th e p u rpose o f arranging their w orking hours to com ply
w ith th e law. U pon th e em ployer o f children w ho h av e no perm its,
o r w ho are a t w ork a t p ro h ib ited em ploym ent, th e W isconsin C om ­
pensatio n A c t m akes a h eavy pressure. U n d e r this act, th e industrial
com m ission m ust aw ard treb le com pensation to m inors of perm it ag e
w ho a re in ju red w hile em ployed w ithout a p erm it o r while w orking
a t a p ro h ib ited em ploym ent. T h e em ployer m ust him self p ay th e
ex tra com pensation, o r tw o -th ird s o f th e w hole am ount, w hich is
a d d e d on account of th e unlaw ful featu re o f th e em ploym ent. H e
ca n n o t insure against this h azard .
E very ph ase of child-labor legislation is negative. A ll th e elem ents
o f such la b o r a re clearly undesirable. T h e legislation is designed to
th ro w ab o u t th e children all types of protection. P rovision is m ad e
b y w hich certain educational training m ay continue. T h ere is restric­
tion as to em ploym ent— th e w hole schem e being to lim it th e o p p o r­
tunities ra th e r th an to extend them . C hild lab o r is wasteful, a n d a
bu rd en so m e thing. It is quite p roper, therefore, th a t th e features of
the ch ild-labor law which co n tem p late th e p rotection of young persons
in in d u stry becom e a t once th e h az ard s to th e em ployers o f th ese
children.
T h e co rrect h andling of th e p erm it business o f th e S ta te is'im p era­
tive. It is also necessary to develop the closest co o p eratio n a n d h a r­
m o n y am ong all th e agencies w ith w hich th e child d ea ls in m aking
his en tran ce into industry. ,
T h e legal p ro o fs necessary fo r a w o rk p erm it a re : p ro o f o f age,
p ro o f o f ed ucational qualifications, p ro o f o f physical fitness, a n d p ro o f
o f a jo b . W e d o n o t require th e child to o b tain a jo b b efo re com ing
to o ur p erm it office; rather, w e encourage him to avail him self o f our
counsel in securing his job.

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O n th e educational certificate w e h av e p ro v id e d fo r th e personal
reco m m en d atio n of th e school principal regarding th e issuance of a
perm it, an d w e h av e further said th a t no perm it shall b e issued w hen
th e school principal recom m ends adversely, except in special cases,
a n d th en only afte r a hearing a t w hich all interested persons m ay p a r­
ticipate. T h e h ealth record is used in th e sam e way. T h e school p h y ­
sician is asked to m ake recom m endation also as to th e issuance of the
perm it. T h e school physician m ay recom m end adversely, o r affirm a­
tively w ith lim itations on th e k ind of em ploym ent. T h e issuing officer
issues th e p erm it as fa r as practicable in a m an n er consistent w ith th e
school physician’s recom m endation.1
It is clearly necessary th a t th e g reatest care b e given th e m echan­
ical en d o f th e w ork. M odern conveniences in office fixtures are quite
as essential in a p erm it office as in any o th er big business institution.
T h e h an d lin g o f various legal reco rd s w hich can n o t b e d uplicated
requires a p eculiar k ind of office housekeeping. T h e perm its contain
tran scrip ts of im p o rtan t docum ents th a t m ay la te r b e used in court
cases; hence a m istake on th e p erm it m eans m o re th a n m erely an
em barrassing recognition of inefficiency.
T h e n eed of a sym pathetic an d friendly atm o sp h ere in th e p erm it
office can n o t b e overestim ated. U n d e r th e p re sen t arran g em en t in
M ilw aukee a child m ay m ak e his first request a t th e issuing office o r
a t th e office of th e school principal. M uch d e p e n d s u p o n th e attitu d e
of th e interview er a t this time. If th e child has alre ad y secured his
w ork, h e h as experienced a v ery vital ev en t in his life. A t this tim e,
th e kin d of job, his hours of labor, his wages, a n d shop supervision
m ean v ery little to him, b u t th e fact th a t h e h as a jo b is a v ery real
thing to him . H e m akes his first acquaintance w ith th e big, ab stra ct
thing know n as th e S tate. I ca n n o t em phasize too m uch th e necessity
of h aving this p h ase of th e S ta te’s business m ake th e m o st w holesom e
im pression u p o n him .
F o r th e ch ild ren w ho h av e n o t b een p ersu ad ed to continue their
education, o r fo r w hom read ju stm en t of their educational p ro g ram
has n o t b een m ad e, a n d w ho are legally qualified fo r w ork, th e la b o r
p erm it m ay b e issued. T h e industrial com m ission, how ever, h as th e
p o w er to refuse a p erm it to a child if b y so doing th e b e st interests
of th a t child are served. T h e child m ust sign th e perm it, a n d if h e
is betw een th e ages o f 14 an d 16, his p a re n t o r guardian m ust cóm e
w ith him . T h e p erm it is issued to th e em ployer an d is sent to him b y
mail, an d th e child is to ld th a t h e m ay re p o rt for w ork th e follow ing
day. F o r th e children w ho are interview ed in any d a y an d fo r w hom
ljn th e ensuing discussion, D r. G eorge P . B arth (D ire c to r, S chool H ygiene
B ureau, M ilw aukee) em phasized th e fact th a t in M ilw aukee no child can secu re a
p e rm it to w o rk u ntil he gets a certificate of p hysical fitness from a physician.

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STANDARDS O F C H IL D W E L F A R E

p erm its a re to b e issued, th e p erm its a re issued a n d m ailed o u t on
th a t day.
W h en issued, th e p erm it is used as a m eans o f enrolling th e child
in th e co n tinuation school. S ubsequently h e is assigned to classes.
It is u sed also to m aintain attendance. In ag g rav ated cases o f nonatte n d a n c e th e p erm it m ay b e rev o k ed fo r such a p erio d of tim e as
is necessary fo r th e child to m ak e up b y continuous atte n d a n c e th e tim e
lost.
A t th e ex piration o f a ch ild 's em ploym ent, th e p erm it is re tu rn ed to
the issuing officer b y mail, a n d th e child m ust com e to th e office w ith
a letter from th e new em ployer to w hom th e p erm it is to b e reissued.
B efore it is reissued, ap p ro v al from th e atten d a n ce d e p a rtm e n t of th e
co n tinuation school is required. If th e re is school tim e to m ak e up,
th e p erm it is h eld an d n o t reissued until a clear school reco rd is
rep o rted . T h e em ployer is notified b y us th a t th e p erm it which h e
h as req u ested will b e h e ld fo r a specified tim e. In th e event, w hich is
n o t infrequent, th a t th e jo b is n o t to b e h eld op en for th e child, the
p erm it is n o t g ra n te d until a new jo b is secured.
P erm its com ing into th e office each d a y rep resen t th e n u m b er of
children w ho h av e left th eir w ork. M any of these perm its a re re ­
issued w ithin a d a y o r tw o, as it is quite custom ary for a child to w ith­
h o ld his quitting n otice from th e em ployer until a new jo b is secured.
O th er re tu rn ed p erm its rep resen t th e groups of children w ho h av e
left th e city, en tered agricultural w ork, o r re tu rn ed to school; o r w ho
h av e b een co m m itted to public institutions; o r w ho h av e secured em ­
p lo y m en t on a false statem en t of age. A ll these children a re know n
as "u n em p lo y ed ” fo r th e p u rposes o f office records, though o u r ow n
surveys in d icate th a t m an y o f th e so-called unem ployed are actually
em ployed w ith o u t perm its. A s soon as a child b etw een 14 an d 1 6
years of age is unem ployed, h e becom es a full-tim e o r p art-tim e school
problem , th ough those em ployed w ithout perm its are clearly a respon­
sibility fo r th e industrial com m ission.
T h e te m p ta tio n fo r th e child betw een 1 6 an d 1 7 y ears o f age to
secure em ploym ent w ithout a perm it, a n d th e ease w ith w hich it is
accom plished, to g e th e r w ith th e h az ard s to th e em ployer u n d e r th e
com pensation act, h a v e m a d e us feel th a t a v ery p ro m p t follow -up o f
these children is necessary. T h eir h o m es are visited, th e place o f em ­
p lo y m en t d eterm in ed, an d th e em ployer notified b y telephone im m edi­
ately. R ep o rts are k e p t in th e office o f th e com m ission show ing b y
historical reco rd th e attitu d e of th e em ploy er to w ard em ploym ent
of children on n o b e tte r evidence th a n their ow n statem ents o f age,
a n d also th e em ployer s atte m p t to im prove th e em ploym ent system
of th e shop follow ing th e discovery o f violation. T h e survey o f unem ­
p lo y ed children h as b een m ad e an d supervised b y v o lunteers w ho

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h av e h a d special social-service training. A ll ch ild ren applying for
reissues to new em ployers, w ho h av e b een loafing o r em ployed w ith­
o u t perm its, o r w ho h av e been otherw ise outside of th e supervision of
th e p erm it officers fo r a p erio d of four w eeks o r m ore, are especially
interview ed. T h e p u rpose of interview ing these children is, first, to
get a list of em ployers w ho habitually accept children into their em ploy
on th eir ow n statem ents of age, to advise th e children of th e d an g er
of m aking false statem ents as to their age, an d to a ttem p t to reduce
as far as practicable th e high la b o r tu rn o v er am ong juvenile w orkers.
A ttem p ts to red u ce lab o r turnover, how ever, should n o t elim inate th e
op p o rtu n ities fo r children to use ju d g m en t in selecting th eir jobs. T h e
things th a t m ak e w o rk desirable for juveniles are frequently identical
w ith th e things th a t m ak e w ork desirable fo r adults, an d m any tim es
in changing th eir jo b s children use m atu re judgm ent.
A ju n io r em ploym ent d ep artm en t, dealing w ith children betw een
th e ages of 14 an d 17 years, has b een established in th e M ilw aukee
p erm it office. T h e agents are engaged in placing children in em ploy­
m ent, filling positions in th e local establishm ents, encouraging children
to retu rn to school, adjusting th eir educational p ro g ram s to fit their
n eed s in individual cases, tak in g p a rt in th e usual routine w ork of
the ch ild -lab o r d ep artm en t, a n d assisting in m aking all em ploym ent
of children of p erm it age legal. C hildren w ho are found to b e illegally
em ployed b y public a n d v o lu n teer agencies a re b ro u g h t to this office,
counseled an d advised on th e law, an d given assistance b y th e em ploy­
m en t d e p a rtm e n t in securing new jo b s u n d e r p ro p e r legal conditions.
C hildren w ho change their w ork frequently an d seem to b e un ab le to
get on in an y p articu lar line are advised in relation to th eir tendencies,
equipm ent, an d th e jo b opportunities, b y b o th th e ju n io r ad v iso r an d
th e apprenticeship supervisor.
O u r aim is to encourage all th e social agencies th a t are concerned
w ith th e w elfare of young p eo p le to use th e p erm it a n d em ploym ent
d ep a rtm en t as a clearing house. It is n o t our wish to discourage in
an y w ay th e fine personal w ork being d o n e b y these agencies w ith
children a n d em ployers, b u t sim ply to see th a t w h atev er placem ents
th ey m ak e are legal, giving th e em ployer no o th er b u rd e n th an the
special o ne in connection w ith th e unusual circum stances o f th e em ­
ploym ent, a n d also to see th a t th e placem ents are m a d e in a m an n er
consistent w ith th e p erm it office p ro c ed u re ; b y th a t I m ean, children
should b e placed, so far as is practicable, in th e shops of th e ad v an ced
em ployers w here th e housekeeping a n d supervision are best, a n d n o t
in th e shops in which difficulty is experienced b y th e com m ission in
m aintaining th e legal stan d ard s. It is especially desirable for an agency
wishing to serve th e em ployers along em ploym ent lines to h av e av ail­
ab le th e equipm ent a n d personnel of th e perm it d ep a rtm en t an d the

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STANDARDS O F C H IL D W E L F A R E

continuation school. N o p lacem en t o f a child betw een 14 a n d 1 7
y ears of ag e should b e m a d e unless b o th th e child an d th e em ployer
a re tho ro u g h ly p ro tec ted u n d er th e law.
T h e relation betw een th e perm it d ep a rtm en t an d th e facto ry in­
spection d ep a rtm en t in M ilw aukee is clearly the strongest featu re of
th e p resen t arrangem ent. T h e w om en factory inspectors survey th e
shops em ploying w om en an d children w ith careful atten tio n to their
special problem s. T h e agents of th e in d u s trie com m ission, w ho in­
spect th e shops w here children w ork, study th e surroundings of th e
em ployees w ith a view to fu rth er extending o r lim iting th e em ploym ent
o p p o rtu n ities of children.
T h e industrial com m ission m ay, afte r thorough investigation, refuse
to issue ch ild -labor p erm its for occupations in w hich th e re is g re at
danger. , T h e com m ission refuses to issue child-labor perm its for occu­
patio n s in w hich th ere are obvious h azard s to young people, a n d to
em ployers w hose a ttitu d e to w ard th eir responsibility u n d e r th e law is
such th a t th e com m ission feels such em ploym ent to b e unsafe. T h e
issuing of perm its to such em ployers is tem p o rarily suspended until
reaso n ab le assurance is given th e com m ission th a t th e m an n er of em ­
ploying children is to b e im proved.
E m ploym ent o f children in establishm ents w here th e m anagem ent
show s re p eated indifference to its obvious responsibility in connection
w ith children w hich it em ploys, is considered undesirable. Every
effort is m ad e b y th e com m ission to m ake clear to th e em ployers th e ir
obligations u n d er th e child-labor law, a n d also th e penalties im posed
u n d e r th e com pensation act fo r failure to com ply w ith th e child-labor
law. W h en these efforts fail to secure a p ro p e r com pliance w ith th e
law, th e com m ission feels justified in im posing severe penalties u pon
th ose em ployers w ho persistently disreg ard w arnings. In m o st cases
of first offense, w here it is clear th a t an em ployer has b een careless
th ro u g h no d esire w ilfully to v iolate th e law, h e is given an o p p o r­
tu n ity to co rrect th e condition w ith th e u n d erstan d in g th a t h e will b e
h eld strictly to account fo r subsequent violations.
'“ T h e com m ission recognizes th e necessity o f bringing these m atters
b efo re em ployers rep eated ly . E m ployers are b u rd e n ed in m any ways
a n d freq uently h an d ica p p ed b y th e m istakes o f their superintendents
a n d forem en, w ho a re alre ad y o v erb u rd en e d w ith p ro d u ctio n p ro b ­
lem s. T h e com m ission has en d e av o re d to show em ployers th a t it is
ad v isab le to give th e responsibility o f th e legal em ploym ent o f chil­
d re n to o ne p erson in th e m anagerial d ep a rtm en t. W h erev er this has
b een done, it h as b een found th a t th e firm has b een reasonably secure
from unintentional violations of th e child-labor law. F u rth e r to assist
em ployers, th e com m ission has published n ew sp ap er stories, w ritten
m an y ex p lan ato ry letters, a n d e n d e a v o re d in e v e iy w ay to give pub
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licity to typical kinds of violations of the law an d their serious conse­
quences, which m ay serve as w arnings to o th er em ployers.
E m ployers w hose records in |Jie com m ission’s office show a constant
repetition of m inor violations, are requested to m eet a representative
of th e com m ission an d to show cause w hy they should n o t b e p ro se­
cuted. T h ese conferences frequently result in a b e tte r u n d erstanding
of the law b y th e em ployer an d a b e tte r u n d erstanding b y th e com ­
m ission of th e em ployer’s problem s. W hen an em ployer is thus p u t
upon p ro b atio n w ith th e d ep artm en t, an d for subsequent substantial
violations is prosecuted, a clearer un d erstan d in g of th e necessity of
such action is evident.
It is clearly d esirable for all th e agencies affecting th e em ploym ent
experience of p erm it children to b e physically so located th a t a m ini­
m um of the child’s tim e is spent in adjusting his entrance into industry.
T h ere should also b e th e closest harm o n y an d cooperation am ong
the directing chiefs of these d epartm ents, w ith no jurisdictional je a l­
ousy, b u t w ith a w orking p lan built aro u n d th e interests of th e children.
In a com m unity th a t is n o t p o v erty stricken an d th a t has educational
institutions of high grade, w ith d ecen t em ploym ent opportunities for
adults, the ch ild -labor situation should b e m uch ab o v e the stan d ard s
set b y law. H eroic efforts should b e m a d e to keep children in school,
to ad ju st th eir educational program , an d to m ak e continued education
p ro fitab le an d possible, w h atev er th e m inim um stan d ard s of law m ay
be. A social ad m inistration of a law is th e reasonable fbrerunner of
a b e tte r law. H o n est adm inistration a n d wise use o f discretionary
pow er, how ever, should n o t b e accepted as a substitute for b e tte r law,
for, afte r all, th e raising of th e stan d ard s for leaving school an d going
to w ork, an d th e further lim itation o r extension of jo b opportunities for
children, can b e accom plished effectively only b y statute.
DISCUSSION
A M em ber: W ill Miss C opp tell us w h a t to h e r m ind a re th e ad v an tag es of
having th e p e rm it office co n n ected w ith th e in d u strial com m ission ra th e r th a n
w ith th e school system ?
Miss C opp: I have n o t b een able to co m p are them , b u t in o u r special case
th e ad v an ta g e is th a t th e in d u strial co m m issio n 'h a s a local office in M ilw aukee
w h ere w e have th e n ecessary office eq u ip m en t a n d th e clerical help. In th e o th e r
p a rts of th e S tate th e w o rk of issuing p erm its has been done by th e co ntinuationschool o r th e public-school a u th o ritie s w ith o u t com pensation. I see no reason
w hy o u r inspection service a n d o u r m ethods of p ro secu tio n w ould n o t be as avail­
ab le for th e school a u th o ritie s as fo r a n o th e r d e p a rtm e n t of o u r ow n office.


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VOCATIONAL GUIDANCE AND PLACEMENT
JU V E N IL E P L A C E M E N T \N G R E A T B RITA IN
By RO N A LD C. D AV ISON
Chief, Juvenile L a b o u r E xchange, E ngland

W e shall all agree th a t in th e contest betw een school an d w age
earning we should wish to see the claim s of th e school adv an ced a t th e
expense of w age-earning. B ut juvenile em ploym ent is still w ith us*
an d it will rem ain even w hen these changes are m ade. It is, therefore,
im p o rtan t to secure th a t th e n atu re an d conditions of th a t em ploym ent
are m ad e as w o rthy of th e education which p re ced e d it as possible.
M y special business is to tell you som ething of th e m eth o d s b y
w hich we h av e tackled this p ro b lem in G re a t Britain. Since 1910 we
h av e h ad a national system of em ploym ent exchanges w hich corre­
sp o n d to th e em ploym ent offices set up b y th e F ed eral G o v ern m en t in
this country. A t th e p resen t tim e w e h av e ab o u t 400 m ain em ploy­
m en t exchanges an d ab o u t 1,200 b ran ch em ploym ent offices attach ed
to th e m ain exchanges. A ll th e m ain exchanges an d som e of th e local
offices d eal w ith juvenile applicants an d w ith th e vacancies notified b y
em ployers fo r juveniles. T h e juvenile age lim it in E ngland fo r this
w ork is now 18. T h e em ploym ent exchange system is divided into ten
divisions, each being co n tro lled b y a divisional office, a n d each
divisional office containing an organization section especially concerned
w ith juveniles. Finally, th e w hole service is controlled from th e cen­
tral office of th e E m ploym ent D ep artm en t in L ondon, w here again th ere
is a special Ju v enile B ranch in charge of juvenile w ork.
T h e o rd in ary functions of our em ploym ent exchanges are to p ro v id e
a m ark et place for la b o r an d to carry out th e system of unem ploym ent
insurance. W e h av e realized th a t far m o re th an this com paratively
m echanical w ork-—though it is n o t w holly m echanical as reg ard s adults,
an d it is becom ing less so— is n ee d ed w here juveniles a re concerned,
an d w e h av e en d e av o re d to secure th a t th e juvenile exchanges o r
bureaus should b e used in th e interest of boys an d girls them selves, a n d
with th e m ain o b ject of helping them to m ake th e b est possible start in
their careers, as w age earners. In this w ay th e juvenile bureaus w ere
to b e th e m ean s of im proving som e of th e evils resulting from th e
industrial system . A n d I think w e carl claim th a t we h av e b een ab le to
bring ab o u t som e im provem ent in the conditions of juvenile em ploy132

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C H IL D LABOR— V O C A TIO N A L G U ID A N C E

W

m en t as a whole, an d to re n d e r th e w hole system of real benefit to the
com m unity.
I will state briefly som e of th e problem s w hich th e juvenile exchanges
an d juvenile em ploym ent com m ittees h av e to m eet. Boys an d girls
w hen they leave school a t 14 are faced w ith a variety of opportunities
of w age-earning. M any of them are attra c te d b y th e deceptive prom ise
of in d ep en d en ce which is offered b y a sm all w age ra th e r th an b y th e
need of looking to their p erm an en t careers an d of taking a jo b w hich
gives them prospects. T h ey are pathetically ig n o ran t of th e task th a t
is b efo re them an d of th e w orld into w hich th ey are going. T h ere was
one b o y w ho cam e to an exchange who, w hen asked w hat h e w an ted to
be, th o u g h t carefully for a little tim e, an d then said, “W h a t I really
w ant to b e is a retired m erch an t.” Boys an d girls are also liable to
ignore conditions w hich m ay b e harm ful to th eir health o r m ay b e
w asting the educational ad v a n ta g es which th ey h av e obtained. A gain,
it is necessary to find som e w ay of dealing w ith th e boys o r girls w ho
can n o t h o p e to tak e up th e em ploym ent w hich they desire o r to get
skilled jobs, either because th ey are too young, being u n d er 16, or
because th ere is no suitable vacancy a t th e m om ent an d is n o t likely to
b e one p erh ap s fo r a m onth o r tw o. T h o se cases h av e to b e d ea lt with
specially.
In general, one m ay assum e th a t it is alto g eth er too easy fo r school
leavers to g et jobs. I d o n o t know w hether th a t is the condition in
A m erica. B ut in E ngland in norm al tim es th ere is a surplus of juvenile
vacancies, m an y of them necessarily being of th e blin d alley type. T h e
d em an d for juveniles is g re ater th an th e supply. T his leads m any ,
children to b e indifferent ab o u t keeping th eir jo b s an d to b e careless
as to w h eth er th ey secure jo b s w hich offer th em perm anence.
O f course p aren tal guidance ought to p lay a p a rt here, an d to a large
ex ten t it does. B ut as regards specialized advice ab o u t a jo b o r about
a trad e, I think th ere are v ery few p aren ts in a n y class of society who
are really ab le to estim ate the exact prospects of an y tra d e except the
one in w hich they h ap p e n to b e them selves engaged, an d it is very often
th e one tra d e into which they d o n o t advise th e b o y o r girl to go.
W h a t is w an ted is ex p ert advice from som ebody w ho is in continual
contact* w ith all th e em ployers in th e district, a n d is giving his w hole
tim e to th e placing of children. T his is highly technical w ork, w orth
doing fo r its ow n sake an d for th e social benefits which can b e obtained.
It is n o t suggested that, b y th e establishm ent of our juvenile bureaus,
w e h av e b een ab le to re m ed y all these ills. B ut w e h av e satisfied
p eo p le th a t th e w o rk is valuable, an d it has b een a p o p u lar feature of
our em ploym ent exchange w ork. N ot th é least of th e ad v an tag es to b e
gained from th e establishm ent of m achinery of this kind is th e d etailed
know ledge an d experiencê of th e local conditions of em ploym ent an d

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of all pro b lem s affecting juvenile w elfare w hich m ay b e o b tain ed a t this
on e cen ter dealing w ith th e em ploym ent of b oys an d girls. Inform a­
tion collected in this w ay has alre ad y b een a pow erful factor in leading
up to im p o rtan t legislative changes an d o th er provisions. F o r som e
tim e b efo re th e w ar th e juvenile exchanges, a n d th e juvenile em ploy­
m en t com m ittees attac h ed to them , w ere ab le in m any areas to obtain
b e tte r by-law s w hich restricted the conditions of juvenile street trad in g
b y raising th e m inim um age a t w hich street trad in g w as allow ed an d
b y securing th a t no license should issue except through them . A n d
com ing to a far m o re im p o rtan t m atter, one of th e factors w hich led
up to th e new E ducation A ct, which has now passed into law, w as a
big inquiry co n d u cted through th e juvenile em ploym ent com m ittees
all o v er th e country, w hich p ro d u c ed inform ation for th e use of the
B o ard of Education.
F u rther, d uring th e w ar w e m a d e an elab o rate investigation of th e
w ar conditions of juvenile em ploym ent. O ver 3,000 firms w ere visited,
an d th e conditions of juvenile em ploym ent re p o rted upon. A re p o rt
w as published on th e results of this inquiry, a n d in th a t re p o rt w ere
outlined the schem es w hich should b e a d o p te d for dealing w ith juvenile
unem ploym ent w hen th e tim e should com e a t th e en d of th e w ar. T h e
tim e d id com e, an d these schem es w ere to a large extent p u t into o p era­
tion, pro v id in g fo r an out-of-w ork d o n atio n fo r juveniles in th e sam e
w ay as for adults, although a t a low er rate, an d providing th a t as a
condition of th e receipt of th e out-of-w ork do n atio n they should a tte n d
a t juvenile u n em ploym ent centers p ro v id ed b y th e educational authority
in each district.
A n o th er inquiry which is being co nducted now is an inquiry into the
h o urs of juvenile em ploym ent all o ver th e country, especially em ploy­
m en t in th ose trad e s n o t a t present covered b y restrictive legislation.
I u n d ersta n d th a t a bill is in d ra ft to p u t into effect certain higher
stan d ard s.
T h ere are, I think, valu ab le benefits to b e secured b y concentrating
th rough one agency a n d one agency only th e filling o f as large a p ro ­
p ortio n as possible of all th e juvenile vacancies in any district. N ot
only can th e experience of p eo p le w ho h av e know ledge of education
an d o f em ploym ent, th e tw o sides being equally im portant, b e bro u g h t
to b e a r upo n th e problem s o f individual children, b u t also this is p ro b a ­
b ly the only w ay of achieving som ething like th e right distribution of
th e juvenile ap p licants for em ploym ent am ong th e available supply of
vacancies. So long as you h av e juvenile em ploym ent, it is im p o rtan t
th a t th e b est vacancies should go to th e b est children, an d th a t th e less
d esirable vacancies should go to those fo r w hom th e b est prospects
can n o t b e en tertained. A central agency also gives th e child a w ider
range in selecting th e em ploym ent in w hich h e will m ake his sta rt in life.

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I could give instances show ing how w e h av e b een ab le to approach
o n e o f th e m o st difficult questions, nam ely, th e placing of children a t a
d istance from th eir hom es, a thing to b e to uched w ith g reat hesitation.
B ut w here th ere J s no skilled vacancy for a b o y in his hom e district,
a n d th ere is a d em an d a t a distance, w e h av e been able to satisfy our­
selves th at it w as desirable an d in th e b o y ’s b est interests th a t he should
leave hom e an d tak e such an opening. W e h av e been able to transfer
to one big shipbuilding firm ab o u t a h u n d re d apprentices, securing th a t
th eir lodgings an d leisure w ere carefully p ro v id e d for an d their general
w elfare assured.
F u rth er, 1 think it is b e tte r for boys an d girls to obtain their jo b s
u n d e r conditions of co m p arativ e publicity ra th e r th an in an obscure an d
casual m anner, as w hen they go to see a forem an o r m anager o r an
em p lo y er a t his ow n w orks.
W e h av e alw ays re g ard e d as th e principal feature of our w ork th e
functions associated w ith th e juvenile em ploym ent com m ittees, which
h av e b een set up in grad u ally increasing num bers during the last nine
years. O v er a h u n d re d w ere set up in th e last y ea r of the w ar in p re p a­
ratio n fo r th e crisis which w e knew w as com ing. W hen I left E ngland
th e re w ere som e 2 5 0 of these com m ittees, an d h ard ly an y im portant
industrial area w as left uncovered. A ll these com m ittees w ere closely
associated w ith th e juvenile exchange, although ab o u t a h u n d re d of
th em w ere set up n o t b y th e M inistry of L abour, b u t b y th e local educa­
tional au th o rity in co operation w ith us. In this connection, I m ight
explain th a t w here th e M inistry of L ab o u r sets up a com m ittee th a t d e­
p a rtm e n t on its side secures the cooperation of th e local educational
au th o rity a n d arran g es fo r th e ap p o in tm en t b y th a t au th o rity of a
m inim um o f six m em bers on th e com m ittee. T h e link is com plete in
all areas w here wo h av e an effective an d successful com m ittee.
E v ery district is left to w ork o u t its m eth o d s according to local needs,
sub ject to a certain general plan. In th e first place it is necessary to g et
a full re p o rt from th e school on th e child’s school career. Such an
arran g e m e n t en ables th e juvenile b u reau to exercise a useful supervision
o v e r those w ho h av e o b tain ed em ploym ent in d ep en d e n t of th e bureau.
Y ou can th en arran g e fo r after-care supervision; you can b e read y to
d eal w ith th e child w hen h e com es b ack la te r an d asks for assistance
in o b tain in g em ploym ent. T h e school-leaving form s show the result
o f th e m ed ical inspection b efo re the child left school, so th a t th e con­
siderations of h ea lth are h o t overlooked. In cases w here th e assistance,
of th e b u reau is d esired th e secretary o f th e com m ittee asks th e p aren ts
to com e up a n d discuss th e future of th e child. T his arrangem ent ten d s
to quicken th e sense o f p aren tal responsibility ra th e r than to relieve
p aren ts o f an y in terest in this im p o rtan t stage of th eir children’s lives.
In m ost areas w e h av e com m ittee m eetings once o r tw ice a week, a t


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w hich on e o r tw o m em bers of the m ain com m ittee sit, a tte n d e d b y th e
officer of th e exchange, in o rd e r to interview juveniles w ho n ee d special
advice.
,i' i
T h en th ere is th e system of after-care supervision, a n d w ithout som e
system of th a t sort we could h a rd ly claim to h av e an effective organiza­
tion. Som e supervision is n eed ed o ver a g re at proportion, b u t n o t
necessarily all, of th e boys an d girls w ho o b tain em ploym ent. I d o
n o t th in k w e wish to m ake a purely m echanical business of th e super­
vision w here it m ay am ount to nothing m o re th a n fussy interference, b u t
w e m ust h av e som e system of keeping in touch w ith those w ho n eed it.
W e w o rk w ith the existing agencies in every district; w ith th e school
care com m ittees (a n organization u n d e r the educational authority,
w hich h as know n th e child during his school career an d is w illing to
keep in touch w ith him afterw ard s) ; a n d w ith th e v o lu n tary clubs, scout
troops, guilds, an d o th er associations of endless num ber. R ecently we
h av e h a d an interesting a n d im p o rtan t d evelopm ent know n as th e
juvenile organizations com m ittees, w hich now exist in m o st large tow ns
for grouping to g eth er all th e juvenile organizations an d looking afte r
the recreatio n an d social w elfare o f th e boys an d girls w ho b elong to
the different bodies. T h e y will p erfo rm a v ery v alu ab le function, I
think, in connection w ith after-care supervision. Such arrangem ents
d o m uch to secure th a t th e com m ittee will h av e d u e notice of any cases
w here th eir in tervention is desirable, o r w here a child should b e advised
to change his em ploym ent. A lso this system of after-care supervision
should p ro v id e a p o in t o f co n tact w ith th e certifying factory surgeons
w ho h av e to see th e children w hen they sta rt to w ork in a factory.
No account of th e w ork of our bureaus, o u r exchanges, o r o u r com ­
m ittees w ould b e com plete w ithout reference to p ro p a g an d a. T h e p e r­
sonal influence of a com m ittee including representatives of th e local
educational au th o rity an d o f leading em ployers, representative tra d e
unionists, an d representatives of all o th er agencies interested in the
w elfare of b o y s an d girls, ca n n o t fail to b e of v ery g reat im portance in
attractin g sy m pathy an d notice to their w ork. In m any districts th ey
h o ld sep arate m eetings for em ployers a n d fo r w orks m anagers, an d
again in som e cases experim ents h av e b een trie d of holding m eetings
w ith forem en an d interesting them g en e rally 'in th e w ork. T eachers’
m eetings, of course, are held, an d m eetings w ith parents. E very com ­
m ittee, w hen it organizes, a n d a t intervals afterw ards, circularizes th e
em ployers in th e district on m atters of im portance, particularly fo r the
pu rp o se of securing their cooperation in rep o rtin g vacancies to the
juvenile exchange.
T his function o f carrying on p ro p a g a n d a in th e district is an o p p o r­
tunity fo r influencing juvenile em ploym ent as a w hole, a p a rt from th e
Individual work of advising o r assisting children. Some of our com
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m ittees h a v e b een ab le to call into conference a group of em ployers in
a certain tra d e o r a group of firms in a certain district, an d h av e been
ab le to get tra d e unions concerned in those tra d e s to m eet w ith them ,
a n d then w ith this three-sided conference they h av e w orked up a new
schem e fo r juvenile em ploym ent in th é tra d e concerned, w ith im proved
conditions, possibly b e tte r wages, sh o rter hours, o r b e tte r provision
fo r a tten d a n ce a t classes o r for securing th e p e rm a n en t ab so rp tio n in a
tra d e of all th e b o ys a n d girls th a t en ter it. T his results in uniform
sta n d a rd s am ong all em ployers covered b y th e agreem ent, a n d these
em ployers tak e it on them selves v ery often to p ersu ad e o th er em ploy­
ers n o t co v ered b y the original ag reem en t to a d o p t th a t general sta n d ­
ard . O bviously th ey h av e to d o th a t in self-protection.
In case of an apprenticeship schem e, such an agreem ent has a special
interest, because th e term s of apprenticeship are alm ost alw ays a m a tte r
of individual b argaining betw een th e em ployer an d th e parent, an d
h ere w e now h av e som ething like a collective apprenticeship schem e
w ith uniform conditions. I am n o t sure how far th a t m ay lead us. W e
m ay find it possible to d o a g re at deal on those lines.
In conclusion, I should like to give you a few figures. First, as to th e
n u m b er of registrations of juveniles th a t w e h av e in th e exchanges in
th e course of a year, th e m ost recent figure 1 rem em b er w as ra th e r over
a h alf a m illion. T h e n um ber of placings w as ra th e r o ver a q u arter of
a m illion. S econd, th ere are ab o u t 6 ,0 0 0 m em bers of juvenile em ploy­
m en t com m ittees. A n d perh ap s we h av e even twice o r th ree tim es th a t
n u m b er of after-care supervisors giving som e of their tim e to look afte r
a certain n u m b er of boys an d girls in th e different districts.

DISCUSSION
M r. W . E. H all (N atio n al D irecto r, Boys’ W o rk in g R eserve, U n ited S tates
E m ploym ent S erv ice) : I u n d e rsta n d , Mr. D avison, th a t y°u o p e ra te u n d e r tw o
acts— th e E m ploym ent E x ch an g e A c t a n d th e C hoice of E m ploym ent A ct. A re
th ese advisory com m ittees a p p o in te d u n d e r b o th of th o se statu tes, o r is it m erely
a v o lu n tary organ izatio n ? Is th e em p lo y m en t of th ese co m m ittees p ro v id ed for
in th e statu te?
M r. D avison: T h e tw o a c ts do exist a n d th e y p ra c tic a lly a m o u n t to d ual legis­
latio n fo r th e sam e p u rp o se . T h e re fo re th e M inistry of L a b o u r a n d th e B oard
of E d ucation got to g e th e r a n d a rra n g e d a system w h ich w ould p re v e n t useless
confusion. T h a t system h as b een in fo rce since 1911.
T h e solution ad o p ted is th a t w h e re local ed u catio n al a u th o ritie s w ish to set
up com m ittees in conn ectio n w ith th e M inistry o f L a b o u r E x ch an g e th e y m ay
do so, a n d th ey receive c e rta in financial assistance from th e B oard o f E d u catio n
am o u n tin g to half th e cost.
W e have fo r eight y e a rs le t a n y of th ese ed u catio n al a u th o ritie s ta k e th e
initiative if th e y w ished to, a n d th a t a rra n g e m e n t still obtains. W h e re th e y do
n o t w ish to set u p a com m ittee, th e n th e M inistry of L a b o u r h as u n d e rta k e n to


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set u p a juvenile ad v iso ry com m ittee a rra n g in g fo r n o t less th a n six m em bers to
be ap p o in ted by th e local ed u catio n al a u th o rity . So co o p e ra tio n & se c u re d in
eith e r case a n d th e m eth o d of w o rk in g is n o t seriously d ifferen t u n d e r e ith e r of
th e tw o system s.
M r. H alls A t th e p re s e n t tim e is th e re a n y co n tro l of th e a p p lic a n t so th a t
he m ust go to o n e p la c e in o rd e r to get a positio n ? In o th e r words* is th e re one
place o f h irin g in ev ery d istrict, o r m ay a child go to seek em p lo y m en t a t th e
facto ry gate?
M r. D avison: No, th e re is no su ch c o n tro l. W e have n o t go t com pulsory
notification of vacan cies o r co m p u lso ry re g istra tio n . A n d on th e w hole I will
say th a t th e balan ce of op in io n is still ag a in st it— I do n o t state m y ow n opinion.
In fact, w e sim ply rely on th e co n ta c t w ith th e schools a n d w ith th e p u b lic to get
children to use th e Juvenile E x ch an g e a n d to ask fo r assistance. T h e existence
of such ag encies has g rad u ally b ecom e know n u n til now w e can say th a t o v e r a
th ird of the_ children leaving school com e to th e ex ch an g es fo r advice, o r in ­
fo rm atio n a b o u t th em is re p o rte d to th e exch an g e, a n d o v e r a n o th e r th ird com e
a t a la te r date for th e ir second o r th ird jobs.
M r. R o b ert C. D em ing (C o n n e c tic u t B oard of E d u c a tio n ): Do th e y h a v e in
E ngland a system by w h ich th e y follow up th e child; in o th e r w ords, a p e rm it
system b y w hich to lo cate th e child, identify him , a n d know w h a t he is doing?
M r. D avison: T h a t is th e a fte r-c a re supervision w h ich I w as try in g to explain.
T h e re is no official v isitation so fa r as w e a re co n cern ed , b u t it is done b y k eep in g
in co n tac t w ith th e child in a v o lu n ta ry capacity.
Miss Julia C. L ath ro p (C hief, C h ild ren ’s B u re a u ) : F o r w h at p u rp o se a re funds
used by th e advisory co m m ittee? A re th ey used fo r su p p ly in g a salarie d officer
u n d e r th e advisory com m ittee, o r w h a t a re th e legitim ate expenses o f these
advisory com m ittees?
M r. D avison: T h e y do n o t a d m in ister a n y funds. T h e only expenses w h ich
th ey m ay ch arg e a re th e ir ow n p erso n a l expenses in c e rta in v e ry re stric te d a n d
lim ited circum stances, w h en th e y a re re q u ire d to tra v e l on th e w o rk of th e
com m ittee. T h e se c re ta rie s a re p aid in th e sam e w ay as all th e o th e r officers
a re p aid th ro u g h o u t th e em p lo y m en t service. T h e y a re n o t specially p a id by
th e com m ittee.
M r. F ra n k M. L eavitt (A sso ciate S u p e rin te n d e n t of Schools, P itts b u rg h ): D r.
C laxton has m ade a d istinction betw een ed u catio n a n d th e schools. It seem s to
m e th a t th e tro u b le w ith o u r schools, a n d I sp eak a s a school m an, is th a t th e y
a re confined too larg ely to th e ed u catio n w hich th e y can a c tu a lly give them selves.
I am in terested also in th e ed u catio n th a t th e schools m ay d irect.
So w hen th e E m ploym ent Service o f th e U n ited S tates D e p a rtm e n t o f L ab o r
cam e to P ittsb u rg h a few m o n th s ag o a n d ask ed th e pub lic schools if th e y w ere
w illing to co o p erate w ith th e E m ploym ent Service in th e field of g u id an ce a n d
placem ent, I grasp ed th e o p p o rtu n ity to h elp ru n th e G overnm ent, o r th e little
p o rtio n of th e G overn m en t th a t w as w illing to do som e w o rk in m y com m unity.
W e sta rte d o u t w ith th e assistan ce of th e Ju n io r S ection of th e U n ited S tates
E m ploym ent S ervice to c re a te so m eth in g in P ittsb u rg h th a t w e th in k u ltim ately
will b e of value. W e h av e ta lk e d to sev eral h u n d re d em p lo y ers a n d a sk ed this
q u estio n : “ P rovided w e c an te ll y o u how m an y y o u n g p eo p le w ill com e into
th e la b o r m a rk e t y e a r b y y e a r from th e schools a n d can give y o u in fo rm atio n


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reg a rd in g th e physical, m en tal, a n d te m p e ra m e n ta l c h a ra c te ristic s o f those y o u n g
people, a re you w illing to u se th e service w h ich w e can give y ou? In addition,
a re you w illing to give us a c e rta in a m o u n t of in fo rm a tio n ; w ill you tell us th e
n u m b e r of y o u n g peo p le y o u h av e in y o u r em ploy now u n d e r 21 y e a rs of a g e;
w ill you tell u s w h a t w ag es y o u a re p a y in g a n d w h a t a re th e o p p o rtu n itie s fo r
ad v an cem en t in th o se positio n s now held ; w ill y o u tell us a p p ro x im a te ly how
m an y y o ung p eo p le you a re re ad y to em ploy ea c h y e a r? ”
W e feel v ery confident th a t w e a re going to g e t th a t in fo rm atio n . W e se n t
o u t last w eek in th e h a n d s of a p e rso n a l re p re se n ta tiv e a le tte r a sk in g th o se
questions. T h a t le tte r w as p re se n te d to fo rty em ployers. O u t of th e fo rty em ­
p lo y ers th irty -n in e said : “ W e sh o u ld b e delig h ted to u se su ch service a s th a t if
you can give us th a t in fo rm atio n .” W e a re sen d in g o u t now 4 0 0 sim ilar le tte rs
b y m ail.
O n th e o th e r hand, inside o f tw o w eeks th e re w ill go to ev ery school p rin c ip a l
in th e city in stru ctio n s th a t he is to sen d to th e office of th e su p e rin te n d e n t of
schools a re p o rt on every child w ho leaves school. If a child o v er 14 y e ars of age
chooses to leave th e school th e re will com e au to m atically to th e office of th e
su p e rin te n d e n t a sta te m e n t re g a rd in g th a t child, his age, his stan d in g in school,
his special likes an d dislikes, his am bitions, his phy sical c h a ra c te ristic s, a n d his
m en tal ch aracteristics. W e shall th e n sen d a school v isito r to th e h om e o f th e
child to get all th e in fo rm atio n w e can from th e p a re n t as to w hy th e child is
going to w ork, an d so fo rth . In brief, w e a re going to get as good a p ic tu re of
th a t individual child as w e possibly can. W e have ta k e n this sta te m e n t to
th e p aro ch ial schools, th e U n iv ersity of P ittsb u rg h , th e C a rn eg ie In stitu te, th e
D uquesne U niversity, a n d o th e r ed u catio n al institu tio n s, a n d said : “ T his is w h at
w e a re going to do w ith o u r stu d e n ts; a re you w illing to do th e sam e th in g fo r
th e U nited S tates E m p lo y m en t S ervice w ith re g a rd to y o u r p u p ils? ” W e have
th e ir prom ise to give us all possible in fo rm atio n w ith re g a rd to th e ir stu d en ts. In
fact, fo r som e o f these schools w e now have on file th e n u m b e r of ch ild ren w ho
will leave b y g rad u atio n a n d th e n u m b e r w ho w ill leave b y d ro p p in g o u t.
W e believe th a t in a v e ry sh o rt tim e w e shall have collected a n am o u n t of
info rm atio n a b o u t th is p a rtic u la r bod y o f ju n io r la b o r th a t w ill b e so v aluable
th a t th e em ployers w ill h av e to co n su lt it. T h e b e tte r em p lo y ers a r e a lre a d y
co nsulting it. W e a re a lre a d y m a k in g p lace m en ts of boys a n d g irls; b u t w e
w ere n o t so m u ch in te re ste d in th e first in stan ce in m ak in g p lace m en ts a s in
developing a system th a t w e h o p e in th e co u rse o f five o r te n y e a rs w ill b e a r
fruit.
I believe th a t u ltim ately th is m a tte r o f v o catio n al g uidance a n d p la c e m e n t is
o n e of education, a n d p a rtic u la rly th e e d u catio n o f th e y o u n g p e o p le them selves
so th a t th ey w ill know e n o u g h to av ail them selves o f th e service. W e m ay have
a very good p lace m en t b u re a u , w e m ay have a n excellent U n ited S tates E m ploy­
m e n t Service, b u t if th e p eo p le do n o t k n o w e n o u g h to u se th a t service it is o f no
avail. I believe it will ta k e som e y e a rs to te a c h th e y o u n g p eo p le a n d th e o ld er
people, th e em ployers a n d th e em ployees, to use intelligently a p la c e m e n t b u reau ,
o r a n em ploym ent service, o r a la b o r ex change.
H on. P. P. C lax to n (U . S. C om m issioner of E d u catio n ) : Mr. D avison said to
m e a s he sat dow n, “ T h e re w as still a n o th e r p o in t.” I w an t to ask w h at it is.
M r. D avison: R eally it w as o nly to give a ra th e r m o re ex ten d e d d escrip tio n of
th e arra n g e m e n ts w e m ade a fte r N ovem ber I Ith w hen th e A rm istice cam e u p o n us.
T h e in q u iry w hich w e m ade w as th e first step th a t I have a lre a d y described. T h e
n e x t w as to provide a com plete n e tw o rk o f co m m ittees th ro u g h o u t th e c o u n try .


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a n d I h av e a lre a d y re fe rre d to th a t. T h e n e x t w as to raise th e a g e o f ju v en iles
fo r o u r p u rp o ses to eig h teen , b ecau se in E ng lan d th e m ilitary a g e b eg in s a t
eighteen. W e did n o t w an t to have som e of th e boys betw een seventeen a n d
eig h teen going into th e d e p a rtm e n t w h e re th e re w ere soldiers a n d o ld e r peo p le,
an d th e p roblem s of th e boys b etw een seventeen a n d eigh teen , ow ing to th e
special circu m stan ces of th e w ar, u n d o u b ted ly w ould be juven ile problem s.
T h e n w hen th e suggestion o f th e ou t-o f-w o rk d o n atio n w as decided u p o n b y
th e C abinet, provision w as m ade to include juveniles from fifteen y e ars of a g e u p ­
w ards, n o t below . F o r th e c h ild ren b etw een fifteen a n d eig h teen y e a rs o f ag e
th e d o n atio n w as fixed ^ t $ 3 .6 0 p e r w eek to boys a n d $ 3 .1 0 to girls fo r a p e rio d
of th irte e n w eeks, o n co ndition th a t th e y re p o rte d re g u la rly th a t th e y w ere
u n ab le to o b ta in em p lo y m en t a n d w ere available fo r w ork. Y ou c a n n o t give
m on ey aw ay w ith o u t im posing som e conditions, a n d th o se w ere th e conditions.
T h e re w as a th ird , nam ely, w h e re th e ed u catio n al a u th o rity se t u p a school,
w h ich w as called a juv en ile u n e m p lo y m en t c en te r, w e w ould n o t p a y th a t o u t-ofw o rk do n atio n to a n y child unless h e a tte n d e d re g u la rly a t th is c e n te r. T h a t
system h as b een c a rrie d o u t.
M r. C lax to n : I should like to m ak e a state m e n t a n d a sk a q uestion. Som e of
us in this co u n try , a n d th e n u m b e r is in creasin g rapidly, believe th a t ed u catio n
fo r citizenship in th e la rg e r d em o cracy w h ich is com ing, n o t o n ly fo r u s b u t
p ro b ab ly th ro u g h o u t m ost of th e w o rld , will re q u ire a k ind of ed u catio n th a t
can n o t b e given to ch ild ren u n d e r fo u rte e n o r even u n d e r sixteen y e a rs of ag e.
A t tw enty-one y e ars of ag e, m en a n d w om en, b u t y e ste rd a y boys a n d girls,
go to th e polls a n d decide b y th e ir v o te th e policies o f th e local com m unity, of
th e S tate, an d of th e N ation, a n d v ery soon th e re b y th e destinies of th e w orld,
b ecause th e re will b e som e clo ser asso ciatio n of natio n s, a n d th e a c tio n of one
can n o t h elp influencing, m o re th a n it h as in th e past, th e destinies of o th e rs.
A nd these problem s a re m o re difficult, m o re cpm plex, th a n th ey have ev er b een
before.
M any of us also believe, a n d th e n u m b e r is increasin g , th a t you c a n n o t give
th e ed u catio n necessary fo r in d u strial life, th e know ledge of th e u n d e rly in g p rin ­
ciples of chem istry, physics, biology, a n d m athem atics, th a t a re n ecessary in
o u r m odern in d u strial a n d co m m ercial life, b efo re fo u rte e n o r even b efo re six­
te e n y ears of age; It re q u ire s ed u catio n th ro u g h ad olescence. A n d all of us like
to believe th a t in a d em o cracy like ours, in a tim e w h en w ith labor-saving
m ach in ery it is possible to c re a te w ealth , th a t a ll ch ild ren h av e a rig h t to w h a t­
ever ed u catio n can be given th em u n til th e y e ars of m an h o o d a n d w om anhood,
for cu ltu re, fo r life, fo r h u m an ity , b ecau se a fte r all e v ery th in g exists fo r th a t.
Now, w ith th a t u n d e rsta n d in g m u st w e n o t find som e m eans of giving system atic
form al education a t least up to th e ag e of eig h teen a n d possibly lo n g er?
O ne o th e r statem en t. Som e o f us have com e to believe in th is c o u n try th a t
vocational guidance is n o t a v e ry easy thing, th a t it is n o t so m eth in g th a t
one can do w ith o u t kno w in g th e child a n d k now ing him w ell; a n d th a t a n o th e r,
possibly an outsider, c an n e v e r do it to full satisfaction fo r a n y individual. T h e re ­
fore th e child him self m ust h av e som e p a rt in his guidance. H e should n o t choose
his o ccu p atio n o r have a n o c cu p atio n chosen fo r him u n til h e know s som ething
of th e ro u n d of o ccu p atio n s, in g en eral a t least, a n d p ro b a b ly n o t u n til h e h as h ad
som e experience, som e know ledge of th em th ro u g h a c tu a l co n tact.
F o r th a t reason th ese p eo p le th a t I h av e re fe rre d to — I th in k it includes n o w
th e la rg e r n u m b er th a t a re responsible fo r guiding ed u catio n al policies— have
com e to believe th a t w e should have som e k ind of half-tim e in stru c tio n (I use


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141

th a t term instead of p a rt-tim e ), som e m ean s b y w h ich w e shall have a n all-yearro u n d school, let us say, of 48 w eek s; th e y believe th a t a rra n g e m e n ts should be
m ade so th a t children o v er a c e rta in ag e, fo u rteen , fifteen, o r sixteen, a s th e case
m ay be, m ay a tte n d half th e day, a lte rn a te w eeks, b y th e fo rtn ig h t, o r p ro b ab ly
b y th e q u a rte r, if n ece ssa ry ; th e y believe th a t th e re sh o u ld be fo rm al in stru ctio n
n o t o nly in th e th in g s th a t h av e re fe re n c e to th e child’s v o catio n , b u t in those
eq u ally im p o rta n t th in g s th a t h av e re fe re n c e to citizenship in a w orld-w ide d e­
m ocracy, to cu ltu re, to m an h o o d , to w om anhood, to all th e o p p o rtu n itie s a n d all
th e duties of life.
T h e re have been exp erim en ts in th is c o u n try th a t have show n th a t th is is a t leastpossible— som e of th em in universities, som e of th e m in th e la s t y e a r o r tw o
y e a rs o f h ig h school, a n d som e fo r ch ild ren a s y o u n g a s fo u rte e n y e a rs o f ag e.
U sually th ese experim en ts h av e succeeded.
I have com e to believe th a t w e m ust find a m eans of doing this, a n d to feel
th a t w ith o u r co n stan t im p ro v em en t of labor-saving m ach in ery , a n d th e possi­
bility of la rg e r p ro d u c tio n fo r th e individual m an, it is n o t n ecessary th a t m ost
children shall begin m ak in g a living, o r give all of th e ir tim e to m ak in g a living,
a t sixteen y ears of age.


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Seçtion III
T h e H ealth o f Children and M others
(T h e m inim um sta n d a rd s for th e pro tectio n of
th e h ealth o f children a n d m o th ers a d o p te d b y th e
W ashington C onference will b e found on pages 4364 3 9 .)


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MATERNITY AND INFANCY
S T A N D A R D R EQ U IR EM EN T S F O R O B S T E T R IC A L C A R E
By DR. J. W H ITRID G E W ILLIAM S
P ro fesso r of O b stetrics, Jo h n s H o p k in s U niversity, B altim ore, M aryland

T ak in g into consideration th e varying conditions obtaining in differ­
en t localities, it is n o t easy to lay dow n universal stan d ard require­
m ents fo r obstetrical care; fo r it is obvious th a t th e p ro b lem will
differ in large cities, in sm all u rb a n com m unities, an d in rural districts.
F u rtherm ore, th e p ro b lem will v ary in large cities according as they
contain m edical schools w ith th eir a tte n d a n t students, w ho m ay b e
utilized in solving som e o f th e problem s, as w ell as b y th e p ro p o rtio n
of th e p o p u latio n th a t em ploys m idwives.
B ro ad ly speaking, it is n o t difficult to lay d ow n sta n d a rd require­
m en ts fo r cities, w hich fo r th e p resen t m ust b e o f such a ch aracter
th a t th ey can b e carried o u t b y general practitio n ers o f average intelli­
gence. In such a sta n d a rd th e follow ing requirem ents seem essential:
(1 )
M onthly p re n atal visits during th e second h alf o f pregnancy,
w ith exam ination o f th e urine; ( 2 ) a careful prelim inary exam ination
fo ur o r six w eeks b efo re th e expected d a te of confinem ent, w hich
should include a general physical exam ination, as well as pelvim etry,
m ap p in g o u t th e position o f th e child an d th e d eterm ination of th e
existence o f any serious d isp ro p o rtio n betw een th e size of th e h ea d
a n d th e pelvis; ( 3 ) reasonable care a t th e tim e of delivery b y one
w ho will o b serv e th e o rd in ary rules o f aseptic technique a n d who
know s enough to ab stain from m eddlesom e m idw ifery, w ith th e u n d e r­
stan d in g th a t suitable hospital accom m odations are available fo r all
p atien ts p resenting such com plications as can n o t b e satisfactorily
tre a te d in th eir hom es; ( 4 ) a careful p o stp artu m exam ination four
w eeks afte r th e b irth o f th e child, for th e p urpose of relieving o r tre a t­
ing m in o r abnorm alities an d o f detecting th e existence of such lesions
of th e b irth canal as m ay require o p erativ e relief; ( 5 ) supervision of
th e b a b y fo r th e y ea r follow ing its birth.
It will b e noticed th a t 1 h av e n o t included th e W asserm ann test as
p a rt 'of th e routine p re n atal care, n o r th e determ ination of th e b lo o d
pressure a t each m on th ly exam ination. T his is n o t because I d o n o t
fully ap p reciate th e serious ro le p layed b y syphilis, b u t because I
consider th a t such exam inations are feasible only in institutions w ith
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STANDARDS O F C H IL D W E L F A R E

w ell-equipped lab o ra to ry facilities, o r in com m unities in wbicli the
h ea lth d ep a rtm en t m aintains an efficient lab o ra to ry an d is willing to
co o p erate in th e w ork. «Of course, it is u n d ersto o d th a t such an
om ission will result in th e b irth of a certain num ber of syphilitic babies,
as well as in th e d ev elo p m en t of h ered itary syphilis in others who
survive. But, a t th e sam e tim e, I feel th a t u n d er average conditions
th e W asserm ann test should b e obligatory only for p atien ts w ho p re ­
sent a suggestive history, o r in w hom th e rep eated occurrence of
p re m a tu re lab o rs o r stillbirths strongly suggests th e existence of
syphilis. R outine b lo o d pressure determ inations w ere om itted for th e
reason th a t in th e v a st m ajo rity of cases th e subjective sym ptom s an d
th e presence of album in in th e urine p erm it a diagnosis of pre-eclam ptic
toxem ia to b e m ad e w ithout their aid.
A t th e p resen t tim e I think th a t it is conservative to estim ate th a t
even such sta n d a rd s as are here outlined will n o t b e applicable to
m o re th an one-half o f th e p o pulation of m ost com m unities. A m ore
liberal estim ate m ight b e m a d e in th e case of large cities, w hich are
a b u n d a n tly supplied w ith hospital facilities a n d o th er philanthropic
resources; bu t, on the o th er han d , th ey w ould p ro v e difficult to carry
o u t if an y considerable p ro p o rtio n o f th e population w e re 'a tte n d e d b y
m idw ives. F u rth erm ore, u n d e r p resen t conditions, such stan d ard s
could n o t b e m aintained in m an y rural districts, an d particularly in the
o p en country, as is evidenced b y th e re p o rts issued b y th e C hildren s
B ureau concerning th e conditions in certain counties of K ansas an d
N orth C aro lin a; for in m any such localities physicians are n o t available,
a n d th e w om an is often fo rtu n ate if she can avail herself o f th e services
o f even a p artially train ed m idwife.
It ap p e ars to m e th a t progress in this re g a rd can b e m a d e only along
th re e lines: (a ) b y a cam paign of education, in w hich th e w om en
a n d th eir h u sb an d s are tau g h t th a t it is their right an d d u ty to d em an d
reaso n ab le care during pregnancy a n d a t th e tim e of la b o r; ( b ) b y
th e institution of S ta te aid a n d b y N ational subventions, p a rtly for
ed ucational purposes, b u t particularly fo r th e carrying out of such
m inim al stan d ard s as seem essential; a n d (c ) b y legislation requir­
ing local h ealth officers, in localities in w hich m id w ives are generally
em ployed, o r in th e open country w here th ey rep resen t th e m ost
av ailab le source o f assistance, to assum e charge of th e situation a n d to
lay dow n certain regulations w hich th e m idw ives m ust b e com pelled
to follow.
I ta k e it th a t th e first step in such a cam paign o f education fo r th e
im p ro v em en t o f obstetrical conditions m ust consist in th e com pulsory
registration of p regnancy through th e local h ealth officer. In this
event, it will b e possible for every p re g n a n t w om an th ro u g h o u t th e
entire co u n try to b e supplied gratis w ith certain o f th e publications

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of th e C h ild ren 's B ureau, an d thereby, if ab le to read, to b e convinced
of th e im p o rtan ce o f insisting u p o n ad e q u ate care. F urtherm ore, it
should b e th e d u ty o f th e local h ealth officer to see th a t th e w om en
w ho register should p ro m p tly arran g e fo r suitable care during p reg ­
nancy an d a t th e tim e o f labor. If a physician w ere engaged, th e health
officer’s responsibility w ould end, b u t if th e p a tie n t-is to b e cared
fo r b y a m idw ife, it w ould b e his duty, o r th a t of a p a id substitute
acting fo r him , to see th a t certain exam inations a n d requirem ents
w ere carried out.
T hus, 1 believe th a t it should b e stipulated th a t m idw ives could
a tte n d only such p atien ts as offer every pro sp ect of having a norm al
labor. T his could b e effected b y providing th a t th ey could n o t assum e
ch arg e o f a p a tien t until a certificate h a d been p ro cu red from a
p ro p e rly qualified m edical m an stating th a t h e h a d m ad e a suitable
p relim inary exam ination an d h a d found everything in o rd e r a n d th at
h e con sid ered a n orm al outcom e likely. T his could b e fu rth er checked
b y th e h ealth d e p a rtm e n t p roviding suitable b lanks fo r th e purpose,
a n d stipulating th a t th e y m ust b e re tu rn ed w hen th e b irth certificate
is filed. F urth erm ore, th e m idw ives should b e required b y law, even
in cases w hich h a d b een certified as p resum ably norm al, to call a
physician w henever la b o r lasts fo r m o re th an 2 4 hours, o r w hen any
unex p ected ab n o rm ality develops.
Such a p ro ced u re w ould h av e a highly educative effect u p o n the
patients, especially u p o n th e foreign b o rn w ho are accustom ed to
believe th a t m idw ives are thoroughly co m p eten t; it m ight also teach
th e m idw ife som ething, an d it w ould certainly constitute an im p o rtan t
step to w ard h er eventual displacem ent. In cities, th e m idw ives m ight
bring th eir p atien ts to th e obstetrical dispensaries, w hen such are avail­
able, w here th e certificates could b e filled o u t gratis fo r th e very
p oor, an d fo r a sm all fee in th e case o f w om en in m o re com fortable
circum stances.
O n the*other h an d , w om en w ho p re sen t som e ab n o rm ality a t th e
p relim inary exam ination should b e referred d irectly to a physician, or
b e sent to th e h ospital a t th e county seat fo r treatm ent.
O f course, th e general ad o p tio n o f such regulations w ould necessi­
ta te a revolution in th e m eth o d s of m edical practice in rural districts,
a n d could only b e carried out if funds w ere available fo r th e em ploy­
m en t of suitable persons to regulate th e m idw ives, as well as fo r th e
institution o f h o spitals a t th e county seats, which w ould b e available
fo r th e reception o f p atien ts urg en tly needing hospital care.
T h e suggestions h ere m a d e d o n o t cover in any w ay th e supervision
o f th e child during th e first y e a r o f life, a n d I im agine th a t in rural
com m unities this can b e effected only b y th e em ploym ent b y th e county
o f visiting train ed p o stn atal nurses, w ho w oqld m ake to u rs through

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STANDARDS OF CHILD WELFARE

th eir districts a t regular intervals an d see th e children u n d e r th eir care.
1 tak e it th a t radical reform in these directions can only b e attain ed
afte r a cam paign of intensive education, for w e h av e learn ed th a t the
m ost efficient m eth o d of safeguarding th e interests of th e child is by
teaching th e m o th er how to care fo r it. No am ount of supervision will
accom plish th e greatest g ood unless a t th e sam e tim e th e m o th er is
tau g h t w h at h er duties are to herself, a n d how th ey can b e best
carried out.
DISCUSSION
Sir A rth u r N ew sholm e (L a te P rin cip al M edical O fficer, L ocal G overn m en t
B oard, E n g lan d ) : In re g a rd to th e n otification of p re g n a n c y w e have in o u r
c o u n try h ith erto p re fe rre d to m ak e provision to in d u ce p ro sp ectiv e m o th ers to
com e, ra th e r th a n to m ak e n otification oblig ato ry . T h e re fo re w e have Set u p in
o u r cen te rs p re n a ta l co n su ltatio n clinics a n d h av e trie d to induce m o th ers to com e,
a n d a t th e sam e tim e have used o u r official m ach in ery in co n n ectio n w ith th e
m idwives, w ho assist in 75 p e r c e n t of th e b irth s, to in d u ce th em to b rin g m o th ers
to these clinics.


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T H E C O N T R O L O F V E N E R E A L IN FEC TIO N
By DR. P H IL IP C. JEANS
A ssociate P ro fe sso r of P ed iatrics, W ash in g to n U niversity, St. Louis
T h e Im p o rta n c e of th e S u b ject

G o n o rrh ea.— T hough g o n o rrh ea plays a large role in th e sterility
an d general ill-health of th e m other, it has, w ith th e exception o f infec­
tio n of th e eye, usually b u t m ild effects upon th e new ly b o rn infant.
O ccasionally gonococcal arthritis m ay b e observed, b u t this condition,
though quite painful, usually ends in com plete recovery w ithout loss of
function. V aginitis m ay occur in the new ly born, b u t m ore frequently
occurs a t a la te r tim e as a result of contagion. V aginitis a t this age is
frequently quite painful an d alw ays disagreeable, b u t it does n o t h av e
th e serious sequellae th a t it has in adults. Infection of th e eye in the
new ly b o rn is serious in th a t it frequently results in p erm an en t b lin d ­
ness, a n d unless tre a te d early a n d vigorously it m ay result in im paired
vision even w ith g o o d treatm ent. It has b een estim ated th a t from 25
to 30 p e r cent of blindness as found in adults is d u e to gonococcal in­
fection o f th e eyes a t birth. T his alone m akes th e condition one of com ­
m on interest.
Syphilis.— In syphilis w e h av e a m uch m ore serious disease. In th e
stu d y of a large n um ber of syphilitic families, it has b een found th a t
75 p e r cent of th e pregnancies result in syphilitic offspring; one-fifth of
these d ie a t or b efo re term from th e infection; one-fourth of those b o rn
alive d ie in infancy as a result of syphilis; a n d b u t one-sixth of all th e
pregnancies result in non-syphilitic children w ho survive the p erio d of
infancy. T h e w aste in infant an d child life in a large group of syphilitic
families is o v er 60 p e r cent as co m p ared to less th an 25 p e r cent in a
sim ilar group o f non-syphilitic fam ilies of th e sam e social plane. T h e
list of serious disabling lesions of syphilis is a long one. T hose infants
who d o n o t die as a result o f th e infection frequently suffer from a
long p erio d of m alnutrition, a n d th e m aintenance of th eir nutrition b e ­
com es a difficult m atter. M ost of th e serious affections o th e r th a n
those m en tio n ed a p p e a r as la te r m anifestations, b u t fo r purposes o f
p rophylaxis should b e considered as a p a rt of the subject u n d e r discus­
sion. O n e-th ird o f these surviving children sooner o r later develop an
inflam m ation of th e cornea. T his condition if u n trea ted o r neglected
frequently results in blindness, an d u n d e r th e best of trea tm e n t th ere
is usually a p ro lo n g ed period of loss o f function. In one-third of
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syphilitic children th e nervous system h as b een seriously in v ad ed b y th e
spirochete of syphilis. It is p erh ap s going b ey o n d our know ledge
to say th a t all of these sooner o r la te r d evelop som e outw ard evidence
of such invasion, though it is certain th a t a large n u m b er of them d o
d ev elo p paralysis, dem entia, blindness, o r o th er neuro-syphilitic m ani­
festations. T h e num erous painful an d disagreeable lesions of syphilis
n eed n o t b e fu rth e r enum erated. Enough has a lre ad y b een said to
em phasize th e seriousness o f h e red itary syphilis.
A p ro p e r question, a n d one w hich can n o t b e answ ered accurately, is
w ith w h at frequency does syphilis occur. Statistics from four cities
of this country show th a t ab o u t 10 p e r cent o f m arried p re g n an t w om en
are actively syphilitic as show n b y th e W asserm ann reaction. It is
to such w om en th a t syphilitic children are born. Statistical studies
m ad e in St. Louis an d N ew Y o rk indicate th a t from 5 to 6 p e r cent
of o ur in fant p o p ulation is syphilitic. T h ese surveys am ong th e m others
an d infants w ere all m a d e am ong th e p o o re r classes.
It is obvious th a t any disease affecting in so serious a m an n er such
a larg e n u m b er of fam ilies is w orthy of o u r b est efforts for prevention.
P rev en tiv e a n d C u ra tiv e T re a tm e n t

G o n o rrh ea.— G onococcus infection of the infant occurs during or
afte r b irth, th e infection occurring directly o r b y contagion from a
localized o p en infectious process in th e m other. In m ost instances
o p h th alm ia n eo n atorum occurs as a result of infection of th e eyes during
th e b irth of th e infant. F o r this, th e m ost serious gonococcus infection
fo r th e infant, th e re exists a m eans o f prev en tio n b o th harm less an d
easy o f application, i. e., the instillation of a 2 p e r cent solution of silver
n itrate into th e eyes im m ediately a fte r birth. C redè, w ho first a d ­
v an ced this m eth o d of prevention, w as able b y its use to reduce th e
incidence of gonococcus ophthalm ia in his hospital practice from 1 36 to
1 p e r th o u san d births. T his m easure, is universally recognized as ef­
fectual in p rev en tio n an d all th a t is n eed ed is som e m eans b y which
those a tte n d a n ts a t confinem ent w ho otherw ise w ould b e negligent
m ay b e com pelled to tak e such a precaution. In m an y S tates this m atter
is well lo o k ed afte r b y follow -up visits an d prosecution b y th e health
b o a rd s u n d er S ta te law. T h e details of m eth o d s of checking an d
follow -up n eed n o t b e enum erated. P ro p a g a n d a through lectures,
m otion pictures, an d leaflets in tèn d ed fo r th e peo p le in general m akes
a v ery useful ad ju n ct to legislation a n d h e a lth -b o ard activity. T h e
F ed eral G o v ern m en t is alre ad y carrying on such p ro p a g a n d a to som e
extent. T h e ra th e r obvious n ex t step w ould b e to h av e suitable laws
p assed in those S tates w hich d o n o t h av e th em a n d to activate those
S tate b o a rd s of h ealth th a t n eed it.
Syphilis.— E xcept in ra re instances, syphilis of infants an d young

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children is a congenital o r h ered itary infection tran sm itted to th e infant
b efo re b irth b y w ay of th e m atern al blood. It is generally agreed th a t
germ transm ission does n o t tak e place an d in o rd e r th a t th e child b e
infected b efo re b irth it is necessary th a t th e m o th er first b e infected.
T hough this view m ay b e show n la te r n o t to b e entirely true, preventive
w ork b ased u p o n this conception has b een d em o n strated to b e effective.
It is p ro b a b le th a t th e fetal infection occurs in all instances b y w ay of th e
p lacen ta a n d th a t th e spirochetes reach th e placen ta b y w ay of th e
m atern al b lo o d stream in w hich th ere occur occasional sm all show ers of
spirochetes from a m o re o r less active focus elsew here in th e body.
W h e th e r o r n o t the child will b e infected d ep e n d s u pon th e activity of
th e process in th e m other, w hich in turn d ep e n d s in a large m easure
u pon the length of tim e which has elapsed since th e m atern al infection.
T h o se children b o rn soon afte r th e m atern al infection are severely a f­
fected. E ven w ithout trea tm e n t th e infection in th e m o th er in m any
instances ten d s to subside to such an extent th a t it is n o t tran sm itted to
th e offspring. T his is n o t necessarily so a t an early d ate. In som e in­
stances a syphilitic m o th er has non-syphilitic children eight to ten
years afte r h e r infection, while in others she continues to h av e syphilitic
children 25 y ears afte r h e r infection. In a few instances th e period
betw een th e infection of th e m o th er a n d th e b irth of th e first child is
o f such a length th a t none of th e .children are syphilitic. It m ay b e
stated as a general an d p ro b a b le tru th th a t th e W asserm ann reaction
will b e positive in any m o th er w hose infection is active enough to allow
th e infection of h er child in utero an d th at a m o th e r\v h o se infection has
subsided sufficiently so th a t th e child will n o t b e infected will give a
n egative W asserm ann reaction. T h e exceptions to this rule m ust b e
v ery few. F ro m this it is seen th a t a W asserm ann reaction on th e serum
o f a p ro spective m o th er m ay b e taken as a criterion, n o t as to w hether
o r n o t she h as syphilis, b u t as to w heth er o r n o t she is likely to infect h er
infant. S om e such criterion as this is necessary for th e reason th a t
n early 90 p e r cen t of th e m o th ers of syphilitic children honestly deny
all know ledge o f infection o r la te r m anifestations of such infection.
In m any instances a history o f abortions an d stillbirths m ay lead one
to suspect syphilis, b u t this alone is insufficient evidence u pon w hich to
m ak e a diagnosis. T h e one m ost co n stan t an d reliable sym ptom o f
syphilis is the positive W asserm ann reaction.
It h as been fully d em o n strated th a t ad e q u ate antisyphilitic treatm en t
o f a m o th er th ro u ghout h er p regnancy will result in th e birth of a nonsyphilitic infant. It is p ro b a b le th a t this trea tm e n t acts to cause a
retrogression of th e m aternal infection o r a t least in its being held in
check to such an extent th a t th e fetus is n o t infected. B ased in p a rt
upon lab o ra to ry studies of th e p ro d u c ts of conception, it is th o u g h t
th at— in m ost instances a t least— fetal infection does n o t tak e place

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until th e later m o nths of pregnancy. U pon this basis m ay b e explained
th e fact th a t even if a m o th er is tre a te d only during th e latte r h alf of
h er p reg n an cy the infant in the g re at m ajo rity of instances will n o t b e
infected. T h e sh o rter th e p erio d of trea tm e n t p rio r to b irth th e m ore
likely is th e child to b e syphilitic, b u t even th e shortest p eriods of
tre a tm e n t are n o t w ithout benefit. T h e cure of syphilis is a t best a
laborious process, a n d it w ould seem greatly p re fera b le to p re v en t in­
fection o f th e in fant in this w ay th an la te r to tre a t th e in fan t for the
disease even th ough eventually it m ay b e cured.
T h e trea tm e n t of th e m o th er during one preg n an cy do es n o t p ro tec t
th e subsequent pregnancies unless th a t trea tm e n t is continued to the
p o in t of “cure” o f th e m other.
In th e p rev en tio n o f inherited syphilis, w e are co n fro n ted w ith a
som ew hat com plicated problem . It is necessary first to m ak e a d iag ­
nosis of syphilis in th e m o th er a t a fairly early p erio d o f h e r pregnancy,
an d it is necessary in our p resen t know ledge to d ep e n d in a very large
m easure u p o n th e W asserm ann reaction fo r this diagnosis. T h e con­
scientious physician will try to verify th e diagnosis m a d e in such a m an ­
n e r in as m an y w ays as possible. Serological a n d physical exam ination
of the h u sb an d a n d of th e o th er children w ould b e v ery useful n o t only
fo r this pu rp o se b u t also as a public-health m easure. In this connection
it is well to rem em b er th a t m an y husbands, though th e source of infec­
tion, will give a negative W asserm ann reaction a t th e tim e o f such
exam ination, fo r relatively few m en will m arry w ith a know n active in­
fection. T h e sta n d a rd s for g ood p re n atal care should include an exam ­
ination of th e b lo o d just as they include urine a n d o th e r exam inations.
T h e diagnosis of syphilis having b een m ade, th e m o th er should b e
tre a te d according to th e b est recent sta n d a rd s for th e trea tm e n t of this
disease.
In th ose instances, in w hich th e infection has n o t b een diagnosed
until the p u erperium th ere is th e a d d e d facto r of m anagem ent of the
syphilitic infant. T h e first goal in th e m an ag em en t is th e diagnosis.
It is necessary to realize th a t a v ery large n u m b er o f syphilitic infants
show no o u tw ard signs of th eir infection eith er a t b irth o r during th e
custom ary p erio d of obstetrical observation, an d an y in fan t th a t does
show m ark ed signs a t this early d a te h as a relatively p o o r prognosis.
T h e W asserm ann reaction on th e in fan t’s b lo o d is also unreliable in
this p erio d to th e ex ten t th a t fully one-th ird o f actively syphilitic new ly
b o rn infants give a negative reaction, though th e reaction if positive
m eans syphilis as m uch as a t an y o th e r tim e. T hese sam e negatively
reacting infants will a few w eeks later give positive reactions. T hough
th e obtaining of b lo o d in sufficient quantity fo r a W asserm ann reaction
is a relatively easy m a tte r in ex p ert hands, th e practical difficulties are
such th a t m an y physicians w ould n o t u n d erta k e it as a m a tte r o f routine.

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N or is it a p ro c ed u re th a t w ould b e universally to lera te d b y p aren ts
unless som e u rgent need w ere shown. A s a substitute fo r taking b lo o d
from th e infant, b lo o d m ight b e tak en from th e p lacen tal en d of th e
co rd a t delivery. T his p ro ced u re has th e a d v a n ta g e of ease of ac­
cessibility. T h e sam e objection h o ld s for this b lo o d as fo r th a t of th e
infant, th a t only ab o u t tw o-thirds of th e infections can b e diagnosed
thus. In th e h an d s of a com p eten t pathologist, a m uch larg e r n u m ber
of infections m ay b e diagnosed b y histological exam ination of the
placenta. P erh ap s 95 p e r cent of th e infections m ay b e diagnosed in
this way. T his m eth o d of diagnosis is b u t little tro u b le either to th e
obstetrician o r to th e pathologist. It also has th e possible ad v a n ta g e
of avoiding w h at m ight b e aw kw ard explanations. A W asserm ann
reaction on th e m o th er’s b lo o d has th e sam e ad v a n ta g e in diagnosis
as it d o es earlier in h er pregnancy, a n d the agreem ent betw een this
a n d th e infection o f th e infant closely ap proaches 100 p e r cent unless
th e m o th er h as h a d antisyphilitic trea tm e n t during h er pregnancy.
E xcept in sm all tow ns a n d rural com m unities, th e obstetrician does
n o t o rd in arily u n d e rta k e the trea tm e n t of syphilis. Since th e nutritional
facto r is often a v ery large one in syphilitic infants, it is desirable to
m ak e ex tra o rd in ary efforts, if necessary, to h av e th e b a b y b re ast fed.
T h e p atien t should b e re ferred a t th e earliest possible d a te to those w ho
are co m p eten t b o th in th e m an agem ent of in fan t nutrition a n d the
tre a tm e n t of syphilis. In th e absence of nutritional disturbance a n d
in tercu rren t disease, infantile syphilis m ay b e com pletely cured, ac co rd ­
ing to o u r p resen t sta n d a rd s of cure, in th e g re at m ajo rity of instances,
a n d th e policy of “w hy n o t let them d ie” ap p a ren tly h eld b y m any is
entirely un w arran ted.
T h e C o n tro l of Syphilis

H av in g m eans to diagnose an d tre a t syphilis w hich are on th e w hole
fairly ad eq u ate, it becom es necessary, in o rd e r to ap p ly these m easure^,
to locate infected individuals. F o r successful prev en tio n it is necessary
to b ring th e m o th ers u n d e r observation early in th eir pregnancy. T h e
public is m o re an d m ore becom ing ed u cated to th e desirability of o b ­
stetrical supervision th roughout pregnancy. F u rth e r p ro p a g a n d a along
this line is n eed ed . It is n o t necessary to ad v an ce an y argum ents here
as to th e desirability of such care. T h e encouragem ent a n d w ider dis­
trib u tio n o f p re n atal clinics will reach a large p ro p o rtio n of those w ho
m ost n eed such care. A “ b lo o d exam ination” should b e m ad e a p a rt
of th e g eneral exam ination of each such p atien t a n d th e finding of a
positive W asserm ann should b e the signal fo r anti-syphilitic treatm en t,
enforced if necessary. T his w hole id ea m ust b e carried out largely
b y publicity, since it is scarcely feasible to require legally a W asser­
m ann test on every m other.

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Failing in p rev en tio n it becom es desirable to diagnose syphilis in th e
infant a t the earliest possible m om ent. T hough g o o d obstetrical stands
ard s should require a W asserm ann on th e m other, a positive reaction is
m erely p resum ptive evidence of infantile infection, though in m ost in­
stances th e p resum ption is correct. A negative W asserm ann on th e
in fant a t this age m ay lead to a false sense of security. T h e m o st con­
stan t evidence o f infantile infection is found in th e placenta. Since
th e exam ination of th e p lacen ta requires so little tim e a n d a t th e sam e
tim e reveals such im p o rtan t inform ation, it should b e a p a r t of p ro p e r
obstetrical routine in every case. B efore carrying this p lan out on a
large scale, how ever, its reliability should b e b e tte r founded. In case it
p ro v es to b e satisfactory, it could b e required th a t all p lacen tae or
p ro p e r pieces of all p lacentae b e sent to th e b o a rd of health. M aterial
from stillbirths a n d m iscarriages should b e included in this requirem ent.
O ne p ath o lo g ist w ith one o r m o re technicians could easily exam ine
p ro m p tly m aterial from all th e birth s of a city. T h e details of the
follow -up b y th e h ealth b o a rd could w ell b e left to d e p e n d upo n local
conditions w ithin certain limits, b u t th ere should b e som e m oans p ro ­
v id ed b y which th e infant w ould receive p ro m p t a n d effective tre a t­
m en t either v o lu n tarily on th e p a rt of th e p aren ts or enforced if neces­
sary. T h e diagnosis m ad e in this m anner should la te r b e checked b y
serological exam ination of th e infant.
F o r those p atien ts h an d led b y p re n atal an d obstetrical clinics, th e
logical sequence is to re fer th e infant to p o stn atal clinics w hether sus­
p ec te d of syphilis o r not. In such clinics overlooked infections w ould
b e diag n o sed as sym ptonis appear.
In conclusion, th e chief points to b e em phasized in th e control of
h ered itary syphilis are as follow s:
1. Infection of th e infant can b e p re v en ted b y trea tm e n t of th e
m o th er d u rin g pregnancy.
2. T h e W asserm ann reaction, checked b y o th er observations, if
possible, is th e o ne m ost d ep e n d ab le criterion as to w heth er o r n o t a
m o th er should receive treatm ent.
3. In ab o u t 95 p e r cent of instances of infantile syphilis p lacen tal
exam ination will show evidence of such infection. O f th e v arious clini­
cal m eans of diagnosis of syphilis in the new ly b o rn infant this exam ina­
tion indicates th e presence of infection w ith th e greatest frequency.
4. B oth a W asserm ann reaction on th e serum of the m o th er a n d an
exam ination of th e p lacen ta should b e included as a p a rt of g o o d o b ­
stetrical stan d ard s.


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DISCUSSION
Sir A rth u r N ew sholm e, M. D . (L a te P rin c ip a l M edical O fficer, L ocal G o v ern m en t
B oard, E n g lan d ) : T h e questio n of v e n e re a l in fection has b een m entioned. In
re g a r d to th a t I th in k w e can claim to have done som e v e ry im p o rta n t w o rk .
R egulations w ere issued b y th e L ocal G o v ern m en t B oard, a b o u t th re e y e a rs ago,
w hich m ade it a n ob lig ato ry d u ty on th e p a r t of th e sa n ita ry a u th o rity in ev ery
larg e c e n te r of po p u latio n , to p ro v id e clinics a t w h ich an y o n e (m illio n aire o r
p a u p e r) could o btain se c re t a n d g ra tu ito u s tre a tm e n t fo r syphilis o r g o n o rrh e a .
A n d w e have in o u r c o u n try now a co m p lete system of free clinics fo r th e tr e a t­
m en t of v en ereal diseases. H av in g p ro v id ed free tre a tm e n t, w e e n d eav o red to
in su re th a t th ese diseases should be tre a te d o nly b y re g u la r p ra c titio n e rs, a n d to
this end w e p ersu ad e d P a rlia m e n t tw o y ea rs ago to pass a n a c t p ro h ib itin g a n y
dru g g ist o r o th e r unqualified p e rso n from tre a tin g th em . In view of th e facts w e
have h e a rd as to th e im p o rta n c e of v e n e re a l disease in th e d e stru ctio n of child
life an d child h ealth, in th e im p airm en t of th e h e a lth of th e m o th e r, a n d in th e
sterilization of p o te n tia l m o th ers, I am q u ite su re you will a g re e w ith m e th a t
this is a n im p o rta n t step fo rw ard in re g a rd to child w elfare.
D r. D o ro th y R eed M endenhall (C h ild re n ’s B u reau ) : I have m ad e som e esti­
m ates from th e p e rc e n ta g e s D r. Jean s h as given us^ in re g a rd to th e p rev alen ce
of syphilis, a n d th e resu lt is ra th e r startlin g . W e have tw o m illion a n d a h a lf esti­
m ated b irth s in this c o u n try , a n d 2 3 4 ,6 0 0 estim ated d eath s u n d e r o n e y ear, in
1916. W e h ad th erefo re , u sing D r. Je a n s’ estim ate, 125,000 stillbirths, a n d of
th ese 4 1,700 w ere caused by syphilis. W e h ad 125,000 live b irth s, th e victim s of
congenital syphilis, an d 3 1 ,3 0 0 of th ese died as a resu lt of syphilis. T h is gives
4 1 ,7 0 0 stillbirths an d 3 1 ,3 0 0 d eath s in infancy, a to ta l of 73,000 in fan t losses in
one y e a r due to cong en ital syphilis.
D r. S. Josephine B ak er (D ivision of C hild H ygiene, H e a lth D ep artm en t, New
Y ork C ity) : I h esitate to questio n D r. Jea n s’ figures on th e n u m b e r of babies
u n d e r one y e a r th a t die from syphilis, b u t th e y a re of e x tra o rd in a ry in te re st b e ­
cause th e y a re so en tirely c o n tra ry to a n y th in g w e h av e e x p erien ced in New Y ork
City.
Syphilis as a cause of stillb irth s is univ ersal, I th in k , b u t w ith u s syphilis as a
cause of in fan t death s does n o t figure larg ely a t all statistically . It is a m in o r
consideration. Inanition, co n g en ital debility, a n d th o se vag u e titles it is possible
m ay have syphilitic origin, b u t if a n y th in g w h ich w ould p ro v e th ey have h as been
done in New Y ork it is u n k n o w n to m e. I do n o t know o f a n y th in g w h ich w ould
w a rra n t us in saying th a t th e re w ere a n y su ch extensive d eath s from syphilis u n d e r
one y ear of ag e as these figures w ould show . In fa c t it is q u ite c o n tra ry to o u r
g en eral opinion.
D r. Jean s: T h e figures th a t I gave w ere av erag es from a la rg e n u m b e r o f
cases from a g re a t m an y sources, som e from New Y o rk a n d som e from o th e r
places. It w as m y im pression th a t th e a v e rag es w ere som ew hat n e a r th e c o rre c t
figures, b u t I m ay be m istaken.
V ery o ften syphilis is a n in d irect cau se of d eath . In a n a rtic le p u b lish ed by
D r. H olt, using m ateria l from New Y ork City, he sta te d th a t a b o u t 25. o r 30 p e r
cen t of th e syphilitic babies studied died from syphilis, a n d th a t, in all, m o re th a n
1 T h ese p ercen tag es w ere given in a p a p e r read b y D r. Jean s b e fo re th e A sso­
ciation fo r th e Study a n d P rev e n tio n of In fan t M ortality a t its n in th a n n u a l m eet­
ing, D ecem ber, 1918. P a p e r pu b lish ed in T h e A m erican Jo u rn a l o f Svohilis.
Vol. Ill, No. 1, Jan ., 1919.


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50 p e r ce n t of th em died. W h e th e r o r n o t syphilis w as th e c a u se of d eath in th e
rem ain d er of those in stan ces is difficult to say. B ut c ertain ly it is n o t a fa c to r to
be ignored.
D r. B ak er: I did n o t questio n t h ^ n u m b e r of syphilitic b ab ies th a t died in
p ro p o rtio n to th e n u m b e r of cases of syphilis. I w as q u estio n in g th e n u m b e r of
syphilitic death s in p ro p o rtio n to th e to ta l n u m b e r o f d eaths.
D r. Jean s: T h e fact th a t 10 p e r c e n t of m o th e rs am o n g th e p o o re r classes
give positive W asserm an n re a c tio n w o u ld seem to m ak e th e su b ject of co n sid er­
able im p o rtan ce, as w ell as th e fa c t th a t 90 p e r c en t of th o se m o th e rs will give no
h isto ry rior show an y signs of syphilis.

/


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T H E C O N T R O L O F M ID W IFE R Y
By DR. CHA RLES V . CH A PIN
S u p erin te n d e n t of H ealth , P ro v id en ce, Rhode1 Island

T h e only m idw ife p ro b lem w ith w hich I am fam iliar is th a t of our
m anufacturing cities w ith a large foreign population, of w hich m y ow n
city, P rovidence, is typical. In P rovidence th e m idw ife is n o t in^ digenous. She cam e to us w ith our recen t im m igrants, from Russia,
from A ustria, from P oland, from th e A zores, b u t chiefly from Italy.
M edical practitioners in general, an d obstetricians in particular, d e ­
nounce th e m idw ife; social w orkers an d public health nurses do n o t
like h er; an d h ealth officers do n o t consider h e r an asset to th e co m ­
m unity. T h e latter, how ever, while desirous of replacing h e r b y som e­
th in g b etter, ad m it th a t she is n o t so inim ical to public health as are
m an y physicians. T h u s in som e cities th e m idw ives re p o rt birth s a n d
cases of o p h th alm ia b e tte r th an d o the physicians. T h ey re p o rt b irth s
m o re p ro m ptly. In P rovidence, though th ere are no accurate d ata,
m idw ives certainly re p o rt birth s m ore com pletely th an d o physicians.
L ast y e a r 1 0 p e r cent of physicians’ re p o rts w ere late a n d only 1 p e r
cen t of th e m idw ives’. F o r th e prev en tio n of infant m o rtality p ro m p t
retu rn s are necessary, an d th e h ealth officer is grateful to w hoever
m ak es them . T h ere are v ery m any physicians w ho know little ab o u t
in fan t feeding, an d their babies die an d th e health officer can do n othing
ab o u t it. W ith th e m idw ives’ babies it is different. T h e nurse engi­
neers th em to th e w elfare station, w here th ey are cared for b y special­
ists. No w o n d e r th a t in P rovidence, in 1917, th e infant m o rtality ra te
of m idw ives’ b ab ies w as 77, w hile of all others it w as 117. It can n o t
be arg u ed th a t this is because th e m idw ives care for a stro n g er stock
of w om en an d h ealth ier babies. A b o u t 85 p e r cent of th e m idw ives’
b ab ies are of Italian m others. In th e years 1902-1909, b efo re th ere
w as an y instructive nursing service fo r m others, th e infant m o rtality
ra te am ong Italians w as 138. In 191 7 it w as 93. T h e m idw ife, th e re ­
fore, d o es n o t thus fa r seem to h av e been a hin d ran ce to th e prev en tio n
of in fant m ortality.
O b jectio n to th e m idw ife is b ased alm ost entirely on a priori reason­
ing. In th e biological sciences this m o d e of reasoning is dangerous,
though I d o u b t n o t th a t in this instance it is valid. M idw ifery is a
b ran ch of m edical practice, an d we h av e ab u n d a n t evidence th a t tra in ­
ing an d k n o w ledge m ake for b e tte r practice. N evertheless, th e re is
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som e tru th in th e o ld ad a g e th a t “ a little know ledge is a dangerous
thing.** W e are safe in assum ing th a t im perfectly ed u cated physicians
a n d im perfectly ed u cated m idw ives are n o t as useful m em bers of so ­
ciety as those w ho are well educated. In m edicine w e n eed th e best.
E ven this, ow ing to th e lim itations of hum an know ledge, is far from th e
ideal. In kno w ledge th e m idw ife.m ust alw ays b e far below th e physi­
cian, an d it is a safe ded u ctio n th a t she is n o t an institution to b e fos­
tered , b u t is ra th e r to b e to lera te d only until such tim e as an acceptable
substitute can b e found. W e allow non-m edical individuals to p ro v id e
glasses fo r o u r eyes a n d to a tte n d w om en in confinem ent, b u t in no
o th e r specialty is this perm itted.
N evertheless, it w ould b e desirable to show b y com parative statis­
tics w h eth er th e practice of th e m idw ife results in sickness a n d death.
W h en com parison is m a d e betw een th e results o f m idw ives’ practice
a n d th a t of physicians, it is a t tim es ap p a ren tly un fav o rab le to th e latter.
Dr. W illiam s, a few y ears since, aroused g re at interest b y his argum ent
th a t p o o r d o cto rs h av e m o re d ea th s against them th an do th e m idwives, an d th a t th ere are m any p o o r doctors. T h e m ajo rity of teaching
obstetricians w ere of his opinion. D r. B aker of New Y o rk says th a t
th e m o rb id ity an d m ortality, b o th of m o th ers an d of babies, is greater
am ong those a tte n d e d b y physicians th an am ong those a tte n d e d by
m idw ives. D r. V a n Ingen has p resen ted figures, relating to th e low er
E ast S id e o f New Y ork, w hich show th a t stillbirths are m uch m ore fre­
q u en t in th e p ractice o f physicians th an in th e practice of m idw ives.
T h e g re at fallacy in all such statistics is th a t th ere is a selection of cases.
Difficult confinem ents grav itate to th e physician o r th e hospital, while
no rm al confinem ents rem ain w ith th e m idwife.
T h ere are several reasons w hy th e re is a d em an d for m idw ives:
1. T h e y are cheaper. In m y ow n city a t th e p resen t tim e th e p re ­
vailing ra te fo r m idw ives is $15, w ith a d o llar o r tw o throw n in the
b a b y ’s b a th fo r tub m oney, a n d for physicians $25 an d upw ards,
th ough a n u m b er of physicians will tak e cases a t th e sam e ra te as m id ­
wives. Such physicians, how ever, are likely to b e below th e average.
It is b eliev ed b y m any th a t econom y is th e m ost p o te n t reason fo r the
reten tio n of th e m idw ife.
2. M any foreign w om en d o n o t wish to h av e a m an a tte n d them
in confinem ent, o r w h at is p ro b a b ly m uch m o re com m on, th eir hus­
b a n d s d o n o t wish it. T his is a custom o r fashion, b u t I ca n n o t believe
th a t it will p ro v e v ery difficult to change it as soon as g ood m edical
service a n d o th er care is available w ithin th e mothers* m eans. W hen
o ne sees th e rem ark ab le change in custom s, clothes, food, drink, etc.,
am o n g foreigners, a fte r only a few m onths’ residence, one can b e co n ­
fid en t th a t th e preference fo r a m idw ife m ust yield to th e force of
A m erican public opinion. T h e Italian will, in time, substitute th e doc
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to r for the m idwife, ju st as she has substituted th e m illiner’s h a t fo r th e
b rig h t co lored h andkerchief th a t form erly covered h e r h ead. In this
process of education th e public-health nurse m ust play an im p o rtan t
p art. H e r influence w ith a fam ily is v ery great, an d she can d o m uch
to teach th e im p o rtance of th e b e st m edical attendance. T h e w om an
physician, too, can b e utilized to give m edical service to those w ho o b ­
ject to a m ale atten d a n t.
3.
T h e m idw ife perform s m o re o r less household service fo r th e
family, “ tidying” th e room s, prep arin g th e m eals, an d caring fo r th e
o ld er child ren ; b u t ap p a ren tly th ere is a tendency fo r th e m idw ife to
d o less an d less of this so rt of w ork.
T h ere is evidence to show th a t m idw ifery is decreasing. Dr. W o o d ­
w ard stated th a t in th e D istrict of C olum bia, betw een 1896, th e d a te of
th e ad o p tio n of th e law regulating m idwives, an d 1915, th e num ber of
b irth s a tte n d e d b y m idw ives in th e D istrict of C olum bia fell from 50
p e r cent of th e to tal b irth s to less th an 10 p e r cent. In 1918 it w as 5.5
p e r cent. T his w as due chiefly to the elim ination o f m idw ives b y ex­
am ination. In N ew Y ork, in 1905, 42.1 p e r cent o f all birth s w ere a t­
ten d e d b y m idw ives, while in 1917 th e p e r cent w as 33.5. T h e decrease
has b een especially ra p id since th e opening o f th e w ar, w hich is in­
terp re te d as indicating th a t it is th e new com ers w ho are m ost in­
clined to rely u p o n th e m idw ife. In P ro v id en ce th e p ro p o rtio n of
b irth s a tte n d e d b y m idw ives increased w ith th e increasing tid e of
Italian im m igration up to 1913, w hen o v er 33 p e r cent of all births
w ere a tte n d e d b y th e m .' In 1918 th e percentage w as 27.5. A n en­
couraging featu re in P rovidence has b een th e alm ost com plete d isap­
p earan ce of th e Jew ish m idw ife. T en years ago n early 150 births
an n u ally w ere a tte n d e d b y Jew ish m idw ives. L ast y e a r th ere w ere b u t
fo u r so atten d e d , although w e h av e a Jew ish po p u latio n of nearly
2 0 ,0 0 0 . T his seem s to b e d u e largely to th e appreciation on th e p a rt
o f Jew ish w om en of th e value o f m edical service. In R ochester th e
n u m b er o f m idw ives a n d th e n um ber of b irth s a tte n d e d b y them has
d ecreased d uring th e last eight o r ten years. In o th er cities, as Newark,
it is stated th a t th e p ro p o rtio n of birth s a tte n d e d b y m idw ives has
rem ained quite constant.
V arious p lan s h av e b een ad o p ted , o r proposed, for solving th e m id ­
w ife problem . O ne is absolutely to forbid h e r practice b y statu te law.
T his is tru e of M assachusetts now an d w as tru e in R h o d e Island up to
last year. In neith er of these S tates w as an y serious a ttem p t m ad e to
enforce th e law a n d to d riv e out th e m idw ives. W hen I saw th a t th e
m idw ife w as to rem ain in P rovidence I tried to secure h er cooperation,
w ith th e result th a t h er b irth s are m o re com pletely an d p ro m p tly re­
p o rte d th an before, as are h e r cases of ophthalm ia, an d h e r babies are
p ro m p tly b ro u g h t u n d e r th e care o f public-health nurses an d physi
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cians, so th a t th e infant m o rtality ra te of m idw ives’ babies has b een re­
d u ced n early 70 p e r cent.
A n o th e r plan, w hich m ay b e d ev elo p ed in different ways, is to
license th e m idw ife. T his has as y et been a tte m p te d in only a few
States. T h e statu to ry provision should b e as b ro a d as possible so as to
allow o p p o rtu n ity fo r experim ent an d th e dev elo p m en t of new m eth o d s
o f control. T h e R h o d e Island law p ro v id es th a t “ th e S ta te b o a rd of
h ealth is h ereb y authorized an d d irected to m ak e rules fo r th e regula­
tion a n d p ractice of m idw ifery, an d for th e licensing of m idw ives.”
T h e N ew Y o rk statute, authorizing th e enactm ent of a sanitary c o d e by
th e public h ealth council, p ro v id es th a t this co d e “m ay contain p ro ­
visions regulating th e practice of m idw ifery.”
U n d e r such g eneral provisions th e licensing m ay am o u n t to a m ere
registration, o r it m ay d evelop into an elab o rate system u n d e r w hich
m idw ives are carefully exam ined, educated, trained, a n d supervised.
T h e ad v o c ates of licensing are d iv id ed into tw o groups. O n e of
these believes th a t th e m idw ife is b u t a tem p o ra ry institution, is. u n ­
necessary, a n d can sooner o r later b e elim inated. T h ey w ould issue a
license annually, p erh ap s establish m o d era te sta n d a rd s of conduct,
an d g rad u ally elim inate those m idw ives show n to b e careless, dirty,
ignorant, o r neglectful. T h ey w ould n o t a tte m p t to teach obstetrics
to th e m idw ife, o r to raise h e r social o r econom ic status, fearing that,
b y so doing, h e r position w ould b e m a d e m o re p erm anent. T h e m id ­
w ife w ho is ed u cated in a school a n d w ho h as a d iplom a will b e in d e ­
p e n d e n t a n d will resent efforts to d raw aw ay h er clientele. S he will
believe th a t she has rights w hich she m ust d efen d . O n th e o th er h an d ,
th e m idw ife w ho is m ad e to feel th a t she has no real status, th a t she
is allow ed to p ractice only on sufferance, an d th a t she is d e p e n d e n t on
th e g o o d will o f th e h ealth officer, will n o t d a re to m ak e m uch fuss if
she sees h er p atien ts leave her. D r. Stone, o u r su p erin ten d en t of child
hygiene, finds th a t our b est qualified m idw ives are th e least to lera n t of
advice a n d correction. If th e m idw ife has no real status, she can th e
easier b e m a d e to obey th e rules of th e d ep a rtm e n t; thus such m id ­
w ives can often b e m ad e to re p o rt b irth s a n d inflam ed eyes m o re
p ro m p tly th an th e physicians. P erh a p s th ey m ay even b e m a d e to re ­
p o rt pregnancies. U n d e r control, such m idw ives are n o t dan g ero u s
to th e babies, as is show n b y th e P rovidence figures previously given.
T h a t th ey a re n o t dangerous to th e m o th er is in d icated b y . d a ta from
P hiladelphia, w here th ere w ere only 1 7 d ea th s in ab o u t 12,000 co n ­
finem ents attended*by supervised m idw ives.
O th ers th in k th a t th e m idw ife will surely rem ain w ith us for a long
tim e an d th ey p re fer to a tte m p t to im prove h e r status. T h e y w ould
fix ed ucational stan d ard s, an d b y definite supervision of h e r w o rk see
th a t these stan d ard s are lived up to, thus follow ing th e ideas of m ost

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E uropean countries. T hus th e New Y ork co d e requires th a t m id ­
wives m ust possess a d iplom a from a recognized school o r m ust h av e
received p ersonal instruction from a licensed physician, of w hich in­
struction he m ust m ake a re p o rt. A school for m idw ives h a d p re ­
viously b een established a t B ellevue H ospital in N ew Y ork C ity in
191 1. T h e New Y ork S ta te D ep artm en t of H ealth has p lan n ed fo r th e
supervision of m idw ives through th e m edium of nurses. T hese nurses
cover chiefly those p arts of th e S ta te outside th e g reat cities. N ew Y ork
C ity h ad previously u n d erta k en sim ilar control in 1911.
New Jersey has a d o p te d m uch th e sam e plan as New Y ork.
In P ennsylvania m idw ives are licensed b y th e bureau of m edical
education an d licensure, an d are also supervised b y th e sam e bureau.
T h e system is b est d ev e lo p e d in th e district in w hich P hiladelphia is
situated. In this district th ere is a supervisor, a specialist in o b stet­
rics, w ho h as u n d e r him a n u m ber of w om en physicians w ho act as in­
spectors. T h e m idw ife m ust call u pon th e inspector fo r advice in every
ab n o rm al delivery, an d definite rules are given to guide h e r judgm ent.
In p ractice n early every p atien t is seen b y th e inspector. T h e m idw ives
receive con sid erab le system atic instruction, but, as I u n d erstan d it, the
authorities lo o k to th e u ltim ate extinction of th e m idw ife a n d think
th a t this result will b e en d an g ered if th e requirem ents are such th a t
w om en of som e edu cation will b e led to p re p a re them selves, a t som e
expense, fo r m idw ifery as a “profession.” In P ittsburgh close super­
vision of th e m idw ives is m aintained b y nurses.
In P ro v id en ce th e b a b y nurses * of the health d e p a rtm en t have,
for som e time, sought, b y personal instruction given to each m idwife,
to m ak e h e r m o re cleanly an d in o th er w ays to tak e b e tte r care of h er
cases. She h as b een m ad e to re p o rt b irth s an d sore eyes prom ptly.
She is show n th e necessity fo r sending fo r a physician in case of any
ab n o rm ality an d is w arned of th e d an g e r o f delay. M any m idw ives
secretly p rescrib e m edicines, an d the e n d e av o r is m ad e to b re ak up this
practice. V e ry m uch w as d o n e along these lines b efo re w e h ad a
license law, an d now it is h o p ed th a t th e S tate b o a rd of health will
refuse licenses to th ose w om en w ho do n o t follow directions.
If m idw ives are to b e supplanted, som e substitute m ust b e offered
which ap p eals to th eir p atro n s as desirable. P erh ap s the m ost im p o rt­
an t reason w hy th e m idw ife is p re ferred is because she costs less th an
a d o cto r. If th e m idw ife is to b e supplanted b y a physician, th e latter
m ust n o t cost m o re th an th e form er, an d th e supplanting process will
b e m o re ra p id if h e does n o t cost as much.
A free o u t-p atien t obstetrical service certainly draw s cases from th e
m idwives. W h erev er th ere is a m edical school, such a service is neces­
sary for teaching purposes. E ven if th e p atien t is able to p ay a m id ­
wife, I con sid er it en tirely legitim ate to draw h er aw ay b y free treat
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m ent, p articularly as the p atien t is to b e used for teaching purposes.
M oreover, som e com pensation m ay b e received even from this kind of
a service. T h u s a t th e B oston Lying-in H ospital the out-patients con­
trib u ted on th e average, in 1916, $ 1.38 each, which w as an appreciable
help in m eeting th e low cost of th e service. T h a t such a service pays
from a public h ealth stan d p o in t is show n b y the fact th a t m aternal
m o rtality in th e last 5 ,0 0 0 out-patients w as .04 p e r cent. T h a t this low
rate w as n o t secured b y sending an u n d u e num ber of difficult lab o r
cases into th e hospital is indicated b y th e m ortality of th e house cases,
which d uring substantially th e sam e p erio d was 1.1 p e r cent, certainly
n o t ab n o rm ally high.
U nfortunately, o r ra th e r fortunately, m ost of our cities are n o t sup­
plied w ith a m edical school, so som e o th er m eans th an th e utilization
of m edical stu d ents has to b e found to p ro v id e obstetrical service for
the poor. A n o u t-p atien t service w ould seem to b e best p ro v id ed in
connection w ith a m aternity hospital. T h e country certainly needs a
m uch larg e r m atern ity service th an it now has. M any general hospitals
are, how ever, now ad d in g a m aternity service, often because a num ber
of S tates are requiring of th eir licentiates in m edicine a hospital in tern ­
ship w ith a prescribed obstetrical training. T his will certainly draw
cases from th e m idw ives, an d will at the sam e time, b y th e training thus
secured, m ak e th e young d o cto r a b e tte r obstetrician, a m ost desirable
result.
T h e cost of o ut-patient obstetrical w o rk is a m a tte r of m uch m om ent
in these tim es w hen th e re are so m any d em an d s on p h ilan th ro p y an d
so m any lines of m unicipal h ealth w ork. W e m ust all ad m it th a t it is
a g reat injustice to ask so m uch gratuitous public service of physicians.
M any of us are trying to draw aw ay from this practice, though it will
p ro b a b ly b e a long tim e b efo re all such public m edical service will b e
ad eq u ately p a id for. T h e tendency in som e places is to utilize in­
ternes, o r o th er m em bers o f a resident hospital staff, for o ut-patient
w ork of all kinds. In this w ay the out-patient w o rk er is likely to b e
p aid som ething besides his b o ard , an d h e m ay even b e p aid a fair com ­
pensation, y e t I am sure th a t less m oney will b e required in this th an
in any o th er way, an d th a t this arrangem ent will b e tte r satisfy th e m edi­
cal m an. T h e utilization of a resident staff fo r out-patient w ork also
m akes for efficiency, as th e w o rk can b e supervised b y th e hospital
m anagem ent an d th e service is sure to b e m o re p ro m p t a n d regular.
H ence o u t-p atien t obstetrical service w ould seem to b e desirable in
connection w ith m atern ity hospitals w henever possible.
A t M anchester, N. H ., a city of about; 8 0 ,0 0 0 people, out-patient o b ­
stetrical service is carried on b y the district-nursing association, which
h as a m edical m an for directo r of th e service. Y oung physicians, just
com ing to th e city, d o m ost of the w ork, a n d they are glad to do it, as

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they are thus b ro u g h t in touch w ith th e m ore influential people. T he
city h as m any textile operatives, an d it is estim ated th a t ab o u t 10 p er
cent of all confinem ents are in need of free service. A b o u t 6 p e r cent
are now served b y the dispensary.
T h e “p ay clinic” has, for various types of m edical service, been
strongly a d v o c ated in B oston as a m eans of securing efficient trea tm e n t
for a class of persons w ho can p ay only a m o d era te sum, b u t yet suffi­
cient in th e ag g reg ate to afford m o d est com pensation to the physi­
cian. It w as d eem ed advisable in E ast B oston to establish such a
service in connection with the M averick D ispensary, a p riv ate institu­
tion, n o t connected w ith any hospital. T his has b een running only a
short time, b u t is draw ing cases from th e m idw ives. A charge of $ 15
is m ade, just th e am ount charged b y m idw ives, a n d of this $ TO goes to
the physician. T h e physicians are m en w ho are g lad tem p o rarily to
tak e this service to p erfect them selves in obstetrics.
E nough has b een said to show th a t in th e U nited S tates a variety
of views prevail as to th e m idw ife an d th a t th ere are various w ays of
dealing w ith her. T hose w ho w ould dispense w ith h e r service h av e
different plans fo r doing so. T his is th e p erio d fo r experim ent, an d our
F ed eral system , w ith its forty-eight legislatures, favors experim enta­
tion. It is too early to stan d ard ize an d n o t a tim e for dogm atism . It
is n o t unlikely th a t different plans will b e found b est fo r different p arts
of th e country. M eanw hile m y own conclusions, applicable chiefly to
o u r cities w ith large foreign populations, are as follow s:
1. T h e m idw ife is unnecessary an d can gradually b e elim inated.
2. T h ere should b e an annual registration, an d supervision should
b e m aintained.

3. The foreign population must be educated, the most Valuable
agencies being nurses and clinics.
4. P ren atal clinics are n eed ed an d especially an enlarged o u t­
p atien t obstetric service, p artly free an d p artly pay.
5. M ore m atern ity w ards are needed.
6. T h ere should b e b e tte r obstetric training for m edical students,
which will b e m ad e possible b y g reater o p p o rtu n ity for clinical in­
struction;
DISCUSSION
D r. Julius Levy (S ta te B oard of HealtH, New Je rse y ) : I w an t to recall som e
of th e points th a t D r. C h ap in m ade v ery tellingly a n d clearly. H e m ade th e p o in t
th a t midwives a re n o t so b ad as som e d o cto rs; he m ade th e p o in ts th a t b irth s a re
re p o rted m o re freq u en tly a n d m o re p ro m p tly by m idwives th a n by doctors, th a t
th e re is less ophthalm ia th a n in cases h andled by doctors, an d th a t m idw ives
a re m ore disposed, u n d e r advice a n d in stru ctio n , to use silver n itra te . H e also
m ade th e po in t th a t in fa n t m o rta lity is low er a m o n g cases h andled b y m idw ives;
an d th en he w ants u s to believe th a t w e a re to elim inate m idwives!


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A« fa r as o u r studies can show , ex p erien ce h as p ro v e n th a t u n d e r regulation
a n d supervision an d p ro p e r in stru c tio n o u r stan d ard s a re b e tte r m ain tain ed by
m idw ives th a n b y do cto rs as th e y exist. A n d I m ay ad d th a t w h e re th a t does not
o cc u r it is n o t th e fa u lt of th e m idwife b u t of th e p u b lic-h ealth officer. I w ill no t
claim th a t w ith th e sam e k ind of reg u la tio n a n d supervision of d o cto rs th e re ­
sults w ould n o t be b e tte r, b u t D r. C h ap in also stated th a t he discovered it w as
m u ch easier to reg u la te a n d supervise th e m idw ife th a n it w as th e docto r.
D r. C hapin also p o in ted o u t th a t as th e m idw ife becam e e d u cated she w as m ore
difficult to handle. Y ou no tice she is gettin g a little like th e d o cto rs a n d th e re ­
sults a re n o t alw ays as good.
I o u g h t to suggest th a t I do n o t th in k th a t o b stetrician s n eed fear th e existence
of th e m idwife in p e rp e tu ity . E levating h e r statu s I th in k is a sly w ay to elim inate
her, if you really w ish to elim inate h er, b ecau se as y o u elevate h e r sta n d a rd she
dem ands m ore for h e r service, a n d w hen she dem ands m o re fo r h e r service, she
is in com petition w ith th e d o cto r. By th e law of th e survival of th e fittest, if th e
d o cto r is a su p erio r individual, he w ill survive.
Sir A rth u r N ew sholm e (L a te P rin c ip a l M edical O fficer, L ocal G o v ern m en t
B oard, E n g la n d ): So fa r as E ng lan d is concerned, a t th e p re s e n t tim e 75
p e r cen t of all confinem ents a re a tte n d e d b y m idwives, w hose p ra c tic e on th e
w hole is satisfactory. F av o rab le statistics could b e q u o ted sim ilar to th o se th a t
D r. C h ap in has qu o ted as re g a rd s P rovidence. B ut w e have m idw ives in E n g ­
lan d u n d e r absolutely com plete c o n tro l. M idwives th a t a re on th e re g iste r to
p ra c tic e can b e rem oved from th e re g iste r if th e y a re guilty of m alp ra c tic e o r in­
efficiency. T h ey a re so rem o v ed freq u en tly . T h e y a re su b ject to reg u la tio n a n d
system atic inspection b y local supervising a u th o ritie s; so th a t a n y m idw ife w ho
gets a b ad re p u ta tio n o r h as a n excessive n u m b e r o f co m plications is su re to be
hau led over th e coals a n d h e r p ra c tic e w ill dim inish v ery seriously. In th o se
various w ays w e h av e secu red th a t m idw ifery is a fairly safe profession.
M oreover, th e L ocal G o v ern m en t B oard h as a rra n g e d fo r G o v ern m en t g ran ts
to fifty p e r cen t of th e to ta l e x p en d itu re fo r th e em ploym ent of m idwives, these
g ran ts b eing given to th e ru ra l au th o ritie s a n d to th e p o o re r d istricts a n d tow ns
w h ere m idw ives a re located, th e o th e r h alf o f th e to ta l ex p en d itu re b ein g p aid
b y v o lu n teer subscrib ers o r b y th e local au th o ritie s.
In addition every m idw ife is re q u ire d w hen a n y co m plication o c c u rs to call in
a doctor. T h e re h as b een g re a t difficulty in th e p a st in p ro v id in g a fee fo r th is
doctor, a n d now it is m ade o b lig ato ry u p o n th e local a u th o ritie s to p a y this
do cto r’s fee, so th a t no d o c to r can b e excused fo r n o t going a t once w hen th e m id­
w ife re q u ires his assistan ce in a n y com plication, h o w ev er m in o r th a t com plication
m ay be. I th in k you w ill a g re e th a t, if th e p ra c tic e of m idw ifery b y m idw ives is
to continue, w e have in th a t w ay safeg u ard ed it.
In th e last tw elve m o n th s I h av e also b een ad v o catin g th a t a n a d d itio n al duty
should b e im posed o n m idwives, to w h ich I p erso n ally a tta c h th e g re a te st possible
im portance. T his is th a t if fo r a n y reaso n d u rin g th e tim e (te n days o r a fo rt­
n ig h t) th a t th e m idw ife co n tin u es h e r a tte n d a n c e a fte r confinem ent, th e m o th er
proposes to give u p b re a s t feeding, it is th e d u ty of th e m idwife to n o tify th e
m edical officer of h e a lth of th a t fact a t once, so th a t he o r his assistan ts m ay
visit th a t house a t once to see th a t b re a s t feeding, w h ich is th e m ost essential
elem ent of th e w elfare of th e child, shall b e co n tin u ed if it be possible to contin u e
it. T his has now b e e n secu red by a reg u latio n of th e C e n tra l M idwives’ Board.
F u rth e rm o re , th e L ocal G o v ern m en t B oard h as given g ra n ts fo r th e fo rm a­
tion of m a tern ity hom es a n d m a te rn ity hospitals, a n d it h as b een p re p a re d ,
a n d expressed its a n x iety , to p a y fifty p e r c e n t of th e to ta l cost of th ese hos-


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pitals an d hom es w ith o u t a n y lim it of th e to ta l a m o u n t w h ich is th u s payable.
Such m a te rn ity hospitals a n d hom es, I am glad to say, a re sp rin g in g up in m an y
p a rts of th e co u n try . T h e y a re , in m y view, o n e of th e g re a te st needs o f tow n
life. It is a g re a t sham e th a t it should be so, b u t it is th e fa c t th a t in a la rg e p ro ­
p o rtio n of th e te n e m e n t houses of o u r big tow ns it is not-p o ssib le fo r a confine­
m ent to ta k e p lace u n d e r conditions th a t can be re g a rd e d as a n y th in g a p p ro a c h in g
satisfactory.
T h e L ocal G overnm en t B oard p ay s d o cto rs’ fees; w e p a y fo r m a te rn ity hom es
an d ¿hospitals; a n d w e also p a y fo r th e p rovision of hom e helps. W e w e re glad to
have th e h elp of th e W o m en ’s C o o p erativ e G uild in se cu rin g th a t ad d itio n al boon.
W e w ere p u sh in g it a t th e sam e tim e, a n d w e even tu ally succeed ed in g ettin g th e
T re a su ry to give m oney w ith o u t a n y lim it of th e a m o u n t fo r th e p rovision o f hom e
helps. T h a t is som ew h at sim ilar to dom estic serv ice; th e h elp ers visit th e hom es
of w om en w ho have b een re cen tly confined; p ro v id e assistance d u rin g confine­
m en t a n d a fte rw a rd s; and, if th e m o th e r is ill d u rin g p re g n a n c y , see th a t she h as a
physician o r n u rse to a tte n d h er.
D r. S. Jo sep h in e B ak er (D ivision of C hild H ygiene, H e a lth D ep artm en t, New
Y ork C ity ) : It is a v ery g re a t p leasu re to have h e a rd S ir A rth u r N ew sholm e
sp eak of th e co n tro l of th e m idw ife in E ngland, b ecau se it is ex actly d u p licated
by o u r co n tro l in New Y o rk City. W e have a six m o n th s’ p re lim in a ry ed u catio n
a t m unicipally co n tro lled schools fo r midwives.
By th e co n stan t supervision o f th e m idwife, a n d th e elim ination from p ra c tic e
of every m idwife w ho violates o u r reg u latio n s, th e n u m b e r of p ra c tic in g m idw ives
has b een red u ced in te n y e a rs fro m 3,000 to 1,600. T h e re is one su re w ay of
elim inating th e m idwife, a n d th a t is to ed u cate h er. M idwives a re a co ndition a n d
n o t a th eo ry . In seeing w h a t can b e done w ith m idwives it is essential to rem em ­
b e r th a t p o o r p eo p le w ho have to deal w ith th em a re guided b y p ra c tic a l co n sid er­
atio n s ra th e r th a n by acad em ic theo ries.
I th in k D r. C h ap in q u ite u n w ittin g ly did us a little in ju stice w h en h e said th e
in freq u en cy of stillbirths a n d th e low m o rta lity am o n g m o th ers a n d babies
a tten d ed by m idw ives w ere due to th e fa c t th a t h a rd cases w ere tra n sfe rre d to th e
doctors. T h a t is tru e, b u t th e y w ere c o u n ted ag a in st m idw ives. E v ery case th a t
h ad a m idw ife in a tte n d a n c e a t a n y tim e w as c o u n te d a s a m idw ife case. O f
qourse th e com plicated cases w en t to th e d o cto rs a n d w e re re p o rte d b y th em as
deaths, b u t n o t re p o rte d ag ain st th em in th e final sense. B ut th a t show s w h a t have
been th e p ra c tic a l results of th e co n tro l of m idw ifery in N ew Y o rk City.
I th in k th a t w e can g ra n t th a t w h a te v e r im p ro v em en t h as b een m ade in o b ­
stetrical p ra c tic e in New Y o rk h as b een c o u n te rb a la n c e d b y th e im p ro v em en t
of o b stetrical p ra c tic e in ev ery o th e r la rg e city in th e c o u n try . W h y is it th en ,
th a t in a study of th e m a te rn a l m o rta lity ra te s in seven la rg e cities of th e U n ited
States, m ade by th e C h ild ren ’s B ureau, th ese ra te s w ere show n to be in creasin g o r
statio n ary in every o ne of th em w ith th e ex cep tio n of New Y o rk C ity, a n d New
Y ork C ity show ed a d ecrease? T h e o nly difference b e tw een N ew Y o rk C ity a n d
th e o th e r cities is o u r m eth o d of co n tro l of m idwives.
B eginning te n y ears ag o w ith n o m eth o d of finding o u t w h e th e r th e re w ere
cases of blindness, w e h a d literally th o u san d s of cases of o p h th alm ia, a n d literally
h u n d red s of cases of blindness— no w ay of co m p u tin g how m an y w e had . L ast
year— w e Jo n o t claim th ese a re e x act figures— w ith th e m o st p a in sta k in g m ethods
th a t w e could devise by a follow -up of ev ery case of so re eyes re p o rte d by th e
m idwife, by a follow -up a t th e h o sp itals w h ere o p h th alm ic cases m ight com e, by
every m eans w e could devise to co n tro l th e situation, w e fo u n d th a t o u t o f 135,000


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b irth s in New Y ork C ity w e h ad 35 cases of o p h th alm ia a n d one case of b lind­
ness.
N othing th a t I know of h as ch an g ed in re g a rd to th e p ra c tic e of doctors, b u t
a v ery g re a t deal has ch an g ed in re g a rd to th e p ra c tic e of m idwives. I am a n a d ­
v ocate for th e stro n g e st k ind of supervision, th e m ost th o ro u g h control, an d
above all th e ed u catio n of th e w om en to su ch a h igh sta n d a rd th a t o nly a w om an
of e x tra o rd in a ry in telligence an d ab ility will be able to b e a m idwife.
D r. M ary Sherw ood (B altim ore, M ary lan d ) : It o ccu rs to me th a t possibly we
m ig h t look a t this from a n o th e r angle. T h e re is no topic th a t p ro v o k es so m uch
discussion as th is questio n of th e m idwife. A n d a fte r all it is n o t th e question of
w h e th e r th e m idw ife is b e tte r th a n th e docto r, o r w h e th e r th e d o cto r is b e tte r
th a n th e m idwife. T h e questio n is, is th e m idwife o r th e p o o rly tra in e d do cto r
good en ough?
Is th e re an y o n e w ho will discuss th e p ra c tic e of o b stetrics from th e p o in t of
view of su rg ery ? Is n o t o b stetrics a b ra n c h of su rg ery , a n d is it n o t en titled to th e
kind of ca re w e a re inclined to give, a n d alw ays do give to a hospital m a tte r—
su rgical o p eratin g room , all th e ap p lian ces of m odern su rg ery , all th e p re c a u ­
tions of m odern su rg ery ? Is o b stetrics som ething th a t can be com prom ised w ith
p o o r doctors an d w ith midwives?
D r. H elen M acM urchy (D e p a rtm e n t of th e P ro v in cial S ecretary , T o ro n to ,
C a n ad a) : I th in k th e b est w ay to m ak e stu d en ts u n d e rsta n d th a t it is a m a tte r
of su rg e ry is to m ak e th em realize th a t a t th e tim e of b irth w e have to c are fo r
w h at is really a n en o rm o u s o pen w ound. O f course it is quite tru e th a t th a t
w ound is physiologically p ro d u ced . It is quite tru e th a t th e d an g er of infection
th ro u g h th a t w oun d is v ery m u ch red u ced by th e w onderful provision of n a tu re
for sh u ttin g these gaping av en u es of infection. • B ut nevertheless th a t is w h at it is.


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ESSEN TIALS F O R PU B LIC C A R E O F M A TER N IT Y
A N D IN FA N CY
By MRS. ELEA N O R BARTON
W om en’s C o o p erativ e Guild, E ngland

A t the presen t tim e m ost countries are turning their thoughts to
th e question of child w elfare. I am sure th a t w e are a t th e beginning
of a new era which will also recognize the m o th er of th e child. S om e­
o ne has said th a t to h av e a health y child you m ust begin w ith its
g ran d m o th er. If w e to d a y can start with the m o th er w e shall b e
m aking a real b id for public health in the best possible way.
In the old days the G recians w ould n o t allow a p re g n an t m o th er
to look on anything unpleasant, let alone feel it. W h a t a difference
b etw een their ideas of th e ex p ectan t m o th er an d those of our w orld
to day. A cam paign to reduce the d ea th ra te am ong infants u n d er
one y ea r of age h as alread y decreased th e d ea th ra te b y n early onethird, showing v ery clearly th a t m any of o u r social evils are am enable
to treatm en t. B ad housing an d sanitation are responsible for a good
deal, b u t ignorance an d the absence of m edical advice an d help are
also responsible for m uch suffering. It is vital to th e w elfare of all
countries th a t an enlightened an d generous care of m atern ity should
rep lace th e presen t indifference an d neglect.
T h e W o m en ’s C ooperative G uild of E ngland has for several years
given special atten tio n to this subject. ^XTien o u r Insurance A c t w as
b efo re th e country, an d b efo re it becam e a law, th e G uild specially
asked th a t a m atern ity benefit should b e included in th e act, a n d it w as
included. Som e of Us w ere asto u n d ed to find th a t this m atern ity b en e­
fit w as th e h u sb an d ’s p ro p erty , especially afte r w e h a d h a d our cities
p laca rd ed w ith huge p lacard s p o rtray in g th e m o th er w ith h e r child in
h er arm s. H ow ever, w hen th e act w as am en d ed we h a d th e m aternity
benefit m ad e th e p ro p e rty of th e m other.
Since th en w e h av e gone on inquiring a n d getting inform ation,
w orking out a schem e w hich w e placed b efo re our Local G o v ern m en t
B o ard in .1914. A s th e outcom e’ of all the inquiries we h av e issued a
b o o k giving an account of th e suffering of th e w ork in g w om en th em ­
selves at the tim e of pregnancy an d of childbirth, show ing v ery clearly
to all thinking p eo p le the g reat need of th e care of m aternity. It has
b een so com m on fo r children to b e b o rn th a t th e large m ajo rity of
p eo p le h av e n o t considered th e question a t all. M ost young m others
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to d a y tu rn fo r advice to o ld er w om en, an d v ery often w hen she is
suffering th ey tell her, “W ell, it is just a sym ptom of p regnancy an d
you will n o t b e b e tte r until you get through w ith it.”
W e realize to d a y th a t pregnancy is n o t a nine-m onths disease an d
th a t w om en can b e cared for an d can b e helped. A v ery pathetic
caise som e tim e ago cam e to m y notice. A young w om an w ho w as
p re g n an t for th e second tim e cam e to one of th e C o o p erativ e G uild
m em bers saying th a t she w ould n o t go through w ith h e r pregnancy,
th a t it was im possible for h er to do so, th a t she h a d suffered in
exactly th e sam e w ay from h er first pregnancy, an d th a t she w ould
p re fer to m ak e a hom e in th e w ater, th a t is, to com m it suicide. She
was finally p ersu ad ed to go to a doctor, an d h er suffering w as m uch
relieved th ro u g h o u t the p erio d of h e r pregnancy. T h e physician said
th a t if she h a d consulted him during h e r first pregnancy h e could
h av e cured her.
W e h av e all sorts of inform ation, all sorts of reasons, all sorts of
statistics b efo re us w hich show th a t w e m ust h av e b e tte r care for
m atern ity in th e future th an w e h av e h a d in th e past. O ne of the
features of th e w ork of the C ooperative G uild is this: W h en ev er w e
tak e up a question we go into it thoroughly, thro u g h all th e branches
, th ro u g h o u t th e country, an d having g o t all th e inform ation w e can and
p ro n o u n ced on it, w e a t once decide upo n som e practical cam paign in
connection w ith it. W e n ever leave a subject th a t w e h av e tak en up
w ithout trying to g et som e practical results from it.\ A s a result of our
inquiry concerning m atern ity w e d ecided th a t it w as b e st fo r th e local
h ealth au thorities an d th e national health authorities to b e th e people
to carry o u t th e g re at m aternity help th a t w as to b e given to th e large
m ajo rity of w om en in o u r country.
So we set o u t to form public opinion. I suppose it is tru e in A m erica
as in all countries th a t th e governm ents will go just as fa r as they are
p ushed from b ehind, o r from underneath, shall W e say, a n d th a t w hat
m ust b e d o n e is to arouse public opinion. In o rd e r to d o th a t w e
published a n d d istributed w idely som e attra ctiv e little pam phlets, each
one on som e subject relative to m aternity. T h e w om en in o u r local
bran ch es co o p e rated w ith th e w om en in th eir areas an d arran g e d
d ep u tatio n s to their h ealth com m ittees an d to m edical officers of health,
pushing fo rw ard these questions of m aternity. D uring th e w ar, espe­
cially in th e early days, w e found m any w om en w ere suffering because
th ey could n o t get food an d milk, an d w e pushed in th a t w ay also.
In 1915 w e h a d secured com pulsory notification of births. W e have
a g o o d schem e of health adm inistration, an d every m other, directly
she gives b irth to a child, is visited a n d advised b y a h ealth visitor w ho
follows th e case up, an d w hen th e m o th er is re a d y to com e out advises
h er to b rin g h er child to a public clinic. So because of th e act of 1915

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we are in touch w ith births a t th e p resen t time. F inally in 1918 we
h ad a m atern ity act passed b y our H ouse of P arliam ent, an d w e are
v ery p ro u d to d a y in E ngland th a t w e h av e g o t so far because w e do
realize it is a g reat step in th e right direction.
W e h av e m atern ity centers w here advice a n d m inor trea tm e n t are
p ro v id ed . W h ere th ere are com plicated cases o r w here real m edical
atten tio n is n eed ed , th e p atien t is alw ays to ld to consult h er ow n doctor.
W h ere trea tm e n t is p ro v id ed for m others during p ren atal an d p o stn atal
periods, h ealth visitors visit th e m o th er in thg hom e. F o o d an d m ilk
are supplied fo r ex pectant and, nursing m others— th e am ount of m ilk
given being d eterm in ed according to th e advice of the person w ho
h as the case. H o spitals o r w ard s are p ro v id ed for com plicated m a te r­
n ity cases an d fo r b abies up to five years; also m aternity hom es for
n orm al cases an d convalescent hom es afte r m aternity. H om es are
p ro v id ed fo r m o th ers a n d babies in fatherless, illegitim ate, w idow ed,
o r d eserted cases; o r g ran ts are m ad e to such m others to enable them
to stay a t h om e a n d care fo r th eir children.
T h e service of h om e helps has also b een organized. P erh ap s I ought
to explain w h at th e service of hom e helps is. I believe this is a g re at
outcom e of o u r inquiry. W e found th a t w hen th e m o th er w as in b e d
p ractically th e w hole of h er household w as disorganized, an d th a t m an y
of o u r w om en g o t up a t th e end of th ree days, o r b efore th ey should
d o so, to a tte n d to th eir household duties. W e found th a t in m any
cases th e m o th er h a d h er b e d carried dow n into th e living room w here
she could lie w ith h e r purse u n d er h er pillow an d direct th e younger
children o r n eighbors to m ake purchases. U n d er th e system of hom e
helps w om en are to b e train ed to go into the hom es, n o t to do an y
m edical w ork o r to d o th e nurse’s w ork, b u t to w ork u n d e r th e direc­
tion of the nurse o r m idw ife w ho is atten d in g th e case, perform ing th e
m o th er’s h o u sehold duties, such as getting th e children off to school
an d p rep arin g th e food. W e feel th a t this is one of th e greatest
essentials to o u r w orking-class m others. O ur bill a t the present tim e
m akes provision fo r it only in this way, b y providing th a t th e local
au th o rity m ay a d o p t th e schem e afte r ap p ro v al b y th e Local G overn­
m ent B oard.
Services of m idw ives, an d of d octors w hen th e d o c to r is called
follow ing th e m idw ife, h av e been regulated u n d er the M idw ives’ A ct.
W e h av e h a d v ery m any sad cases w here w om en’s lives h av e been lost
because th ere w as no d o c to r to follow th e m idwife. Som etim es a
d o cto r has b een sent fo r b u t refused to a tte n d th e case because h e was
n o t sure w h eth er h e w ould get his fee or not. T h e G o v ern m en t gives
a g ra n t of 50 p e r cent of th e n et cost of all this service I h av e outlined,
p ro v id ed the local schem e has been sanctioned b y the central authority.
W h ere a local au th o rity a d o p ts a schem e of this kind they m ust

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ap p o in t a m aternity com m ittee on which th ere m ust b e tw o wom en.
T h e C o o p erativ e G uild is very anxious th a t w orking w om en should
b e on th e m atern ity com m ittee as they will u n d ersta n d the lives and
hom es of th e w om en w ho will b e tre a te d u n d er this scheme. Mr.
H ayes Fisher, of th e Local G o v ern m en t B oard, him self has expressed
th e h o p e th a t w orking-class w om en will b e appointed. In recent
y ears th ey h av e becom e articulate an d h av e b een able to give very
v alu ab le service an d inform ation to all com m ittees of this kind. Now
we are h o ping th a t all local authorities will tak e a d v a n ta g e of this
schem e an d will m ake this provision for m others an d babies.
I ought to say th a t th e m aternity benefit is 30 shillings to the child.
T his m atern ity benefit is given to th e w ives of m en w ho are insured
an d com e u n d e r th e incom e tax limit. A n d the w om en w ho go out to
w ork, if they them selves are insured, w ould also receive benefits in
they: ow n right, thus m aking a d ouble m aternity benefit.
W e m ust rem em ber th a t u n d er th e p resen t industrial system th e
w ages d o n o t p erm it w om en w ho are bearing children to get th e
m edical atten tio n o r th e help in the hom e w hich th ey need. W e
m ust try to relieve their financial burdens. W e h av e h a d som e ex­
cellent lessons during the w ar p erio d in th e allow ances p aid to m others
an d children, an d m any people to d ay are hoping th a t w e shall b e
ab le to outline som e schem e fo r an endow m ent u n d e r which the m other
will n o t b e so w orried because of th e com ing of an o th er child into
the h om e an d will th erefo re b e able to b e a r h er children better.
W e believe th a t the w hole question of m aternity should com e u n d er
th e M inistry of Relief, now in th e process of form ation, instead of
being m an ag ed largely b y insurance societies an d organizations of th a t
kind, as it is a t th e p resen t tim e. W e h av e h a d cases which h av e shown
us th a t these are th e very w orst institutions u n d er which our m aternity
benefits can b e paid. A t th e present time, therefore, we are considering
a M inistry of R elief in w hich th ere shall b e a m atern ity d ep a rtm en t
w ith a w om an a t th e h ea d of it. W e are asking th a t th ere should b e
w om en ad eq u ately rep resen ted on all those com m ittees. "V^e are
asking, too, th a t in ad d itio n th ere shall b e w hat we are calling a
council of m en an d w om en representing the p eople w ho have to b e
trea ted b y o ur public-health officers because, as w e found in reg ard to
our food supplies during th e w ar, these are the peo p le w ho know
the difficulties an d these are th e p eople w ho can b est deal w ith them .
W h a t I feel th a t we w ant now in all countries is to raise th e sta n d ­
a rd of m aternity. W e w an t to b e p ro u d of our expectant m others; we
w an t to a lter th e id ea th a t we h av e h ad , an d instead of thinking about
m aterial things, think m ore ab o u t Human things; instead of building up
huge industries an d huge warships, let us build up ab le-bodied m en
an d w om en. I think it w as an A m erican w ho said th a t w here th e

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greatest n um ber of ab le-bodied m en an d w om en stood, there stood
the greatest city. Now, it is up to each country to see w here th e
g reatest city shall be.
It* will be g o o d to h av e com petition in th a t direction. It will cer­
tainly raise the w hole sta n d a rd of life. It will raise the stan d ard of
w om en an d children; an d w e m ust rem em ber th at w hen w e raise th e
stan d ard of w om en we raise the stan d ard of the race.

DISCUSSION
D r. H elen M acM urchy (D e p a rtm e n t of th e P ro v in cial S ecretary , T o ro n to ,
C an ad a) : M ay I tak e this o p p o rtu n ity to say one th in g ? Do you th in k w e p ay
enough atte n tio n to th e fa th e r?
I w ould say to him, “ Now, you a re th e w hole
thing, w e a re ju st actin g u n d e r y o u r o rd ers. It is for you to ta k e c a re of th e
m o th er; it is fo r you to pro v id e fo r th e child.” I do th in k th a t th e ed u catio n of
th e fath e r is a m ost im p o rta n t th in g fo r us all to a tte n d to. I do n o t know ju st
w here you w ould in sert it in th e v ery excellent o utline th a t has b een p re p a re d ,
b u t I do n o t like to see th e fa th e r neglected.
M rs. B arto n : T h e re a re m an y p eople w ho say today, “Yes, th e h u sb an d and
fa th e r should provide in this w ay, b u t we in E ngland, a t an y ra te , have got a
free elem entary-school service an d recognize th a t o u r elem en tary -sch o o l service
is very m uch b e tte r th a n in th e days w hen th e fa th e r did p rovide individually.
W e should have this system in exactly th e sam e w ay as w e have p ublic lib raries
for th e use of all citizens, w h e th e r rich o r p o o r. T h e fa th e rs c an n o t do it. T he
m oney th a t com es into th e w orking-class hom e, even w ith w ages up as th ey are,
is n o t sufficient. H as n o t ev ery th in g else gone up, a n d a re th e w ages v ery high
in p ro p o rtio n ? N ot a t all. T h e w orking-class hom e is n o f fitted to receive a co n ­
finem ent case in a p ro p e r w ay. T h e re a re th o u san d s of hom es unfit fo r a w om an
to lie in, even if it w ere a question of policy a n d n o t of w ages.
W e w an t exactly th e sam e th in g ap p lied to o u r m a te rn ity service. It is no t
enough fo r us to say th a t th e m an should provide. W e w an t th e pu b lic service.
A fter all, th e child is th e asset of th e natio n , a n d w e w an t th e n atio n to recognize
th a t th e w elfare of th e child is its business. D u rin g th e w ar w hen th e S tate
w an ted the boys th ey p u t th e ir h an d s on th e ir shoulders an d to o k them , w ith o u t
an y questions being asked. Now w e w an t th e S tate to realize th a t it is responsible
in exactly th e sam e w ay fo r its children.
T he th in g you m ust consider is w h e th e r you can get a b e tte r service by a
com m unal service, as it w ere, o r by leaving it to th e individual. I th in k th e indi­
vidual system has b ro k e n dow n absolutely, a n d now w e w a n t to p u t in its place
m unicipal an d n atio n al service.
If w e a re going to have a system th a t will w o rk efficiently a n d do th e b est fo r
th e m others, w e have to m ak e it a n atio n al thing, so th a t ev ery w om an can feel
th a t she is accep tin g th a t service as a rig h t a n d as a citizen. If th e re w ere a n y ­
thing th a t savors of a ch aritab le in stitution, o u r w om en w ould n o t a c c e p t it.
W hile I am on this p o in t I w an t to em phasize th a t it should be n a tio n al a n d
free. T he book w e have issued (M a te rn ity ) show s te rrib le exam ples of suffering,
an d y et w e have to recognize th a t o u r w o rk in g w om en a re th e m ost self-respecting,
th e b e tte r class of w ork in g w om en. T h e G uild w ould n o t ad v o cate a n y th in g th a t
savors of charity.
W h at we have to do a t th e p re se n t tim e v ery largely is to ed u cate th e m o th er

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to ta k e h e r baby to th e child-w elfare cen te r. T h e w om en a re g rad u ally seeing
the advantages of this, a n d a re com ing to th ese ce n te rs m o re a n d m o re, feeling
th a t it is th e ir right, as m u ch as it is th e rig h t of th e elem en tary -sch o o l child to
receive its education in th e free school. I w a n t to em phasize th e fa c t th a t w e
w ish to p u t th e w hole questio n of m a te rn ity u n d e r n a tio n a l supervision, so th a t
a w om an can receive m a te rn ity ca:.e a n d nobo d y shall a sk w h e th e r she is ric h o r
poor.
A M em ber: M ay I a sk how th e E nglish w om en a p p re c ia te th e n u rses? W h a t
has been th e ex p erien ce? Do th ey en jo y h av in g th e n u rses com e to th em ?
M rs. B arto n : I saw a case in W ales, in th e m ining district, w h ere th e h u sb an d ,
a m iner, w as o b jectin g to th e n u rse telling his w ife, w ho h ad h ad several children,
w h at to do. I th in k on th e w hole th a t th is a ttitu d e is g rad u ally b ein g g o tten rid
of, how ever.
M rs. W illiam Low ell P u tn a m (B oston, M a ssa c h u se tts): W e have a schem e
som ew hat sim ilar to th a t of th e m o th e r helps of w h ich Mrs. B arto n h as spoken,
th a t is, provision fo r th e c are of sickness in th e hom es of p erso n s of sm all o r m o d ­
era te m eans. T h ey c a n n o t possibly affo rd tra in e d nurses, a n d y e t th e y m u st have
c are in sickness as w ell as d u rin g confinem ent. A cco rd in g ly w e u n d e rta k e to
provide tra in e d helpers, giving th em a co u rse of study. T h ese w om en a re su p e r­
vised by tra in e d nurses, w ho visit th e hom es a n d see th a t th e w o rk is b ein g done
p ro p erly . W e can fu rn ish th ese w om en w ith supervision fo r $18 o r $20 a w eek.
T h a t is n o t a sm all sum , b u t is v e ry differen t from th e p ric e d em anded b y tra in e d
nurses, a n d I believe th e re is a v e ry g re a t fu tu re fo r th a t so rt of care.
D r. S. Josephine B ak er (D ivision o f C hild H ygiene, D e p a rtm e n t of H ealth ,
New Y ork C ity ): A lth o u g h I am a stro n g A m erican , a n d ad v o cate o u r form of
governm ent, it is refre sh in g to get th e m essage th a t M rs. B arto n b ro u g h t us. It
w ould be a w o n d erfu l th in g if th e F ed eral C h ild ren ’s B ureau, o r a n y o th e r n a ­
tional organ izatio n could solve this e n tire p ro b lem of in fan t m o rta lity by one
stro k e of th e p e n in th e w ay th a t E n g lan d h as done it. B ut w e have to do it 48
tim es.
T h e ir m eth o d of hom e help s is p ra c tic a lly new to us. T h e idea of h av in g o n e
visitor to every 500 children, as I believe th e y h av e in E ngland, is so m eth in g th a t
w e o u g h t to copy. T h e fa c t th a t th e G o v ern m en t gives g ra n ts to h elp th ese w om en
d u rin g th e p erio d of p re g n an cy , a n d to see th a t th e ir ch ild ren have th e p ro p e r
care, is som ething th a t w e should give h eed to. E ngland, I believe, h as set u s a
v ery h ig h stan d ard . A n d E n g lan d h as re a p e d its re w a rd becau se E n g lan d s in fan t
d eath rate, as w e all know , is e x tra o rd in a rily low a n d h as gone dow n v e ry m u c h in
th e last few years.


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SER B IA N E X PER IEN C E
By DR. RAD M ILA M ILO C H EV ITC H L A Z A R E V IT C H
L egation of th e Serbs, C ro ats, a n d Slovenes, W ashington, D. C.

T h e question of child w elfare is an urgent question to us. H ow
u rgent it is these few w o rd s will show you, w hich w ere spoken in P a r­
liam ent in B elgrade on the 2 4 th of F ebruary, this year, by one of our
p ro m in en t m em bers, an ex-m inister,' Mr. V . V eljkovitch. H e said:
W e h av e in S erbia 100,000 invalids, 100,000 children w ho need
im m ediate care, an d 5 0 ,0 0 0 o rp h an s.” I w ould ask you to rem em ber
th a t these nu m b ers are tak en from a co u n try th a t h a d b efo re this w ar
4 ,5 0 0 ,0 0 0 inhabitants.
I w an t to try to tell you som ething ab o u t th e urgent conditions
prevailing am ong o u r children in S erbia because I love m y country,
an d know ing th e g re at generosity of the A m erican peo p le to w ard all
opp ressed natio n s a n d all w ho are in m isery, I wish to aw aken y o u r
interest in o u r children.
In attem p tin g to tell you w h at w e h av e d o n e in S erbia fo r th e p ro ­
tection of th e child, I shall n o t b e able to com pare it w ith w hat you
h av e d o n e here, b u t I shall try to give you a little picture of th e history
of th e co u n try w hich will explain to you w hy w e are no fu rth er a d ­
v an ced in this respect. F o r 150 years m y country has b ee n fighting
fo r h er deliverance, during w hich tim e w e h av e h a d ab o u t ten w ars an d
fifteen revolutions. F ighting alw ays for our liberation, w e neglected
m an y o th er im p o rtan t m atters, am ong which was th e scientific stu d y
o f child w elfare.
O u r co u n try h o ld s a high place in th e percentage of large families.
O u r b irth ra te p ro v es this record, b u t alas, our infant m o rtality ra te is
also v ery great. W h y ? B ecause notw ithstanding th e fact th a t our
p eo p le are v ery strong a n d healthy, b a d hygienic conditions exist a n d
ignorance of th e fu ndam ental rules for th e p ro p e r care of th e ex p ectan t
m o th er an d th e b a b y prevails. T h e S tate, w hich has b een obliged to
b u y guns an d m unitions to insure its v ery existence, has h a d neither
the tim e n o r th e m oney to d ev o te to hygienic conditions a n d th e care
of th e m o th er a n d th e baby.
O u r w om en in th e country give b irth to an d b rin g up th eir children
w ith only G o d s help. T h e p re g n an t w om an w orks in th e household
an d in th e field until th e last m om ent. It often h ap p e n s th a t th e b ab y
is b o rn in th e field, w hen th e m o th er picks up h er little o n e an d carries
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it hom e. O n th e m orrow you can see h er again in th e field, b u t this
tim e w ith h e r b ab y so she can nurse him.
O ur m o thers in th e country alw ays nurse their babies; they know of
no o th er k ind of feeding. But in th e cities th e m others h av e a d o p te d
b o ttle feeding. A lthough th e country m o th er nurses h er child, she
know s nothing ab o u t the technique o f nursing an d p rep aratio n an d
technique of artificial feeding if b re ast feeding is n o t possible. T h e
m oth ers are healthy, how ever, an d th e new born b a b y is usually healthy,
to o ; he weighs from eight to tw elve pounds. A lthough I speak in the
presen t tense, this splendid condition existed only b efo re our last
tw o wars. Now afte r seven y ears of h a rd fighting, which h av e b rought
m isery an d privations, w e h av e Jost th e one g ood thing w hich w e had,
nam ely, th e h ealthy new born baby. Epidem ics (especially ty p h u s),
hu n g er an d misery, an d their com panion, tuberculosis, h av e nearly
d estro y ed o ur nation,
h av e lost one-fourth of our population
th rough epidem ics an d w ar, an d those rem aining are m ostly tubercular.
If you are In terested, I beg th a t you will allow m e to re ad you a few
statistics th a t m ay give you a b e tte r id ea of w h at w e h av e b een called
u p o n to m eet in this war.
T h e p o p u latio n of S erbia b efo re th e w a rN v a s.......................................... 4 ,5 0 0 ,0 0 0
I . N um ber killed o r died from w ounds from A u g u st, 1914, to D ecem ­
ber, 1915 . . . . . . ............................................. .. . .............................. .. - • 170,925
* 2. D eaths in civilian p o p u la tio n from ep idem ics. .............................. ..
3 5 0,000
3. Soldiers killed d u rin g th e re tre a t in th e au tu m n of 1 9 1 5 ............... .. 150,000
4. Soldiers dead fro m h u n g e r a n d starv atio n in A lb an ia d u rin g th e
sam e p e r i o d ........... v . . ..................................................................... ..
60,000
5. Boy recru its dead from h u n g e r d u rin g th e r e tr e a t.................................
80,000
6. D eaths from h u n g e r a n d cold am o n g civilian p o p u la tio n d u rin g th e
re tre a t ..................................................................... ............................... • • • 2 50,000
7. P riso n ers and in te rn e d in B ulgaria, A u stria, an d G e rm a n y .......... ..
130,000
8. N um ber killed (h a n g e d a n d sla u g h te re d ) by th e B ulgarians, A us­
trians, an d G e rm a n s.......... .......................................................................*
60,000
9. N um ber killed d u rin g a revolution in N ish ,P ro k o u p ile,an d L esk o v a tz
40,000
10. Soldiers killed on th e Saloniki f r o n t................... .....................................
40,000
T o t a l ................................ ..................... ............................... . 1 ,3 3 0 ,9 2 5

So y ou see w e are n o t w hat w e Were b efore this terrible conflict.
O u r m oth ers can give no m ore little giants to their country. T h e
w om en as well as th e m en h av e d eterio rated in health.
B efore th e w ar w e h a d b egun to d ev o te som e atten tio n to th e w elfare
o f th e child, b u t only through p riv ate associations, w ithout th e help of
the S tate. N ow we are beginning to realize the im portance of th e
h ealth o f th e child to th e nation. In 1917, after our retreat, we
started in V o d e n a th e Society for th e P ro tectio n of C hildren, w ith Dr.
P opovitch as president. T h e aim of th e society w as to look afte r th e

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physical an d m oral health of th e children; to find out th e causes of all
sickness an d if possible to p ro v id e rem edies; to reduce th e m ortality
am ong children, an d also to care for the ab a n d o n ed children of refu­
gees an d soldiers. N ow our U nited K ingdom of the Serbs, C roats, an d
Slovenes started on th e 5 th of F ebruary, 1919, th e S tate D ep artm en t
fo r C hild W elfare. T h e vice-m inister p resident is in charge of it, which
show s how earnestly the S tate takes the problem . T h e n u m b er of
children w ithout b o th p aren ts is ab o u t 120,000; the n u m ber w ith only
one p aren t lost, 5 0 0 ,0 0 0 .1
1 T h e statistics are n o t y e t com plete.


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U R B A N PR O B LEM S
By DR. HENRY F. H ELM H OLZ
M edical D irecto r, In fan t W elfare. Society, C hicago

T h e care of infants in a city falls logically into th ree divisions:
1. T h e care of th e u n b o rn infant.
2. T h e care of th e infant during an d im m ediately a fte r th e b irth act.
3. T h e p o stn atal care of th e infant.
A t th e p resen t tim e in m ost com m unities th e p re n atal care of th e
in fan t is alm ost entirely neglected. T h e p o stn atal w o rk has reduced
th e d e a th ra te from d iarrh eal diseases an d respiratory infections very
m arkedly, b u t h as n o t affected th a t of congenital diseases, w hich has
rem ained p ra ctically constant. O ne-third of th e to ta l d e a th s of in­
fants u n d er on e y e a r occur in th e first m o n th of life. T w o-thirds of
these d ea th s occur in th e first ten days. T h e y a re caused largely b y
conditions th a t are p re v en tab le b y p re n atal care. P rem aturity, syp
ilis, stillbirths, an d b irth injuries can in a larg e m easure b e overcom e by
g o o d p re n atal care. T h e supervision o f th e m o th er should include ( )
ad vice as to diet, ( 2 ) control of th e urine an d b lo o d pressure, (3 )
pelvic m easurem ents, a n d ( 4 ) a routine W asserm ann exam ination of
all m others. W ith ad e q u a te trea tm e n t during p regnancy th e ravages
of syphilis w ould b e v ery m ark e d ly reduced. Law s to p re v en t m others
from w orking in factories during th e last m onths of th eir confinem ent
w ould increase th e w eight o f th e new born* b a b y b y p o u n d s a n d so
red u ce th e group th a t are a t p resen t dying from prem aturity. F u rth er­
m ore, th e exam ination an d m easurem ent of th e pelvis w ould cull out
th a t group of m o th ers th a t w ould p ro b a b ly n eed hospital care an d
should n o t b e tak en care o f in th e h o m e a n d b e rushed a t th e last
m inute to th e hospital w hen it is to o la te to save th e b a b y a n d p ro b a b ly
th e m o th er also. C o n stan t w atching a n d control of urine a n d b lo o d
pressure will reduce m aterially th e m atern al as w ell as th e in fan t d ea th
A s a m inim um to d o this w o rk one nurse to every th re e h u n d re d
b irth s w ould b e required. T his v ery im p o rtan t p e rio d has received
relatively little atten tio n a n d deserves v ery m uch m ore. T h e results
of p ren atal care will becom e especially ev id en t if th e w o rk is d o n e
in close coo p eration an d coordination w ith th e actual b irth care of th e
child. O nly w hen p ro p e r facilities in hospital an d h o m e are a t h an d
can th e results of pren atal care m anifest them selves. If th e lying-m
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hospital facilities are insufficient to care fo r th e p ro b a b ly difficult cases
th a t h av e b een discovered in the routine exam ination of th e pren atal
w ork, th en natu rally m uch of th e w ork will go fo r naught. It is th ere­
fore im p o rtan t th a t ad e q u ate hospital facilities are a t h an d to care for all
difficult cases an d an am ple obstetrical out-patient service to care for
th e m oth ers w ho rem ain a t hom e. W h a t th è ultim ate outcom e of th e
m idw ife o r obstetrical nurse question will b e I d o n o t know , b u t certain
it is th a t i f th e busy general practitioner alone is in atten d a n ce th ere
will b e entirely too m any forceps deliveriés. W e m ust h av e som eone
w hose d u ty it is to carry through th e w atchful expectancy necessary
to a n orm al labor.
|
Im p o rtan t as is th e close coordination betw een th e p ren atal an d
th e obstetrical w ork, still m ore vital to th e w elfare of the infant is
co n stan t u n in terru p ted supervision from birth. T o o frequently at p res­
ent v alu ab le tim e is lost, an d instead of bringing a norm al b reast-fed
infant to th e infant-w elfare station th e m oth er brings an infant th a t
is w eaned and. is suffering from som e gastrointestinal disturbance. In
our w ork in C hicago o v er tw o-thirds of all babies com e to us for the
first tim e w hen th ey are o v er tw o m onths old. A s th e d ea th ra te is
highest d uring th e first m o n th of life, our p o stn atal w ork has m issed
this v ery v alu ab le p erio d for its w ork. .
T h e p o stn atal w ork m ust begin early. T h ere m ust b e a regular
tran sfer of the case from th e obstetrical nurse to th e infant-w elfare
nurse. A s is quite generally accepted a t th e present time, th e m ost
successful p o stn atal care is given in th e inf ant-w elfare station to which
th e m o th er brings h e r b a b y a t regular intervals to b e w eighed an d
exam ined, a n d to receive instruction from th e d o c to r regarding th e
care an d feeding of h er child. T h e station nurse follows up this instruc­
tion b y visiting the m o th er in h er hom e a n d showing h e r how w ith h e r
utensils she can p re p a re th e b a b y ’s food an d arran g e h e r hom e hygienically. W ith reg ard to feeding, th e em phasis m ust b e placed first an d
forem ost on b re ast feeding. T h e closer th e cooperation w ith institu­
tions doing th e obstetrical w ork th e g re ater will b e th e num ber of
m o th ers th a t can nurse their babies. In our experience, im p ro p er
teaching a n d technique of nursing, an d n o t th e unwillingness to nurse,
account fo r th e large n u m b er of artificially fed babies.
T h e artificially fed child m ust h av e goo d milk, constantly controlled
an d supervised. It seem s to m e likely th a t in the n o t v ery d istan t
future p o w d e red m ilk will in a large m easure replace th e fresh m ilk b e ­
cause it is safer a n d cheaper. T h e supervision of th e milk, th e housing
question, w ater supply, garb ag e disposal, an d flies are o f g reat im p o rt­
ance to the child of th e city. T h ey m ust b e closely w atched b y our
h ealth d ep artm en ts. T h e housing question is one th a t needs m ore
atten tio n th an any of th e others because th e public has n o t b een edu
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cated up to th e im portance of this factor in its relationship to infant
m ortality.
T h e hygiene of th e hom e, on the o th er hand, the ventilation, the
bath, the sleep, th e clothing, an d th e fresh air m ust b e looked -after
by th e station d o cto r an d nurse. In th e postnatal w ork th e nurse
can care for n o t o v er 150 babies. In close cooperation w ith the. infantw elfare stations w e m ust h av e am ple dispensary an d hospital facilities
to w hich th e sick infants can b e referred from th e stations. Ju st one
w o rd w ith reg ard to th e preschool age. T h e care of the child from
two to six can in all probability b e b est looked after in connection
w ith th e inf ant-w elfare station. W e h av e a t present in C hicago six
such stations in operation.
In every city we ought to have an organization th a t is doing b o th
th e p ren atal an d the postnatal w ork, this organization to b e closely
affiliated w ith th e various organizations th a t are doing the city’s o bstet­
rical w ork, connecting an d consolidating the w ork which is being done
fo r m o th er an d child so as to keep them constantly u n d er supervision.


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M A T E R N IT Y C EN TER S IN N EW Y O R K C ITY
By DR. R. W . LOBENSTINE
New Y ork City

W e are considering to d a y the m om entous question of providing this
country with the m eans of m ore adequately safeguarding m otherhood.
U pon our decisions m ay rest the ultim ate fate of m illions of w om en
and children, w ho are dying or who are crippled because of p o o r m edi­
cal an d nursing care, o r no care a t all.
N ever b efo re h av e nations been b ro u g h t to such a keen realization
of the value of the m o th er an d h er child. 'With th e frightful losses at
th o front, with ( the startling ravages of th e w orld plague continually
b efo re us, an d w ith th e inevitable injuries w rought in th e hom e b y the
strenuous efforts of war, conservation of life stan d s out as th e pressing
n eed of th e hour. .
O u r aim should b e to furnish every m o th er during p regnancy with
intelligent oversight, to p ro tec t h e r from th e d an g ers incident to indus­
trialism, an d to re n d er childbirth reasonably safe. R eckless sacrifice of
in fant life should stop. C hildbearing has long b een re g ard e d as m erely
th e natu ral lo t of w om en, an d its h azard s h av e been either neglected or
accepted as inevitable. C an a function, how ever, th a t kills thousands
of w om en annually, th a t cripples m an y th ousands m ore, an d th a t is re­
sponsible fo r a v ery large infant m ortality, b e called safe? C hild­
bearing still possesses for the m o th er m any dangers— som e of which
are av o id ab le an d som e of which "are n o t; b u t this w e know , an d we
know it v ery definitely, th a t th e closer th e supervision during pregnancy
an d th e b e tte r the care a t th e tim e of delivery, the few er will b e these
com plications an d th e m ore satisfactory will b e th e results.
W e find, m oreover, th a t approxim ately fifty p e r cent o f gynecologi­
cal o perations are p erfo rm ed fo r injuries resulting a t th e tim e of l a b o r injuries m an y of which are p rev en tab le an d m ost of w hich could be
fairly satisfactorily trea ted a t th e tim e o f their occurrence o r soon
after. T h e tru th is th at w e can n o t estim ate th e num ber of partial or
com plete invalids who are invalids as the result of either p o o r nursing,
inefficient m edical attention, o r m eddlesom e m idw ifery a t th e tim e of
m iscarriage or a t the tim e of labor. F urtherm ore, spontaneous an d
crim inal abo rtio n s occur w ith astounding freqüency. T h é g reat m a jo r­
ity of w om en h av e little o r no care a t such times. A s a result o f ignor­
ance, thoughtlessness, an d th e failure to grasp th e real significance of
unnatural term ination of pregnancy, thousands never recover their
health.
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T u rning to the new born child, w e find th a t although th e loss in life
du e to stillbirths is unduly high, an d th a t although approxim ately
fo rty p e r cent of all d ea th s of infants u n d e r one y ear of age are d u e to
congenital causes, nevertheless, progress in rem edying such a d e p lo ra ­
b le state of affairs is v ery slow. In New Y o rk C ity during th e thirtyy ea r p erio d from 1884 to 1914, th e d e a th rates from diarrheal, resp ira­
tory, an d contagious diseases h av e b een m ark e d ly red u ced — ap p ro x i­
m ately seventy-five p er cent, fifty-three p e r cent, an d eighty-eight p er
cent respectively— while th e d ea th ra te from congenital diseases has
b een red u ced b y only pne an d one-half p e r cen t.1
Since th e first y ea r of th e w ar o u r b irth rate, as in E urope, has gone
d ow n everyw here, while our m o rtality ra te has steadily gone up.
A ctual d ea th is one thing, b u t w h at ab o u t th e child th a t lives fo r a
sh o rt time, o r fo r m any years im m ature in b o d y a n d m ind o r actually
d efo rm ed ? T hese abnorm al o r subnorm al beings are so in p a rt because
of causes o v er which w e h av e m o re o r less control, an d in p a rt because
of factors arising in th e course o f p regnancy o r during labor, over
which w e m ay a t tim es b e alm ost pow erless. T h e studies carried on
b y th e F ed eral C hildren’s Bureau, as w ell as b y certain public an d
p riv ate organizations in this country, all strikingly reveal th e fact th a t
“th e nine m o nths of intra-uterine .life coupled w ith th e first m o n th after
b irth rep resen t th e high m ark of d an g e r in th e life span of every in­
d iv id u al.’* It is high tim e th a t every com m unity should b e roused to
the fact th a t th e logical tim e to begin guarding infant life is n o t afte r
birth, b u t ra th e r in th e earlier perio d s of developm ent.
T his is th e era o f p reventive m edicine. It is because w e believe in
prevention, co u p led with coordination of effort, th a t w e m eet in con­
ference a t this tim e. W ith p ro p erly organized clinics, such as can b e
established in progressive com m unities, w e feel justified in stating th a t
th ere should result a reduction of from th irty to thirty-five p e r cent
in th e d ea th s u n d e r one m onth of age; a m aterial low ering in the
n u m b er o f stillbirths; a reduction in p rem atu re birth s o f a t least tw entyfive p e r cent an d in th e m atern al d ea th ra te of from sixty to sixty-five
p e r cen t b elow th e general ra te of unsupervised cases. T his g reat con­
servation m o v em ent is, aside from its m edical an d nursing aspects, a
g re at social u n d ertaking. It is a fight against p overty, filth, rum , tu b e r­
culosis, a n d ignorance of the b arest fundam entals of health. , These
are th e hostile forces th a t are ever busy, ever eager to accom plish
th e physical an d m oral undoing of th e com m unity. E x p ectan t m others
an d yo u n g children fall easy p rey to th eir attacks. A s Mrs. W est, of
th e C hildren’s B ureau, h as well said, “ O ne of th e reasons which es^ a c o b Sobel, M. D., D e p a rtm e n t of H ealth , New Y o rk C ity: “ In stru ctio n an d
S upervision of E x p e c ta n t M others in New Y o rk City,** in New Y ork M edical
Jo u rn al, V ol, CVII, No. 2 (Ja n . 12, 1 9 1 8 ), p. 49.

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pecially justify the necessary expenditures for giving p re n atal care, is
th a t in studying th e pro b lem of th e m o th er w e g et closer to th e fu n d a­
m ental causes of suffering th an in alm ost an y o th e r w ay.” In passing,
we should recall th a t ap proxim ately forty p e r cent o f th e lab o rs
th ro u g h o u t th e co untry h av e b een h an d led , in m o st p art, b y careless
an d unclean m idw ives; an d th a t a v ery considerable p ercentage of
the o th er sixty p e r cent o f th e w om en h av e been in th e care of physi­
cians p o o rly train ed in obstetrics, w ho h av e been g ra d u ated from
the m edical schools w ith only a m inim um am ount of practical equip­
m en t fo r this b ran ch of m edicine.
T h e p ro b lem of th e city differs in m any respects from th a t o f rural
districts. O n th e one h a n d it is easier because distances are less g re at
th an in th e country, thus offering g re ater accessibility to doctors, to
nurses, an d to h o sp itals; on the o th er hand, it is m ore com plex because
of th e overcrow ding, th e frightful poverty, an d — in m an y cities a t
least— because of th e g reat m ixture of races.
In N ew Y o rk C ity w e began tw o years ago to d evelop a p lan for
th e co o rd in atio n an d extension of m atern ity care am ong th e poor.
A fte r th o ro u g h investigation, it w as found th a t w hile m uch g ood w ork
w as being carried on b y th e d ep a rtm en t of health, b y m aternity h o s­
pitals, an d b y a few lay organizations, y et on the w hole th e situation
w as unsatisfactory. T his w as d u e in p a rt to th e inadequacy of th e care
given, in p a rt to th e confused sta n d a rd s of m edical a n d nursing super­
vision, a n d p erh ap s especially to th e ev id en t lack of coordination a n d
to th e relatively sm all n u m b er of ex p ectan t m o th ers reached. W e
th erefo re b eg an to look a t th e n eed s of the obstetrical com m unity n o t
from th e stan d p o in t of th e individual clinic o r of a particular society,
b u t from th e stan d p o in t of com m unal interest.
T h e first question to p resen t itself w as one of distribution of hospital
cases. B y m ean s of a m ap, th e house location of every w om an cared
for b y th e different m atern ity hospitals in th e B orough of M anhattan
during th e y e a r 1915 w as graphically shown. By studying th e dis­
trib u tio n of these erases in their relationship to existing clinics, a n d a t
th e sam e tim e com puting th e to tal n u m ber of births in different sections,
th ere w as d ev e lo p e d a zoning system . A s it now stands, th e borough
is d iv id ed into ten zones, each zo n e com prising a group of official census
districts. T h e p lan itself, how ever, is n o t an official one. T h e B orough
of M an h attan has, roughly, tw o an d a h alf m illion in h ab itan ts w ith
from sixty to sixty-five th o u san d birth s annually. T h e districting has
m an y ad v a n ta g es: First, it encourages the hospitals to d raw their
p atien ts from th eir particu lar zo n e ra th e r th an from a g re at distance*
th u s ren d erin g p re n atal oversight of their registered cases fa r easier,
b y econom izing th e tim e o f b o th p atien t an d visiting nurse; second, it
encourages p atien ts to seek hospital aid m ore readily because of their

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g re ater fam iliarity w ith th e hospitals in their ow n neig h b o rh o o d ; and
th ird, it form s th e basis for our entire m aternity center plan. T h e
M atern ity C en ter A ssociation early in its career d ecided on a b ro a d , farreaching p rogram . T h e difficulties w ere in a large m easure foreseen,
b u t th e g re at call for help could n o t go unheeded. T h e originators of
th e m o v em en t h a d in m ind th ree fundam ental purposes:
First, th e co o rd in atio n of th e w ork of those agencies already in th e
field engaged in m atern ity w elfare.
Second, th e aw akening of com m unity interest in the needless sacri­
fice of h ealth a n d life an d in th e value of p ren atal care b o th to m other
an d child.
T h ird , the p ro viding of ad d itio n al nurses for field w ork, an d the
establishm ent of new p re n atal clinics in th e several zones w henever
existing agencies should p ro v e unable to cope w ith th e dem and.
W ith these definite objects in m ind, w e felt th a t th e m ost satisfactory
m eth o d of attack in g th e p ro g ram w as through th e establishm ent of a
m atern ity cen ter in each zone.
In th e B orough of M an h attan ab o u t thirty-three p er cent of th e births
w ere cared fo r b y th e in d o o r an d ^o u td o o r services of m aternity h o s­
p itals; y e t a t th e beginning of this m ovem ent m ost of these either h a d no
follow -up system during pregnancy, or h a d a t b est a very inadequate
one. By arousing com m unity interest, w e h o p ed n o t only to reach
g rad u ally th e rem aining sixty to seventy-five p er cent of ex p ectan t
m others, b u t w e confidently lo oked forw ard to th e tim e w hen the
hospital b o a rd s w ould b e aroused to th e need of system atic social an d
nursing service in the hom es of their registered m others.
D uring this first y ear of definite organization, nine of th e ten zones
h av e m atern ity centers; th e ten th zone, having b u t a sm all annual
b irth rate, h as b een left for later developm ent. O ne of th e great
difficulties in N ew Y o rk City, as in m ost o th er com m unities, lies in th e
fact th a t th ere are available all too few “ freje o r m o d erately p riced ”
obstetrical beds. In th e large B orough of M anhattan, w ith its great
congestion, w e find th a t th ere are n o t m ore th an 725 available b ed s
to acco m m o d ate the m any w ho are really in sore n eed of hospital
attention. In the B orough of B rooklyn, w ith approxim ately tw o m illion
inhabitants, a careful survey m ad e b y som e of th e physicians there
recently show ed th a t they h a d scarcely 275 available beds. T hink of it,
a n d we are progressive!
T h ere are engaged in this p ren atal w ork, a t th e present tim e, ab o u t
58 nurses an d p erh ap s a half score of social w orkers. T h e num bers
em p lo y ed fluctuate som ew hat, from m onth to m onth. Several of th e
h o sp itals are now giving their u n d erg rad u a te nurses, through the
m atern ity center, a num ber of w eeks’ training in m aternity care in the
tenem ents. F urtherm ore, a certain num ber of student nurses, w ho are

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taking the public-health course a t th e T eachers’ College, a n d a t the
H en ry S treet S ettlem ent, are likewise receiving p o st-g ra d u ate training
in th e care of obstetric p atien ts u n d er th e difficult conditions presented
by tenem ent-house life.
T h ere are at the present time, tw enty-one clinics for ex p ectan t m o th ­
ers in th e B orough of M anhattan, in ad d itio n to th e regular hospital
ones. A ll of these aim to follow th e sam e general standards, an d all, I
am sure, are looking forw ard to continued im p rovem ent in th e service
ren d ered th e com m unity.
A m atern ity center should b e th e cen ter of an educational cam ­
paign fo r p ren atal care of the m others of the district. (T h e fathers,
too, need education an d should n o t b e n eg lected !) It should b e the
co o rdinating agent o r clearing house for th e expectant m others in th e
zone. It should keep records of every case com ing u n d er th e care of
th e clinics in th e neighborhood an d follow up each case so th a t no
w om an who registers will b e allow ed to slip o ut from u n d e r m edical
care b y reason of illness, carelessness, o r o th er causes. It is this fol­
low -up system , afte r all, which is the chief p oint of th e .w hole scheme.
Nurses an d social w orkers should b e used as follow -up visitors in o rd e r
to keep in touch w ith each ex p ectan t m o th er in th e district. H ow im ­
p o rta n t this is m ay b e realized from th e studies of th e B ureau of Child
H ygiene in New Y o rk City, w hich has disclosed th e fact th a t from thirtyfive to fo rty p e r cent of th e p o pulation of childbearing age of a given
section m o v e during th e year; an d th a t som e of these families m ove
as frequently as th ree o r four tim es during th e year.
T h e cen ter should p ro m o te an d extend the w ork of every agency
w orking w ithin th e zone, th at is engaged in th e problem s of m aternity
an d child w elfare. It should secure th e opening of new p ren atal clinics
conveniently lo cated w hen n o t enough of these clinics exist to serve the
need s of th e district. T h e district d octors an d m idw ives should be
urged to b ring their cases to these clinics fo r consultation. It should
be open d a y an d night for em ergency calls an d should see th a t a d o cto r
or m idw ife is supplied for all cases of labor, an d a nurse for abnorm al
labors. T his b ey o n d question is p erh ap s our h a rd e st pro b lem to solve,
an d on it b u t v ery little w ork has as y et b een done. In the districts in
which th ere is no hospital w ith an ou t-p atien t obstetrical service, the
pro b lem of supplying th e p atien ts with even fair m edical atten d a n ts
(e ith e r d o cto r o r m idw ife) is a difficult one. T h e m idw ife situation
in New Y o rk C ity is greatly im proved, b u t th e m edical aspect is less
satisfactory. In the new p ren atal clinics th a t are being d ev elo p ed by
th e M aternity C en ter A ssociation, w e are endeavoring to p ro v id e
w om en physicians as far as possible, in o rd e r through these clinics to
reach the large class of foreigners w ho go to the m idw ife because of
their prejudices to w ard s th e m ale physician. T hese prejudices m ay

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b e considered u nim portant, b u t they can only b e b ro k e n dow n slow ly
an d cautiously.
A ll th e clinics are stan d ard iz ed so far as records, nursing care, an d
m edical oversight are concerned, an d an effort is being m a d e to en­
courage all *'ab n o rm al cases” to go to th e hospitals fo r supervision an d
delivery. . Such a system will g radually ex ten d its benefits to a large
p a rt of th e p o o re r classes in th e com m unity; in tim e it should gradually
a n d effectively elim inate th e m idw ife; it should raise m ark e d ly the
general averag e of obstetrical know ledge am ong th e d o cto rs w ho m ost
n eed this experience; it should lessen th e m aternal invalidism so often
a result of p o o r obstetrical care; an d it should do aw ay w ith m an y of
the evil results affecting th e child d u e to im m aturity o r injury during
labor.
T his is a com prehensive plan fo r th e guarding of in fan t life from
th e p re n atal state through childhood to young adolesence. If carried
out it offers a progressive, system atic schem e for the com pilation of
accurate statistics in this country. W e n eed national, state, an d m u­
nicipal action. T h e m achinery m ust b e p ro v id ed b y w hich th e p o o r
can find it possible to raise fam ilies w ithout u ndue sacrifice of health
o r unreaso n ab le financial strain.
S ta n d ard s of p ren atal requirem ents for b o th hospitals an d m aternity
cen ter clinics w ere form ulated b y th e M aternity Service A ssociation of
Physicians. T h ese requirem ents are:
1. P atien ts should b e urged to register a t a clinic early in p re g ­
nancy. T h is is of g reat im portance in order- to obtain p re n atal care
a t an early d ate, a n d in o rd e r th a t th e physicians m ay d eterm in e th e
présence o r absence of abnorm alities. S trange as it m ay seem, tw o of
o u r leading obstetrical hospitals h av e until recently b een unw illing to
exam ine ap plicants until in th e fifth an d seventh m onth of pregnancy,
respectively.
2. A t th e first visit patients should b e given p rin ted instructions
fo r th eir general guidance during pregnancy. T h e instructions given
are sim ple an d concise an d will b e re ad w hen m o re elab o rate ones
w ould b e d isreg arded.
3. P atien ts should b e urged to return every four w eeks (ev ery
tw o w eeks fo r m atern ity center p atien ts) up to th e en d o f th e sixth
m onth, an d every tw o w eeks th ere after (fo r m aternity cen ter p atien ts
every ten day s up to eight m onths a n d every w eek th e re a fte r). If
th ey d o n o t d o so, a postal should b e sent, an d if th ere is no answ er
w ithin tw o days, a nurse o r social w orker should visit th e house. In
case th e p atien t’s condition is n o t entirely satisfactory a t th e tim e
o f an y on e visit, an d in case she does n o t return on an y ap p o in ted
day, th e visit to th e hom e should b e m a d e a t once. By such w atch­
fulness a considerable n um ber of com plications m ay b e avoided. T hese

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h o m e visits are of particu lar value in obtaining th e confidence an d in ­
terest of the p atient. T hey enable th e visitor to fam iliarize herself w ith
th e p articu lar social a n d econom ic difficulties of each fam ily u n d er
h e r care, a n d afford an o p p o rtu n ity of teaching the fundam entals of
perso n al hygiene.
4. T h e p atien t should bring a specim en of th e urine a t each visit.
5. T h e m edical exam ination shall include:
(a )
T h o ro ugh physical exam ination.
(b )
U rine exam ination every four w eeks up to six m onths,
a n d every tw o w eeks th ere after (m atern ity center cases every week
d uring th e last m o n th ).
(c )
A b lo o d pressure estim ation a t each visit.
(d )
A W asserm ann test in every suspicious case (this can be
carried o u t th ro u g h th e b o ard of h e a lth ).
DISCUSSION
M rs. W illiam Low ell P u tn a m (B oston, M assach u setts) : I have a v e ry stro n g
belief th a t th e peo p le of m o d erate m eans a re th e p eople w ho a re least c a re d fo r
in this m a tte r of p ro te c tio n of th e h e a lth of m o th ers a n d children. F o r five y e ars
w e have carried on an e x p erim en t in Boston to try to b rin g this c are W ithin th e
re a c h of those m others w ho c a n n o t affo rd th e p rices re q u ire d by th e b est p h y si­
cians, a n d y et w ho should n o t be offered ch arity , a n d w ho u n d e r no circu m stan ces
w ould consent to ac c e p t it. W e have n o t y et m ade this ex p erim en t pay , b u t
w e have m ade a sta rt. W e have been given th e use o f tw o room s a t a hosp ital fo r o u r clinic. O u r p lan re q u ire s a t least tw o visits by th e p a tie n t to th e
clinic fo r m edical c a re ; th e n ev ery ten days a visit to th e hom e by th e n u rse from
a s early in th e p re g n a n c y as th e p a tie n t can be p ersu a d e d to ap p ly . T h e n u rse
is also p re s e n t w ith th e d o cto r a t confinem ent, w hich, if possible, tak e s place
m th e hom e. If th e re is a n y com plication, th e p a tie n t m u st be ta k e n to th e hos­
p ital. A fte r confinem ent follow tw o to fo u r m o re visits b y th e d o cto r, acc o rd in g
to th e n eed ; visits tw ice a day fo r th re e days b y th e n u rse ; once a day fo r th e n e x t
tw o days, a n d th en less fre q u e n tly u n til th e m o th e r is able to g e t up, b y w hich
tim e she has h ad a good o p p o rtu n ity to observe th e p ro p e r w ay to c a re fo r h e r
child.
W e have th o u g h t th a t w e could su p p ly such c a re w ith th o ro u g h ly tra in e d
p hysicians a n d n u rses fo r $25 a case fo r th e w hole perio d . A s I say, I am n o t
su re of th is; w e m ay have to raise th e p ric e . T h e o nly th in g I am su re o f is th a t
w e shall n o t tak e a case fo r ch arity , becau se th e w hole o b je c t is to provide c a re fo r
those of lim ited m eans an d to provide it w ith o u t d ep en d en ce on m edical schools
w h ere stu d en ts can be used w ith o u t expense.
I th in k th a t if this can be done, o u r ex p erim en t o u g h t to be w o rth y o f being
copied m o th e r places. If w e can p ro v e th a t this care can be given fo r $30 o r
even $35 a case, th a t ought, to be of value to th e com m unity, a n d I hope w e shall
be able to b rin g this ab o u t.


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R U R A L PRO BLEM S
By MISS ELIZABETH G. FO X
D irector, B ureau of P ublic H ealth N ursing, A m erican R ed C ross

T h e rural m o th er needs the sam e p renatal, natal, an d p o stn atal care
an d ad v an tag es as th e city m other. She needs to b e k ep t well, p ro ­
tecte d from av o id ab le com plications, p ro v id ed with ad eq u ate m edical
an d nursing care during th e lying-in period, pro p erly instructed in in ­
fan t hygiene, an d guided in caring for h er infant.
T ran slated into concrete term s, she should h av e a t least one tho ro u g h
m edical exam ination including pelvic m easurem ents an d urine an d
b lo o d tests. W h ere a venereal disease is discovered, suitable tre a t­
m en t should b e available. She should b e visited frequently b y a publich ealth nurse w ho w ould teach h er how to care for h er health an d to
p re p are fo r confinem ent, w ould help h er to arran g e for m edical care,
an d w ould m ak e urinalyses. Som e arran g em en t should b e m ad e to
relieve h e r of h er m ore arduous duties such as washing, carrying w ater,
an d m ilking. A hospital should b e w ithin reach for th e care of all
com plicated cases, an d possibly also for those norm al cases th a t m ight
b e ab le to tak e ad v a n ta g e of it. A fte r confinem ent th e m o th er should
continue to b e visited frequently b y a public-health nurse, who w ould
w atch an d g u ard th e b ab y ’s grow th an d w ould teach h e r how to give
it intelligent care; w ho w ould encourage m aternal nursing, an d w ould
show h e r th e relation betw een this function an d h er ow n health. It
should b e possible for h e r to secure advice from a d o c to r fam iliar w ith
m o d ern p ed iatrics if th e b a b y shows any d e p a rtu re from norm al o r if
it becom es necessary to reso rt to artificial feeding.
It is one thing to outline these essentials; it is quite an o th er thing
to p ro v id e them . A num ber of difficulties lie in th e w ay of such p ro ­
vision, som e o f which are now slowly being rem oved while others re­
m ain. O ne of the chief difficulties is th e iniaccessibility of ad eq u ate
m edical care. In m any rural localities, the distance (between farm
houses, p o o r roads, a n d th e large area covered b y one d o cto r m ake his
atten d a n ce a t confinem ent v ery uncertain an d often im possible, an d
also p artly account fo r th e frequent absence of p re n atal an d postnatal
visits. It has b een show n th a t m any co untry w om en d o entirely w ith­
out m edical supervision b o th b efo re an d afte r confinem ent, relying
entirely upo n th eir ow n resources except for th e actual delivery.
F urtherm ore, m any country people, unused to handling m uch re ad y
186

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m oney, are u n ab le o r not inclined to afford the cost of good m edical
care. T h ey h av e not y et learned to regard childbirth as a serious an d
im p o rtan t event an d do n o t u n d erstan d th e justice of th e seem ingly
high price w hich th e d o cto r places u pon this service. Even should they
recognize his fee to b e a p ro p e r one, p o v erty w ould m ake it im possible
fo r som e of them , p erh ap s a g ood p ro p o rtio n of them , to p ay it. M any
co u n try doctors, m oreover, are n o t inform ed concerning th e best o b ­
stetrical practice, to the g reat an d som etim es fatal disad v an tag e of th e
w om an w hose p regnancy or delivery m ay b e com plicated.
T h e result of all this is th a t m any country w om en are cared for en ­
tirely b y neighbors, w ho m ay o r m ay n o t h av e acquired som e skill from
experience; o r b y their h usbands; or in som e p arts of th e country, by
m idw ives. N orm al cases usually survive this am ateu r assistance, b u t
ab n o rm al cases suffer a high injury an d d eath rate. E xcept to those
living n ea r sm all tow ns o r cities, hospital care is practically unknow n.
C om plicated cases no m a tte r how serious rem ain a t hom e. V ery few
farm ers’ wives w ould find it possible to leave their hom es well in a d ­
vance of confinem ent in o rd e r to travel to a hospital in som e distant
city.
M any counties an d com m unities h av e n o t as yet installed a publich ealth nursing service. M oreover, even w here public funds are avail­
ab le fo r m aintaining a public-health nurse, h er w ork is often directed
to w ard th e d ev elo p m en t of school nursing. W here th ere is b u t one
public-health nurse in th e county, as is usually th e case, an d she is ex­
p ected to m ak e school nursing h er p rim ary duty, she cannot u n d ertak e
also to dev elo p a p ren atal an d m aternity service. If she is allow ed to d e ­
v elop a general service, she can give prenatal, natal, an d postnatal care
a n d can elim inate m any of the dangers which now surround childbirth
in th e country.
A n o th er condition which causes m an y m iscarriages an d underm ines
th e h ealth b o th of m o th er an d b ab y is th e heavy w ork w hich the m other
m ust perform . M any a farm er’s wife does h er daily chores, even to
carrying w ater long distances, up to the v ery eve of h e r confinem ent;
a n d she resum es them within a v ery few days afte r it. T hese duties
m ust b e carried on, an d servants are h a rd to secure even w hen the
fam ily b u d g et p erm its of tKeir em ploym ent. R elatives an d neighbors
are generous w ith their services, b u t usually h av e families of their own,
an d can n o t b e expected to assum e household duties o th er th an their
ow n fo r an y length of time.
A n o th e r foe, usually m ore b efo reh an d th an the d o cto r or th e nurse
can be, is th e p atent-m edicine vendor, who finds all too read y a sale for
his wares. A n d finally, behind all of these difficulties lies the ignorance
o r th e indifference of the farm er an d his wife. A lthough th ere is a
g reat aw akening everyw here— as a result of the lessons tau g h t b y th e

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STANDARDS O F C H IL D W E L F A R E

w ar an d th e w o rk of th e C h ild re n s Y ear C am paign— to th e im p o rt­
ance of safeguarding pregnancy, m aternity, a n d child life, m uch m ust
still b e d o n e to tran slate this new know ledge into conviction, d eterm in a­
tion, an d action. T his pro b lem has b een discussed fo r a n u m ber of
years, an d various partial rem edies h av e b een suggested. No definite
experim ents h av e y et b een re p o rted to p ro v e their w orth.
T h e ra p id d ev elo p m en t of rural public-health nursing seem s to
offer one of th e m ost im m ediate a n d tangible rem edies. In o rd e r to
m ake th e nurse’s w ork a t all effective, counties m ust b e d iv id ed into
districts w ith a general nurse in each district. S he will then h av e tim e
to teach th e rural w om en th e hygiene of pregnancy, to visit them fre­
quently, to w atch for sym ptom s of complications,^ to m ake urinalyses, to
care fo r w om en during an d afte r confinem ent, a n d to teach them th e
principles of in fant an d child hygiene. S he to o can convince th em an d
th eir husb an d s of th e necessity for p ro p e r care throughout this p eriod
an d m ay b e ab le to find w ays to help them lessen their household
burdens.
Som e w ay m ust b e found of providing ad e q u ate obstetrical service.
A s such service m ust b e of th e b est it will necessarily b e costly. It m ust
b e p u t w ithin the reach of all, nevertheless, through health insurance,
m o thers’ pensions, o r som e form of S tate aid, o r else through a m ore
ju st econom ic distribution of th e profits of labor. C o ttag e hospitals or
county m atern ity hospitals are necessary for th e p ro p e r care of com ­
p licated cases. T h e atten tio n of a child specialist m ust b e available for
all country b ab ies in need of special treatm ent. Som e form of itinerant
ch ild ren ’s clinic m ight m ake this possible. Som e provision m ust also
b e m ad e fo r supplying m others w ith household help b efq re an d during
th e lying-in p erio d. T h e public-health nurse m ight b e ab le to arrange,
direct, an d supervise an a tte n d a n t o r practical nurse service.
It has b een suggested th a t all of these agents m ight w ork to g eth er as
a unit on th e county basis, radiating out into th e co untry from a center.
Dr. G race M eigs C ro w d er has described this p lan in h er paper, “ R ural
O bstetrics,’’ given b e fo re the A ssociation for th e S tu d y an d P revention
o f Infant M ortality in 1916. S he says: “T h e fundam ental provisions
necessary to m eet this p ro b lem naturally v ary w ith th e density of th e
pop u latio n an d w ith th e differing living conditions found in various
p a rts of th e country. It is p ro b a b ly safe to say th a t th e county w ould
in general b e th e unit in any plan, an d th a t county centers of m aternal
an d in fant w elfare could b e established, ord inarily a t th e county seat,
b u t accessible to all th e w om en of a county, w here th ey could obtain
free o r for p ay sim ple inform ation as to th e p ro p e r care of them ­
selves an d their babies. T h e plan for such a cen ter w ould naturally in­
clude, first, a county nursing service; second, a co ttag e m atern ity h o s­
pital o r b e d s in a general hospital, for th e care of com plicated cases or

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fo r n o rm al cases w here w om en can leave hom e fo r confinem ent; third
provis.on fo r skilled atten d a n ce fo r norm al cases a t their hom es, w ith
access to especially skilled assistance fo r com plicated cases; a n d lastly
provision fo r obtaining tem p o rary household help fo r m o th ers w hether
co n h n ed a t h o m e o r a t the hospital.”
H a d n o t the w a r d raw n aw ay so m any o f o u r d o cto rs a n d nurses,
som e such p lan w ould u n d o u b ted ly h av e b een tried out a n d its p rac­
ticability p ro v e d o r disp ro v ed . L et us h o p e th a t th e new an d universal
in terest m h ea lth a n d th e p ro tectio n o f child life resulting from th e
w ar Will m ak e m any such experim ents possible an d successful.
I h e R ed C ross through its p lan to p ro m o te rural health nursing
opes to co n trib u te tow ard th e protection of m atern ity an d infancy m
tn e country.
DISCUSSION
_ M is .M a iy P o w e r (D ire c to r, C hild W elfare B u reau , O n ta rio ),

I am g reatly

th e clt d m ,r " ra
hyusiI com e from th e P ro v in ce o f O n t
t h l « " S°
f
,fi“ r|,y ” e li o rg an ized a n d th e chief c o n cern of o u r b u re a u i,
th e extension o f m edical a n d n u rsin g service to th e ru fa l com m unities. By ru ra l

,—
O o Z ' mr c o m m u n i t y
other th a n th e ' " S '
th a n 5,0 0 0 p o p u latio n to stric tly „ „ la te d c o u n try d istricts. O u r B ureau is a t th e
p re se n t tim e considerin g th e possibility, a n d w e h o p e th e pro b ab ility , o f dem onstra tm g p u b h c-h ealth w o rk fo r ru ra l com m unities in o u r p ro v in ce. W e hope
to use th e co u n ty seat o r som e o th e r c o n v en ie n t p o in t a , a c e n te r fo r th e surv Z g ’n u rs e Unn
T “ '
°
f **
a P 1* « ' “ " a " d • s u p c ing n u rse. T he p h y sician in c h a rg e m ig h t p e rfo rm th e du ties o f m edical inm irf.t°d m t e, r
a' “
m ig h t h ° Id W eekly b‘ by clinics- T1>' « » P o i s i n g n u rse
g h t d ire c t th e n u rsin g service in th e district. T h u s w e w ill b e ab le to do th e
follow -up w o rk in con n ectio n w ith m edical inspection, a n d in ad d itio n ta k e c are
m a v ^ s k v “ “ an<J g en eral sickness c a s e , w h ich re q u ire visiting n u rs e ,. It
kb T " e nSr ,n g * g r' a* .‘i' a l lor a 8ma” »»¡t, b u t w e w a n t to show
” e , ° n e ' B efore o rg an izin g this u n it w e d esire to secure th e h e a rty
co o p eratio n o f ev ery p ra c tic a l n u rse in th e d istrict a n d to en list c e rta in v o lu n te e r
w o rk ers w ho o u g h t b e called "h o m e h e lp e rs" fo r th e a id o f th e superv isin g n urse"
w hL I

work w b ” ' W\ , , ° u
age . J h r a d u l^

"

! , ‘° haVe « d' ” tist *° f° ” ° " “P A e medical inspection
* ° r *'

biW' akIy

*” «“ * - o f preschool

m o rta r,“ " a y ,We T h ° p in g *° accom Plish som ething in th e red u c tio n o f m a te rn a l
m o rtality m atern .1 sickness, a n d in fa n t a n d child m o rtality . A t th e sam e tim e
we hope to b rin g th e w hole com m unity, th ro u g h th is h e a lth c e n te r, to a h ig h er
p lan e of gen eral h ealth .
B
d e J e ^ T r t v * 13* Wi ereaS ° Ur d iarrh eaI d i^ a s e s a n d re sp ira to ry diseases have
d ecreased slightly, w e have n o t y et by th e m eans w e have used been able to m ak e
a n y im pression u p o n th e la rg e g ro u p of d eath s u n d e r one y e a r due to co ngenital
causes; a n d w e tr u s t this n ew d e p a rtu re will be a help in re d u cin g th e larg e m ort o a l ^ / e 'T hT
eaSe8’
^ 1917 COnstituted 50 P « c en t o f O n ta rio 's
to tal death s u n d e r one y ear, excluding stillb irth s from b o th b irth s a n d deaths
in 7 Z mSPeCt0r C t dUT ti0 ? WiJ h Wh° m 1 ta lk e d r e c e n tly ^ d w ho w as in terested
He provi8Ion of h o t lu n ch es fo r ch ild ren in ru ra l schools said th a t he h ad been

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w o rk in g a t th e problem o nly since last S ep tem b er b u t h a d b een able to accom plish
a good deal in th a t tim e. In 100 ru ra l schools th ey a re now serving h o t lunches
to th e school children. H e m entioned, how ever, th a t a g ra n t of $40 is given to th e
school an d $20 as a special bo n u s to th e te a c h e r. I ask ed him if he th o u g h t he
w ould have been able tod ay to re p o rt th e sam e results h ad no g ra n t b een offered,
an d he said absolutely, ‘‘No.
,
' .
1 am hop in g th a t as a resu lt of th is m eetin g w e shall be ab le to arriv e a t th e p o in t
w h ere w e can say th a t g ran ts in aid from c e n tra l a u th o ritie s will be th e g reatest
h eltf w e can h ave in o u r w o rk . Mrs. B arto n says th a t in som e cases w h ere th e
agen cy has been a p p ro v e d by th e L ocal G o v ern m en t B oard, th e B oard g ran ts 50
p e r cent of th e n e t cost; on th e o th e r hand, th e m unicip al go v ern m en t will give 50
p e r cen t of th e n e t cost. In o th e r w ords, th e e n tire cost of a m a te rn ity a n d childw elfare schem e in E ng lan d can be m et, h alf by th e ce n tra l a u th o rity a n d half by
th e m unicipal au th o rity .
M rs. E dna Hatfield E dm ondson (F ield S ecre ta ry , Indiana C hild W elfare C om ­
m ittee, an d Field W o rk e r, Indiana U n iversity E xtension D ivision) : 1 com e from
a S tate w h ere o u r pro b lem s a re strictly ru ra l. W e have one city of ap p ro x im ately
2 5 0,000 p o p u latio n a n d only 25 cities of over 10,000 p o p u latio n . T h e rest of
th e S tate is m ade up of sm all cities a n d tow ns of less th a n 10,000 p o p u latio n an d
c o u n try districts. O u r pro b lem is one of pro v id in g m ach in ery to get this service
into th e ru ra l districts.
Miss Lydia H olm an (N o rth C aro lin a ) : T w en ty years ago a call to à special
p a tie n t to o k m e into a rem o te m o u n tain co u n ty in W estern N o rth C aro lin a, a
county one h u n d red p e r cen t A m erican . B efore m y p a tie n t h ad fully recovered,
I discovered th a t m o th ers a n d babies w ere dying a t such a ra te th a t I felt th a t
th e m a tte r should be in v estig ated a n d th a t som ething should be done fo r these
neglected A m ericans. T h e re w as n o t a n o rg an ized S tate b o a rd of h e a lth a t th a t
tim e, D r. Lewis bein g a v o lu n teer se c re ta ry . T h e re w ere no vital statistics.
T h o u g h I told th é p eo p le I w as o nly a n u rse th ey insisted u p o n calling m e
a d o cto r. 1 have b een obliged in this w o rk to do m an y th in g s w h ich as a n u rse I
w as ta u g h t n o t to do. F o rtu n ately , in m y tra in in g I h ad observed th e m ethods
of first-class doctors a n d su rg eo n s a n d in consequence m et m any em ergencies
successfully. G rave necessity h as even driven m e to p e rfo rm m in o r o p eratio n s.
In fact I have been b ro u g h t b efo re th e c o u rt fo r p ra c tic in g m edicine, th o u g h th e re
w as b u t one p racticin g g ra d u a te p hysician in th e county, a n d he w as freq u en tly
incapacitated. But o u r ju d g es a re o u r m ost en lig h ten ed m en, k now ing usually
th e needs of a district, a n d th e y ra re ly in te rfe re w ith a n essential fo r th e b e tte r­
m en t of th e people.
T h e w o rk grew . D oing c arefu l m a te rn ity w o rk , I h ad m o re calls th a n o n e
p erson could respond to in such ro u g h c o u n try . T ea c h in g careful an d cleanly
m ethods a t each place h elp ed th e situ atio n a n d stam p ed o u t of m y d istric t “ child­
bed fever.” It can be done.
In m y trav els th e re w ere tim es w h en th e riv ers w ere up a n d th e trails so b ad
th a t it w as im possible fo r h o rses to trav el fast; n atu rally , w e w ere n o t alw ays in
tim e for th e b irth . H ow ever, o u t of 500 m a te rn ity cases th e re w ere no losses of
m o th ers o r babies.
.
W e have by publicity secu red m ore a n d b e tte r th in g s; g re a t is th e n e e d still.
: O u r doctors have ta k e n p o stg ra d u a te w o rk . T h e e x p e c ta n t m o th ers a re so well
in stru cted th a t th e y d em and good clean service. T h e ir h u sbands a re am bitious
to secure th e b est atte n d a n ts.
A t first w e w ere 28 m iles from a railw ay station. T w en ty y ea rs is a long tim e


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191

to talk about, b u t a t last we a re read y to p u t up a new building— a com m unity
cen te r w ith a ten -b ed infirm ary fo r m o th e r, a n d b .b ia , an d fo r em erg en cy case,.
T he w o rk of th e S tate b o a rd of h ealth h a , n o t y et re a c h e d o u r co u n ty
W ill
the m o u n tain counties b e re a c h e d by th e S .a te f In m y . „ ¡ m. tio n 0„ ,y th e
r e m e T T i“ “
fig h t COnditions a n d give su ch service as will
rem edy the long neglected p roblem of ru ra l m o th ers a n d babies.
M rs. K ate B rew V au g h an (N o rth C aro lin a S tate B oard of H e a lth ) :

I do n o t

b T i s T ^ r t h C I - tH W I n ° PUbliC-Kealth — k
fo r m o th ers an d
babies m N o rth C arolin a. W e have a v ery v ib ra n t S tate b o a rd of h ealth . W e
of h e a h h ^ T 6’
fUndS fr° m W hich’ 1 P resum e« » e a rly all S tate b o ard s
of h ealth suffer. T h e differen t ag en cies fo r child w elfare in N o rth C aro lin a have
usuully h e reto fo re been o f th e p h ila n th ro p ic k in d - u s u a ll y th e m ission c h u rc h a n d
he m ission nurses. T his p a st y ear, how ever, th e G o v ern o r o f N o rth C aro lin a n ro posed som e excellent h e a lth bills w h ich w ere p assed by th e leg islatu re. W e have
m„T, seem I k P r“ d ‘0"
$u
« " « > " * » . » U c h , to som e o f you,
dea
wTk
* t° P
r h '“ ,'“ *' bU* *° N° rth C" oIi“ * 3«=ms like a g re a t
deal. W e have a trav e lin g d e n ta l clinic a n d o u r ad en o id a n d tonsil clubs w h ich
° n ly '° ,h' t Wren b" ' ,0 tb'
“ -« •
th ey teac h hygiene as th ey go alo n g . W e have also ru ra l n u rs e ,.

Incidentally]
F o u r nursed

th e w l7 k th .tn M
F
k S i ir“ tly U'’de'' tb ' S la' e b ° " d ° f I“ »M> doing
M ‘SS. F o x Sp° k ' ° f »« " ' “ „ a r y . W e have tw o c o o p e ra tin g w ith
R ed C ross a n d fo u r c o o p e ra tin g w ith th e p h ila n th ro p ic org an izatio n s.
1 he biggest pro b lem w e have to co n ten d w ith is o u r m idwives. E ig h ty p e r c en t
of o u r co lo red m o th ers a r e delivered by m idw ives. T h e y a r e ig n o ra n t, th e y l i v e
a ° ‘ M . ? .° eanhness. E d u c a te d w om en w ould h a rd ly u n d e rta k e th e w o rk of
these m idwives, fo r th e y a r e p aid so little. F o rty p e r c e n t o f o „ r w h it, m o th ers
Ti nat
h a uis' V
k 'r p
W bblem
l ' ' "s feW
k f ,b eto
m m
Weet.
bi,e WO," e" ° f n ° ‘
o„e„re
n e o0 rf ythe
pro
w e have

c - c e lle n , status,

b e e n f! F * 8“ ‘r ' ed “ m e,h i” * ”
» a y o f hygiene. F o r th re e y e a rs th e re h a .
b iW . , T T * Wlth reE ard
30*1 p o llu tio n w o rk in th e S outh, w h ic h " ! th e
Refe W° rk f herfe’ S1T G ^ rem ° Ves th e h o o k
a n d th e d ia rrh e a l diseases,
rrin g to in fan t hygiene, n e a rly o n e-fo u rth of th e d e a th s in N o rth C arolina

I 'r r t i r d t t . “

m05‘ ^ ‘h“ e ”

at‘rib“teble *° — - 3

di~

d

it ¿ 7 T r V “,
k? ° W tb a t N° rth C aro lin a ha3 W* possibilities. F o r instan ce
it h , th e hig h est b irth ra te of a n y S ta te in th e w hole U nion in p ro p o rtio n m h i

l

:

are goias ,o reduce ,be dea,b — ^

c*~>-

realize 0 “,“ ! ^
i N' 7 J ' r3 e y S *a te B° a ld ° f H e a lth ) : I th in k it i, im p o rta n t to
I
f
re a l solution o f th e ru ra l p ro b lem lies in th e responsibility of th e
C ross Pa
n * ° f h e a lth ‘ 1 beIieve ‘b a t ‘He m ost w o rth-w hile e ffo rt of th e R ed
h e a h h ^ r L l r ° ; gani2ati° fn iS
lation and^ t h a t A f
^
things th a t a re n

e

e

d

e

T

h

* ***

‘he S tate d ep a rtm e n t G1

* P r° t6Cting th e h eaItb <>f th e ru ra l po p « T

r

l

r

a

l

*

°

d° * p iecem ea1 * •

Id
^
S
^
CXPerienCe SerVCS 3 m agnificent p u rp o se if it is used p ro p e rly
sav
‘H h m k Ha T
g r7 P ° f Citizens could listen
Her w ith o u t b ein g read y to
dav J.*1J t* **• SOmetbm^ tk a t ‘be S tate d e p a rtm e n t of h ealth o u g h t to solve ” To

tn o tZ e T T

an<1 ^ T Cral h 6alth W° rk 18
have to d em o n strate how it should be done.


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W e have p assed th e dem on-

192

STANDARDS ÔF CHILD WELFARE

stratio n stage. W e know sufficiently w h a t w e o u g h t to do a n d th a t it can be done.
W e have a rig h t to say th a t w e kn o w w h a t w e o u g h t to do.
In N ew Jersey w e o b ta in e d th is p a st y e a r, av ailab le Ju ly I st, a n a p p ro p ria tio n
of $125 ,0 0 0 fo r th e child-hygiene w o rk . T h e C ouncil of D efense w as of co n sid er­
ab le help. O u r p lan calls fo r ap p ly in g to ev ery city in th e S tate a p ro p e r p re v e n t­
ive hygiene p ro g ram . I p erso n ally believe w e should fo rg e t som ew hat th e distinc­
tions b etw een ru r a l a n d u rb a n p o p u latio n , reco g n izin g th e d ifference w holly in
th e ap p licatio n of details. Y ou n eed th e sam e k in d of w o rk in th e ru ra l p o p u la ­
tion in N o rth C aro lin a a n d New Jersey th a t you do in th e city o f N ew ark. W e
m u st do it differently in o rd e r to p u t it acro ss.
I th in k I h e a rd m en tio n ed th e questio n of tra v e lin g clinics. In N ew Je rse y w e
p re fe r th e idea o f hav in g a m o to r c a r w h ich w ill b rin g th e p eo p le to a p e rm a n e n t
station. I will n o t go into th e reaso n s w hy, b u t I th in k y o u w ill find it w ill have
m any advantages. W e a re so d istrib u tin g o u r stations— w h e th e r th e y be infantw elfare clinics o r m en tal-h y g ien e clinics— as b e st to a d a p t th em to th e ro ad s a n d
tra n sp o rta tio n conditions, a n d g et th e c o o p eratio n of m o to r cars so th a t w e can
b rin g th e w om en a n d child ren to th e sta tio n s; a n d th e n w e divide th e com m unity
u p am o n g n u rses in o rd e r th a t e a c h o n e m ay g et th e g re a te st possible benefit.
New Jersey intends to p u t on 100 w o rk e rs Ju ly 1. T his staff is p aid fo r by
th e S tate. In addition, th e city of N ew ark h a s n u rses o f its ow n. I tr e a t th a t as
I w ould a n y p a rt of th e S tate, since th e n u rse s a re th e re a n d w e do n o t have to p u t
th em th e re . W e should stim u late th e city to c a rry o n its ow n w o rk . T h e ru ra l
com m unities can n o t c a rry on th e ir ow n w o rk unless w e can m ak e larg e com ­
m unities.
D r. A n d rew W ilson (W heeling, W est V irg in ia ) : W e a re ta lk in g a b o u t stim u ­
latin g th e S tate b o a rd of h ealth , stim u latin g th e social o rganizations, stim u latin g
this organ izatio n a n d th a t o rg an izatio n . W e a re co n sid erin g th e p roblem , w hen
th e th in g w e should co n sid er is th e specim en. W e ta k e it coldly; w e do n o t c o n ­
sider, a p p aren tly , th a t it h as b rain s. T h e fu n d am en tal th in g to do is to te a c h p e o ­
ple to ta k e c are of them selves. W e have o rg an izatio n s e n o u g h to do this alread y ,
in th e public-school system of th e U n ited S tates. It is th e m o st fa r-re a c h in g o r­
ganization fo r th e te a c h in g o f h e a lth th a t w e h ave. T h e o rg an izatio n is m ade a n d
is h ere. W hy n o t use it? W h y nob have th e d e p a rtm e n t of pu b lic h e a lth teac h
p ublic h e a lth in ev ery p u b lic school in th is lan d ?
D r. D o ro th y R eed M endenhall (C h ild re n ’s B u re a u ) : I th in k th a t th e ru ra l
p roblem is th e m ost vital a n d in te re stin g h e a lth p ro b lem th a t w e have to face,
a n d I believe th a t w e a re going to solve it. in th e n e x t te n y ears. I do n o t
a g re e w ith D r. L evy o n o n e p o in t, a n d th a t is th a t th e ru r a l p ro b lem is th e sam e
in th e different com m unities. T h e ru ra l p ro b lem in New Je rse y is v ery different
from th a t in W isconsin, fo r one th in g b ecau se of th e d ifference in size of th e tw o
States. T h e la rg e st counties in W isconsin a re a b o u t o n e -q u a rte r o f th e size of th e
S tate o f N ew Jerse y ; a n d th e re a re 71 counties, la rg e a n d sm all, in W isconsin.
T h e re is n o t a p u b lic-h ealth system in a n y of th e counties. W e h av e a n excellent
S tate b o a rd o f h ealth , b u t w e c an n o t, w ith th e sm all a p p ro p ria tio n w e h ave, ex p ect
to do v ery m u ch w o rk in S tates as la rg e as m ost o f th e M iddle W estern S tates.
W e all know th a t ru r a l com m unities should h av e th e sam e o p p o rtu n itie s th a t
cities now en jo y . W e w a n t e v ery child to h av e p ro p e r c a re a t b irth , p ro p e r
p re n a ta l care, p ro p e r c are d u rin g infan cy a n d d u rin g th e p resch o o l age, as w ell
a s p ro p e r schooling a n d c a re d u rin g th e p e rio d o f adolescence. S afeg u ard in g th e
social w elfare as o rg an ized fo r city ch ild ren is also needed. H ow is it possible
to b rin g this a b o u t in th e co u n try ? W h a t is th e sh o rt c u t? I believe w e have

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found it in th e p u b lic-h ealth nu rse. „ I believe th a t W isconsin in m aking it m an ­
d ato ry to have p u b lic-h ealth n u rses in its 71 counties is p av in g th e w ay to w ard s a
solution of h e r problem , fo r w h ere you have a p ublic n u rse, if she is a visiting
nurse a n d n o t a school n u rse only, th e re is th e b eg in n in g of a h e a lth c e n te r a n d
th e re is th e beg in n in g of th e best e d u catio n al w o rk in th e hom e.
Miss H olm an has show n w h at a p u b lic-h ealth n u rse can do in one o f th e
isolated counties in N o rth C arolina. I th in k h e r splendid w o rk show s w h a t can
be done elsew here. If you can p u t th e rig h t so rt of a n u rse into a ru ra l co u n ty ,
she will soon have a pub lic h e a lth c e n te r a n d p e rh a p s itin e ra n t clinics sta rte d such
as th ey a re having in M innesota a n d su ch as th ey have also sta rte d in New Y ork,
so th a t w e can begin to safeg u ard th e life of th e m o th e r a n d h e r child in ru ra l
districts. It is co n tin u ity of c a re th a t w e m u st w o rk for— from co nception to
adolescence.
I believe th e best w ay w e have to e d u cate th e pub lic .in th ese isolated c o u n ­
ties to w an t this w o rk is to s ta rt w ith a p u b lic-h ealth n u rse. She will b rin g in a
public cen ter, a m a te rn ity c e n te r, a social c en te r, a n d pave th e Way fo r th e b est
school w o rk ; a n d w e w a n t all th ese fe a tu re s in o u r h e a lth w ork.
I w a n t to re fe r fo r a m o m en t to a bill th a t w as p re se n te d a t th e last C ongress
for th e p ro te c tio n of m a te rn ity a n d infan cy in ru ra l districts. It w as fav o rab ly
re p o rte d by th e com m ittee of th e H o u se to w h ich it w as assigned, b u t did n o t go
an y fu rth e r. In th is bill th e a tte m p t w as m ade in a w ay to a d o p t th e p rin cip le of
th e Sm ith-L ever Bill fo r th e p ro m o tio n of a g ric u ltu re a n d to copy w h at th e D e p a rt­
m ent of A g ric u ltu re has c a rrie d o u t so successfully. T h e bill is fo r th e p u rp o se
of p ro m o tin g th e care of m o th e rs a n d babies in ru ra l districts, a n d of pro v id in g
in stru ctio n in th e hygien e of m a te rn ity a n d infancy. It p rovides fo r F ed eral aid
to be given th ro u g h S tate a u th o ritie s to ru ra l counties to help them c a rry o u t this
w ork th ro u g h p u b lic-h ealth n u rsin g , co n su ltatio n cen te rs, th e provision of m ed i­
cal an d n u rsin g c a re fo r m o th e rs a n d infants a t hom e or, w hen n ecessary , a t a
hospital, an d o th e r m ethods. A c co rd in g to th e bill a c e rta in sum of m oney w ould
be given o u trig h t to e ach S ta te ; th e rem ain d er of th e sum to w h ich th e S tate
w ould be en titled w ould be given only a fte r a n eq u al sum h ad b een a p p ro p ria te d
fo r th e p u rp o se by th e S tate. It is, as you see, a m a tte r of giving F ed eral aid on
a fifty-fifty basis. If such a bjll is passed, th e re m ig h t b e a c e n te r of p u b lic-h ealth
n u rsin g in every county. I th in k th a t th is bill is one of th e m ost im p o rta n t p ro ­
posals th a t have been m ade in co n n ectio n w ith th e w elfare of th e w om en and
children of this co u n try , an d th a t, of course, m eans th e w elfare of th e nation.

#


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THE PRESCHOOL CHILD
H E A L T H C EN TER S F O R P R E S C H O O L C H ILD R EN
By DR. MERRILL E. CHA M PIO N
D irector, Division of H ygiene, M assachusetts S tate D e p a rtm e n t of H e a lth

A h ealth center, w ithin th e m eaning of this paper, is a place w here
p eo p le m ay com e to learn how to keep well. T h e term “health cen ter”
is g rad u ally com ing into use an d replaces, in p art, th e less desirable one
o f “ clinic.” T o m any persons th e w ord “clinic” m eans nothing a t all,
while to m an y others it carries an unpleasant connotation of sickness
an d m edical trea tm e n t of one sort o r other. T h ere is danger, how ever,
th a t th e term “h ealth cen ter” will, for a tim e a t least, carry to m any
persons a less definite im pression th an do es th e o ld er term . T his is only
a n o th e r w ay of saying th a t as y et th e id ea of disease prevention, an d
especially h ealth preservation, is less clearly defined in peo p le’s m inds
th an th e id ea of m edical trea tm e n t an d disease cure. N evertheless, th e
h ealth cen ter will b e a positive force in th e future.
W hile this p a p e r is entitled “ H ealth C enters for Preschool C hil­
d re n ,” I d o n o t m ean to im ply th a t a h ealth cen ter fo r children of this
age should b e considered to h av e an y peculiar attrib u te n o t possessed
b y one for children of any o th er age. It m ay safely b e said, how ever,
th a t a t th e p resen t tim e th e public is n o t sufficiently aw ake to th e fact
th a t th e child of preschool age is being considerably neglected. T h e
reasons for this are in d u b itab ly th a t th e high infant m ortality an d the
general helplessness of th e b a b y call atten tio n to his needs; an d on th e
o th er han d , th e som ew hat b e tte r organized activities fo r th e protection
of th e child of school age d e tra c t atten tio n from th e younger child.
In th e S ta te of M assachusetts w e h av e annually ab o u t 3,500 deaths
am ong children o v er one y ea r an d u n d er five years of age. T his re p re ­
sents ab o u t one-fifteenth of our to tal m ortality of all ages. A p a rt from
th e d e a th rate, m any of th e defects an d disabilities discovered in chil­
d ren of school age tak e origin in th e earlier age group.
It m ay well b e said th a t u n d er our m o d ern conditions strait is the
g ate an d n arro w is th e w ay which lead eth u nto good health, an d few
th ere b e th a t find it; an d w ide is the g ate an d b ro a d is th e w ay th a t
lead eth to self-indulgence an d neglect of health, an d m any th ere b e w ho
go in th ereat. A s far as th e child is concerned, this is d u e to the ignor­
ance of th e p aren ts; hence the g reat function of a health center is to
ra d ia te an ed ucational influence. T h e w ork d o n e th ere should b e posi194
/


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H E A L T H — T H E P R E S C H O O L C H IL D

195

tiv e; the w orkers should deal in “ d o ’s” ra th e r th an in ' d o n ’ts.” T his
being th e case, a different ty p e of nurse an d physician is n ee d ed from
th a t often fo u n d in clinics for th e sick. T h ey m ust h av e th e enthusiasm
to inspire in p eo p le th e desire to pursue an ideal, w ithout having th e
ad v a n ta g e of th e keen incentive w hich goads to action th e sick m an in
his pursuit of health.
T o repeat, a h ealth center, then, is a place w here peo p le m ay com e
to learn how to keep well. T his does n o t necessarily call fo r any p a r­
ticular m achinery. Like th e college which consisted of M ark H opkins
on one en d of a pine bench an d a stu d en t a t th e other, a health cen ter
for preschool children m ight well consist only of a ro o f sheltering an
enthusiastic public nurse o r physician, a n d a m o th er w ith h er child of
preschool age. In fact, I think the em phasis in th e p ast has often b een
laid too m uch on the surroundings an d too little on th e essentials.
T h e ideal should b e th a t of th e ben efacto r of th e N ew Z ea lan d S o­
ciety s B aby H ospital, q u o ted b y D r. T ru b y K ing: “ I specially d e ­
sire that, so far as possible consistent w ith doing full justice to th e babies
ad m itted , th e hospital will continue to b e so directed an d m an ag ed th a t
an y m o th e r in o rd in ary circum stances visiting it m ay feel th a t alm ost
everything d o n e in th e institution could b e effectively carried out b y
herself in h e r ow n hom e afte r receiving the necessary instruction. A s
conducing to this end, it is h o p ed th a t strict econom y an d sim plicity
in reg ard to buildings, furnishings, appliances, clothing, etc., will b e
m ain tain ed as h eretofore, an d th a t th e trea tm e n t will continue to b e
co nducted, as far as possible, on b ro a d , sim ple, practical, scientific
lines, easily com prehensible b y the ordinary m o th er.” T w o o r th ree
room s in an y cen tral location, even in a business block, will furnish an
office an d exam ining room for th e doctor, a w aiting an d w eighing room
for th e children, an d an office for th e nurses; on occasion even one
room is enough. A ccom m odations can b e varied to suit th e circum ­
stances of th e case.
T his brings us to the question: “W ho should co n d u ct th e h ealth
c e n te r? ” I m ay as well say a t once th a t I believe this to b e th e plain
d u ty o f th e m unicipality. T h e health of th e citizen is of vital im p o rt­
ance to th e com m unity. T h e com m unity calls upon th e citizen to p e r­
form certain duties; it is equally im p o rtan t th a t th e com m unity furnish
th e citizen th e o p p o rtu n ity to fit him self for the perform ance of these
duties. T his principle is well recognized so far as cultural education is
concerned. F u rth erm ore, it is recognized th a t as a m a tte r of self-pro­
tectio n th e com m unity h andles com m unicable disease, spending m oney
in th e process w ithout legally pauperizing th e persons involved, ^^hy
sh ould this n o t b e equally tru e of physical education an d noncom m unicable disease? T o quote T ru b y King again, “T hey (th e w orkers
of the Special H ealth M ission) h av e recognized throughout th a t the

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STANDARDS O F C H IL D W E L F A R E

n eed fo r m o re light an d higher stan d ard s is as essential for one class
as for an o th er— a m atter for friendly cooperation an d free education,
n o t a m atter for p a tro n a g e o r charity.”
It will b e noticed th a t I use the phrase “ d u ty of th e m unicipality”
ra th e r th an th a t of the S tate o r county. In m y S tate, M assachusetts,
th e principle of h om e rule is highly cherished. T here, th e tow n o r city
is th e unit ra th e r th an the tow nship o r county. But w h atev er th e unit,
it w ould seem th a t th e ultim ate com m unity responsibility should b e on
the collection of hom es ra th e r th an on th e collection of m unicipalities,
subject, of course, to a certain unifying control on th e p a rt of th e larger
b o d y — the S tate. .In m any instances, how ever, th e individual com ­
m unity is too sm all o r too p o o r to m aintain th e p ro p e r agencies for the
w ell-being of its citizens. T heoretically, such a com m unity has no ex­
cuse fo r existence, b u t nevertheless it does exist. T h e only recourse,
then, is fo r such a com m unity to com bine w ith one o r m o re sim ilarly
situated to get th e service b o th desire; or a county m a d e up of such
tow ns m ay assum e the responsibility. O ften th e question of tra n sp o rta ­
tion in w inter m ust b e a governing factor.'
T o o often, on th e o th er hand, the com m unity as a w hole is n o t aw ake
to its d u ty of seeing th a t physical education is available for its citizens,
U n d er such circum stances, priv ate organizations m ust furnish a d em o n ­
stration of th e value of such service in th e h o p e of educating th e m unici­
p ality to a sense of its obligations. This, I presum e, has b een th e usual
m eth o d of p ro ced u re in th e m ajo rity of places. O f these p riv ate bodies,
the hospital w ould seem to b e the least suitable for clinics fo r well
children o r for health centers. It is far b e tte r from a psychological
p o in t of view to em phasize th e value of health as an end in itself ra th e r
th an as a m eans of avoiding disease. T h ere are, how ever, m any p riv ate
organizations suitable for this w ork of establishing h ealth centers.
Visiting nurses’ associations, those w hich lay the em phasis on publich ealth nursing ra th e r th a n on b ed sid e nursing, can do it well. So can
child-w elfare com m ittees, w om en’s clubs, settlem ent houses, a n d other
such p h ilan th ro p ic agencies.
A n unusual exam ple of the health cen ter as con d u cted u n d e r sem i­
p riv ate auspices is afforded b y th e so-called H ealth D em onstration a t
Fram ingham , M assachusetts. T h e prim e o b ject of this dem onstration
is to show w h at can b e do n e in th e w ay of control of tuberculosis
b y a w ell-financed p riv ate enterprise w orking in cooperation w ith th e
local h ealth authorities. A ll m o dern m eth o d s are em ployed to this
e n d : physical exam inations of various age groups, w ith special refer­
ence to tuberculosis; school inspection; child-w elfare w ork; an d educa­
tional w o rk along public-health lines. T h e F ram ingham d em o n stra­
tion is, how ever, an unusual instance, in view of th e am ount of m oney
av ailable from p riv ate funds, an d in view of the national interest in the

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w ork. A n o th er w ell-know n exam ple is th e w ork d o n e through th e
N ational Social U nit O rganization in C incinnati.
T h e re is, how ever, one very real d an g er in m uch of this. It is th at
th ere will b e a m ultiplicity of organizations, each w ith its ow n o v erh ead
expense, running a variety of poo rly su p p o rted enterprises, each in
com petition w ith th e other. T his is fatal to good w ork an d is u tterly
inexcusable from an econom ic standpoint. T h e m unicipality can d o
the w o rk m uch b etter. It is often argued in fav o r of p riv ate organiza­
tions, th a t th ey can conduct such enterprises m o re efficiently a n d w ith
less political interference th an can the m unicipality! T h e claim is
m ade, furtherm ore, th a t such projects, sponsored b y aggregations of
allied p riv ate interests, are conducted in an especially dem ocratic m an ­
ner. I d o n o t agree w ith this view. If public health w ere to b e looked
afte r in this w ay perm an en tly it w ould represent a reversal to the
earlier days b efo re self-governm ent becam e an accom plished fact.
T h e ven ality of certain form s of m unicipal control is no valid argum ent
against m unicipal control. If the sam e am ount of effort w ere p u t by
the public into correcting m unicipal abuses as is often p u t into wellm eaning p riv ate enterprises, there w ould b e no occasion to lam ent such
abuses, fo r th ey w ould n o t exist.
It will b e seen, now, w hy I h av e n o t gone into g reat detail as to plans
for a cen ter fo r th e child of preschool age. It is because w e m ay say
th a t th ere should n o t b e an y such thing, p e r se. W e should h av e health
centers w hich should include all, from th e b a b y to th e adult. T h e d ay
is n o t fa r d istan t w hen even adults will seek periodical h ealth exam ina­
tions. T h ese h ealth centers for all ages should b e co nducted b y th e
m unicipal b o a rd of health, w hose d u ty it is to guard th e health of all th e
people. In sm all com m unities th e w hole h ealth ce n te r will b e u n d er
one roof. In large places th ere should b e one m ain center, preferab ly
in som e m unicipal o r county building, w ith as m any b ran ch offices as
are necessary to reach all th e people conveniently an d to give a sense
of n eig h b o rh o o d proprietorship.- I believe this n eig hborhood p ro ­
prietorship is absolutely essential.
T his p lan saves ov erh ead expense an d m akes for econom y as well
as efficiency. U n d e r this roof could b e grouped th e b ranch of th e
h ealth w o rk having to do w ith p ren atal care; th e infant could b e
b ro u g h t h ere to b e w eighed an d m easured, an d to h av e his feeding
supervised; th e o ld e r child, n o t y et of »school age, w ould also h av e his
place a n d consultation day s here. T h e school work, of necessity, m ust
largely b e d o n e in th e school an d th e hom e, b u t th e special exam inations
n ee d ed m ight well b e m ad e a t the health center. T h e child in in­
dustry, too, n eed n o t b e excluded from such a center; regular physical
exam inations w ould check up th e healthfulness of his w ork. Lastly,
th e a d u lt could learn here how to live a little longer.

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I h av e p u rposely left out th e obstetrical w ork. I d o u b t if it is wise to
com bine a hospital w ith a health center. T his sam e objection w ould
h o ld g o o d fo r nose an d th ro a t operations. I do n o t see th a t th ey belong
in a h ealth center. Eye an d den tal exam inations, how ever, m ight b e
included w ith p ropriety. D ental trea tm e n t w ould b e on th e b o rd e r line
and, a t first a t any rate, w ould b e included sim ply because p eople
d em an d it.
N eedless to say, the cen ter w ould serve as* h ea d q u arters fo r th e
public-health nursing force of th e city o r tow n, since ad e q u ate publich ealth w o rk w ould now b e unthinkable w ithout th e services of th e p u b ­
lic-health nurse a t the cen ter an d especially in th e hom e. Indeed, one
m ay say p arad o xically th a t th e real w o rk of th e h ealth cen ter m ust b e
d o n e b y th e nurses in th e hom es. T his phase of th e subject, how ever,
is being tre a te d elsew here. P ro p e r m edical social-service w ork, too,
w ould b e included as an essential facto r in th e success of the center.
Such an outline as I h av e p resen ted belongs p a rtly to th e p reseñ t
an d p a rtly to th e future. A cen ter is sketched from w hich w ould ra ­
d ia te all effort directed to w ard keeping t h e ’citizen an d his fam ily
physically an d m entally fit. It w ould recognize com m unity responsi­
bility an d yet, w ith a little S ta te regulation, w ould n o t b e unduly n a r­
row ; it w ould b e econom ical b o th in m oney an d in tim e; it w ould b e
sim ple. B est of all, it w ould serve as a g reat educational center, com ­
p arab le only to our public schools.


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T H E PU B LIC H E A L T H N U RSE
By DR. C.-E. A . W INSLOW
P rofesso r of P u b lic H ealth , Y ale S chool o f M edicine

W hen the m o d ern m ovem ent for health protection began in E ngland
fifty years ago it w as chiefly concerned w ith th e sanitation of th e en ­
vironm ent. Sir Jo h n Sim on a n d his follow ers w ere occupied w ith the
purification of w ater supplies, th e supervision of foods, th e disposal
of sewage, an d th e elim ination of “ accum ulated obvious m asses of
filth, w hich th rea ten ed th e health of th e com m unity through th e ex­
posure of excreta an d th e incubation of insect carriers of disease. It is
tru e th a t Sir Jo h n Sim on him self h a d a w ider vision. H e said:
L ong before o u r m o d ern codes of pub lic sa n ita ry law h ad b eg u n to sh ap e
them selves, elab o rate counsels of p e rso n al hyg ien e h ad b ecom e c u rre n t in th e
w orld; counsels as to th e w ays a n d h ab its of life w hich w ould m o st co n d u ce to
healthful longevity; counsels, above all, fo r m o d eratio n in life— ‘th e ru le o f n o t too
m u ch ; an d those counsels fo r p e rso n al self-governm ent, en fo rced from a g e to age
by the ever grow ing com m on ex p erien ce of m ankind, a re n o t now to b e deem ed
superfluous because b o ard s of local g o v ern m en t have a risen . In relatio n to th e
sexes a n d th e ir union, a n d to th e m an y p e rso n al influences w h ich a re h e re d ita ry ;
in relatio n to eatin g an d d rin k in g ; in relatio n to w o rk a n d rep o se a n d re c re a tio n
fo r m ind an d b o dy; in relatio n to th e c h arg e of infancy, a n d to p ro p e r differences
of regim en for th e different a fter-p erio d s of life; th e re a re hyg ien ic rules, p e rh a p s
n o t less im p o rtan t to m an k in d th a n th e rules w hich c o n stitu te lo cal a u th o ritie s.”

A t the beginning of any public-health cam paign, how ever, it is neces­
sary to d eal first w ith th e g reat sw eeping pestilences w hose origin lies
prim arily in the environm ent. W hen G eneral G orgas w ent to P an am a
his first p reoccupation w as necessarily w ith th e engineering difficulties
involved in obtaining a supply of p u re w ater an d elim inating m osquito­
b reed in g m arsh lands. A fte r a tim e, how ever, these engineering p ro b ­
lem s are in a m easure solved an d becom e m atters of routine, a n d th e
p rim ary interest of th e public-health official is th e n focused on an o th er
ty p e of problem , th a t of the com m unity infections, d u e n o t to defects
of sanitation b u t to th e sp read of th e germ s of disease from person to
person b y th e m o re o r less d irect routes of contact. O n th e first p erio d
th e p erio d of th e engineer— follow s th a t of th e bacteriologist; an d
th e d etectio n o f carriers, the isolation of infected persons, th e disinfec­
tion of discharges, an d treatm en t b y the use of sera a n d vaccines occupy
th e m ost p ro m in en t place in th e health cam paign.
T h e control of com m unity infections in its turn is grad u ally being
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accom plished, although the recent pandem ic of influenza m akes it clear
th a t w e h av e y et m uch to learn in this field. T h e statistics for even
1918, how ever, w hen th e figures for th e last th ree terrib le m onths are
m erg ed w ith those for the rest of the year, show th a t o th er causes of
d e a th are q u antitatively m ore im p o rtan t th an even influenza an d pn eu ­
m onia. A fte r all th e d ea th ra te for th e y ear only carries us b ack about
ten years; it w as only ab o u t th e norm al d ea th ra te for ten years ago.
T h e g reatest p ro b lem s which w e face, d ay b y day, require for their solu­
tion n o t m erely the sanitation of the environm ent, n o t m erely th e control
o f com m unity infections, but in addition, an d in an even m o re im p o rt­
a n t degree, atte n tio n .to daily individual h ab its df hygienic living.. In
th e future th e sanitary engineer an d th e bacteriologist will, I believe,
b o th yield to th e physiologist th e prem ier role in th e d ra m a of health
p ro tection. I m ay say th a t m y confidence in this analysis of th e phases
of public h ealth is strengthened b y th e fact th a t a y e a r o r tw o ago Dr.
C hapin an d I b o th in d ep en d en tly p resen ted th e sam e analysis of th e
histo ry of th e h ealth m ovem ent a t tw o different m eetings w ithin a w eek
o r tw o of each other. So since h e agrees I think p ro b a b ly th e analysis
is correct.
T a k e fo r exam ple th e problem of infant m ortality w ith w hich we
are here specially concerned. T h ere is no o th er line of activity in th e
w hole field of public health th a t will yield m ore definite a n d tangible
results th an can b e o b tain ed b y w ell-directed efforts a t th e reduction of
th e in fan t d ea th rate. Infant m o rtality m ay b e red u ced in p a rt by
sanitation, b y th e pasteurization of milk, b y th e rem oval of conditions
w hich facilitate th e breed in g of disease-carrying flies, a n d b y b e tte r
housing, w hich will m ake possible th e m aintenance of low er room tem ­
p eratu res d uring th e h o t sum m er w eather. Infant m o rtality m ay b e re ­
d u ced in p a rt b y m easures of isolation an d disinfection, w hich te n d to
p ro te c t th e in fan t against th e germ s of com m unicable disease, so m uch
m o re d ea d ly to th e infant th an to its elders. Y et even g re ater is th e
n eed fo r hygienic instruction of th e m other, fo r th e training in the
k n o w led g e of child physiology an d child hygiene w hich is th e p rim ary
essential in keeping a well b a b y well. S anitation an d th e control of
com m unity infections m ay b e accom plished b y official regulationis; b u t
th e inculcation of hygienic h abits of living an d hygienic m eth o d s of in­
fa n t care can b e accom plished only b y education of th e individual
m o th er in th e individual hom e. T h e g reat tasks o f m o d ern public
h ea lth are educational tasks. \
W e h av e found in this country th a t b y far th e m ost effective agent
fo r th e co n d u ct of this ty p e of educational w ork is th e public-health
nurse. H e r hospital training gives h er n o t only a fundam ental know l­
ed g e of th e h um an b o d y an d its needs, b u t a discipline, a loyalty, an d a
trad itio n o f service th a t fit h e r in an unusual deg ree for th e ard u o u s

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tasks of h er profession. A b o v e all, th e fact th a t she is ab le to bring im ­
m ediate physical relief in a thousand em ergencies ensures h er a w el­
com e, an d m akes it possible for her to d eliver h e r m essage in a w ay
th a t is quite b ey o n d th e reach of one w ho enters th e hom e m erely as a
teacher. T h ere are others w ho think differently ab o u t this question.
T h ere is a ten d en cy ab ro ad , an d to som e extent in this country, to
in tro d u ce a n ew ty p e of health educator, an d w e are all interested to
see Jiow th a t w orks out. Personally, how ever, it seem s to m e th a t th e
wisest ten d en cy is in th e o th er direction, to com bine m ore an d m ore
closely th e educational w ork an d the bedside care in the person of th e
h ealth nurse.
T h e public-health nurse is alw ays in atten d an ce a t th e infant-w elfare
station to weigh th e babies an d p re p are them fo r exam ination an d
to give instruction to groups o f m others in the p rep aratio n of artificial
feeding an d in th e o th er essentials of infant care. By far the m ost im ­
p o rta n t p a rt of h er w ork, how ever, is accom plished in th e hom e. T h e
infant-w elfare nurses spend a d a y o r a h alf d ay each w eek a t the
w elfare stations an d d ev o te th e rest of th eir tim e to visiting in th e hom es
w here th ey teach th e m others how th e food of th e b a b y should b e
p re p are d , how it should be clothed an d bath ed , an d w here an d w hen it
should sleep, an d do these things w ith the actual utensils an d u n d er the
actual conditions w ith which the m o th er m ust deal. A s Dr. j . H.
M ason K nox s a id :
A ll th e w o rk hinges u p o n th e 'b e tte r c are of individual babies com ing u n d e r
o u r m fluence, an d it is h e re th a t th e tra in e d n u rse should be given th e first place,
o th because of h e r uniqtfe o p p o rtu n ity a n d becau se of th e good resu lts w hich
she has a n d does accom plish. It is she w ho e n te rs th e hom e, a w elcom e visitor
b u t o ne arm ed w ith e x p e rt know ledge a n d kindly ta c t. It is she w ho can o pen
th e closed w indow s, rem ove su perfluous clothes, p re p a re th e b ab y ’s feedings, give
it a b ath as a n o b ject lesson to th e m o th er, a n d p e rfo rm a h u n d re d o th e r services
w hich to g e th e r m ean th e difference betw een life a n d d e a th .”

T h e d ev elo p m en t of public-health nursing in the infant-w elfare field
has b een a ra p id one. A ccording to a study m ad e b y th e C hildren’s
B ureau in 1915,1 th ere w ere in th a t year, in 142 cities of 10,000 popuatm n o r over, 539 infant-w elfare stations in operation, m aintained
by ¿05 different agencies. In the sum m er these stations m aintained a
co rp s of 8 6 6 nurses, reduced to 604 in w inter. In the sam e y ea r 466
nurses, n o t con n ected w ith infant-w elfare stations, d ev o ted their entire
tim e in sum m er to infant-w elfare w o r k /w h ile 122 w ere assigned

en?Aa , t0 thlS dUty in Winter’ In addition’ 460 nurses in summer
and 4 9 1 m winter, were employed for a part of their time in the infantXA T a b u la r Statem ent o f Infant W e lfa re W o r k h v
in the U n ited States, b y Etta R. G o o d w n
U S
16, Infant M ortality’ Series N o. 5 W a X g t o n 1 9 ^


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R ^
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w elfare educational cam paign. In o th er w ords, th ere w ere in these
cities, in 1915, nearly 2 ,0 0 0 nurses engaged in w hole or in p a rt in
infant-w elfare w ork, an d th a t num ber has b een since greatly increased.
W e are still v ery far from th e ideal, how ever. T h e infant-w elfare
nurses of th e visiting nurses association in New H av en care for a p ­
p ro x im ately 4 0 0 babies each, b u t it is the conviction of those m ost
fam iliar w ith activities of this kind th a t th e num ber of babies assigned
to one infant-w elfare nurse should b e n o t over 150. O n this basis
w e should h av e som ething like 16,000 nurses d ev o ted to this type of
public-health activity in th e U nited States.
T his calculation is b ased on the assum ption th a t inf ant-w elfare nurs­
ing is to b e co n d u cted as a specialty, b y public-health nurses w ho d e ­
v o te all of th eir tim e to this particular task. P ersonally I am far from
convinced th a t this is th e wise policy. It is th e opinion of a m ajo rity o t
those who h av e h a d experience in the public-health field th a t specializa­
tion in public-health nursing has in th e p ast b een carried too
fric ­
tion an d confusion result from th e visit to one hom e of several different
public-health nurses, a n d th e larg e area covered b y a nurse doing only
infant-w elfare w ork, o r only tuberculosis w ork, causes w aste of tim e
an d m ilitates against intim ate personal know ledge of fam ily a n d social
conditions. P ublic-health nursing should b e organized on th e lines o t
localities ra th e r th an specialties. T his is one phase of a pro b lem
which seem s to m e to b e confronting us in alm ost every field of social
organization, th e p ro b lem of functional o r regional organization. W e
are m eeting it even in th e question of instruction in m edical schools.
Shall w e go on teaching physiology, anatom y, an d histology, or begin
to teach th e system s of th e b o d y ? A n d so h ere: Shall w e organize
this w ork functionally o r locally? In business th e functional organiza­
tion is replacing th e local organization. In health nursing, how ever,
I believe the organization will h av e to b e local w ith a functional staff
for consultation. I think th e ideal w ay is to h av e your local nurse d o ­
ing all th e w ork in y o u r district, an d h av e h er b ac k ed up b y various
kinds of special nurses w ho will assist h er w hen she gets into difficulty.
In this w ay th e nurse m ay know h er district thoroughly in all its as­
pects, an d m ay com e to b e a sort of com m unity m other, a trained
an d scientific m o d ern representative of the good neighbor w ho nursed
th e sick an d h elp ed out in all sorts of em ergencies in th e village life o t
I am inclined to think th a t th e m ost successful public-health educa­
tio n 'in th e future will b e d o n e b y th e district nurse w orking w ith a
sm all p o p u lation unit, re ad y to do ordinary visiting nursing, infantw elfare w ork, or tuberculosis w ork, an d com bining in every field the
care of th e sick w ith th e educational activities of th e m o d ern publich ealth cam paign. I do n o t agree w ith Dr. C ham pion here. I do n o t

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believe in separatin g this educational w ork from th e m edical w ork. 1
believe, on th e o th er hand, we have g o t to ab so rb m edical an d nursing
w ork into public health an d keep them m ore closely com bined than ever
before.
U n d er av erag e conditions a public-health nurse can p erh ap s care
in this w ay fo r a population of 2 ,0 0 0 persons. T hat, it seem s to me,
is th e pro g ram w e should set for ourselves— 5 0 ,0 0 0 w om en of this type,
public-health nurses, devoting p erh ap s on the average, v ery roughly, a
th ird of th eir tim e to infant-w elfare work, a third to tuberculosis, an d a
th ird to th e general task of visiting nursing. In addition, of course,
school nurses an d factory nurses are necessary. T hese are special
lines th a t m ust b e organized functionally, b u t these nurses could turn
th eir hom e w ork o v er to th e district nurse, I think.
T h e p ro g ram is an am bitious one; b u t in New H aven, a city of
160,000 population, our visiting nurses’ association has a b u d g et for
the com ing y ea r of $ 100,000, an d will em ploy a to tal of ap proxim ately
50 nurses, ab o u t tw o-thirds of the ideal n u m ber indicated b y th e calcu­
lation above. So th a t this ideal is n o t b ey o n d th e lim its of achieve­
m ent.
A n d I m ay say th a t this visiting nurses’ association in N ew H aven
m o rd e r to g et this b u d g et w ent out for a four-day drive for $80,0 0 0 .
A t th e end o f th ree days they h a d a h u n d re d thousand. T h a t shows
th e p o p u lar su p p o rt th a t you can get for w ork of this kind. T h ere is
c-bsolutely nothing you cannot secure for a visiting nurses’ association
which is doing its jo b well.
It is evid en t th a t fo r th e conduct of educational w ork o f this ch a r­
acter w e n eed w om en of a high type w ith a sound an d b ro a d educa­
tion. Y ou see, w e are outlining a p ro g ram w hich calls for 5 0 ,0 0 0
public-health nurses, an d w e w ant g ood ones. W e m ust go further
th an this. W e h av e to create the dem and, on th e one han d , a n d we
h av e to do som ething to create the supply, on th e other. W h a t does
the public-health nurse need to know ? W h a t d o w e n eed for this
w ork? I am n o t discussing w hat th e d o c to r n eed s for b ed sid e assist­
ance w ith sick cases. W e are talking ab o u t a public-health nurse.
F o r h er w ork she should b e well gro u n d ed in th e fundam ental sciences
of chem istry, physics, an d biology, for these sciences form th e basis
fo r all scientific thinking an d all scientific applications. She should
know som ething of the principles of sociology an d econom ics, for h er
w ork is closely related a t every p o in t w ith th a t of th e social reform er.
A know ledge of foreign languages is very helpful. In som e cases the
ability to speak Italian o r Polish o r Y iddish m ay b e essential, an d I
h ea rd recently of a case w here C hinese w as a prerequisite. T h e re­
quirem ent of high-school graduation b efo re entrance upon th e course
of the nurses’ training school should represent a m inim um of prelim i
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n ary general education for th e nurse w ho is planning to en ter th e field
of public health, an d a full college course w ould furnish th e m ost
desirable prep aration.
T h e course in the training school itself m ust b e fundam entally re ­
constructed in o rd e r to supply the type of training th a t is n ee d ed by
the public-health nurse of the future. T raining schools in th e past
hav e grow n up in a h ap h a zard fashion a n d h av e often b een actu ated
ra th e r b y th e n eed for obtaining u n paid help in th e hospital th an b y
any educational ideals. H ours are too long an d form al instruction
to o casual. T h e lengthening of th e training-school course from tw o
to th ree y ears w as inspired b y th e h o p e th a t th e th ird y ear w ould
b e d ev o ted prim arily to education, b u t such has n o t b een th e case,
an d w e are a t present in this co untry face to face w ith th e n eed for a
radical reform . T h e first essential, as I conceive it, is th e com plete
divorce of the training school from hospital control. It m ust b e in d e­
p en d en tly en d o w ed an d g overned like any o th er educational institu­
tion b y authorities prim arily interested in education, th e relation to th e
hospital being essentially th e sam e as th a t m aintained b y th e m edical
school of th e present day. M uch progress has b ee n m ad e in this d i­
rection b y th e establishm ent, a t som e dozen different places, of training
schools as an integral p a rt of universities, an d a t th e b est of these
schools tw o y ears of college w ork are required for entrance a n d th e
b ach elo r’s d eg ree is conferred for th e com pletion of th e training course.
I am personally of the opinion th a t for w om en w ho h av e h a d tw o years
of college, a six m onths’ course of theoretical instruction, follow ed b y
eighteen m onths in th e w ards an d a y ea r of special training in publich ealth nursing w ould p ro b a b ly furnish th e ideal ty p e of education.
In an y case, th e in d ep en d e n t endow m ent of the training schools is a
fu n d am ental need, an d there is no pro b lem in the w hole field of public
h ealth th a t seem s to m e m ore urgently pressing th an th e obtaining of
endow m ents of this sort.
A s soon as you g et educational authorities interested in th e educa­
tion of th e nurse, ra th e r th an solely in running th e hospital, these
things will com e. T his question of the end ow m ent of training Schools
is th e biggest single problem in public h ealth an d th e biggest o p p o r­
tu n ity for p hilanthropy. I h av e nothing to d o w ith training schools
except delivering fifteen lectures a y ea r in one, an d I am n o t interested
in th e question personally, b u t if an y b o d y asked m e w here to give
a m illion dollars, I w ould say, “ D on’t give it to a d e p a rtm e n t of public
h ea lth ; give it to endow a nurses’ training school,’’ because th e first
person th a t endow s a nurses’ training school will do w h at Jo h n s H o p ­
kins d id fo r m edicine, an d w hat ^X^illiam B arton R ogers d id for en­
gineering w hen he established th e Institute of T echnology.
Finally in closing- let m e p oint out th e significance of such develop
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m ents as h av e b een here discussed in relation to th e b ro a d e r problem
of organizing th e resources of m edical science for efficient service along
p rev en tiv e lines. A s I p o in ted out a t th e beginning of m y address,
public h ealth is becom ing m ore an d m ore preoccupied w ith th e hum an
m achine a n d its efficient operation. W e m ust n o t b e satisfied to teach
m erely th e b ro a d principles of personal hygiene as th ey ap p ly to one
an d all alike, b u t ra th e r to bring to each individual th e particular
know ledge th a t h e n eed s in o rd e r to use his ow n b ody, w ith its physical
defects an d lim itations, to th e b est ad v an tag e— just w h at Dr. Edsall
po in ted o u t in connection w ith em ploym ent an d factories. In speaking
of dang ero u s occupations, h e suggested th a t w e should ask dangerous
to w h o m ? ” Is it dangerotis to Jo h n Jones? P erhaps. Is it dangerous
to Sim on S m ith? P erh ap s not.
S o un d instruction in personal hygiene can b e b ased only on a p re ­
lim inary diagnosis w hich will reveal physical defects in their incipient
stage. T h e line b etw een public health an d p riv ate m edicine m ust b e
b ro k en d ow n in th e interests of b o th ; for th e physician as well as th e
public-health w o rk er realizes th a t u n d e r our present organization th e
resources of m edical science are generally applied to o late. W e in
A m erica are fa r b eh in d som e of th e o th er nations rep resen ted a t this
conference in th e d ev elo p m en t of an organized system of social m ed i­
cine; w e can b o ast of reiatively slight accom plishm ent in m aking the
resources of m edical science available for th e prevention of disease;
b u t th e organization of public-health nursing b y our b est visiting nurses
associations furnishes a striking lesson of w h at m ay b e d o n e to attain
a sim ilar en d in a re la ted field. T h e accom plishm ents of th e publich ealth nurse are n o t only fruitful in them selves b u t p reg n an t w ith
inspiration for th e task of organizing th e know ledge of the physician
in a sim ilarly effective way.
DISCUSSION
D r. Julius Levy (S ta te B oard of H ealth , New Je rse y ) : I shall discuss P ro ­
fessor W inslow ’s p a p e r in p a rtic u la r, b ecau se he raises a v ery im p o rta n t p ra c ti­
cal q uestion in th e co n d u ct o f p rev en tiv e child-hygiene w o rk . I believe w e
o u g h t to m ake a distinction in th e v ery b e g in n in g b etw een p u b lic-h ealth n u rsin g
w o rk a n d d istrict-n u rsin g w o rk . T o m y m ind p u b lic-h ealth w o rk deals w ith
th e p re v en tio n o f disease a n d n o t w ith its tre a tm e n t o r cu re. If th a t is tru e ,
th a t p h ase of th e n u rses’ w o rk w h ich deals, for instance, w ith th e b an d a g in g of
an u lcerated leg can n o t be included in p u b lic-h ealth w o rk . T h e re fo re th e g reatest
developm ent of p u b lic-h ealth n u rsin g w o rk m ust n o t b e ex p ected to com e from
district n u rsin g associations, a lth o u g h I realize th a t sick -n u rsin g w o rk m akes a n
especial a p p eal in raising funds a n d fo r p h ila n th ro p ic su p p o rt.
T h e n ex t p o in t is th a t a logical a n d w ell-organized p u b lic-h ealth child-hygiene
p ro g ra m can n o t be com bined w ith d istrict n u rsin g , becau se in p u b lic-h ealth w o rk
you w ish to re a c h a s m a n y babies as possible a n d h elp m ain tain th em all in h ealth ,


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an d you m ust lay o u t a sy stem atic p ro g ra m . Sick jnursing does n o t p e rm it th a t sys­
te m .. It is of n ece ssity 'e m e rg e n c y w ork.

For instance, in a rural district you can not say you are going to give a
certain nurse a district covering four or five small communities, and that she is
to he on a certain day in each one of these communities, because if she had a
confinement case in one town she would have to stay there, and work that she
expected to do in another town would have to go by the board. 1 know that
those of you who are in practical work will Understand the reasons why emer­
gency sick nursing can not be combined with a logically developed preventive
health program.
In th e second place, I do n o t believe th a t th e n u rse as now tra in e d is th e best
p erso n fo r p u b lic-h ealth w o rk . P ro fesso r W inslow h as fully realized th a t, as
evidenced by th e p ro g ra m h e h as laid o u t fo r h e r p ro p e r edu catio n . I w an t to
stress p a rtic u la rly th e defect of th e hosp ital tra in in g of th e n u rse as a publich ealth w o rk er. She has been ta u g h t th a t h e r g re a te st fu n ctio n is n o t to th in k
independently b u t to do only as she is o rd e re d b y a su p e rio r p erso n , th e docto r.
P ublic-health n u rsin g in a b ro a d child-hygiene sense can be done p ro p e rly o n ly
by a p erson w ho h as developed in d ep en d e n t th in k in g in th e solution of p ro b ­
lem s connected w ith th e fam ily a n d w ho is w illing even to te ll th e d o c to r th a t
he does n o t know how to feed a c e rta in baby.
Now, in re g a rd to th e specialized a n d th e generalized nu rse, som e distinction
should be m ade. I th in k w e can ap p ro v e of th e specialized n u rse in child-hygiene
w ork if w e w ill include u n d e r child h ygiene p re n a ta l care, in fan t c are (b u t n o t
a c tu a l m a te rn ity o b ste tric a l c a re ) , p resch o o l w ork, a n d school hygiene. I b e ­
lieve th a t a child-hygiene n u rse o u g h t to b e specialized in th a t w ay. I see no
excuse in p lacin g school h ygiene u n d e r a b o a rd of education. A b o a rd of e d u ca­
tion can n o t p ro te c t th e h e a lth of th e school child; th a t is p a rt of a health, p ro g ra m
an d belongs to th e school n u rse . T h a t is to m e a v ery im p o rta n t p o in t. M oreover,
in S tate w o rk w e o u g h t to have a specialist in stru c to r in p re n a ta l care, infan t
hygiene, a n d school hygiene, w ho will help th e n u rses to stim ulate th a t p a rtic u la r
phase.
D r. S. Josephine B ak er (D ire c to r, D ivision of C hild H ygiene, D e p artm en t of
H ealth, New Y ork C ity ) : Som etim es p ra c tic a l ex p erien ce is of m ore value th a n
th e m ost delightful th eo ries. A s a m a tte r of fact, I a g re e p erfectly w ith D r. Levy
th a t p u b lic-h ealth n u rsin g is n o t n u rsin g th e sick. P u b lic-h ealth n u rsin g is n u rs ­
ing th e w ell; it is th e p rev e n tio n of disease a n d n o t th e c u re o r co rre c tio n of
disease o r th e tre a tm e n t of disease.
A nd secondly, from a p ra c tic a l p o in t of view th e tw o c a n n o t go to g e th e r.
W hen I say th a t, I say it n o t b ecau se I believe it an d alw ays have believed it,
b u t because I have trie d it. F o r tw o years in New Y o rk w e trie d o u t a system of
com bined n u rsin g in one of o u r larg e b o roughs, th e B orough of Q ueens. It w as
a to ta l failu re for th e reaso n th a t, ju s t as D r. L evy h as said, th e em erg en cy
w ork alw ays to o k p reced en ce. W eeks w e n t by w hen no school ch ild ren w ere
visited. W eeks w en t by w hen no babies w ere visited. W hy? B ecause it w as
n o t essential; th e y could w ait.
In a w ell-evolved p ro g ra m of p u b lic-h ealth w o rk fo r ch ild ren th e w o rk is n o t
ready-m ade to y o u r hand. You have to go o u t a n d m ak e it fo r yourself, a n d if you
have o th e r duties especially p ressin g a n d essential, you a re n o t going o u t to
m ake it for yourself, a n d necessarily th e b ab y w o rk , th e child w ork, will alw ays
be neglected.
O ne of th e g re a t arg u m e n ts a g ain st th is so-called overspecialization— and
m my view th e re is ju s t as g re a t a d a n g e r in o v erg en eralizatio n as th e re is in


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overspecialization— has been th e questio n of w h at w e call o v erlap p in g . People
have said th a t a t tim es y o u m ay see a tuberculosis, a school-hygiene, a d istrict, an d
a child-hygiene n u rse all visiting th e sam e fam ily. I know o f investigations in
D etroit, an d in G rand R apids, covering a g re a t m an y cases, to settle th a t point.
In New Y ork w e investigated 2 5 ,0 0 0 consecutive visits fo r th e sam e p u rp o se.
In no o n e of those cities w as th e re th re e p e r c e n t of du p licatio n . T h a t is, n o t
th re e p e r cen t of th e fam ilies h ad h ad m o re th a n one n u rse visiting th em a t an y
tim e. T h e re w as p rac tic a lly no duplication.
If th e re is no duplicatio n th e n ex t q uestion is th e cost, a n d c arefu l studies th a t
w e have m ade to determ in e as n e a rly as m ay be th e expense of th e m a tte r have
show n th a t it is n o t m o re costly to em ploy a n u rse w ho know s h e r business an d
w ho goes to th e house w ith a definite purpsose, th a n it is to send th e gen eralu tility n u rse w ho does ev ery th in g a n d p e rh a p s n o t a n y th in g v e ry well.
It is a specialized th in g to c are fo r children. W e a re q u ite su re of th a t. W e
have b u reau s of child hygiene, an d in th a t co n n ectio n I do n o t a g re e w ith D r.
C ham pion th a t w e can have a h ealth c e n te r w h ich will ta k e c a r e 'o f babies a n d
ta k e care of adults. W e m u st specialize if w e a re going to acco m p lish an y th in g .
A s long as child w elfare w as considered a p a rt of th e generalized w o rk w e ' did
n o t get results. If w e a re going b a c k to th is old idea of doing ev ery th in g , a n d
ex p ect to do ev ery th in g equally well, I th in k w e a re going to be d isappointed
in th e outcom e.
A s to th e need of pro fessio n al tra in in g fo r n u rses fo r child-hygiene w o rk o r
fo r p reventive h ealth w ork, th e re can be no tw o opinions. D r. W inslow h as ex­
pressed th e opinion of ev ery o n e w ho know s a n y th in g a b o u t p u b lic-h ealth n u rsing,
th a t w e a re n o t g ettin g tra in e d n u rse s; w e tra in th em a fte r w e g et th em . T hey
a re tra in e d to tr e a t disease, to cu re disease, an d I th in k I am n o t e x a g g eratin g
w hen I say I have ra re ly ev er fo u n d a n u rse— a n d w e have som e 350 doing childhygiene w o rk in New Y ork— w ho u p o n h e r e n tra n c e into th e d e p a rtm e n t knew
w hat p reventive h ealth w o rk w as. W e have to begin a t th e b eg in n in g a n d give
them th e en tirely new p o in t of view of w hich D r. Levy spoke, th e p o in t of view of
initiative, of th e p rev en tio n of disease, of k eep in g th e child well, of lo o k in g a t th e
w ork as a unit.
W h en w e ta lk a b o u t specialization as confined to ch ild ren I am a g re e d th a t
in certain places w e a re overspecialized, a n d it is possible th a t w hen o u r w o rk is
a little b e tte r developed w e can have n u rses w ho w ill ta k e c a re of th e child d u rin g
th e e n tire p erio d of childhood. T h a t is m ost essential in ru ra l com m unities
now . In larg e cities w ith larg e staffs w e seem ed to get b e tte r resu lts if w e k e p t to
specialization a n d did n o t have th e school n u rse do in fan t-w elfare w ork. H ow ever,
w e a re o pen to arg u m e n t u p o n th a t point. It m ay be th a t in tim e w e shall feel
th a t it is b e tte r to consider th e child as a unit, fo r I firm ly believe th a t it is
tim e fo r us to stop th in k in g of activities a n d tu rn o u r th o u g h ts to th e child. W e
have talk ed en tirely too m u ch a b o u t child school life, child re c re a tio n , child
physical train in g , an d a h u n d re d o th e r th in g s th a t affect th e child. W e have
w o rk ed from th e activ ity inw ard, a n d it is tim e fo r us to w o rk from th e child
outw ard.
Sir A rth u r N ew sholm e, M. D. (L a te P rin cip al M edical O fficer, L ocal G overn­
m en t B oard, E n g la n d ); O n th is vexed question of .the p u b lic-h ealth n u rse, it
a p p e a rs to m e th a t th e descrip tio n given of this official as a “ n u rse ” ra th e r begs th e
p o in t a t issue. W e call h e r a h e a lth visitor, w hich indicates h e r hygienic fu n ctio n s
as contrad istin g u ish ed from n u rsin g functions. A n d in E ng lan d h e r fu n ctio n s a re
alm o st entirely, if n o t solely, hygienic. It is tru e th a t d u rin g epidem ics, especially
of m easles, she is som etim es d iv erted to a c tu a l n u rsin g , b u t th a t is th e ex cep tio n


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a n d n o t th e rule. W e have h e a rd a g re a t deal, as D r. B ak er has, of th e o v e r­
lap p in g of different visitors, b u t th e o v erlap p in g is n o t so considerable as is
com m only supposed. But w e p erso n ally p re fe r th a t h e a lth visitors sh o u ld be
confined a t th e p rese n t, a t a n y ra te , in th e m ain to hygienic Work.
W e have ad o p ted in th e cities th e specialized p lan . A s a ru le th e h e a lth
visitors visits only m o th ers a n d babies. B ut in c o u n try d istricts w e have ad o p ted
th e m ore generalized p lan fo r th e sake of convenience of trav el. Indeed, in som e
places th e h ealth visitor is also tu b ercu lo sis n u rse a n d school n u rse ; a n d som etim es,
in scattered ru ra l districts w h ere difficulties of tra v e l a re g reat, th e h e a lth visitor
is th e d istrict n u rse of th e district, doing a c tu a l n u rsin g , a n d som etim es is also
th e village m idwife. But those cases a re ex ceptional.
I th in k th e best solution of th e pro b lem is n o t to so lv e-it b u t to let e ach case
be decided on its local m erits— in sc a tte re d a re a s com bining differen t functions,
an d in crow ded a re a s specializing o r no t, acco rd in g to circum stances.
A s reg ard s th e k in d of tra in in g w hich is w an ted I am q u ite c le a r th a t th e
usual n u rse ’s train in g is n o t th e chief o r th e o nly - qualification needed. M uch
m ore hygienic in stru ctio n is req u ired , as w ell as som e of th e know ledge of a
sa n itary in sp ecto r; a n d a g re a t deal of social know ledge is re q u ire d if th e h ealth
visitor is to b rin g b ack to th e child-w elfare c e n te r in fo rm atio n w h ich th e
physician needs in re g a rd to th e cases u n d e r his tre a tm e n t. P ersonally, I re g a rd
th e sym pathy of th e h e a lth visitor as quite as im p o rta n t as special know ledge.
T he h ealth visitor w ho does th e b est w o rk is th e o n e w ho m an ag es to instil th e
m o th er w ith confidence a n d to m ak e h e r feel th a t she is a frien d . T h a t is a
p rin cip le w hich is im pressed on all of us in E ngland. A tech n ical know ledge of
an y k ind will n o t suffice.
I en tirely a g ree w ith w h at D r. W inslow h as said, th a t h e a lth visiting is th e
m ajo r p a rt of th e child-w elfare w ork. T h e c en te rs in E ng lan d n e v er have
a ttra c te d m ore th an a b o u t a th ird of th e m others, a th ird of th e babies. M ore
th an half of th e m o th ers m u st be visited a t hom e if th ey a re to receive th e p ro p e r
instruction.
Now w ith re g a rd to th e question as to w h e th e r ig n o ran ce is th e ch ief enem y
w hich w e have to fight, I g a th e r from P ro fesso r W inslow ’s p a p e r th a t h e ra th e r
leans to th a t view. U nless a v ery w ide view is ta k e n of w h a t ig n o ra n c e m eans,
I can n o t ag re e w ith th a t. I am quite c e rta in th a t to suggest, as m an y h igh
a u th o rities have done, th a t all w e h av e to do is to in s tru c t th ese p o o r ig n o ra n t
m others, is to ta k e an erro n e o u s view of th e m atter. W e have to th in k o f these
people living in th e hom es in w hich th ey have to live, of th e b ad h o u sin g condi­
tions; we have to th in k of th e b ad san itatio n w hich still exists in m an y of o u r
m unicipalities. In fa n t m o rta lity is larg ely d eterm in ed by th e d e g ree a n d th e
quality of m unicipal san itatio n a n d b y th e q u ality of th e housing. W e h av e to
th in k of th e fact th a t a larg e p ro p o rtio n of these m o th ers a re o v erw o rk ed ; th ey
have no n u rses w hen th e ir ch ild ren a re sick; th a t th ey have no dom estic servants,
m ust a tte n d to th e fam ily w ith o u t a n y of th e helps w ith w h ich all of us a re
fam iliar. A n d unless w e p rovide help as w ell as advice I am q u ite c e rta in th a t
w e a re n o t going to get th e resu lts w h ich a re n ecessary . I p erso n a lly a tta c h
very g re a t im p o rtan ce to th at, a n d th e L ocal G o v ern m en t B oard, as rep re se n tin g
th e C en tral G overnm en t in this m atter, also a tta c h e s g re a t im p o rta n c e to it.
W e have gone so fa r as to subsidize to th e ex te n t of h alf th e to ta l cost th e p ro ­
vision of n u rses w hen req u ired , b o th d u rin g th e lying-in p e rio d a n d a fte rw a rd ,'th e
provision of n u rses fo r sick children, a n d th e provision of h o sp ital beds fo r children
an d th e ir m others. If th e m o th er can n o t go to a lying-in hom e, w e a rra n g e fo r
th e children to be ta k e n aw ay from th e hom e in o rd e r th a t th e m o th e r m ay be


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qu iet a n d n o t be d istu rb ed by th e little ch ild ren w hom she is n o t ab le to a tte n d
to. F u rth e rm o re , w e have b eg u n to subsidize th e provision of hom e helps
d u rin g th e confinem ent of th e m o th er, su p e rio r dom estic h elp ers w ho have b een
p a rtia lly tra in e d fo r th e p u rp o se a n d w ho will give n o t skilled n u rsin g a tte n tio n
b u t help in th e dom estic circle, so th a t th e m o th e r m ay feel she can lie quietly
in bed u n til"sh e has com pletely re c u p e ra te d . I am confident th a t m ere skilled,
enlig h ten ed n u rsin g does n o t co v er th e ground, a n d th a t w hen w e can com bine
h ealth a n d in stru ctio n w e will o b tain th e b est results.
Miss E lizabeth Fox (D ire c to r, B ureau of Public H e a lth N ursing, A m erican R ed
C ross) : It m ay be in te re stin g fo r you to kno>v th a t a t a re c e n t Conference of
a b o u t 75 S tate superv isin g n u rses, d irecto rs of th e R ed Cross, an d o th e r n u rses
engaged in executive w o rk , w e alm o st all sw ung a r o u n ^ t o D r. W inslow ’s p o in t of
view. A n u m b e r of th ese n u rses h ad h ad D r. L evy’s a n d D r. B aker’s p o in t o f view
an d h ad been w o rk in g a t it fo r som e little tim e. T h ey have concluded th a t
gen eral n u rsin g including n u rsin g c are is m o re p ractical, especially in sm aller
cities an d in th e co untry .
It seem s th a t D r. B ak er a n d D r. Levy have b o th u n co v ered th e fa ilu re of a d ­
m in istratio n a n d n o t th e fallacy o f a p rin cip le. If it is n o t possible, as D r. B ak er
an d D r. L evy seem to th in k , to com bine n u rsin g a n d in stru ctio n , if th e n u rse
is n o t a t th e place she is n eed ed a t th e tim e she is needed, th a t is b ecau se th e
m an ag em en t of th e w o rk is n o t p ro p e rly do n e; it is b ecau se th e re is n o t a
sufficiently larg e staff of nu rses, o r becau se th e re is no a rra n g e m e n t fo r floating
nurses w ho can ta k e ca re of th e em erg en cies w hen th e y arise. It is quite possible
to a rra n g e staff an d w o rk in such a w ay th a t in stru c tio n a n d te ac h in g will n o t
be n eg lected o r p o orly done.
A b o u t th e p o o re st w ay to te a c h p eo p le is by th e p rin te d w o rd — by dispensing
p am p h lets a n d circu lars. If w e tell them a th in g b y w o rd of m ou th , a con­
siderably g re a te r im pression is m ade, an d if w e ac tu a lly do it fo r th em w e a re
em ploying th e m ost valuable te a c h in g m eth o d of all. T h e re is no b e tte r w ay of
te ac h in g hygiene th a n by th e a c tu a l re p e a te d giving of n u rsin g care. W e seem
to th in k th a t o u r A m e ric a n p eo p le a re m ost anx io u s fo r advice. I do n o t th in k
p u b lic-h ealth n u rses w ould a g re e w ith th a t p o in t of view. A m erican p eo p le th in k
th e y know how to ru n th e ir ow n affairs p re tty well, an d a re n o t anx io u s to b e told
b y som e one else how to do it. B ut w hen th e n u rse w ho com es into th e hom e a n d
n u rses th em w hen th e y a re sick, a n d does so m eth in g fo r th em w hen th e re is
suffering, tells th em w h a t th e y o u g h t to do, th e y a re going to ta k e h e r advice,
b ecause it is n o t advice, b u t frien d ly counsel from a p erso n w ho h as h elped them
o u t in tim e of need.
W e have all gone into hom es a n d trie d to tell m o th ers a b o u t th e c are of th e
fam ily, an d w hen w e have gone b ack w e have found th a t w e h ad n o t m ade m u ch
im pression. T h ey have said politely, “Y es,” b u t th e y did n o t do w h a t w e told
them to do. It is th e p e rso n w ho has been th e re repeatedly, w ho h as done som e­
th in g fo r them , an d w ho has d ro p p ed th ese little k ern els of advice as she w en t
alo n g in casual rem ark s, w ho really gets th e th in g o v er to th e fam ily. T his m ay
n o t seem to be p rev en tiv e m edicine, b u t in th is w ay th e n u rse m ay w o rk a re v o ­
lu tio n in th e hom e w hich she could n o t possibly b rin g a b o u t in a n y o th e r w ay.
I should like to say also th a t if th e re is no o v erlap p in g th e re o u g h t to b e ; th e
nu rses have n o t done th e ir w o rk if th e y have n o t fo u n d in th e hom es occasion
fo r b rin g in g in all th e o th e r n u rses in th e city.
D r. H . J. G e rsten b erg e r (B abies’ D ispensary a n d H ospital, C leveland, O h io ):
In C leveland w e m ade a n in v estigation of overlap p in g , a n d w e found th a t it


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o c c u rre d in n o t m o re th a n o n e p e r c en t of th e hom es. T h is in v estigation included
th e visits of social w o rk e rs as w ell as nu rses.
P erso n ally 1 ta k e a m iddle stan d betw een th e tw o groups. I believe th a t in th e
fu tu re w e shall have a g en eral p ra c titio n e r n u rse, b u t I do n o t th in k th a t th e
old er cities a re rip e fo r th a t developm ent a t th e p re se n t tim e. I have ad v o cated
in m y ow n city th e use of one district fo r a p e rio d of te n y e a rs fo r th e gaining
of ex p erien ce in this field.
I th in k it is absolutely essential to develop first p ro p e rly tra in e d heads. W e
have n o t th e institutio n s w h ere w e can tra in th em a t th e p re se n t tim e, a n d th e r e ­
fore w e have n o t e n o u g h m en a n d w om en to ta k e th e positions th a t w ould
n ecessarily have to be filled. Secondly, w e have n o t th e funds to p a y th e salaries
th a t w ould be n ecessary to h old su ch w o rk e rs p erm an en tly .
D r. B ak er: P u b lic-h ealth n u rses do n o t b y a n y m eans m erely talk to th e p eo p le
in th e house. T h ey te a c h by doing, q u ite as m u c h as th e n u rses w ho c a re fo r th e
sick. T h ey go in a n d b a th e th e baby, a n d clothe th e baby, a n d in stru c t th e
m o th er. In fact, th e n u rse w ho goes to th e hom e sim ply to m ak e a social call
very soon finds herself o u t; w e do n o t keep su ch n u rses. I do n o t th in k th a t
p o in t should go u n ch allen g ed b ecau se I am su re th a t a n y o n e w ho h as a n y th in g
to do w ith p u b lic-h ealth n u rsin g know s th e w o rk is p ractical, in structive, a n d
educational.


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F R E N C H E X PER IEN C E
By DR. C LO T H ILD E MULON
W a r D ep artm en t, F ra n c e

T o obtain a clear und erstan d in g of w hat has been d o n e in F rance
in connection w ith children’s w elfare, it is well to record th e m ain lines
of th e situation created in th a t co untry b y the state of war.
T w o v ery different periods are to b e considered. D uring th e first
p erio d , g eneral u nem ploym ent was caused b y a real econom ic panic.
T h re e d ay s afte r the beginning of th e m obilization, th ere w ere in P aris
alone 100,000 w om en out of w ork. T his occurred to a g reater or less
ex tent all o v er F rance all our industries su d d en ly a n d com pletely
collapsed. B ut as soon as th e end of 1914 p eo p le b egan to realize th a t
the w a r w as n o t to last for a few m onths, as w as th o u g h t in th e begin­
ning. A m m unition w as running low on account of th e great loss during
th e M arne b attle. A rap id industrial reaw akening to o k place, b u t only
fo r th e m anufacturing of am m unition. A M inistry of A rm am ents was
established, which, w ith M. A lb ert T h o m as a t its head, succeeded in
creating a g re at n u m b er of new w orks. T h e increase w as constant, an d
even a t th e tim e of th e arm istice factories w ere being built. A trem en ­
do u s am o u n t of m anual lab o r w as of course n eed ed for all these estab ­
lishm ents, an d the n u m ber o f train ed m echanics an d w orkm en th a t
could b e called b ack from the arm y w as m uch too sm all to m eet this
em ergency. N inety p e r cent of this lab o r h ad therefore to b e d o n e by
w om en.
C ity w om en w ere th e first to en ter upon this w ork— unem ployed
w orkers o f all kinds, especially those w hose livelihood d e p e n d e d m ore
o r less on luxury, as well as servants, teachers, governesses, an d house­
wives. B ut this was n o t sufficient, an d train loads of w om en com ing
from th e rural districts p o u red into the factories. M ost of these w om en
w ere can to n ed n ea r big towns, u n d er scarcely b e tte r conditions th an
soldiers a t th e fro n t; th ey h a d to live in huge provisional w ooden huts,
w ithout an y physical com forts, a n d — far w orse for creatures, th u s sud­
d en ly d ep riv ed of their hom es a n d families— w ithout any m oral sup­
p o rt o r protection. T his v ery h a rd life w as nevertheless b o rn e b y these
girls, n o t only b y reason of th e high salaries, b u t also on patriotic
grounds.
Now, w h at ab o u t m atern ity in these conditions? W e find here, also,
tw o v ery different periods. U p to th e beginning of th e industrial

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m obilization, n o t only did infant m ortality rem ain w ithin its norm al lim ­
its, b u t it und erw ent a m ark ed decrease. A lthough this m ay seem p a ra ­
doxical, it has b een observed, m ore or less, in several allied countries,
an d even in in v ad ed Belgium. T h e explanation lies in th e fact that,
being o u t of w ork, the w om en rem ained a t hom e. A s a consequence,
b reast feeding becam e m uch m ore com m on. B ottle feeding becam e
a t th e sam e tim e v ery difficult owing to the scarcity of milk. Now,
although th e absence of the husband, th e h ard m oral an d m aterial con­
ditions, an d th e g reat anxieties of these first m onths h a d injured the
h ealth of m any m others an d severely strained their nerves, an d although
in consequence the infants d id n o t receive as good m ilk as form erly,
th ey d id not, nevertheless, die in such large num bers as usual. This, by
th e way, constitutes a m ost interesting physiological experim ent, and
goes far to p ro v e the crushing superiority of b re ast feeding. D uring this
first period, th e m ost im p o rtan t thing w as therefore, as far as child w el­
fare was concerned, to support th e m o th er herself. F o r th a t purpose,
all existing charities increased their w ork, an d new ones w ere started.
L et us now consider th e second period, w hich corresponds to th e in• dustrial m obilization. Its characteristics were, first, th e g reat decrease
in th e b irth rate, an d a t the sam e time, th e increase in th e infant d ea th
rate.
T h e first condition is readily accounted' for: A ll our young m en
w ere rushed to th e b o rd er, an d no leaves w ere g ra n te d b efo re th e m id ­
dle of 1915. T h a t “ strike of the new born children,” if I m ay v en tu re to
call it so, reach ed such an extent that, in Paris, Several of the lying-in
hospitals w ere closed. T his is all the m ore to b e n o ted because, m ost
of th e obstetricians being m obilized, even th e w om en of th e w ell-to-do
classes h ad to b e delivered in hospitals. T h e granting of leaves as well
as th e retu rn of som e w orkm en afte r a while slightly increased th e
natality ; but, as alread y stated, the infant m o rtality increased too. T h e
reasons fo r this w e shall now exam ine.
First, it can n o t b e d enied th a t abnorm al conditions of life during the
w ar h av e in to o m any cases resulted in th e low ering of th e stan d ard of
m orality. N ot only did the practice of crim inal ab o rtio n becom e m ore
com m on, b u t the p ro p o rtio n of illegitim ate birth s reached m uch higher
figures th an form erly. W orse still, desertions of children becam e m ore
num erous, an d it m ust b e b o rn e in m ind th a t children thus d ep riv ed of
their m oth ers an d taken care of b y the “A ssistance P ublique,” d ied at
th e appalling ra te of 50 p er cent. Second, as an o th er consequence of
th e state of w ar, all those w orking w om en w ere v ery soon overw orked,
especially in th e beginning, w hen nothing h a d y et b een done, as it was
later on, to a d a p t th e m achinery to fem inine labor. So overw orked
w ere they th a t th ere is practically no case on reco rd of one of them b e ­
ing ab le to b e a r it fo r m ore th an eight o r ten m onths, w ithout breaking


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d ow n so com pletely th a t she h a d to b e ad m itte d into a hospital. A
g reat nu m b er of p rem atu re births ensued, these children being naturally
w eak. E ven am ong those w ho w ere n either a b a n d o n ed n o r p re m a­
turely born, a heavy m o rtality w as caused b y th e im possibility of b reast
feeding b y th e m others a t w ork.
W h en w e realized the full d an g e r o f th e frightful fall in th e birth
rate, an d w om en’s m obilization, a g reat em otion w as felt in all m edical
an d social circles. T h ree m ain opinions w ere p u t forw ard on the sub­
ject. T h e first one w as th a t every pow er m ust b e used to repulse the in­
vaders. T h erefo re no w om en should b e taken from th e am m unition
w orks, w h atev er th e consequences m ight b e for th e children a n d for
the race.
T h e second opinion was d efen d ed b y P rofessor P inard, a t th e M edi­
cal A cadem y, who said th a t expectant m others ought to b e replaced
in th e w orks b y o th er w om en (chiefly, in his m ind, of th e w ell-to-do
classes), an d b e com pelled to rest for 5 m onths b efo re th eir confine­
m ent, an d 8 m o n th s after, during which time, of course, they w ere to re­
ceive an allow ance from th e S tate, the figure of 5 francs (o n e d o llar)
p er d ay being proposed.
A th ird opinion w as: “ It is tru e th at we m ust resist till th e end, an d
¿ru e also th a t an y shortage of am m unition m ay b e responsible for th e
d eath of som e of our soldiers; but, while they are sacrificing their lives
in o rd e r th a t F rance m ay survive, how can we b e a r th e th o u g h t th a t
even o ne of o u r children shall die if we can p re v en t it? L et us m ake
th e w om en w ork, b u t a t th e sam e tim e let us do it in such a w ay th a t
they m ay b e ab le to b e a r children an d to nurse them . T h e nation
need s b o th lab o r an d children.”
T his last opinion, I firm ly believe, w as the b est u n d er the circum ­
stances an d will p ro b a b ly prevail in the future. I quite agree th a t it
w ould b e b e tte r if m o th ers could stay a t hom e; b u t their w ork will b e ­
com e m o re an d m ore a necessity b o th to enable them to earn their
livelihood an d for th e pro sp erity o f the nation.
P a rd o n m e for expressing an opinion which is n o t y et v ery w ide­
sp read in F ran ce an d m ight seem a trifle revolutionary: T h ere is som e
injustice in attem p ting to forbid a w om an to w ork for the reason th at
she expects a b a b y o r th a t she ju st h a d one. Experience shows th a t
six w eeks of rest b efo re th e confinem ent, an d six w eeks after, is generally quite sufficient to safeguard th e w om an s health an d p re v en t p re ­
m atu re births. M oreover, if the husband does n o t earn enough, o r if
h e h as escaped his duty, th e S ta te m ust support her. T his it never
do es v ery generously, less th an the h u sb an d ’s salary being granted,
an d th e w om an is com pelled to live in a restricted way, because she is
ab o u t to m ake th e gift of a new citizen to th e com m unity. M ost
w om en h ate th e id ea of living a t th e expense of th e com m unity, an d I

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think th ey are quite right. W o rk carries w ith it th e jo y of action a n d
in d ependence. H as the com m unity the m oral right to deprive a w om an
of it? H as it n o t struck you th a t these regulations alw ays ap p ly to the
p o o r w om an? N obody ever th o u g h t of m aking a law to keep a t hom e
a rich w om an w ho wishes to travel, to ride, to dance, or forbidding a
lad y d o cto r to visit patients w ith contagious diseases. This, how ever,
is as dan g ero u s fo r th e b ab y as industrial w ork.
I h o p e th a t future laws will b e b ased on the principle th a t th e health
of th e p o o r o r th e rich w om an alike m ust b e pro tected , n o t only b e ­
cause she has a right to it, b u t because she represents all th e future of
th e race. L et us struggle against all sorts of evils th a t th rea ten th e
child through his m o th er’s ignorance, exhaustion, o r overw orking,
w h eth er its cause b e th e care of th e hom e o r w ork outside. L et us
a d a p t w om an’s lab o r to h e r physiological characteristics; let us reserve
for h er those professions w hich n eed less physical effort. L et us ask
for sh o rt days of w ork; n o t only d o they exhaust the w orkers less, b u t
th ey leave to th e m other, to th e father, too, m ore tim e to sp en d a t
hom e. L et us p ro tec t h er in a special w ay w hen she is p re g n an t o r
feeding h er child.
M edical inspection is indispensable, b u t is n o t sufficient. T hese
w om en ought n ev er to w ork unless sitting. T h ey ought never to w ork
during th e night o r carry heavy loads. T h ey ought to rest six w eeks
b efo re an d six w eeks afte r confinem ent. B ut w e should n o t b e satis­
fied w ith giving th a t piece of advice. W e should en d eav o r to enable
h er to follow it. E very w om an w orking a t a gainful occupation ought
to receive th e w hole of h er salary during those days of forced u n em ­
ploym ent. It is n o t a t th e tim e w hen th e expenses are increasing th a t
th e salary ought to decrease. A n d furtherm ore, if because of h er
p regnancy th e m o th er becom es ill o r is com pelled to give u p h er
w ork as to o h ard , let us give h er a d ecen t indem nity.
A n d w hen at last the child is b o rn I am Convinced th a t it m ust n o t
b e d ep riv ed of its m other. T h e m o th er’s m ilk belongs to the child, as
Dr. P in a rd says, an d I a d d th a t th e child needs its m o th er’s care as
m uch as it need s h e r milk. T h e new -born is n o t a finished being; th e
m o th er m ust finish h er w ork w ith all h e r love. W h enever th e m o th er
is obliged o r even prefers to w ork out of h er hom e, let us allow h er to
do so, an d let us m anage things so th a t she can feed h e r b a b y w hile
she is w orking.
B ut let us retu rn to th e situation in France. T h e m atern ity benefit
law of 1913 com pels every w orking m o th er to rest 4 w eeks b efo re
an d 4 w eeks afte r h er confinem ent if she wishes to b e p aid an allow ­
ance; this allow ance varies from 0 .9 0 to 1.75 francs p e r d ay (1 6 cents
to 31 cents) according to th e tow ns; 10 cents p e r d a y is a d d e d if she
nurses h er child. D uring the w ar it w as seen th a t this w as too little to

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p re v en t th e ex p ectan t m others from w orking as late as they could;
therefore, th e aim of this law, w hich was to p re v en t p rem atu re births,
w as n o t attain ed .
T h e ' allow ance could n o t possibly b e raised for all th e m others, b u t
th e G o v ern m en t d ecid ed to raise it a t least in all th e factories w hich
w ere directly u n d er its control. O ne m onth of rest w ith a full salary
w as g ran ted b efo re th e confinem ent an d one m onth a fte r w ith h alf of
th e salary, plus a fixed sum of 5 0 francs ( 10 d o lla rs ).. M oreover, if th e
m o th er could p ro v e th a t her health n ee d ed it an d th a t she w as nursing
h er b aby, she could h av e th ree m onths m ore rest, being p aid oneq u arte r of h er salary,
A g reat n u m b er of w om en asked for this extension, w hich g av e v ery
g o o d results, b u t m any others p re ferred to go b ack to w ork because
th ey n eed ed all th eir salary. So it w as necessary to m ake som e p ro ­
vision to en ab le th e m others to continue b re ast feeding in o rd e r n o t
to com pel them to h av e their b abies b o a rd e d out, w hich so often m ean t
th e b a b y ’s d eath . A s th e em ployers d id n o t realize th e situation quickly
enough, the law of 1917 w as passed, in accordance w ith th e w ishes a t
the m eeting of B o rdeaux for th e pro tectio n of infancy of th e C om ­
m ittee of W om en L ab o r an d of eight v ery im p o rtan t w om en’s associa­
tions. T h a t law gave' th e right to all nursing m others to leave their
w o rk twice a d a y for th irty m inutes. A ll em ployers of m ore th an 100
w om en h a d to p ro v id e nursing room s in their factories. A sim ilar law
exists in Italy an d in several countries of Europe.
W h a t h av e b een th e results of th e establishm ent of these nursing
room s?
B efore the w ar 52 of them existed in F rance in textile factories. A
v ery charm ing one w as established on the ro o f of th e biggest tra d e
shop in Paris. T h ey all h av e been entirely beneficial fo r th e child, an d
th e m o th ers b o re well the double burden, w ork an d m aternity. In ¿i
factory n ea r Lille the sam e young w om an b o re an d nursed tw o children
in th ree y ears w ithout any h arm to h er health. D uring th e w ar m any
m ore nursing room s h av e been created. E ven b efo re th e law of 1917
I m yself w as asked b y th e S urgeon G eneral of th e F rench A rm y to
organize one in a m ilitary factory w here tw elve h u n d re d w om en w ere
doing cam ouflage w ork.
It is, of course, v ery difficult in such a tro u b led p erio d to account
quite scientifically for the influence on m others of b re ast feeding car­
ried along w ith industrial w ork, so num erous h av e b een th e o th er factors
of th eir m aterial an d m oral life. H ere, how ever, are som e of the
results.
T h re e of the 5 3 m others in m y nursing room have b een ill. O ne of
these h a d lost a g ood deal of w eight since h er husband w as killed b u t
ultim ately regained h er form er w eight w ithout ceasing b reast feeding.

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T w o others h ad tuberculosis; th e first, aged 1 7, h a d lost b o th p aren ts
a n d several relatives from tuberculosis. T h e second’s husband, a sol­
dier, d ied b y h e r side of the sam e disease. She w as depriving herself
of h er fo o d in o rd e r to feed on h er little salary h er h u sb an d an d tw o
o th er children. A ll the o th er 50 m others w ere in g ood health in spite
of th e difficulties of their life. I therefore think th a t in nprm al tim es
w ell-supported m others p ro p erly exam ined b y d o cto rs could fulfill
b o th duties w ithout harm . O f th e 5 3 babies, of these m o th ers none
died, an d th ere w as no case of transm ission of contagious disease.
B ut I also believe th a t m y d u ty is to show you th e d an g ers of these
nursing room s. A ccording to our experience a v ery careful inspection
of th e b ab ies is absolutely necessary every m orning o n their arrival from
hom e to p re v en t the spreading of contagious diseases. A ll th e b abies
th a t d o n o t look quite w ell m ust b e p u t into th e isolation room until th e
d o cto r has visited them . T his inspection only serves its p urpose if it is
d o n e b y a nurse w ho has b een specially train ed in a hospital for th a t
work. A ll th e d a y nurseries o r nursing room s w hich d id n o t com ply
w ith th a t riile hav e h a d epidem ics. In m y nursing room,) w here it was
strictly enforced, although in several cases children w ere b ro u g h t from
hom e w ith contagious diseases such as scarlatina an d bronchial p n eu ­
m onia, th ere was no case of transm ission.
P erh ap s it m ight interest you to know som e F rench definitions. W e
call nursing room s, those w hich are reserved for b reast-fed children in
the factories. W e call d a y nurseries th e ones which only keep chil­
d ren up to 3 years. T h e m atern al schools are those which tak e children
up to seven y ears of age. W e h av e 300 public m aternal schools in
Paris.
I m ust say that, as reg ard s d a y nurseries, m ost of our pediatrists call
them a necessary evil an d ask fo r im p o rtan t im provem ents. T h e
nurses receive only 6 francs p e r d a y for fourteen hours w ork w ith the
result th at their technical know ledge is too little an d th e babies suffer.
W e felt th e n eed of creating a special course of instruction for them ,
a n d in 1916 1 w as asked to organize it. T h e A m erican R ed Cross o r­
ganized o th ers in 1917 in several tow ns. T h e sam e y ea r a central
school for th e teaching o f child w elfare w as established in Paris. T h e
teachers are th e b est pediatrists in Paris. T h e courses are supple­
m en ted b y practical training in d ay nurseries.
D uring th e w ar, too, w e ad o p te d a long-sought-for m easure in o rd e r
to raise th e sta n d a rd s of th e m idwives. T h ey all h av e tw o years’ train ­
ing, b u t from 1916 on the schools of m idw ifery h av e accepted only girls
having co m pleted th e high school course.
I will show you how th e w ar has benefited F rance in o th er waysj al­
th ough in th e m ain it has affected h er so terribly.
First, the u nem ploym ent which becam e quite general after th e

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m obilization, an d im poverished h u n d red s of thousands of w orkers, led
to th e excellent result th a t the principle of the unem ploym ent com pen­
sation was ap p lied for the first tim e an d has com e to stay w ith us. T h e
allow ances are p aid b y the S tate L ab o r Exchanges w hen th ere is no
w ork, in o rd e r to av oid volu n tary unem ploym ent.
A n o th er h a p p y result of the w ar is the dow nfall of th e b arriers w hich
used to keep p eo p le of different classes a p a rt from each other. Since
A ugust, 1914, a n ational com m ittee for relief has centralized the gifts
an d d istrib u ted them am ong the different relief agencies. It w as o r­
ganized b y the d ean of th e Science C ollege in Paris. F rench union le a d ­
ers sat in th e com m ittee to g eth er w ith th e A rchbishop of Paris. T h a t
m ay b e quite usual w ith you, b u t such a thing w as n o t v ery often to
b e seen in p rew ar days in our country.
T h e children h av e becom e b e tte r pro tected . I m ust of course except
th ose refugee children w ho h ad to flee, pursued b y the enem y. I shall
n ev er forget those p o o r little ones who w ere b ro u g h t to th e hospital only
to die th ere w ithout an y definite sym ptom s of illness. T h ey really
seem ed to h av e b een killed b y th e te rro r th a t still w idened th eir eyes.
T h eir m others, stan ding b y their d ea th beds, lo oked h ard ly less o v er­
com e b y fright. B ut if w a r has been responsible fo r the d ea th of m any
children, it has, on th e o th er hand, show n th e necessity of cooperation.
T h e B ureau for th e A ssistance of M others an d C hildren g ath ered to ­
g eth er all th e experienced w orkers. T h e num ber of m aternal an d
p ren atal centers grew considerably. Social service was introduced into
the lying-in hospitals, even though so m any d octors an d nurses h ad to
leave fo r th e front. I ho p e this will n o t only survive th e w ar, b u t also
dev elo p considerably, thanks to the efforts of the m any w om en w ho
h av e becom e experienced in the w ar hospitals. T h e w om en now can
no m o re lead th e useless lives which satisfied them form erly. T h e
A m erican R ed C ross has help ed considerably in this m ovem ent, in
P aris as well as elsew here.
T h e b o m b ard m e n t of P aris began in M arch, 1918; I w ould n o t go
as far as to say th a t it w as agreeable to th e Parisians. It cam e to g eth er
w ith th e G erm an d riv e a n d th e air-raids, so th a t it w as especially dis­
astrous for th e children, w ho caught m any diseases in th e cellars. T h e
consequence w as th at, fo r th e second time, w e sent as m any children
as possible to safer places, 75,000 in less th an six weeks. T h e m u­
nicipality p aid tw o-thirds of the b o ard in g expenses; th e relief agencies
m ad e up th e rest, an d th e A m erican R ed C ross gave $ 2 0 ,0 0 0 for
clothing. T h e children stayed four m onths aw ay from th eir hom es.
T his co o p eratio n betw een the open air agencies a n d th e m unicipality
will survive th e w ar. P aris will send m ore children than ever to th e
country. W a r has also helped to create a favorable atm osphere for
th e establishm ent of a health m inistry. M any efforts are m ad e to cen
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tralize study a n d action in th e lines of m edico-social questions, a n d a t
this v ery m o m en t an international conference is m eeting to consider th e
hygiene w o rk re la ted to reconstruction of the d ev a sta ted areas. T h e
A m erican R ed C ross has organized in C annes a m eeting of th e com ­
m ittees of th e A llied R ed Cross. O u t of this m eeting a lasting b en e­
fit will accrue to m ankind.
I d o n o t w an t you to think th a t because of these benefits I like w ar;
y et on e of th e g re at benefits th a t w ar has b ro u g h t to F rance is the
b ro th erly love of A m erica, which is m o re evident to m e from d a y to
d a y as I b eco m e fam iliar w ith y o u r country. I ard en tly h o p e th a t our
countries will u n d ersta n d an d help each o th er b e tte r every day, th at
m o re an d m o re F rench p eo p le will com e to this country, w here they
will find again th e love of life an d learn m uch. I h o p e th a t w e shall
m ore a n d m o re exchange th e children of our schools an d th e students
of o ur universities. I hope, indeed, th a t all th e citizens of th e future
will sp en d several years far aw ay from their own hom es. By th a t
m eans only will th ey learn to know o th er civilizations, to respect other
w ays of thinking. By th a t m eans only will they becom e m o re con­
scious of hum an solidarity.


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D A Y N U R SER Y ST A N D A R D S
By DR. S. JO SEPH IN E BAKER
D irecto r, Division of C hild H ygiene
D e p artm en t of H ealth , New Y o rk City

D ay nurseries as conducted in th e U nited S tates generally furnish
d a y care for babies a n a children from a few w eeks to five o r even six
years of age. T h e d ay nursery n o t only is a d ay hom e for infants, but,
because it also cares for the child of preschool age, frequently includes
a k in d erg arten as a prom inent feature. A s a rule, these nurseries are
u n d er th e auspices of p riv ate organizations, o r are endow ed b y in­
dividuals. T h ey exist alm ost entirely as sep arate units an d they m ay
b e lo cated in buildings erected fo r th e p urpose o r th ey m ay occupy
room s in a fam ily dw elling o r tenem ent house. Because of their d i­
versity of location an d control an d th e b ro a d age group of th e children
u n d er supervision, it has seem ed of distinct im portance to establish
som e m eth o d w hereby their adm inistration an d m aintenance m ight be
stan d ard iz ed an d definite a n d responsible supervision m aintained.
T h e pu rp o se of this p a p e r is n o t to trace th e history of d a y nurseries,
nor, indeed, to discuss th e extent to w hich they h av e b een organized.
It is p roper, how ever, to speak of their im portance w ith relation to th e
preschool age. It is well know n th a t this age— from tw o to six years—
is the neglected p eriod of child life. C om prehensive public-health
p ro g ram s h av e been fo rm ulated an d carried out for th e benefit of
infants an d children of school age, b u t the child of preschool age has
h a d no such ad v an tag e. T h e possibilities of this age group in p re ­
v entive h ealth w ork are of v ast im portance, b u t they h av e a ttra cted
little atten tio n from public-health authorities. E ven superficial investi­
gations an d surveys, how ever, will show th a t n o t only does this age
p erio d offer th e b est o p p o rtu n ity for constructive w ork in child health,
b u t it is also in itself th e tim e of life w here m any of our com m on p re ­
v en tab le diseases are m ost likely to occur.
It has b een estim ated th at in th e U nited S tates 81 p e r cent of th e
d ea th s from contagious diseases an d 85 p e r cent of th e illnesses from
contagious diseases occur u n d er five years of age. Physical exam ina­
tions of children of this age group reveal a prevalence of physical d e ­
fects from 10 to 15 p er cent in excess of those found in children of
school age. U n d ernourishm ent has been found to b e a t least one-third
m o re p rév alen t in children betw een tw o an d six th an in children from
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six to fifteen y ears of age. T hese statem ents are a m ere indication
of th e necessity of com petent health supervision a t this time.
It can n o t be claim ed th a t the d ay nursery as a t p resen t constituted
is a p re d o m in an t factor in the ca re of the preschool age child, b u t its
possibilities are alm ost unlim ited. T his has b een recognized in E ng­
land, particularly, w here provision w as m ad e in 1918 for th e establish­
m en t of nursery schools u n d er Section 19 of th e E ducation A ct, which
w ent into op eration A ugust 8 of th a t year. C arefully draw n an d m ost
com prehensive stan d ard s are established b y this act.
In th e U nited S tates th ere are no universal stan d ard s a t th e p resen t
tim e. In fact, v ery few of our S tates or cities h av e established any
stan d ard s a t all an d the d a y nursery, in a n um ber of instances, has
com e to b e lo o k ed upon as a com m ercial proposition, m aintained for
gain, an d som etim es to the actual detrim ent of th e children who are
cared for.
P ublic-health authorities should n o t lose this o p p o rtu n ity to reach
children of th e preschool-age group. D ay nurseries should b e m ain­
tain ed u n d e r p ro p e r an d com petent supervision, w hich can b est be
carried out b y g overnm ental authorities. F o r this reason all com m uni­
ties should include in their public-health law s provision th a t no nursery
shall b e co n d u cted w ithout a perm it therefor, issued b y th e local b o a rd
of health, o r otherw ise th an in accordance w ith th e term s of this perm it
an d w ith such regulations as th e said b o a rd of h ealth m ay issue from
tim e to time. T his perm it should specify th e n u m b er of children th a t
m ay b e received b y th e d ay nursery, an d this num ber m ust n o t b e ex­
ceed ed in an y instance.
Such supervision has b een tried. In New Y ork C ity th e enforcem ent
of such an b rd e r has resulted in standardizing th e conduct of day
nurseries in th a t city, a n d they are a t present an active a n d p o te n t force
in th e public-health pro g ram for child w elfare.
S ta n d a rd s fo r d a y nurseries m ust tak e cognizance of th e construction
an d equipm ent of th e building in which th e d ay nursery is to b e located;
the provision of th e necessary room s an d their p ro p e r furnishing; gen­
eral hygiene an d m aintenance of nursery routine; m edical supervision
of th e children for th e purpose of controlling epidem ic diseases, as well
as th e p rev en tio n of disease in general an d th e correction of existing
physical defects; an d general physical care, including rest, exercise, an d
p ro p e r diet. In addition, th e d ay nursery m ust offer to children of the
tw o-to-six age group som e m ental an d social training.
C o n stru c tio n a n d E q u ip m en t

W h erev er it is possible the d a y nursery should occupy a sep arate
building co nstructed for th e purpose. It m ay b e assum ed th a t th e lo ­
cation of these nurseries will alw ays b e w here th e n eed is greatest, which

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generally m eans in th e m o re crow ded p arts of com m unities. F o r this
reason sep arate buildings are rarely feasible o r available an d changes
in construction m ust b e m ad e in alre ad y existing tenem ents o r dw ell­
ings. F requently, d ay nurseries can b e m ad e p a rt of com m unity health
centers o r social settlem ents. A s p aren ts have becom e accustom ed to
these n eig h b o rh o o d houses, they are particularly desirable for this p u r­
pose, giving th e m o th ers a sense of security w hen leaving their babies or
v ery young children.
A d e q u ate space, fresh air, an d sunshine are th e m ain requisites to b e
considered in the selection of day-nursery prem ises. If possible, out­
d o o r space should b e p ro v id ed an d o u td o o r life encouraged through
the g re ater p a rt of th e year. If y ard s are n o t available, roofs can often
b e utilized.
N ecessary R oom s

T h e m inim um requirem ents for room s are: (a ) k in d erg arten or
play ro o m fo r children from tw o to six years of age; (b ) nursery w ith
cribs for children u n d er tw o years of a g e ; (c ) d in in g ro o m ; ( d ) kitchen;
(e ) lav ato ry a n d b ath ro o m ; (f ) cloakroom ; an d ;(g ) isolation room .
K in d erg arten .— T h e kin d erg arten or playroom for th e children from
tw o to six y ears of age should p ro v id e a t least fifteen square feet
of floor space fo r each child. A d eq u ate ventilation, lighting, an d
heating should b e p ro v id ed . E xcept in extrem ely cold w eather, th e
ventilation should b e m aintained b y m eans of open w indow s. T h e
room s should h av e th e necessary kin d erg arten furniture, an d , in a d ­
dition, w o o d en o r iron b e d fram es o r bunks, so arran g ed th a t they
m ay b e let d ow n from th e w all an d form low, easy d ay b ed s fo r th e
children.
N ursery for C hildren Linder Tw o Y ears.— S ep arate iron b ed s or
cribs m ust b e p ro v id ed for each child. T h ey should b e so placed th at
th ere will b e a space of tw o feet on all sides except w here th e h ead or
sides of a b e d o r crib touch the wall. W oven iron springs should b e
p ro v id ed o v er w hich a folded blanket, p ro tec ted b y a ru b b e r or oil­
cloth sheeting, m ust b e placed. M attresses should n ev er b e allow ed.
A m inim um of tw o h u n d re d cubic,feet of air space for each child should
b e p ro v id ed .
D ining R oom .— T h e air an d floor space requirem ents h eretofore
m entioned m ust b e m aintained in the dining room , an d ad eq u ate light
an d v en tilatio n are essential.
K itchen.— T h e stan d ard s in kitchen equipm ent relate to simplicity,
accessibility, cleanliness, an d ease w ith w hich b o th utensils an d equip­
m en t m ay b e k e p t clean. T h e exact type of equipm ent does n o t need
to b e stan d ard ized , b u t should b e a d a p te d to individual requirem ents.
O rd e r an d cleanliness, how ever, m ust b e insisted upon at all times.
L av ato ry an d B athroom .“ -—
^ /a sh b a sin s should b e sufficiently low to

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STANDARDS OF CHILD WELFARE

b e easily used b y th e children. R unning w ater should b e p rovided,
an d each child should h av e for his exclusive use a towel, toothbrush,
drinking-cup, an d com b. . T h e toilets should b e of a child size so th at
they m ay b e used by th e children w ithout assistance. T h ey should b e
of m o d ern type, easily flushed, an d in th e ratio of one toilet to each
tw enty children. T h e use of com m on washcloths, towels, com bs, and
h air brushes should b e prohibited.
C loakroom .— A w ell-ventilated room fo r children’s outer garm ents
m ust b e p ro v id ed . In this room th e clothing rem oved from the chil­
d ren in th e m orning m ust b e placed, an d unless all clothing w orn by
th e child on adm ission is clean, it should b e changed for clothing
belonging to the d ay nursery, o r a suitable overapron, th e p ro p e rty of
th e d a y nursery, should b e w orn through th e d ay an d each individual
ap ro n m ark ed for identification unless a clean ap ro n is p ro v id ed daily.
Isolation R oom .— A n isolation room for cases of suspected
contagious disease should b e p ro v id ed in each d ay nursery.
G eneral H ygiene a n d M aintenance of N u rsery R outine

T h e p u rp o se of the d ay nursery is n o t m erely to p ro v id e a shelter for
children during th e daytim e. Its ideal m ust b e further, to afford them
com plete p ro tection from disease an d to establish necessary health
habits. T h e h ealth control, therefore, resolves itself into several p arts:
1. T h e control of contagious diseases.

Such pro ced u re should b e:

(a )
T h e d ep a rtm en t of h ealth an d th e nursery physician
should b e notified im m ediately by telephone of any suspicious
rash or illness occuring am ong th e children a t any tim e, an d chil­
d re n so affected should b e placed a t once in th e isolation room .
(b )
T h e m atro n m ust m ake daily inquiry of each m o th er or
o th er p erson bringing a child as to w hether o r n o t any sickness
exists in th e child’s hom e, an d if suspicion is aroused as to th e
possibility of such hom e sickness being of an infectious nature, th e
child should b e excluded an d th e d e p a rtm en t of health notified.
(c )
E ach child as it enters th e nursery m ust b e inspected b y
a co m p eten t person, either th e m atro n or th e nurse.
(d )
T h e physician of th e d ay nursery m ust m ake a system atic
exam ination of every regularly atten d in g child a t least twice a
m onth, such exam inations to b e m ad e a t least tw o w eeks apart.
(e )
W hen any child w ho has n o t previously a tte n d e d th e d ay
nursery applies for adm ission th e physician should exam ine such
child a t once an d exclude it from atten d a n ce a t the nursery if any
suspicious signs of infectious disease are present. If no infectious
disease is found to exist, th e m atro n in charge of th e nursery
should b e given a certificate to th a t effect a n d th e child adm itted.

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(f)
W henever, in th e case of fem ale children, th ere is evi­
d ence o f any vaginal discharge on th e clothing, a sm ear fo r b ac­
teriological diagnosis should b e m ad e an d exam ined to determ ine
th e presence of gonorrheal va'ginitis.
2. M edical inspection an d health supervision:
(n )
T h ere should b e on file in th e office of th e nursery an
original certificate o f health, signed b y th e nursery physician, for
each child who is a regular atten d a n t.
,
(b )
T h ere should b e on file in th e office of th e nursery a
reco rd fo r each child regularly attending, show ing th a t it has
b een exam ined by the nursery physician a t least tw ice a m onth,
such exam inations being a t least tw o w eeks ap art.
(c )
W henever, upon exam ination, a child is found to b e suf­
fering from any physical defect or abnorm ality o r from an y con­
dition which requires health supervision o r instruction, th e case
should b e referred to the nurse, w hose d u ty it should b e to super­
vise the h ealth care of the child tmtil p ro p e r tre a tm e n t has been
o btained.
3. A nurse should b e attach ed to each such nursery w hose duty
it should b e:
(a )
T o assist the d o cto r in th e physical exam inations;
(b )
T o m ake daily visits to the nursery to tre a t m in o r ail­
m ents, m ak e regular health inspection of th e children, a n d give
h ealth advice o r aid w hen in d icated ;
(c )
T o b e responsible for th e cleanliness of th e children an d
the m aintenance of th e health regulations of the b o a rd of health
w ith reg ard to sanitation, hygiene, an d health care;
(d )
T o visit th e hom es of th e children .at regular intervals,
instructing th e families as to the individual needs of th e children;
w ith reference to hom e hygiene, feeding, a n d physical care.
4. C are of infants:
(a )
A d e q u ate care m ust b e taken of th e milk, bottles, an d
nipples used in infant feeding.
(b )
Individual form ulae should b e prescribed for each child
afte r exam ination b y the nursery physician.
(c )
P ro p er infant care an d hygiene m ust b e m aintained a t all
times.
(d )
E ach infant on adm ission m ust h av e its clothing rem oved,
b e given a bath, redressed in fresh clothing belonging to the
nursery, an d k ep t in such clothing during the day.
(e )
A ll d iap ers th a t m ay becom e soiled during the d a y m ust
b e im m ediately placed in w ater an d th ere after th o roughly w ashed
an d boiled. No diapers in an unclean condition should b e re­
m o v ed from the prem ises.

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5.

STANDARDS O F C H IL D W E L F A R E

C are of children from tw o to six years o f age:
(a )
Each child from two to six years of age should receive one
h o t m eal in th e m iddle of the day. This m eal should include
one h o t m eat or vegetable dflh, with soup, an d cocoa o r milk.
B read, fruit, an d eggs should b e included in th e dietary.
(b )
Each child should h av e a m orning lunch a t eleven o’clock
an d an afternoon lunch a t four o ’clock, consisting of a glass of
m ilk an d b re ad an d butter.
(c ) T h e to tal am ount of m ilk supplied to children betw een
tw o an d six years of age should n o t b e less than th ree pints p er
capita p e r day. P a rt of this m ay b e given to the child in th e form
of soups, custards, or o th er types of fdod.
(d )
Each child should h av e a suitable rest p erio d a t a regu­
lar tim e each day. Experience in the open-air classes has seem ed
to p ro v e th a t the m orning rest hour is the m ost desirable. C hil­
d ren m ay b e given their m orning lunch a t eleven o ’clock an d
then required to lie on th e 'cot b ed s which, w hen n o t in use, fold
up against th e wall. T hey should b e encouraged to sleep during
this period, an d sitting up o r talking -should n o t b e allow ed.
(e )
R egular an d system atic exercise is essential.
G roup
gam es, sim ple setting-up exercises, o r unrestricted p lay m ay b e
allow ed. Biologically, children of this age n eed m uch activity
an d o p p o rtunity for free action. Lesson periods, therefore, should
b e shorjt, an d children should n o t b e required to sit still fo r m ore
th an a few m inutes a t a tim e. C hairs should b e m ovable, an d
the child’s interest should b e k e p t up through the ty p e of ed u ­
cational gam es which allow free m ovem ent an d free in te rp re ta ­
tion. W h en ev er exercises such as deep -b reath in g drills, setting­
up exercises, o r o th er vigorous form s of physical exertion are
practiced, the w indow s of the playroom should b e open, except in
severely cold o r storm y w eather. W h en ev er possible, th e ex­
ercises m entioned should b e tak en out of doors, either in the
y ard or on th e roof. In w arm w eather, practically all th e class­
room w ork should b e do n e in the open air.
(f)
C hildren m ust b e k ep t clean a t all tim es an d particular
atten tio n should b e paid to th e condition of th e hair.

D uring th e p ast few years it has becom e evident in som e of our
large cities th a t th e w ork of th e d ay nursery m ust b e ex ten d ed to
p ro v id e a certain am ount of night care in em ergency cases o r fo r short
p erio d s of time. H ealth visitors h av e long felt th e n eed of som e place
w here little children m ight b e tem p o rarily cared for, d a y an d night,
w hile th e m o th er w as tem porarily incapacitated b y illness o r necessary
absence from hom e. In N ew Y ork C ity appeal w as m ad e to th e d a y

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nurseries to m eet this problem , w ith th e result th a t several of them set
aside one room for a night nursery. A nurse was p laced in charge
an d children w ere k e p t a t th e nursery, d a y an d night, for period's n o t to
exceed on e m onth.
*
T h e possibility of thus utilizing th e nursery p lan t is a v aluable a d d i­
tion to o u r p ro g ram for child health. Such use, how ever, n eed s ca re­
ful supervision. If unrestricted, it m ay easily lead to m aking th e d ay
nursery an institution taking entire care of children fo r long p eriods of
time. It w ould thus, in g reat m easure, d efeat its ow n p urpose b y d e ­
taching th e child w holly from its hom e environm ent. P ro p erly re ­
stricted an d supervised, how ever, the n eed fo r tem p o rary night care
of children can b e m et b y utilizing th e d ay nursery p lan t pit a tim e w hen
it is g enerally idle. No such w ork, how ever, should b e carried on
w ithout a special p erm it w hich indicates th e purpose an d th e extent to
which such care m ay b e given.
T h e d ev elo p m en t of p ro p e rly supervised d a y nurseries o r nursery
schools fo r children u n d e r six years of age m ay well b e considered as
an im p o rtan t contribution to. th e solution of our present problem as to
how to care fo r the child of preschool age.
DISCUSSION
D r. M ulon ('W ar D ep artm en t, F ra n c e ) : I should like to say th a t th e day n u rse ry ,
w ill b e a sim ple failure, a n d w o rse th a n a n y b ad conditions in th e fam ilies, if it is
n o t p lace d u n d e r th e supervision o f a p hysician. A n d n o t only th a t, b u t it m ust
be u n d e r th e supervision of a n u rse, a n d a sufficiently p aid n u rse. W e h ad a long
ex p erien ce w ith those th in g s in F ra n c e ; a n d if w e h ad n o t ch an g ed conditions in
o u r day n u rseries w e w ould still have, as w e fo rm erly had, a v ery h igh m o rtality
f i n th o se institutions.
Miss M yrn B ro ck ett (M ary C ran e N ursery, C h icag o ) : T h e stan d ard s o utlined
by D r. B ak er p re se n t a basis fo r c are of children, w hich, if a d o p ted a n d p ra c tic e d
in day n u rseries an d o th e r in stitu tio n s c a rin g fo r children, w ould m ean m u ch in
th e lives of th e children u n d e r such care.
T h e en tra n c e physical exam ination should re su lt n o t only in th e exclusion from
th e n u rse ry of children w ith com m unicable affections, b u t also in th e fo rm u latio n
of a h e a lth p ro g ram fo r each child, th e n u rse ry assum ing th e responsibility fo r
ca rry in g o u t th e plans. T his involves intim ate an d m ore o r less individual a tte n ­
tion to th e diet of th e child ren , w hich, in day nu rseries, m akes n ecessary also a
know ledge of th e hom e diets. If surg ical o r h o sp ital c are is advisable, th e n u rse ry
should see th a t it is provided. T h e re should be also, as th e te st of effective tr e a t­
m ent, th e m o n th ly w eig h in g a n d m easu rin g o f each child, w ith carefu l n o te of
gains o r losses a n d provision fo r co rrectiv e tre a tm e n t w hen needed. T h e ch ild ren
w hose physical exam inatio n s re su lt in th e ir exclusion from th e n u rse ry should
be re fe rre d to th e p ro p e r ag en cies fo r tre a tm e n t. W h en a n in fan t-w elfare statio n
is available, it is a n excellent p lan to re g iste r th e n u rse ry child ren of suitable age
an d to C ooperate w ith th e in fan t-w elfare n u rses in c a rry in g o u t th e h e a lth p lan .
D r. B aker s recom m en d atio n of hom e visiting is a reco g n itio n of th e fa c t th a t
effective service to th e child m ust be based u p o n a know ledge of his hom e environ-


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m en t an d th a t th e fam ily ra th e r th a n th e individual child m ust be m ade th e u n it
of effort. Such a p lan, in m y opinion, involves th e assu m p tio n by th e n u rse ry 6f
th e c are of th e old er ch ild ren of th e fam ily. If th e n u rs e ry ac c e p ts th e y o u n g
children of a fam ily, th u s releasin g th e m o th e r from th e hom e, a n d does n o t a c cep t
the responsibility of th e c a re of th e o ld er children, its social co n trib u tio n is likely
to resu lt in m ore h a rm th a n good to th e g en e ra l fam ily situation, b e c au se it
deprives th e o ld er ch ild ren of th e m o th e r’s c are a n d also of th e ir in te re st a n d
responsibility in th e c are of th e ir y o u n g e r b ro th e rs an d sisters a n d leaves th em
to th e d an g ero u s influences of th e streets a n d alleys. In a n u rse ry w h ich h as
been p lan n ed fo r th e c a re o f y q u n g ch ild ren only, this w o rk p re se n ts a difficult
problem b u t one w h ich th e n u rse ry can a n d should accep t.
T h e co n tac t w ith th e hom e a n d fam ily, besides fu rn ish in g a basis fo r n u rse ry
effort, should also m ak e c le a r th e financial situ ation of th e fam ily, so th a t if th e
incom e of th e w o rk in g m o th e r is c u t off by illness of herself o r of a child, th e
relief-giving ag en cy w ill be p re p a re d w ith d ata a t h an d to fo rm u late a definite
p lan for relief, if necessary, d u rin g th e p e rio d o f distress.
T h e o b ject of d ay -n u rsery effort is fu n d am en tally to raise th e sta n d a rd of hom e
a n d fam ily life, a n d follow -up visits to th e hom e will readily reveal w h e th e r o r n o t
th e n u rs e ry service is h elp in g to acco m p lish this result.
A n y a d e q u a te service to a n o rm al child m ust include a p lan fo r his m en tal de­
velopm ent th ro u g h su itab le o ccu p atio n s a n d p lay. M ost of th e day n u rse rie s
of good stan d in g p ro v id e a b rie f k in d e rg a rte n p e rio d fo r child ren of p resch o o l
agd, eith e r a t th e n u rse ry o r a t a n e a r-b y school o r settlem en t. T h e d ay n u rse ry ,
how ever, offers a m ost ex cellen t o p p o rtu n ity fo r th e e n larg em en t of th e k in d e r­
g a rte n p la n to include th e activities of th e child fo r th e e n tire day. T h e p ro g ra m fo r
th e day should be carefu lly p la n n e d u n d e r th e advice of e x p e rts in th e v ario u s
lines of n u rse ry service. T h e k in d e rg a rte n te a c h e r, th e food econom ist, th e nu rse,
a n d th e p h ysician should all b e co n su lted in d eterm in in g th e p la n s fo r th e h o u rs
of sleep, th e m ealtim es, diets, playtim es, a n d th e c h a ra c te r of th e o ccu p atio n al
w ork a n d of th e play.
T h e p a rtic ip a tio n o f th e child in th e w o rk involved in his c are is of g re a t in­
te re st to him an d is valu ab le e d u catio n al m aterial. T h e en la rg e m e n t of th e day-^
n u rse ry ideal to include th a t of th e all-day k in d e rg a rte n , giving th e children
o p p o rtu n ity to exp ress them selves in p leasu rab le a n d h elpful activities, should be
accom plished u n d e r th e directio n o f th e tra in e d child te a c h e r a n d w ith definite
educational intent. T h e tec h n iq u e o f th e child’s activities— th e settin g , serving,
a n d clea rin g of th e tab les; th e w ashing, drying, an d settin g -aw ay of th e dishes;
th e toilets a n d b ath s— should b e as carefu lly w o rk ed o u t as is th e rh y th m , circle,
a n d tab le w o rk of th e sh o rt-tim e k in d e rg a rte n session. S u ch a p la n re q u ire s th e
all-day services of a k in d e rg a rte n te a c h e r of a h igh type. F u rth e r, if th is w ork
can b e co nducted u n d e r th e in sp iratio n a n d supervision of a good k in d e rg a rte n
college, it is of g re a t valu e to th e n u rse ry a n d offers to th e k in d e rg a rte n stu d en ts
an o p p o rtu n ity fo r th e m o st ad v an ced ty p e o f k in d e rg a rte n ex p erien ce in th e ir
w ork as cadets. F o r th e p a st tw o y e a rs th e N ational K in d e rg a rte n a n d E lem en ­
ta ry C ollege a n d th e M ary C ra n e N u rsery of C hicago have b een w o rk in g out,,
such a p la n w ith m ost g ratify in g resu lts fo r b o th th e college a n d th e n u rse ry .
T h e o rganization of day n u rse rie s h as usually b een th e re su lt of th e efforts of
a gro u p of p h ilan th ro p ic w om en w ho have sought, b y pro v id in g d aytim e c a re for
children, to enable m o th ers w ho m ust w o rk outside th e h om e to k eep th e ir child ren
w ith th em ra th e r th a n p lace th em in in stitu tio n s. T h e in itial efforts have been
co nducted as a ru le on a sm all scale, a n old h o u se o r a p a rtm e n t b ein g ad a p te d
to th e p u rp o se, w ith eq u ip m e n t p a rta k in g of th e sam e m ak esh ift c h a ra c te r. T h e


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g ratify in g re tu rn s in child w elfare a n d h appiness have h ad a ten d en c y to m ak e
th ese m akeshifts accep tab le, a n d th e n eed of a b e tte r ty p e of h o using a n d fu rn ish ­
ing has o ften b een lost sight of. A carefu l study of ideal h o u sin g a n d eq u ip m en t
fo r day n u rseries w ould be m ost helpful in m ak in g a differen tiatio n betw een ex­
pediencies a n d ideals a n d w ould be a g re a t help in th e w o rk o f stan d ard izatio n .
A sim ilar condition has existed in re g a rd to th e n u rse ry staff. T h e o p p o r­
tu n ity fo r intim ate and effective service to th e fam ilies u n d e r n u rs e ry c a re is quite
w o rth th e efforts of th e b e st-train ed w om en. T h e re should be a cap ab le g rad u ate
n u rse to supervise th e c a rry in g o u t of th e h e a lth p ro g ra m s a n d o th e r m a tte rs p e r­
tain in g to n u rsin g a n d h y g ien e; a child e d u c a to r w ith ab ility fo r creativ e w o rk
to develop a n d standard ize a n all-d ay p ro g ra m fo r th e n u rse ry child; a tra in e d
household econom ist to d irect th e selection a n d p re p a ra tio n of food, th e b u ying
of furnishings a n d equipm ent, a n d th e g en eral household p lan s; an d , fu rth e r, a
tra in e d social w o rk e r to b rin g a b o u t effective co o p eratio n b etw een th e n u rse ry
a n d hom e life. T o secu re su ch e x p e rt service a co o p erativ e p lan m ig h t b e w o rk ed
o u t by a g ro u p of nurseries. W ith th e ex cep tio n of th e k in d e rg a rte n te a c h e r,
p a rt-tim e w o rk w ould seem to be sufficient fo r th e o th e r services. T h is g ro u p
w o rk w ould also have a ten d en c y to w a rd con so n an cy of d a y -n u rse ry effort, th e
supervision of th e edu catio n al w o rk of th e g ro u p by th e k in d e rg a rte n college
accom plishing a sim ilar re su lt alo n g th a t line. T h ese e x p e rt w o rk e rs m ight be
affiliated w ith a c e n tra l o rg an izatio n of d ay n u rseries, a c tin g u n d e r th e directio n
of a g en eral supervisor o r secre ta ry , w ho w ould c o o rd in ate th e ir w o rk a n d in te r­
p re t it to th e m em bers of th e go v ern in g b o ard s of th e v ario u s n u rse rie s a n d to
th e c e n tra l organization .
T h e re has been in d ay -n u rse ry w o rk th e w h o le-h earted p u rp o se of b rin g in g
happiness to th e child in kindly, loving service. A t th e sam e tim e th e re h as been
a p ro n en ess to isolation a n d a too g re a t relian ce u p o n sen tim en t fo r g u id an ce in
m ethods. T h e p a st few years, how ever, have m a rk e d a d istinct p ro g re ss alo n g
this line a n d have resu lted in a m ore co o p erativ e a n d in tellig en t effo rt to b rin g
real happiness to th e child th ro u g h a b ro a d in te rp re ta tio n of his needs in term s
o f th e highest stan d ard s of child w elfare.
M rs. E lean o r B arto n (W o m en ’s C o o p erativ e Guild, E n g lan d ) : I am going to
ta k e a n en tirely opposite p o in t of view from th a t w hich has b een given y o u this
evening. I am absolutely opp o sed to d ay n u rseries. I th in k th a t d ay n u rse rie s
a re Pa ^
th e g re a t in d u strial p roblem . I w onder, if w e a sk ed e ach p erso n
in this room w h at is th e g re a te st need of a child, how m an y v arieties of an sw ers
w e should have. I th in k w e could all a g re e u p o n o n e thing, th a t th e child
needs m ost o f all its m o th e r; a n d th a t is th e position I tak e. D r. B ak er did
m ention th a t th e day n u rse rie s in N ew Y o rk h ad b een especially h elpful d u r­
ing th e influenza epidem ic. I will bow to th a t sta te m e n t; I th in k th a t is rig h t.
I th in k th e re o u g h t to be som e p rovision fo r those w om en in th e w o rkingclass hom es, w h ere th e m o th e r is ev ery th in g — w o rk -m ate, w asherw om an, cook,
a n d ev ery th in g com bin ed ; w hen she is stric k e n dow n, th e re should b e som e
provision fo r th e c are of h e r children.
B ut if th a t m ean s th a t w e a re to ta k e c are of child ren w hose m o th e rs go into
in d u stry fo r som eone else to m ak e a p ro fit o u t of them , th e n 1 am to tally opp o sed
to it. W ith all th e tro u b les w e h ad in Englancf d u rin g th e w ar, w ith a ll th e w om en
in industry, I consistently to o k th is stand.
I to o k this stand, n o t b ecau se
I am afraid o f w om en going o u t to w o rk . I am a suffragist. I believe a w om an
should do th e w o rk she is best fitted for. B ut D r. M ulon has to ld us o f th e dif­
feren ce betw een th e in d u strial m o th e r a n d th e o th e r m o th er. I w an t to see
th e in d u strial m o th er m ore like th e o th e r m o th er, a n d in re g a rd to th e w elfare of

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h e r child, it seem s to m e th a t she is n o t b ecom ing so th ro u g h th e settin g up of
day n u rse rie s.'
,
W e had d u rin g th e w ar ra th e r a n in terestin g ex p erim en t in th e tow n th a t I
cam e from . W e have a v e ry pro g ressiv e m edical officer of h ealth , w ith his
staff, a n d a v ery good w elfare ce n te r fo r th e children, w h e re th e babies a re
w eighed, w h ere th ey a re inspected, w h e re th e ir m o th ers a re advised as to th e
feeding of th e children, a n d so on. T h e child ren a re w eighed each w eek, a n d th e ir
p ro g ress w atched. T h is tow n is a la rg e m u n itio n -m an u factu rin g c e n te r, w h ere
m any of th e w om en w orked. A d ay n u rse ry w as established th e re , in a good
house, w ith a n a d eq u a te n u m b e r o f a tte n d a n ts fo r th e n u m b er of children, a n d
so on.
T h ey c a rrie d o n th e sam e ex p erim en ts th a t w e do in o u r child-w elfare c en te rs;,
they w eighed th e children, a n d advised w ith us as to th e food, a n d so on. But
those children, in spite of b ein g w ell c a re d fo r in this w ell-equipped day n u rse ry ,
did n o t m ake th e sam e p ro g re ss as did th e ch ild ren of th e m o th ers from o u r p o o re st
q u a rte rs w ho b ro u g h t th e ir ch ild ren to o u r w elfare cen te r. So w e w ere fo rced
to th e conclusion th a t, even th o u g h th e child w as b e in g c a red fo r in th e day n u rs ­
ery, w ith fresh a ir a n d b a th s a n d all th e p ro p e r care, th e re w as so m eth in g th a t
w as lack in g ; it did n o t com e up to th e sam e sta n d a rd as th e child in its ow n
hom e an d u n d e r th e child-w elfare d irectio n of o u r m edical officer o f h e a lth . It
is n o t only th e fresh a ir an d th e cleanliness th a t th e child n eed s; th e re is som e­
th in g else, a n d th a t som ething else th e m o th e r a lo n e can give.
I w o n d er if w e have con sid ered th ese th in g s? W h en w e co n sid er th e m we
o u g h t to go dow n as deep as w e can, b ecau se th e re is no d o u b t th a t th e w o rk of
this conference will c a rry g re a t w eig h t in th e S tates. W e have all so rts o f opinion
h ere. W e have really in tellectu al opinion, a n d p eo p le a re going to w a tc h w h at
w e do. I do n o t w a n t to m ak e a false step, if it is possible fo r us to do o th e r­
wise. It seem s to m e th a t w e m u st co n sid er k e ep in g th e m o th e r a n d th e child to ­
g eth er. T o se p arate th e m d u rin g th e w a r m ight have b e e n allow ed, from th e
fa c t th a t o u r w om en w ere w an ted in in d u stry — th o u g h I n e v e r w as convinced of
th at, b ecause I found m an y w om en, w ho had no children, th a t m ig h t have b een o u t
in industry. T h ey could have h elp ed th e m o th ers to stay a t hom e a n d a tte n d to
th e ir children. But now w e have no lo n g er w a r conditions. W e a re se ttin g up
new standards, a n d w e a re h aving new ideals— a n d ideals p reced e p ra c tic e . So let
us get o u r ideals rig h t, a n d th e p ra c tic e will be rig h t; le t u s n o t se p a ra te m o th e rs
an d children.
Som e p eople will say, " I t will h elp in d u stry ." T h e y told us th a t in th e e arly
days, w h en v ery y o u n g ch ild ren w ere going to w o rk in th e c o tto n m ills; a n d
w h en w e trie d to raise th e a g e o f th e children, th e c o tto n m a n u fa c tu re rs o p p o sed
us. T h ey said: "W e m ust have these child ren in th e c o tto n m an u facto ries, b e ­
cause th e ir fingers a r e m o re supple th a n th o se of a d u lts.” Well* w e succeed ed
in ta k in g o u r ch ild ren o u t o f th e m ills; w e did n o t listen to w h a t th e c o tto n m a n u ­
fa c tu re rs h a d to say ; w e to o k th e ch ild ren o u t, a n d th e c o tto n m ills a re now flo u r­
ishing. T h e v ery sam e p eo p le w ho m ade th a t co m p lain t h av e m ad e th e ir fo rtu n es,
a n d o th e rs have m ad e th e ir fo rtu n es, o u t of co tto n m ills. T h e sam e w ill a p p ly
very larg ely if w e ta k e w om en o u t of in d u stry . I a m v e ry certa in , a t least, th a t
w e have no reaso n to fo rce m o th e rs in to in d u stry.
Now, if y o u a r e going to have d ay n u rseries, w h a t so rt a re y o u going to h a v e?
If you a re going to have them , y o u m ust have th e v e ry b est. N one of us, even
if w e w ere convinced th a t d ay n u rse rie s a re n ecessary , w ould a p p ro v e o f a n y th in g
n o t th e very b est possible. You m u st have th em u n d e r p u b lic-h ealth a u th o rity ;
you m ust have gardens, a n d b ath s, a n d e v ery th in g th a t w ill m ak e th em th o ro u g h ly

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equipped. In addition to th a t, th e p eo p le w ho a tte n d th e ch ild ren m ust he w ell
train ed . A n d w ith re g a rd to th e h e a lth visitors, it is n o t o nly tra in in g th a t is
im p o rta n t; it is th e ir sy m p ath y a n d th e ir w ay of a p p ro a c h in g th e fam ily. Nowth a t all m eans m oney ? y o u m ust have m oney to set u p y o u r day n u rseries, a n d
you m ust have m oney to tra in th e p eo p le w ho ta k e c are of th e child ren . W ell,
w hy n o t spen d y o u r m oney on th e m o th e r ? W hy n o t give it to th e m o th er, a n d
let h e r stay in h e r ow n hom e? W e in E ng lan d a t th e p re se n t tim e a re discussing
som e of th ese problem s. W e a re discussing fam ily endow m ent, w hich, it seem s to
me, will solve th e pro b lem of th ese children.
A n d it seem s to m e th a t if w e have found d u rin g th e w a r th a t it w as good to
give th e m o th er a n allow ance fo r herself a n d a n allow ance for each child, a n d if
w e a re able to p rove, as w e a re able to p ro v e, th a t d u rin g th e w a r children
have b een b e tte r k e p t a n d b e tte r fed, a n d m o re h ealth ily no u rish ed , a n d have
h ad m o re w o rk in g ability, a n d th a t people have b een able to send th e ir ch ild ren
from th e elem en tary schools to th e seco n d ary schools th ro u g h this allow ance, w hy
n o t co n tin u e this allow ance in p e a c e tim es?
I am ag ain st day n u rseries, b e c au se I do n o t th in k w e should sen d o u r w om en
o u t of th e ir hom es to go into ind u stry . I am n o t a g ain st day n u rse rie s w hen
th e y a re necessary. But I do a g re e w ith D r. M ulon as to th e g re a t difference b e­
tw een th e in d u strial m o th e r a n d th e o th e r m o th e r. T h e o th e r m o th e r m ay go
o u t to w o rk if she is a d o cto r o r a te a c h e r; b u t she has h e r ow n tim e each day.
T h e w orking-class m o th e r h as no t. A n d I know th a t all th e c o u n try w illljen efit,
an d th e children will benefit also-, if th e w om en do n o t go o u t into ind u stry . Do
n o t le t us ad v o cate things th a t will b e d e trim en tal to th e ch ild ren of Jthe fu tu re .

Dr. M ulon (W a r D ep artm en t, F ra n c e ) ; P e rh a p s w e a re too tim id in F ran ce, b u t
w e n ev er p u t in th e sam e room a n u rsin g b ab y a n d a n old er child, becau se
w e a r e v ery anxious to p re v e n t co n tag io u s disease; a n d if w e p u t th e tw o classes of
children to g e th e r contag io u s diseases w ould sp read . F o r th e sam e reaso n we
k eep a p a rt th e b ab y th a t is bo ttle-fed a n d th e b ab y of th e sam e ag e th a t is b re a s t­
fed, becau se w e very often find th a t th e y a re n o t of th e sam e sta n d a rd ; a b aby
th a t is b o ttle-fed gets co n tag io u s diseases m o re easily. In th e day n u rse ry th a t
I should like to h avei w e should have m an y room s— room s fo r b o ttle-fed babies,
n u rsin g babies, babies betw een tw o a n d th re e years, a n d so on. E v ery room
should be different— th e p erso n n el, th e food, a n d th e education, if w e can ta lk of
ed u cation fo r such y o un g babies. A n d ed u catio n has to .begin from th e first.
I p erfectly ag re e w ith M rs. B arto n th a t m o th er a n d child m u st n o t b e p a rte d .
A n d it is fo r th a t reason th a t w e have n u rsin g room s. But if th e m o th e r is obliged
to w ork, w h at can w e do? Y ou say : “ Do n o t sp en d th e m oney on th e day n u rs e ry ;
give it to th e m o th e r.” W ell, th e day n u rse ry m ay cost a g re a t deal, b u t. th e
m oney w ould n o t be en o u g h fo r th e m o th e r; it w ould be o nly en o u g h to k eep h e r
from starv atio n . So if a m o th e r is n o t su p p o rte d by h e r husband, she m ust
choose b etw een th e best fo r herself a n d th e b est fo r h e r child. T h e re is o nly
one o th e r th in g th a t she m ay do. S he m ay send th e child aw ay to a p e a sa n t
h o m e; a n d in 50 p e r cen t of th e tim es she w ill have no ch an ce to see it ag ain .
W e have n u rsin g room s n o t only fo r o u r fa c to ry w o rk ers, b u t fo r th e shop
girls. W e have a ch arm in g n u rsin g room now in one of o u r b iggest shops, on
th e roof, a n d th e babies th e re a re beau tifu l. B efore it w as established, th o se girls
w ere obliged to send aw ay th e ir babies a n d th e babies died. A larg e p o rtio n of
th e babies ,sent aw ay to b o a rd in g hom es died. But all these ch ild ren a re v e ry
b eau tifu l; an d th e ir n u rsin g a t th o se room s m eans n o t to se p a ra te th e m o th e r from
h e r children.

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STANDARDS O F C H IL D W E L F A R E

M rs. B arto n : I have ju st one o th e r point. T his relates to o u r big in d u strial
centers, w h ere o u r w om en a re going o u t to w ork. In th e c o tto n mills th ey go o u t
a t six o’clock in th e m orn in g . It is n o to rio u s th a t in those n o rth e rn tow ns of ours,
w h ere m arrie d w om en go o u t to w o rk , th e re is a h eav ie r in fan tile d e a th ra te
th a n in a n y o th e r pjart of E ngland. A n d it is n o t only th a t th e d e a th ra te is v e ry
high, b u t a n u m b er of th e ch ild ren a re w eak en ed . A n d I rem em b er th a t a g en ­
tlem an living in th e S o u th of E ngland said to m e, “ Do you know w h a t "im pressed
m e m ost w hen I first w en t to th e N o rth ? ” I said, “ No, w h at w as it? ” H e said,
"T h e sm all sta tu re of y o u r p eo p le .” “ H ow do you a c c o u n t fo r it? ” I a sk ed ; a n d
he sa id, “ it is th e ir mill life” ; a n d I said, “ Yes, b ecause th e ir m o th ers w ere
■not ab le to give them w h a t th ey n eed ed in th e ir child life.”
By p u ttin g day n u rse rie s in th e m u n itio n cen ters, w h at is going to h a p p e n ?
T h e h o u rs a re even w orse th a n in th e co tto n mills. In th e c o tto n mills, it w as
from six in th e m o rn in g to -five-thirty in th e evening; b u t in th e m un itio n facto ries
th e re a re th re e shifts; a n d th e w om an w ould be ta k in g th e.c h ild to th e day n u rse ry
a t five in th e m orning, a n d ta k in g it hom e a t tw o; o r ta k in g it to th e n u rse ry a t
tw o a n d ta k in g it hom e a t te n ; o r ta k in g it to th e n u rse ry a t six in th e evening,
a n d g ettin g it b ack th e n e x t m orn in g . A suggestion w as m ad e by D r. B aker
th a t th e day n u rserie s ta k e ch ild ren fo r th e n ig h t, as w ell as fo r th e day. O f
course, D r. B aker said th a t should be lim ited to one m onth. B ut o u r w om en have
been w o rk in g „that w ay fo r n e a rly five years.
You •will have to rem em b er this also : I th in k D r. M ulon said th a t th e F re n c h
w om en could n o t w o rk m o re th a n seven o r eig h t m onths on w a r w o rk w ith o u t
a b reak d o w n . T h in k of w om en w o rk in g u n d e r those a rd u o u s conditions! If
a w om an w o rk s tho se eig h t ho u rs, she does n o t go hom e a n d re st; she goes first to
th e day n u rse ry an d gets h e r baby, a n d th e n she h as to go hom e an d p rovide
a m eal a n d ta k e ca re of th e b ab y u n til th e n ex t day, a n d so on.
If you will look into th e m a tte r, it is v ery p le a sa n t to ta lk a b o u t th e b a th fo r th e
children, an d th e k in d e rg a rte n , a n d all those thin g s. I a g re e w ith o u r frien d from
C hicago; I th in k ta k in g th e o ld e r children off th e stre e ts i3 a good thing.
B ut it seem s to m e th a t th e p eo p le w ho a re stud y in g this q uestion a re too
tim id. L et us n o t be n erv o u s. If w e th in k a th in g is rig h t, let us n o t consider
p re se n t m an u factu rin g a n d in d u strial conditions; let us have an ideal. If you do
n o t g et y o u r ideal, you will a t least have th e satisfactio n of know ing th a t y o u y o u r­
self h ave w o rk ed th e th in g o u t in w h a t you th in k i3 th e rig h t w ay ; a n d if p eo p le do
n o t c a rry o u t y o u r ideal, th e irs is th e blam e, a n d n o t yours.
D r. M ulon: I should be glad to an sw er th a t. W h en w e sp eak of th e ideal, I
ag re e w ith M rs. B arto n ; b u t I c a n n o t foresee th e fu tu re . I live in th is tim e, a n d I
sp eak o nly of o u r a c tu a l p re s e n t conditions. I know th a t it w ould b e b e tte r to have
a v ery n ice hom e, a n d th a t th e m o th e r should stay a t h o m e; b u t I sp eak o nly fo r
th e m o th e r th a t can n o t stay a t hom e. H ow ever, th e w o rk in g o f m o th ers a t n ig h t
m ust be absolutely p ro h ib ited . No w om an m ust w o rk a t night, u n d e r a n y co n ­
ditions. In o u r co u n try th e m o rta lity am o n g th e ch ild ren of w o rk in g m o th ers
is very high, ju st as in M rs. B arto n ’s. In all in d u stries it is th e sam e. A b o u t 80
y e a rs ago, a ro u n d 1830, a m an th a t h a d a fa c to ry in F ra n c e , w ho w as v ery g en ­
erous, installed a d ay -n u rsin g room in his facto ry . T h a t m a d e co n d itio n s b e tte r
th a n th ey h ad been.
It is n o t m y ow n op in io n m erely, it is th e o p in io n of m an y d o cto rs w ho have
th e supervision of factories, th a t th e d e a th ra te a m o n g child ren in th e in d u strial
cities w h ere th e m o th e r is obliged to w ork, is app allin g . O ne y e a r th e police b o a rd ’s
figure w as 86 p e r c e n t a m o n g th e b ab ies w hose m o th ers h ad to go o u t to w o rk an d
leave th e ir children to be ta k e n c a re of b y som e old w om an. B ut w h en those

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children w ent into n u rsin g room s, th e re w as p rac tic a lly no m o rta lity am o n g them .
I have had no child th a t died ex cep t one w ho died tw o m o n th s a fte r h av in g left
th e n u rsin g room .
Dr. Jessica B. Peixotto (U niv ersity of C alifo rn ia) : I v e n tu re to sp eak b ecau se I
com e from th e S tate of C alifornia, w hich is, I th in k , o n e of th e few S tates th a t
license day n u rseries; an d 1 am a m em ber of th e S tate b o a rd of c h arities a n d c o r­
rection, w hich has th e p o w er to do th is licensing. C alifornia is n o t a n ind u strial
S tate in th e stric t sense of th e w o rd ; a n d y e t w e have o u r in d u strial cen ters, a n d in
those cen ters day n u rseries have ten d ed to grow . I ta k e em p h atically th e p o ­
sition of Mrs. B arton, an d w hen I w ent on th e S tate b o a rd of c h arities I resolved to
see th a t som ething w as done so th a t day n u rse rie s should n o t grow in o u r S tate.
If th e b o ard of m anage m en t of th e n u rse ry really investigates th e fam ily it finds
o ften th a t th e situ atio n th a t seem s to re q u ire th e m o th e r to ad d to th e incom e
can be w o rk ed o u t in som e o th e r w ay th a n by se p a ra tin g h e r from h e r hom e a n d
h e r fam ily. P e rh ap s I am sp eak in g fo r a m ore p ro sp e ro u s S tate, a n d fo r a less
crow ded p a rt of the c o u n try ; C alifornia is n o t w h at th e A tla n tic co ast is, I know .
B ut o rd in arily it has been found th a t th e people w ho send th e ir ch ild ren to th e
n u rseries a re follow ing th e tra d itio n a l n o tio n th a t if th e incom e is a t all w eak
th e y m ust n o t fight to force up th e m an ’s incom e, b u t m u st see th a t th e m o th er
ekes o u t th e fam ily incom e a n d th a t ev ery child w ho can be p u sh ed into in d u stry
also ekes o u t th e incom e.
A s a n e n terin g w edge b etw een th e p ra c tic e of kindly, friendly, co rd ial c are of
o th e r p eo p le’s children, w h ich is th e ideal of th e day n u rse ry , an d th e idea w h ich I
sh are w ith Mrs. B arton of abolishing th e day n u rse ry as fast as possible, it seem s
to m e th a t it w ould be of g re a t benefit to re q u ire ev ery case in a day n u rs e ry to
be tre a te d exactly as a case in a n y o th e r ty p e of relief. T h a t is, a definite in q u iry
into hom e conditions should be m ade, a n d a p lan devised fo r im proving th e fam ily
conditions so th a t a n a d e q u a te living w age is received.
T h e responsibility is p u t u p o n a b o a rd of m an ag ers, and, if th e y a re th e k ind
of people th a t a re ru n n in g n u rse rie s in o u r p a rt of th e w orld, th e y w ill face it.
A n d facing it, th e y will re d u c e th e p o p u latio n of n u rse rie s w on d erfu lly . It m ay
be th a t in o th e r p a rts o f th e w o rld m ore crow ded conditions will n o t p e rm it early
ad o p tio n of this plan. In th a t case it seem s to m e th a t ev ery w o rk e r fo r child ren
o u g h t to join the fight fo r a living w age fo r m en, a n d to see th a t th e w om en do
n o t go into in dustry. T h u s th e child ren of this c o u n try m ay a t le a st h av e a
p o te n tia l hom e th ro u g h an incom e w hich is reasonable.
O u r ch ild ren ’s agencies fight th e n u rseries, because th ey say th a t th e y definitely
b rin g a b o u t in creased in fan t m o rtality . T h e little ch ildren com ing to g e th e r to u c h
each o th er, p lay w ith each o th e r; th e children c an n o t be exam ined ev ery day.
T h e th e o ry of n u rserie s is good, b u t th e p ra c tic e does n o t w o rk o u t. So th e
b est agencies th in k th a t th e n u rse rie s a re a m istake, a n d do n o t p lace th e ir children
in them .
In San F rancisco w e have a w idow ’s pension system , w h ich gives $12 fo r each
child, $ 12 for overhead , a n d $ 12 for th e m o th er. Even if th e re a re fo u r o r five
children, th e fam ily is ta k e n c are of o u t of co u n ty a n d S tate fu n d s; th e re a re
co u n ty funds for d eserted w om en.
Dr. M ulon: W e have b een to ld a b o u t contag io u s diseases, a n d th a t it is n o t
possible to p re v e n t them , b ecau se w hen th e child goes h om e h e is in c o n ta c t
w ith his b ro th e r o r his sister, o r th e re st of his fam ily, a n d so gets contag io u s
diseases w hich he m ay b rin g to th e day n u rse ry . ' T h a t is p erfectly tru e . T h a t
is th e g reatest d an g er of th e n u rsin g hom es a n d th e d ay n u rseries. B ut it is a

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STANDARDS OF CHILD WELFARE

p o in t o n w hich I a sk perm ission to insist, th a t if you have th e p ro p e r p erso n n el
you will n o t have th a t condition. E very m o rn in g th e child m ust be in sp ected
before e n te rin g th e n u rse ry . In th e in terv al w hen he is undressed, w h en th e
n u rses see him com pletely, th ey can exam ine him . W e have n e v er h ad a case of
transm ission of con tag io n in m y little hom e. A n d b ecau se m y n u rses w e re v ery
w ell train ed , th ey ha ve b een able to discover diseases in th e ch ild ren com ing
to th e hom e w hich a m o th e r w ould n ev er have seen o r ask ed fo r m edical advice
ab o u t. A nd som e of th em w ere diseases th a t could have com prom ised all th e
fu tu re of th e child. So th a t th e children n eed supervision. I am v ery so rry th a t I
can n o t show you m y ch ild ren ; I th in k th a t w ould be th e b est a rg u m e n t.
Miss Julia C. C o rc o ra n (F a c to ry Inspection D ep artm en t, C o n n e c tic u t) : My ex ­
p erien ce has been v e ry sim ilar to th a t of D r. B aker, becau se I w o rk w ith w ork in g
w om en. A nd I w ould like to ask w hen you w ould consider a day n u rse ry n o t a
day n u rse ry ? I w ould consider it n o t a day n u rse ry w hen it is a ro o m in a fa c to ry
set a p a rt fo r th e care of th e ch ild ren o f th e w o rk in g m o th ers. A n d I th in k th a t
public sentim ent should g et b a c k of th e m ovem ent fo r m o th ers’ pensions.
I have investigated a g re a t m an y cases of w h at w ere su p p o sed to be w o rth y
widows, an d ju s t a s M rs. B arton said, th e y have th e ir h o u sew o rk to do, an d
of course th e ir h o u sew o rk is n eglected.
D u rin g th e w a r I p lead ed w ith
m any m en a n d w om en w ho w an ted to p u t m oney into day n u rseries, to p u t
th e m oney into these d ifferent fam ilies an d keep th e m o th e rs a t hom e. In
looking u p th e fam ily budgets, w e found in m an y cases th e incom e w as
am ple to keep th e m o th ers a t hom e. But th e p re ssu re fo r th ese w a r w o rk e rs
w as so g reat, a n d is still so g reat, th a t now w e have o u r in d u strial day n u rse rie s
su p p o rted by o u r m a n u fa c tu re rs; a n d I am a fra id th ey have com e to stay. A n d
I am afraid th a t is w h at th e m a n u fa c tu re rs w an t— ju s t as M rs. B arto n said as
to th e tex tile industries.
If th e re is still a n eed fo r th e m a rrie d m o th ers to e n te r ind u stry , a visiting
h o u sek eep er should be em ployed to cook th e ir food a n d keep th e ir hom es in
o rd e r; th e m o th ers m ust n o t be obliged to go hom e a n d do th e ir ho u sew o rk .
I am v ery m uch opposed to th e in d u strial n u rse ry , a lth o u g h I am a fra id it has
com e to stay, unless you w o rk to secu re mothers* pensions o r S tate a id for w idow s;
an d even th en th e re m ay be day nu rseries, b ecause th e re m ay be w om en w ho will
n o t ac c e p t th e pension, b u t will go o u t to w ork, in C o n n ecticu t provision for
such S tate aid fo r w idow ed m o th ers w ho can give good c are to th e ir children
becam e a law a t th e last session of th e legislature.
Miss Lydia B urcklin (F rien d sh ip H ouse, W ashington, D. C .) : I th in k th e fact
th a t w e have h ad p ractically no stan d ard s fo r o u r d ay -n u rse ry w o rk in this
c o u n try is giving som e w o rth-w hile w o rk a b ad nam e. I have been co n n ected
w ith a day n u rse ry f o r 't e n y ears. W e have n e v e r ta k e n a child from its hom e
w hen th e re w as an y o th e r possible p lan . W e co o p e ra te w ith ev ery ag en cy
th a t w e have, an d w e believe th a t th e b est p lace fo r th e child is in th e hom e.
W e have no m o th ers’ p ensions; b u t in a case w h ere a m o th e r can give good care
to th e child, w e ta k e th a t child aWay o nly tem p o rarily , o r w hile w e a re w o rk in g
o u t som e plans so th a t th e m o th e r can rem ain in th e hom e.
I feel th a t it is to o b ad th a t th e re should b e n u rse rie s c o n n ected w ith in ­
dustries. T h a t is all w rong. I have visited n u rse rie s in m an y cities, a n d I have
been h eartsic k o v e r th e conditions I have fo u n d in som e of them . T h e ir o n e
idea seem s to be how m an y child ren th ey can ta k e c are of. T h ey have no idea of
p ro p e r supervision, ph y sical o r m oral. Now, th a t is n o t th e kind o f n u rse rie s we
should have. T h e best possible ex am in atio n should b e m ade, an d th e th in g should

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b e done th a t seem s to be b e st fo r th e child a n d fo r th e fam ily. I am so rry to
say th a t day n u rse rie s a re a n ecessary evil in o u r p re s e n t sta te o f social d evelop­
m ent.
Miss B ro ck ett: I w o n d er w h e th e r th e conditions cited by p rev io u s sp eak ers
w ould hold tru e in a n u rs e ry o p e ra te d o n th e p lan w hich D r. B ak er gave us?
I should like to ask Mrs. B arto n w h e th e r th e sta te m e n t w hich she m ade in re g a rd
to th e h ealth of th e d ay -n u rsery ch ild ren as co m p ared w ith ch ild ren in th e ir hom es
re fe rre d to children ov er n in e m o n th s o f age, w hich is acc e p te d as th e m inim um
ag e of n u rse ry children in th is co u n try ?
M rs. B arto n : 1 could n o t say w h a t th e ag es w ere, b u t a t a n y ra te , th e ag es of
b o th classes com pared w ere alike, j C h ild ren visiting th e child-w elfare c e n te r w ere
co m p ared w ith children of th e sam e a g e w ho w en t to th e day n u rse ry . E v ery th in g
w as done in an im p artial w ay; and, a lth o u g h 1 w as ag ain st d ay n u rseries, I w as
su rp rised a t th e result.
v
I am ag ain st day nu rseries, b ecau se I th in k th ey a re a t th e c e n te r of ev ery ­
th in g th a t is w rong. It seem s to m e th a t it is n o t th e socialists w ho a re going
to b re a k u p th e hom es, b u t it is in d u stry w h ich is going to b re a k u p th e hom es.
It w as w ith th a t p o in t of view th a t I w as w atch in g th e re su lt o f th e com parison,
a n d I w as v ery m u ch su rp rise d to find w h a t it w as. T h e p eo p le w ho co n d u cte d
th e te st w ere v ery im p a rtia l; th ey to o k ch ild ren ' of th e sam e a g es in e a c h case.
Miss B ro ck ett: I th o ro u g h ly a g re e w ith you a b o u t ch ild ren u n d e r n in e m o n th s
old; a n d I do n o t know b u t th a t I w ould p u t th e a g e a t a y e a r. B ut I c a n n o t
believe, from m y ow n ex p erien ce a t least, th a t it is tru e of o ld er children, o r of
children o v e r o ne y e a r old, w ho receive n u rse ry c a r e ; I believe th e n u rse ry children
o v er a y e a r old a re b e tte r ch ild ren th a n th e av e ra g e child ren c a re d fo r in th e
hom e— a t least, th a t is tru e in o u r city.
M rs. B arto n : T h a t m ay be tru e as to child ren receiving th e b e st of c a re in
a w elb eq u ip p ed n u rsery .
D r. M ulon: W e can co m p are o nly th e child th a t is b o ard in g o u t a n d th e child in
th e facto ry n u rsin g room . I th in k ev ery b o d y is of th e sam e opinion, th a t th e
hom e is su p e rio r to a n y o th e r solution. B ut w e m u st bow to th e necessity fo r th e
m o th er to w o rk ; a n d decide w h e th e r it is b e tte r fo r h e r to h av e th e child b o ard in g
out, o r to h ave th e child in th e d ay n u rse ry . If you can give th e m o th e r a su f­
ficient allow ance, th a t is v ery well— so th a t th e b ab y will be in a b eau tifu l house,
w ith a b a th , a n d u n d er h y gienic co nditions; th e n I am su re th a t th e b ab y w ill be
b e tte r off th a n in th e n u rsin g room .


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D E N T A L CLINICS
By M A JO R LEW IS TERM AN
L eland S tan fo rd Ju n io r U niversity

I w as especially im pressed b y one of Dr. W inslow ’s rem arks, th a t
A m erica has p ro gressed n o t nearly as far along certain lines of social­
ized m edicine an d hygiene as som e o th er countries in the w orld. I am
afraid th a t is true. In reg ard to den tal clinics, before th e w ar th e
prom ise w as th a t b efo re v ery long w e w ould b e am ong th e leading n a ­
tions in th e w orld. I u n d ersta n d th a t th e trem endous expenses along
o th er lines, th e large am ount of energy th a t h a d to go to o th er things,
have, for th e tim e being, p re v en ted further d evelopm ents in dental
clinics, an d in som e cases even lost us som e of th e clinics w hich h a d
been established. I h o p e th a t everyone here will m ake it a p o in t to
use his influence to restore th a t k ind of w ork a n d to bring ab o u t its
increase.
P erh ap s m any of you rem em ber from y o u r ch ild h o o d read in g of D on
Quixote, th a t th e a u th o r in telling ab o u t one of the h ero ’s u n fo rtu n ate
adventures, in w hich h e lost a n u m b er o f teeth, p u t into his m outh these
w ords, “A las,’ a to o th is m ore precious th an a d iam o n d .” I suppose
C ervantes m ean t th a t as a hum orous exaggeration, an d doubtless we
so to o k it w hen w e re a d it, b u t a fte r all these years of dev elo p m en t
along lines of p reventive m edicine, w e can now h a rd ly tak e it as ex­
aggeration. I am sure th a t no one here w ould exchange his thirty-tw o
teeth fo r an equal n um ber of precious diam onds.
Y ou m ay rem em ber, too, th a t a few years ago D r. O sier stated th at
in his opinion th e evils which cam e from neglect of d en tal hygiene w ere
m o re serious in the long run th an th e evils p ro d u c ed b y alcohol. T hat,
too, we p ro b a b ly to o k as a p leasan t exaggeration b y th a t prince of all
jokers, D r. Osier, an d I am n o t sure w hether D r. O sier him self m ean t it
literally. W h en w e think of it, how ever, it do es n o t seem so unreason­
able, because th e affections of th e teeth concern practically ninety p er
cent o f th e population, w hile th e evils of alcohol affect im m ediately
p erh ap s only a fourth, o r a fifth, or a ten th of th a t num ber. D ental
caries a t any ra te is said to be, b y th e b est authorities, th e m ost w ide­
sp read of hum an diseases, one from which p ro b a b ly ninety p er cent of
the p eo p le suffer. A t least, extensive investigations in our schools have
shown th at ninety p e r cent of school children h av e one o r m ore decay234


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P R E S C H O O L C H IL D

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ing teeth. M ore th an that, these investigations h av e show n th a t som e­
thing like tw en ty p e r cent of all th e teeth o f school children are in a
m o re o r less serious state of decay. T h a t is a v ery serious, hum iliating
adm ission th a t w e h av e to m ake, considering th e progress w hich scien­
tific m edicine h as m a d e ; especially hum iliating since, d en tal caries is a
disease th e cause o f w hich is perfectly well know n.
W e k now th a t it is theoretically a p re v en tab le disease. W e know
th a t a clean tooth, a to o th th a t is k e p t clean, ca n n o t decay. W e
k now th a t p ro b ab ly som ething like fo rty o r fifty m illions of dollars
w ould p u t all the teeth of all the children in o rd e r as n early as dental
science is ab le to d o it/ 'W g know th a t som ething like tw enty-five or
th irty m illions p e r year— it m ight run a little higher— w ould b e suffi­
cient to keep them in order. A n d y et th e conditions w hich I m ention
still exist, although of course cities here an d there h av e d o n e an d are
doing a goo d deal to b e tte r th e conditions.
1 shall n o t sp en d tim e in enlarging o r in em phasizing th e evils which
are p ro d u c ed b y decaying teeth. Y ou know th e facts as well as I. But
I w ould like to em phasize th e fact th a t d en tal caries is a disease w hich
affects p red o m in an tly children an d youths. T ee th w hich are k e p t clean
a n d sound until th e individual is 25 y ears old are likely to rem ain
sound until a g o o d o ld age. T eeth w hich are neglected until th e age of
20 o r 25 are v ery often p a st salvage. I th in k th ere is now here else
a n o th e r case in w hich an ounce o f prev en tio n will com e as n e a r literally
being w o rth a to n o f cure.
B esides d en tal caries I w a n t to em phasize ulcerated te e th because
we are likely to o v erlook th e seriousness of th a t disease, a n d especially
its frequency. O f course w e know how serious it is in a 'yvay. W e know
th a t it is th e cause of a v ery g re at d eal of rheum atism , h e a rt disease,
a n d m an y o th er ailm ents. W e know th a t b y this condition children are
frequently k e p t in a chronic state o f ill health, a n d th eir v ery lives even
jeo p ard ized . W e d o n o t as a rule know so well how com m on it is.
In tw o o r th ree school surveys I found (m an y others h av e found the
sam e th in g ) th a t ap p ro x im ately one child in a h u n d re d a t an y one
tim e in an o rd in ary school has an ulcerated to o th . It m a y vn o t b e an
acute ulceration a t th e tim e b u t it is one which involves a condition
presen t th a t is p ro d u ctiv e of injury.
T h e only w ay I know to g et th e teeth of all th e children p u t in o rd e r
is to d o it in connection w ith th e schools. If th ere w ere an y o th e r w ay
I should n o t in th e least hesitate to cham pion it. I am n o t one to urge
th e schools to tak e up duties w hich could just as well b e p erfo rm ed by
som e o th e r institution o r m eans. T h e p la in fact is th a t in th e v ery b est
com m unities as a rule som ething like 60 to 75 p e r cent o f th e school
children h av e n ev er gone to a dentist. This, in ad d itio n to th e fact th a t
ap p ro x im ately 20 p e r cent of all th e teeth of o u r school children are a t

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least in initial decay, is sufficient argum ent for th e extension of dental
clinics.
T h en how different is the problem of getting th e w ork d o n e in a
d en tal clinic from th a t of persuading p aren ts to h unt up a dentist, and
h av e th e w ork d o n e a t their ow n expense. P ro b ab ly 20 to 40 p e r cent
of the fam ilies in th e U nited S tates really can n o t afford th e services of
a g o o d dentist. H aving school nurses go over an d o v er again to the
hom e to p ersu ade th e p aren ts to tak e ap p ro p riate action, involves an
alm ost inconceivable am ount of lost m otion. It can all b e d o n e in the
schools w ith a fraction of th e expenditure of energy an d a t no very g reat
ex penditure of m oney. T h e tim e will unquestionably com e w hen the
school d en tist will b e considered ju st as necessary a p a rt o f th e school
system as th e school principal himself. T h e w ork can b e carried on in
th e schools w holesale a n d th erefo re v ery cheaply co m p ared to th e
price th a t m ust b e p a id th e p riv ate practitioner.
I w ant to p ro test, too, against th e custom w hich is com m on in a g o o d
m an y cities of p u ttin g the m a tte r on a charity b asis; having th e asso­
ciated charities, fo r exam ple, investigate a fam ily b efo re th e children
are allow ed to go to th e school dentist, a n d th ere b y b ra n d in g the
p aren ts as p au p ers if they can n o t afford to secure th e services o f a p ri­
v ate practitioner. T h ere is absolutely no justification for this, an d in a
g o o d m an y cities an entirely different m eth o d is ad o p te d . T h e dentists
are em ployed, a n d all children w ho w an t to go to them are encouraged
to go.
O f course th ere are peo p le w ho will say even y et— it w as v ery com ­
m on for it to b e said ten years ago— th a t this is an u n d u e interference
w ith th e rights of a g reat profession, th e profession of d en tistry ; th a t
dentists h av e sp ent a.great deal of m oney in their education an d deserve
an o p p o rtu n ity to m ake a living from th e profession fo r w hich th ey
h av e p rep ared . O f course th e sam e argum ent once w as b ro u g h t against
free schools. T h ere w ere m any p riv ate teach ers w ho h a d invested a
g o o d deal of m oney in p riv ate schools, an d education a t public expense
w as in a w ay a transgression on their chosen profession. O f course we
no longer consider th a t argum ent for a m om ent. W e will n o t consider
it for a m o m ent in connection w ith d en tistry o r even m edicine, w hen
w e h av e once p u t th e question in som e such form as this. A n d I w ould
like you to p u t it this w ay in your thinking, nam ely, Is disease a resource
to b e conserved fo r th e benefit of a profession, o r is it an evil to b e
go tten rid of?
T h ere is one o th er po in t I w ant to m ake, nam ely, th a t in o u r school
d en tal w ork w e ought, w herever w e are unable to ta k e care of all the
teeth of all th e children, to em phasize especially th e w o rk w ith th e
y o unger children. It is too b a d th a t we h av e to neglect any, b u t if
th e schools in the city cannot afford to tak e care of all, th ey ought first

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to tak e care of the teeth of th e children in th e first tw o o r th ree grades.
T h u s afte r a while th e task will h av e b een p re tty well accom plished for
all children.
DISCUSSION
S ir A rth u r N ew sholm e (L a te P rin cip al M edical Officer, L ocal G overn m en t
Board, E n g lan d ) : I should like to express m y h e a rty en d o rsem en t of w h at M a­
jo r T e rm a n has said as to th e e x trem e im p d rta n c e of th e pu b lic d en tal services.
I am su re those w ould b e b est established in m ost in stan ces in co n n ectio n w ith o u r
d en tal school service.
I h ap p en to have been a m em b er of a d e p a rtm e n ta l com m ittee dealing w ith
th e question of d en tistry in th e U n ited K ingdom , a n d I w ould like to re a d to you
tw o sentences from th e re p o rt m ade b y it. T h e first sen ten ce ru n s as follow s:
“ T h e evidence b e fo re th e com m ittee as to th e condition of th e te e th of
m ost of th e peo p le p re se n ts a p ic tu re of alm ost hopeless neglect, ex cep t in
so f a r as it is relieved by d en tal w o rk established by g ra n ts from th e B oard
of E ducation an d th e L ocal G o v ern m en t B o ard .”
In re g a rd to those g ran ts 1 should say th e B oard of E d u catio n have b een doing
a larg e am o u n t of w o rk in th e tre a tm e n t of te e th in th e school child. It is only a
sm all fractio n of w h at needs to be done, b u t ra p id p ro g re ss has b een m ade. In
addition , th e re a re g ran ts to p u b lic-h ealth a u th o ritie s of h alf th e to ta l e x p en d itu re
fo r th e d en tal tre a tm e n t of e x p e c ta n t m o th ers w ho a tte n d p re n a ta l clinics a n d for
th e d en tal tre a tm e n t of th e y o u n g child in th e p resch o o l p e rio d ; a n d th ese th re e
services a re being linked up to g e th e r so as to pro v id e so m eth in g to w ard s a p ublic
den tal service.
In th a t connection I will read you a n o th e r reco m m en d atio n o f th is com m ittee
w hich is far-re a c h in g an d w h ich I th in k will show to you how fa r w e a re ad v an cin g
tow ards th e socialization of m edical service in G re a t B ritain. T h e reco m m en d a­
tion is as follow s:
“ T he provision o f a d e q u a te d en tal service to m e e t th e existing n eed s is
im possible a t p resen t, ow ing to th e sh o rta g e of dentists, b u t y o u r com m ittee
a re stro n g ly of opinion th a t sim ultaneously w ith th e e n fo rcem en t of p ro ­
hibition of th e p ra c tic e of d en tistry by unqualified persons, th e nu cleu s of
a public den tal service should be set up, a n d d en tal tre a tm e n t fo r such service
should be available fre e of c h a rg e fo r p erso n s n eed in g it. W e th in k th a t
service should be established as a definite b ra n c h of p u b lic-h ealth w o rk an d
should be e n tru sted to th e p u b lic-h ealth a u th o ritie s.”
D r. H . J. G ersten b erg e r (B abies’ D isp en sary a n d H ospital, C leveland, O h io ):
M ajor T erm a n , in his address, em phasized th e im p o rta n c e of cleanliness in p re v e n t­
ing caries in teeth . I should like to call a tte n tio n to th e v ery g re a t im p o rtan ce of
th e state of n u tritio n of th e child. I believe th a t th e d en tal w ork, th a t is th e c u ra ­
tive w ork, is going to b e re d u ced m o re by th e p ro te c tio n of th e p ro p e r n u tritio n in
th e child th an by th e clean in g of th e tee th . I th in k th a t if w e w ill p re v e n t rickets,
w e shall red u ce d en tal caries to a m inim um .


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THE SCHOOL CHILD
N U T R IT IO N CLINICS
By DR. W ILLIAM R. P. EMERSON
Boston, M assachusetts

A ll children of preschool a n d school age m ay b e div id ed for th e
sake of discussion into th ree groups: th e sick, th e well, an d th e m al­
nourished. T h e sick are cared fo r a t hom e an d in th e hospitals. T h e
?vell are inspected an d receive a certain am ount of p reventive care
from school physicians. T h e m alnourished, ab o u t a third of all,
receive no tre a tm e n t for their m alnutrition as such because th ey are
co n sidered well b y b o th p riv ate a n d school physicians. T hese un d erp a r children m ake it im possible fo r th e schools to reach reasonable
sta n d a rd s of achievem ent. A t th e sam e tim e the system of school
organization com pels the teacher to a ttem p t to crow d th e pupils
th rough th e v arious g rad es a t high pressure, thus ad d in g to the b u rd e n
o f th e u n d er-d ev e lo p e d an d delicate child. A s a result 20 to 40 p er
cent of those g raduating from elem entary schools are physically unfit.
It is rem ark ab le th a t this group of children has received so little
m edical atten tio n. T h ey pass through hospital clinics unnoticed b e ­
cause m alnutrition am ong o ld er children is n o t considered a p athologi­
cal condition.
Weighing and Measuring

T h e sim ple p ro ced u re o f w eighing an d m easuring each child will
identify all b u t th e bo rd er-lin e cases. A ll children habitually 7 p e r
cent o r m o re u nderw eight for their height are n o t only undernourished
b u t m alnourished, re ta rd e d in b o th w eight an d height from one to
four years.
Nutrition Clinics

T h e o b ject o f th e nutrition clinic is to identify this group o f children,
an d th en o n th e basis of physical, m ental, an d social exam inations to
m ak e a diagnosis of the cause of th e m alnutrition, thus leading to its
p ro p e r treatm en t. It is of as m uch im portance to m ak e this accurate
diagnosis in m alnutrition as it is in o th er illnesses. It w ould b e ab su rd
for a physician to ask a group of nurses to care for a w ard filled w ith
p atien ts affected w ith various diseases w ithout inform ing them of th e
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diagnosis in each case. Y et w e are asking school nurses, health
w orkers, an d p aren ts to carry out general directions w ith practically
no atte m p t a t diagnosis, resulting in an enorm ous w aste of time, energy,
an d expense. T h e nutrition clinic corrects all this b y determ ining th e
cause of the m alnutrition in each instance an d then indicating m easures
fo r its treatm en t.
Physical an d M ental E xam inations.— T h e physical exam ination re­
veals an av erag e of m ore th an five defects in each child. W hen defects
interfering w ith nutrition, especially obstructions to breathing, are
corrected, the child is considered free to gain. T h e m ental exam ina­
tion is m ad e in m ost instances during th e course of th e physical ex­
am ination, w hen it is d eterm ined w hether th ere is any question of
m en tal deficiency o r retard atio n . A n essential p a rt of th e m ental
exam ination is to learn th e child s disposition an d reaction to his
environm ent.
Social E xam ination.— T h e hom e life of th e child is investigated
b y a 4 8 -h o u r record of his program , which includes a list of food
tak en during th a t time, his hours of sleep, of w ork, of play, tim e in
th e open air, an d in fact all his various activities.
Sim ple causes, such as the following, are found ad eq u ate to explain
m alnutrition of th e m ost severe ty p e: fast eating, insufficient food, th e
use of tea an d coffee, late hours, closed w indow s a t night, too little
tim e in th e open air, p o o r hygiene, over-pressure an d long hours in
school. Such definite diagnoses are essential to successful treatm ent.
N u tritio n C lasses

H av in g th en found th e causes of th e m alnutrition b y m eans of these
physical, m ental, a n d social exam inations, it requires th e cooperation
of the child, physician, teacher, an d p a re n t to rem ove them a n d a t the
sam e tim e to secure for th e child th e essentials of health. T hese
essentials a re th e rem oving of physical an d m ental causes of p o o r
nutrition, getting th e children to take* sufficient an d p ro p e r food a t
frequent intervals, securing fresh air b y d ay an d night, prev en tin g overfatigtie, an d establishing sufficient hom e control to insure g o o d food
a n d h ealth habits. If these results are accom plished, th e child should
rap id ly gain w eight an d becom e w ell an d strong, because of a p o w er­
ful force in n atu re th a t m akes for health.
P rep a ratio n fo r th e Class.— C ooperation for the essentials of health
is b est o b tain ed b y m eans of nutrition classes of n o t m o re th an tw enty
children in each. T h e nutrition w orker p rep ares for th e class b y th e
w eekly w eighing of each child an d th e recording of this w eight on a
chart. T h e ch a rt show s th e average w eight line, corresponding to the
ch ild ’s height, a n d also his actual w eight line as h e gains o r loses.
The worker also checks up th e d iet lists w hich are carefully kept b y

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STANDARDS O F C H IL D W E L F A R E

pupil o r p a re n t in a sm all record b o o k for tw o consecutive days of
each w eek. O n these days each article of food tak en is re c o rd e d ;
th e am o u n ts are indicated in tablespoonfuls or ounces. A t this tim e
erro rs in d iet should b e corrected an d helpful suggestions m ade, esp e­
cially in reg ard to taking m ilk an d cereals. T h e 2 4 -hour am o u n t
should b e large enough fo r gain, usually 2 ,0 0 0 o r m ore units (c a lo rie s).
A b lu e sta r is given fo r rest p eriods an d a red star for lunches, if each
h a s b een tak en every d ay o f the preceding week. In case of failure
to gain, personal conferences are held w ith each pupil in o rd e r to
disco v er an ad e q u ate cause, which alw ays exists, an d th erefo re should
b e fo und b y either th e nutrition w orker o r th e physician.
C lass C o n d u ct.— T h e charts having thus b een p rep ared , th e children
are assem bled b y th e nutrition w orker in a room b y them selves w here
tw o row s of seats are arranged, ten seats to each row. T h e child
gaining m ost is given a gold star an d is p laced a t th e h ea d o f th e class.
T h e o th er children are arran g ed in o rd e r o f their gain. T h e w eight
c h a rt o f each child is hung opposite his p lace in th e class; T h e n u tri­
tion w o rk er keeps a history an d reco rd ca rd of each child which
contains th e d o cto r s directions an d h er own follow -up notes. T hese
cards are used b y him in considering each child.
W h en th e class is in o rd e r th e d o c to r conducts th e exercise in such
m an n er as to leave a clear id ea in th e m ind o f each child as to w hat
h e is to d o the follow ing w eek th a t h e m ay gain. T h e room should
b e quiet an d free from interruptions. P arents should occupy the b ack
seats, b u t th e teacher an d nutrition w orker should b e seated in fro n t
w here th ey m ay show b y th eir atten tio n lively interest in each ch ild ’s
progress. T h e physician praises th e children w ho h av e gained, b u t it
is his special d u ty to discover th e causes for loss in those w ho h av e
n o t gained. T hese causes are usually failure to tak e regular lunches
o r rest periods, overtim e, late hours, etc. T his gives an o p p o rtu n ity
to show th e im p ortance o f these factors in th e gain o r loss o f th e
p articu lar child. A h alf h o u r is.sufficient tim e for th e physician to tak e
for this exercise. T h e nutrition w orker m akes notes a n d explains
th e recom m endations to each child o r p arent. U sually th e child losing
on e w eek is a t th e h ea d of th e class th e follow ing week. W h ere th ere
is com plete co o p eration an d th e essentials of health can b e w holly
o b tain ed , th e child should rea^h his ow n norm al sta n d a rd of w eight
in ten o r tw elve weeks. F rom 5 to 10 p e r cent o f th e children p resen t
serious m edical problem s requiring m ost careful study b y th e physician.
E ven in these cases, how ever, th e class m eth o d provides the m ost
satisfactory m eth o d o f treatm ent.
C o o p eratio n w ith th e H om e.— T h e nutrition w o rk er should visit
th e child in his h om e m o rd e r to gain th e cooperation of his p aren ts
a n d to learn h is h ea lth h abitsf especially w ith reference to eating an d

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sleeping. P lans should b e m ad e for open w indow s a t night an d . for
p len ty of tim e in th e fresh air b y day.
P rev en tio n of O ver-fatigue.— D uring the p erio d of trea tm e n t th e
children should b e placed in open-air o r a t least open-w indow classes
an d school pressure should b e reduced. Som e children will n eed only
sufficient ad d itio n al tim e fo r rest an d lunch perio d s; m any will w ork
to b est a d v a n ta g e on a half-d ay schedule; a few will n eed to b e reduced
to tw o hours a day, w hile certain cases can n o t profitably a tte n d school
a t all for a time. O ne rest p erio d of a t least h alf an h o u r should, b e
tak en b efo re th e m id d ay m eal. T h e child should lie flat on his back,
thus correcting his usual fatigue position of stooping shoulders, re ­
trac ted chest, a n d p ro m in en t abdom en. In th e m id -afternoon a sim ilar
rest p erio d should b e tak en b u t fo r a longer time.
F o o d .— M id-forenoon an d afternoon lunches should contain ab o u t
2 5 0 units o f such fo od as will n o t d estroy th e ap p etite fo r th e follow ing
m eal. Sw eets should b e av o id ed a t this time. C hildren gain faster
on less fo o d tak en in sm all am ounts five tim es a d a y th a n w hen a
larger am o u n t of food is taken in th ree m eals.
A u th o rity of th e Class M ethod.— T h e class m eth o d appeals to th e
im agination o f th e child an d m akes him d o for him self w hat n o one
else can d o fo r him . It teaches an d inspires him to “train for h ea lth ’*
in th e sam e w ay h e trains to b e a b o y scout o r a g ood athlete. T h e re ­
fore ask him w h at you will an d h e will do it cheerfully if h e is co n ­
vinced it is g o o d “ d o p e .” T h e b o y of seven o r eight years steals off
by him self, w raps up in his blanket, a n d takes his re st periods, o r
teaches him self to tak e an d to like foods to w hich previously h e !h a d an
aversion. H e stops drinking te a an d coffee, goes to b e d early; p re ­
p ares his b e d w ith h o t w a te r jug an d p ap e rs betw een blankets, th a t
he m ay sleep w ith his w indow open on th e coldest night. A ll this h e
does th a t h e m ay see his w eight line go up each w eek a n d th e stars
registered on his chart.
Successful trea tm e n t in. th e m ajo rity of cases is b o th easy a n d sure,
p ro v id ed either th e physician, nutrition w orker, or teacher has sufficient
vision to p ain t tru e pictures in the child’s im agination, thus securing
his co m plete cooperation.
THESES ON N U TRITIO N CLINICS A ND CLASSES

1.
In th e p resen t organization of hospital clinics, school m edical
inspection an d child-helping agencies th ere is little provision m ad e for
th e care o f a large group of m alnourished children— fully one-third
o f all— who are n o t sufficiently sick to require hospital care n o r are
th ey “ w ell,” although they are re p o rted as such because th eir tru e
condition is so little u nderstood.

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2. T h e w ork of these nutrition clinics an d classes, although fu n d a­
m entally m edical, is for th e m ost p a rt educational. T h ey furnish a
qnedium fo r th e inspection, exam ination, an d trea tm e n t of children in
the schools, an d should b e an integral p a rt of school organization.
3. T hese clinics an d classes are especially a d a p te d to m ake b e tte r
use of th e resources of the fam ily a n d afford a m eans of giving training
to m o th ers b y teaching them how th e child m ay becom e well.
4. A ll children found to b e seven p er cent underw eight for their
height require special consideration an d treatm ent. T his rule does n o t
identify all cases of m alnutrition, b u t it furnishes th e b est single sta n d a rd
of selection which w e h av e b een able to form ulate.
5. T h e first step is th e identification of th e m em bers of this group.
T his can b est b e d o n e in th e schools w here all children should b e
w eighed an d m easured periodically.
6. T h o se children w ho are found to b e seven p e r cent underw eight
for th eir h eig h t should b e given special trea tm e n t an d relieved for th e
tim e from a p a rt of th e usual school pressure.
7. T o each of these children should b e given an intensive exam ina­
tion. T his exam ination should b e m ad e in so far as possible in the
presence of th e child’s p aren ts.1 A ll clothing should b e rem oved a t
least to th e w aist in o rd e r th a t no defects m ay b e overlooked.
8. T h e d a ta com ing from this exam ination should b e p u t in form so
th a t th ey can b e used b y th e specialists to w hom th e child m ay b e sent fo r
fu rth er exam ination an d study. F o r the sam e reasons all d a ta ac­
cum ulated b y th e specialists should b e available in duplicate form for
th e physician in charge of th e nutrition clinic. T h e am o u n t of tim e
required fo r these records will b e found to b e less ra th e r th an m ore
th an th a t now used in rep o rts an d reco rd s which, on account of their
lack of stan d ard izatio n an d definiteness, are often of v ery little value.
9. T h e sam e p lan should b e follow ed w ith reference to th e records
grow ing out of th e m ental an d social exam inations a n d th e agencies
w hich these h av e b ro u g h t into the case. No defect o f any kind should
b e co n sidered in isolation.
10. A n organization sim ilar to th a t used for open-air classes will b e
found m o st serviceable in caring fo r th e m alnutrition group. Even from
th e stan d p o in t of th e child’s studies it will b e found to b e econom ical
to red u ce th e pressure of school responsibilities an d w ork on a p ro ­
gram which w ithout delay will m ake it possible for him to b e b ro u g h t
up to his ow n norm al standard.
tin E ngland as w ell as in o u r clinics it h as b een fo u n d possible to secu re th e
atte n d a n c e of m o th e rs a t th e g re a te r n u m b e r of exam inations co n d u cted in th e
schools. It is th e testim ony of m edical officers in th a t c o u n try th a t th e resu lts
of th e p resen ce of th e m o th ers a re th e roost im p o rta n t of th e m any valuable out­
com es of th e w ork.

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11. It will b e found th a t som e children in this group will b e able
to a tte n d school b o th m orning an d afternoon, p ro v id ed ad eq u ate a r­
rangem ents are m ad e for rest periods. In o th er cases an alternation can
b e arran g ed placing one group in school m ornings an d an o th er afte r­
noons. T h o se who are excessively underw eight can n o t afford to a tte n d
school fo r m ore th an tw o hours a day. O f course individuals m ay
n eed to b e rem o v ed from all school pressure for a time.
12. C hildren should b e m ad e free to gain b y having all necessary
m edical an d surgical atten tio n given to them prom ptly. T his should
include th e rem oval of diseased tonsils an d adenoids, th e p ro p e r care
of th e teeth, et cetera.
13. F ro m 20 to 40 p er cent of th e children of school an d p re ­
school age will b e found to b e in the seven p e r cent underw eight for
th eir h eight group.
14. It will b e found th a t a reasonable p ro g ram such as w e h av e out­
lined will m ake it possible for the g reater p a rt of this group to return
to th eir regular w ork in from th ree m onths to half a year, an d th a t
practically all will com e up to their ow n norm al sta n d a rd s b y th e end
of th e school year.
15. T h e open-air class organization will serve best as a clearing
house fo r the various types of health -n eed cases. It will accom plish
m o re as a station in which these special n eed s can b e m et th an as a
m o re o r less p erm an en t re treat for chronic cases.
16. A certain n u m ber of pro b lem cases will require a special sta ­
tion fo r diagnosis in which they can b e u n d e r co n stan t observation.
1 7. »Special consideration should b e given to children w ho are con­
valescing from any attack of severe illness so th a t it m ay b e c o m e .a
custom in th e school to help such children reach a state of com plete
reco v ery b efo re they are allow ed to return to th e heavy pressure of
th e reg u lar classroom w ork.
18. R elations should b e established w ith sum m er cam ps to avoid
ch ild ren being sent to them w ithout diagnosis.
19. It is desirable to keep th e responsibility for im proving th e
grow th conditions of th e child u pon th e parents. P erm an en t results re­
quire control by th e forces n earest to th e situation.
20. U n d e r conditions of sym pathetic cooperation betw een the
m em bers of th e clinic staff, th e school corps, an d the o th er agencies
involved, it should b e possible to d o som e v aluable experim ental w ork
w ith reference to th e m ost favorable hours for school w ork, th e length
of school sessions, th e conditions of recess periods, th e value of school
lunches, training in hygiene, et cetera.
21. . M any of th e conditions of th e nutrition clinic are especially fa­
v o ra b le for th e w o rk to b e accom plished in the exam inations given
for w orking certificates. T h e m ost serious problem s m et a t this stage

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of a child’s life are those of grow th. T h e m ore th e results secured a t
this p erio d are in terp re ted in term s of school life, th e b e tte r will th e
school b e ab le to w ork out an econom ical an d efficient program .
22.
T h e re are m any reasons w hy th e w ork to b e d o n e w ith chil­
d re n o f th e preschool age should b e in th e h an d s of those agencies
w hich h av e h a d charge of th e p erio d of infancy. M uch of th e w aste
m et in th e school years could b e elim inated during these earlier years
b y m ean s of m o re ad eq u ate provision for this m ost neglected p erio d of
grow th. It is n o t infrequent to find serious cases a t th e school age who
h av e excellent records w ith reference to nourishm ent an d grow th w hen
th ey w ere infants. It is im p o rtan t th a t th ere should b e close cooperation
b etw een th o se w ho are w orking w ith m em bers of th e school a n d p re ­
school groups. It is especially desirable th a t th e la tte r group should
n o t h av e a th ird set of agencies built up to com pete in its d em ands
u p o n th e tim e of th e m o th er w ith those alre ad y caring fo r th e needs
of th e school children a n d th e infants.
23.
T h e n utrition clinic is especially well a d a p te d to care for d e ­
p en d en t, delinquent, an d defective children. N utrition classes for S tate
w ard s h aving foster m o th ers h av e p ro v e d to b e rem ark ab ly effective.
DISCUSSION
Dr. David M itchell (B u reau of E d u catio n al E xperim ents, New Y o rk C ity ) : I
do n o t like to be pessim istic a b o u t n u tritio n classes in pu b lic schools, b u t, having
b een co n nected w ith th e b u re a u w h ich h as b een responsible fo r th e New Y ork
n u tritio n classes, I should like to p re se n t several facts w hich I th in k it is well
fo r us to th in k ab o u t. D u rin g th is p a st y e a r w e have h a d a p p ro x im ately n in ety
ch ild ren in fo u r n u tritio n classes; tw o of th em w ere o p e n -a ir classes, th e o th e r
tw o, re g u la r grad e classes.
O ne of th e op en -air classes is com posed alm ost e n tirely of ch ild ren w ho w ere
included in o u r n u tritio n classes la st y e a r. T h e y h a d th e in stru c tio n a n d th e c are
w hich w as given to all th o se ch ild ren d u rin g ap p ro x im a te ly n in eteen w eeks.
O f tw en ty -th re e child ren w ho w ere in last y e a r’s n u tritio n classes, eleven have
failed to in crease as m u ch as th e av e ra g e child in th e o rd in a ry school gro u p s. T a k ­
ing th e resu lts fo r all th e child ren of th e class, w e find th a t th ey h av e in creased
ab o u t seventeen p e r c en t fa ste r th a n w as ex pected. F o r th e ch ild ren w ho m ade
gains in excess of th e n o rm al o r ex p ected gain, th e a v erag e in crease in excess of
n o rm al w as a b o u t th irty -tw o p e r cent. T h ese ch ild ren have few of th e socalled physical hand icap s. A ll fo r w hom it w as recom m ended, h av e h a d o p e ra ­
tions fo r th e rem oval of en larg ed tonsils o r adenoids. B ut th e y a re still a pro b lem
fo r u s; th ey a re still alm ost as m u ch u n d erw eig h t as th e y w e re w h en th e classes
w ere first organized.
H ere is a n o th e r fa c t: D u rin g th e last w eek of S eptem ber, 191 8, w e w eighed a n d
m easu red ap p ro x im ately one h u n d re d a n d tw enty-five fifth g rad e childen. A t th a t
tim e w e found th a t th irty -n in e o r ap p ro x im ately th irty p e r c e n t w ere seven p e r cent
o r m o re u n d erw eig h t for th e ir h eig h t. O w ing to th e conditions in th e school system
a n d to th e epidem ic of influenza, it w as im possible to o rg an ize n u tritio n classes


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fo r a p erio d of seven w eeks. A t th e tim e of th e first session of th e class, these
th irty -n in e children w ere ag ain w eighed a n d m easu red a n d w e fo u n d th a t tw entytw o had com e up to w ithin seven p e r cen t of th e a v erag e w eig h t fo r th e ir h eight.
Som e of these children h ad com e up to w ithin one a n d tw o p e r c en t of th e av erag e
w eight fo f th e ir h eigh t. T his resu lt cam e a b o u t w ith o u t a n y train in g , w ith o u t
a n y a tte n tio n to rem oval of p hysical defects, a n d w ith o u t a n y in stru c tio n in h e a lth
habits a n d hygiene. - In o th e r w ords, w e did n o t need to do a n y th in g w ith these
ch ild ren to m ake them w h at w e call fairly w ell n o u rish ed children.
T his led us to th e q uestion as to w h at w e should do in o rd e r to find o u t w hich
of o u r school children a re u n d ern o u rish ed . It seem s to m e ex trem ely im p o rta n t
th a t gro u p s of children should be w eighed a n d m easu red freq u en tly , w eekly if
possible, m o n th ly if w eekly w eighings a re n o t feasible, a n d th e am o u n t o f v ariatio n
w hich these children u n d erg o in w eight should fee determ ined. It is now a b o u t
tw en ty -th re e w eeks since th e classes w ere organized a n d in th a t tim e th o se chil­
d ren have n o t increased m ore rapidly, in fact have in creased less rapidly, th a n
th ey did d u rin g th e seven w eeks betw een th e o rig in al w eighing a n d th e first m e e t­
ing of th e n u tritio n classes.
T h e re a re exceptions to this g en eral rule. O n e child, w ho w as considerably
u n d erw eig h t in th e beginning, has m ade alm o st a co ntinuous a n d ra p id in crease in
w eight. H e is now as m u ch o v erw eight as he w as u nd erw eig h t a t th e b eginning
of th e class. T his resu lt has com e a b o u t despite th e fa c t th a t he las consistently
ig n o red p ractically all th e reco m m en d atio n s m ade. H e h as re f sed to rest, he
has refused to give u p th e use of te a a n d coffee, h e h as refu sed to go to b ed early
en o u g h to get w h at w e consider a req u isite a m o u n t of sleep, he h as refu sed to have
defective te e th rem oved o r tre a te d , a n d in gen eral d isreg ard ed all th e q uestions
of slow eating, of n o t u sin g w a te r to w ash dow n th e u n m asticated food, a n d re ­
m ain in g seated d u rin g th e m eal h o u r. T h e one th in g w h ich he h as done is to
increase th e caloric in tak e. It is one of th e cases w h ere m o re food seem ed to be th e
essential req u ire m e n t; a n d h av in g th a t g re a te r a m o u n t of n o u rish m en t he w as able
to overcom e all th e han d ica p s of p hysical defects, b ad habits, a n d b a d e n v iro n ­
m ent.
T h e g en eral condition can n o t, how ever, b e d ealt w ith in this superficial m a n ­
n e r. T oo m an y children a re u n d erw eig h t, a n d co n stan tly so, fo r us to b e satis­
fied w ith a n y special cases su ch as this. W e m ust seek a reaso n fo r th e failu re
of th ese children to in crease in w eight. T h e first condition w h ich w e m ay co n ­
sider as a n ex p lan atio n fo r this failu re is th a t of a possible biological v ariatio n
w hich has n o t y et b een com pletely u n d ersto o d . W e have assu m ed th a t th e
m axim um v ariatio n possible fo r a n o rm al child is seven p e r cent. C e rta in in ­
dividual cases lead us to suspect, how ever, th a t a n o rm a l v aria tio n of considerably
m ore th a n this is possible. It m ay b e th a t som e child ren a re biologically m u ch
lig h te r in w eight fo r th e ir h e ig h t th a n o th e r children.
O th e r considerations a re th o se of em otional d istu rb an ces a n d th e u n u su a l stress
of ce rta in perio d s of th e school life. W e have in fo rm atio n w h ich leads us to
believe th a t em otional d istu rb an ce s influence th e processes of n u tritio n . C annon
has show n th a t th e em otions of fear a n d a n g e r a re a tte n d e d b y a cessation of
th e ch u rn in g m ovem ent of th e sto m ach a n d th e cessation of flow of th e gastric
juice. In o u r classes w e h ad ch ild ren w hose failu re to gain in w eig h t w e th o u g h t
m ight be due to th e o p e ra tio n of th ese facto rs. W e m ay also consider th e stress
of th e p ro m o tio n perio d . A t th e tim e w hen p ro m o tio n s w ere b ein g considered
in this group, th e failu re to gain w as v ery m ark ed . W hile th e m a jo rity of th e
ch ild ren h ad gained in th e e a rly w eeks, d u rin g th e w eek p rev io u s to p ro m o tio n a n d
th e w eek of pro m o tio n , v ery f^w of th e children show ed a n y in crease in w eight.

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Finally, w e m ust con sid er th e influence of p hysical defect o r failu re in p hysiologi­
cal functioning. C o n cern in g c e rta in of th e defects, w e a re fairly w ell convinced
th a t th ey a re im p o rta n t d e trim en tal facto rs. T h e rem oval of diseased tonsils and
adenoids has freq u en tly b een follow ed by m a rk e d in creases in w eight. T h e defect
in physiological functio n in g m ay b e th e m o re im p o rtan t. W e have cases,w h ere th e
o rd in ary physical defects have b een rem oved a n d w h ere th e in stru c tio n in h e a lth
hab its seemfe to be follow ed b u t in w hich little p ro g re ss is noted. T hese m ay be
cases of biological variatio n . O n th e o th e r hand, in fo rm atio n as to th e m etabolism
of n u tritio n is still m e a g e r and, in o rd e r to decide w h e th e r som e of th ese child ren
a re fu nctioning norm ally, p ro lo n g ed a n d intense ex p erim en tatio n will b e n e ces­
sary.
D espite all these facts, I w ould stro n g ly recom m end th e in a u g u ra tio n a n d th e
co n tin u an ce of n u tritio n classes fo r h e a lth education. It m ay be th a t w e a re
n o t able to solve th e p ro b lem in this g e n eratio n by this p a rtic u la r m ethod, b u t
certain results indicate th e fa r-re a c h in g effect of th e p ro c e d u re . T h e ch ild ren
w ho a re th u s being ta u g h t th e d esirability of re g u la rity of h abits a n d th e n e ces­
sity of eatin g p ro p e r food a n d th e necessity of elim inating h arm fu l stim ulants,
such as tea a n d coffee, w ill u n d o u b ted ly influence th e n u tritio n of th e n e x t g e n e ra ­
tion. H ow w ell th ey will do th is m ay be indicated b y th e follow ing illu stra tio n :
O ne of th e boys in th e class cam e to th e te a c h e r w ith th e re m a rk th a t h e h a d b een
try in g to p ersu ad e his m o th e r th a t “ a n ou n ce of p rev en tio n is w o rth a p o u n d
of c u re .” T h e te a c h e r did n o t get th e significance o f th e com m ent a t first a n d
ask ed th e boy w h at h e h ad b een try in g to do. H is rep ly w as th a t he h a d b een
in terested in th e class w o rk . H e h ad b een read in g a b o u t n u tritio n a n d h a d com e
acro ss this statem ent. H e concluded, “ I tried fo r tw o h o u rs to show m y m o th e r
w h at th a t m eant, a n d a t th e end of th e tim e she did n o t know a th in g a b o u t it.
If a ttem p ts a t th e ed u catio n of p a re n ts a re m ade in th is w ay, w h a t m ay w e n o t
hope fo r in th e ed u catio n of children? W e m ay n o t c u re m aln u tritio n by e d u ca­
tion, b u t w e can develop hab its a n d m ethods of living w hich will have a decided
influence fo r good w ith o u r n e x t gen eratio n .
M rs. A n d rew W ilson (S ta te C h airm an , W est V irg in ia C hild W elfare C om ­
m ittee) : D r. L usk tells u s th a t m ilk is essential. D r. E m erson also h ad te a in his
d ietary lists, b u t D r. Lusk, w ith som e of th e rest of us, th in k s th a t tea a n d coffee
a re b e tte r left out. If w e could c o rre la te th o se facts I should like to h e a r th e ex­
p lanation.
D r. E m erson: In th e first b re a k fa st w as th e list of food as b ro u g h t by th e child,
in w hich he w as hav in g tea. My co rre c tio n w as to su b stitu te cocoa. T ea a n d
coffee are, I th in k , p e rh a p s th e m ost im p o rta n t single cause of m aln u tritio n . In
o u r gro u p to w hich D r. M itchell h a s 'ju s t referred , in New Y ork, o v er 80 p e r c en t
w ere ta k in g te a ,a n d coffee. It raises havoc w ith grow th. T h a t is th e first th in g
to stop. A n d th e children stop it w hen th ey see th a t it in terfe res w ith th e ir gain.
T h e question of diet in th e fam ily, in th e hom e, is a v ery difficult one. My idea
is to w o rk alo n g lines of least resistance. If th e fa th e r likes ce rta in th in g s a n d
you u p set him he resen ts it. So I do n o t m ak e changes ex cep t w hen n ecessary .
T hese children will u sually gain if w e b rin g th e 2 4 -h o u r am o u n t of food above
2,000 calories. So th a t a b o u t th e only suggestion I m ak e is th a t th ey use cereal
an d m ilk, a n d m ake su re th a t th ey have th e p ro p e r a m o u n t of m ilk. If w e get
th e ir tw o-day list an d m ak e th ese changes, th a t seem s to b e en o u g h to co v er th e
question of difct so th a t w e can go on w ith o th e r th in g s w h ich a re often of g re a te r
value.

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I w ant to say in re g a rd to D r. M itchell’s p ro b lem s— w e have b een w o rk in g to ­
g e th e r-—th a t in P ublic S chool 64 w e have a gro u p of ch ild ren com ing in w ith o u t
th e ir m others, w hose p resen ce is v ery essential. T h ey a re o v er 90 p e r c en t
H ebrew , an d m any of th e m o th ers a re a t w o rk in stores. T h e p ro b lem is m ost
com plicated w hen w e have n o t th e n ecessary co n tro l day a n d n ig h t. You can
w ork y o u r h e a rt o u t d u rin g th e day w ith th e children, b u t w hen th ey a re aw ay
from you, you can n o t tell w h at h appens. O n th e q uestion of going to bed,
fo r instance, a little fellow said, 1 have been b e tte r since I cam e to th e class a b o u t
going to bed.
I said, ^X^hat tim e do you g o ? ” H e said, ” 1 go a t 10 o ’clo ck .”
W h at tim e did you go b e fo re ? ” “ I used to go a t 12.” W h en n e ith e r p a re n t is
p re se n t a t o u r classes to learn a n d th en to c a rry o u t in stru ctio n s a t hom e, the
elem ent of overfatigue m ay u p set all o u r calculations.
A M em ber:

Is it safe to ta k e cocoa each day?

Is it n o t too stim ulating?

D r. E m erson: C ocoa is likely to be too sw eet, especially if ta k e n w ith o u t o th e r
food. I try to lim it cocoa to once o r tw ice a day, a n d be carefu l to have them
m ak e th e ir cocoa w eak, sim ply using it as a flavoring fo r m ilk.


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H E A L T H EX A M IN A TIO N S A N D T H E S C H O O L NURSE
By DR. TH O M A S D. W O O D
C hairm an , C om m ittee on H ealth P roblem s in E ducation
N ational C ouncil of E ducation

T h e conservation an d the cultivation of th e child’s h ealth are recog­
nized to d a y as fundam ental an d essential factors in th e p ro g ram of
public education. Practice, how ever, lags far b ehind accepted p rin ­
ciples in this as in o th er phases of education an d of life. E nough ex­
p erim en tatio n an d dem onstration h av e b een accom plished in th e field
of child h ealth to convince sensitive, tender, a n d socially-m inded citi­
zens of th e h ealth needs of children an d th e responsibility of com ­
m unity, state, an d nation regarding these crying needs.
T h e w ar h as show n us w ith dram atic illum ination th e w eakness of
th e n atio n ’s young m anhood, d ep e n d en t in v ital m easure u p o n the
neglect of child h ood an d youth. A stunning indictm ent of our dem oc­
racy is in v o lv ed in th e fact th a t th e trag e d y o f a w orld w ar w as n eed ed
to reveal such a vital source of national peril an d w eakness. T h e
statistics of th e d ra ft show ed th a t one-third of th e young m en a t th e
age of th e flower of m an h o o d w ere unfit fo r first-class service in the
defense of th e country in tim e of w ar. But it has b een know n b y
som e, for years, th a t three-fourths of th e 2 2 ,0 0 0 ,0 0 0 school children
in th e U nited S tates h av e health defects w hich are actually o r p o te n ­
tially injurious to them as prospective citizens of th e republic. Efforts
in this h ealth p ro g ram for school children h av e so far b een desultory,
spasm odic, an d uncoordinated. N ational stan d ard s are n ee d ed to d a y
for genuine constructive progress in this b ranch of the g reat program
of child w elfare.
T h e h ealth exam ination of school children involves tw o distinct
phases o f inspection an d adm inistration:
( a ) T h e daily h ealth inspectidn.
( b ) T h e annual (o r if required in individuals, m o re frequent)
h ealth exam ination.
T h e daily inspection a n d supervision are necessary to d eterm ine th e
child^fe fitness for atten d a n ce u pon school, w hich fitness is d ep e n d en t
u p o n th e absence of signs of health disturbance. Such signs m ay
d en o te th e pupil’s personal unfitness for school th a t day, an d such signs
m ay also rep resen t the prelim inary sym ptom s of definite com m uni­
cab le disease. T h e possession of these signs m ay re n d er th e child a
248

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249

source an d cen ter of infection fo r his fellow pupils. F o r th e best in­
terests of him self an d of his school com panions he should b e k e p t a t
hom e u n d er such circum stances, an d thus excluded from school before
these indications of health disorders h av e dev elo p ed into d ie recog­
nizable an d distinctive sym ptom s of disease. T h e school is b y its very
n atu re perfectly ad a p te d to serve as an agency for assem bling an d
distributing ch ild ren’s diseases throughout th e com m unity, an d all too
frequently this is just w hat occurs.
T h e best know ledge an d skill of parents, teachers, nurses, physi­
cians, an d even of th e children them selves are requisite for a satisfac­
to ry m inim izing of these diseases of child life. If th ere is reasonably
intelligent an d conscientious cooperation of the individuals an d agen­
cies involved, th ere need b e no epidem ics in schools, an d th e school
will b e m ad e in this vital respect a real health center.
No child should ever know ingly b e exposed to contagious disease.
T h e o ld er th e child is b efo re being exposed b y accident to contagious
disease th e less ap t h e is to catch it. T h e o ld er a child is b efo re having
a contagious disease of childhood, the less severe, on th e average, it
is likely to be.
T h e follow ing are indications of health disorders in children for
which p aren ts should keep children a t hom e an d notify th e school:
N ausea o r vom iting; chill; convulsions (fits ); dizziness, faintness,
or unusual p allo r; eruption (rash ) of any k in d ; fever; running nose;
red o r running eyes; sore o r inflam ed th ro a t; acutely sw ollen glands;
cough; failure to eat the usual b re ak fa st; any distinct o r disturbing
change from usual ap p earan ce o r conduct of th e child.
T h e foregoing signs shoüld b e used also b y teachers as a basis for
excluding pupils from school fo r th e day, o r until the signs h av e dis­
ap p eared , o r until th e p ro p e r h ea lth officer has authorized th e retu rn
of th e pupil to school. C hildren m ay b e tau g h t—-w ithout developing
disturbing fears, o r attem p ts to deceive— to notice the abovem entioned signs in them selves o r in th eir com panions, a n d thus help
to p ro tect the school from contagious disease. T h e detection o f these
first signs of h ealth disturbance a t hom e, b y the p a re n t o r th e child,
before th e child starts for school, is of especial im portance in th e co u n ­
try, w here th e lo n ger trip to school w ith g re ater physical exertion,
som etim es in b a d w eather, w ould b e particularly injurious to a child a t
the beginning of an illness. In cases of . contagious disease am ong
school children, the length of tim e of exclusion from school m ust b e
determ in ed b y the h ealth an d th e school authorities.
T h e second phase of th e h ealth exam ination of school children in ­
cludes th e investigation to ascertain th e health status of th e child, a n d
the presence of th e m ore p erm an en t health defects an d tendencies.

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STANDARDS O F C H IL D W E L F A R E

A t least one p e r cent, or 2 0 0 ,0 0 0 of th e 2 2 ,0 0 0 ,0 0 0 school children
in th e U nited States, are m entally defective.
O v er one p e r cent, or 2 5 0 ,0 0 0 , a t least, are h an d ica p p ed b y organic
h e a rt disease.
A t least five p e r cent, o r 1,000,000, h av e now , o r h av e had, tu b e r­
culosis, a d a n g e r often to others as well as to them selves.
Five p e r cent, or 1,000,000, h av e defective hearing which, unrecog­
nized, gives m any th e u ndeserved repu tatio n of being m entally d e ­
fective.
T w enty-five p e r cent, o r 5 ,0 0 0 ,0 0 0 , h av e defective eyes. A ll b u t
a sm all p ercen tag e of these can b e corrected, an d y et a m ajo rity of
th em h av e received no attention.
T w en ty p e r cent a t least, o r 4 ,5 0 0 ,0 0 0 , are suffering from m alnutri­
tion. E very child who is 10 p er cent or m ore below w eight for his
h eight a n d age is suffering from m alnutrition, a n d persistent efforts
b y coo p eratio n of school, hom e, an d com m unity should b e m ad e to
co rrect this. P o v erty is n o t th e m ost im p o rtan t cause of this serious
b arrier to h ealth developm ent.
F ro m fifteen to tw enty-five p e r cent, 3 ,0 0 0 ,0 0 0 to 5 ,0 0 0 ,0 0 0 , h av e
adenoids, diseased tonsils, o r o th er g landular defects.
F ro m ten to tw enty p e r cent, o r from 2 ,0 0 0 ,0 0 0 to 4 ,0 0 0 ,0 0 0 , h av e
w eak fo o t arches, w eak spines, o r o th er jo in t defects.
F ro m fifty to seventy-five p er cent, o r from 1 1,000,000 to 16,000,000, of o ur school children (a n d in m any com m unities as high as 98
p e r ce n t) h av e defective teeth, an d all defective teeth are m ore o r less
injurious to health. Som e of these defective teeth are d ea d ly m enaces
to th eir owners. T his is th e greatest problem , from th e stan d p o in t of
its seriousness an d from th e stan d p o in t of its enforcem ent, th a t w e have.
T h e teeth of th e children of A m erica can never b e b ro u g h t into p ro p e r
shape w ith o u t a social p ro g ram to p ro v id e for th e p ay m en t of tre ­
m endous bills. M ay I ask you to rem em ber th a t Sir W illiam Osier,
o u r greatest living English-speaking m edical authority, said ten years
ago th a t m o re n ational physical deficiency in G re a t B ritain w as d u e to
defective teeth th an to alcohol.
E very school child should h av e a health exam ination once a year.
M ore frequent exam ination should b e p ro v id ed for individual pupils
who n eed special attention. AH health exam inations an d h ealth care
in rural a n d in city schools should b e u n d e r th e supervision of regularly
ap p o in ted school physicians thoroughly train e d for their w ork. E very
S tate should h av e a S tate health inspector of schools who should give
special atten tio n to th e health w ork of th e rural schools.
T h e ro u tin e tests of vision an d hearing can best b e m ad e b y th e
teachers, as these tests involve, to an unusual extent, m ental an d ed u ca­
tional as well as h ealth factors an d require know ledge of th e pupils,

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possessed by th e teacher, as well as sim ple m eth o d s of exam ination
which all cap ab le teachers can easily learn. I am referring of course
only to th e routine tests of vision of all the children, n o t the examina^
tion of those found to b e defective. In the rural schools th e general
h ealth exam inations can often b e do n e m ost advantageously b y th e
school nurse w ith the help of th e teacher.
T h ere should b e fo r every child a health as well as a scholarship
reco rd w hich accom panies him through his school career. A n d this,
let m e say, should b e a continuation of th e record started w hen th e
child w as bo rn , which is h a n d e d dow n to th e school w hen th e child
enters school. W h a t has b een said ab o u t the care of children during
th e preschool age will of course ap p ly here. T his should b e a p a rt
of th e reco rd of the school which th e child is attending. T h e following
form o r b lan k has b een tested sufficiently in rural as well as city schools
to p ro v e its practical value:
H EA L T H RECO RD
N a m e .................................... B orn i n .........................................on ( d a t e ) .................................
......................... N ationality of F a th e r ...................................... M o th e r......................................
N um ber in fa m ily .......................A d u lts ..........................C h ild re n . . . . ................N um ber
of b ir th ........................................... H isto ry of M easles........................................... S carlet
fe v e r......................... ..
D ip h th e r ia ................ ................. W hoo p in g c o u g h . ................
• ............................ P n e u m o n ia ........................................ In flu en za................................... . .
D ate of first e x a m in a tio n .......................' .................. in sc h o o l...................................... : . .

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1 I.
12.
13.
14.
15.
16.
1 7.
18.
19.
20.
2 1.
22.

--------- y e a r --------1
2
3
4
5
6
7
8
A ge a n d y e a r ................................................
....................................................................
G r a d e ..................................................................................................
•.............................
C lass ................................... .'
......................... ..........................................
...
...
R e v a c c in a t io n s .................................................. .............................
...
...
.
D iseases d u rin g y e a r ...............................................................................................
...
D ate of e x am in atio n s...............................................................................................
....
H e i g h t .......................................... .. .
..............................
..............................
...
W eight .......... .. .................................................................................................... .. .
...
N utrition ..............................
...
A nem ia .................................
........................................ ..
...
. . . " ..................
E n larg ed glands ...............
. ........................................
...
...
. .
...
N ervous d is e a s e s .........................
/,
C ardiac d i s e a s e s ............................................................ .. .
..............................
...
P u lm o n ary d iseases.............................. .. .
......................... .. .
...
...
...
S kin d is e a s e s .......... ............ ............................... .. .
...
..................
...
...
O rth o p ed ic d e f e c t .........................
................................................................................
D efect of vision. . . . . . . .
...
.................. * ...................
. ....................... .. .
D efect of h e a rin g ............................ |.......................................................
...
...
D efect of nasal b re a th in g
...........................................
...
D efect of p a la te ............... .
..............................
...
...
..................
...
D efect of te e th ..........................................................
.....................................................
H ern ia ...................................
...........................................
...
..............................


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252
23.
2 4.
25.
26.
27.
28.
29.

STANDARDS OF CHILD WELFARE
H y p e rtro p h ie d a n d dis­
eased tonsils.........................................................
...............................
..................
A denoids .............................
...
.....................
•••
' ' * -...................*
M entality ..............................
. . . ..............................
•••
•••
C o n d u c t ................. .. . . . ......................... ..
•••
.......................................................
E f f o r t ....................................
« > ............................ ..
•••
•••
............... *
•••
*** • *’
P r o f ic ie n c y ....................................................
T re a tm e n t n ecessary ..........
...
................................................................. ..
*

T h e eyes of children w ho w ear glasses should b e tested w ith the
glasses, a n d if found norm al should b e so recorded. T h e following
m eth o d should b e u s e d :
H an g th e Snellen test letters in a good, clear light (sid e light prefe rre d ) on a level w ith th e head, an d so placed th a t th e child does n o t
face a strong light. P lace th e child 20 feet from th e letters. C over
one eye w ith a card h eld firm ly against the nose, w ithout pressing on
th e co v ered eye, an d h av e him read aloud, from left to right, th e
sm allest letters h e can see on th e card. M ake a record of th e result.
C hildren w ho h av e n o t learn ed their letters, obviously, can n o t b e
given this eyesight test until afte r th ey h av e learned them . Pupils w ho
ca n n o t re ad m ay, how ever, b e tested b y a chart w ith pictures of
fam iliar objects designed fo r this purpose.
T h ere is a n u m ber over each line of the test letters w hich show s th e
d istance in feet a t w hich these letters should b e re a d b y a norm al
eye. F ro m to p to b o tto m th e lines on th e ca rd are num bered, re ­
spectively, 50, 40, 30, an d 20. A t a distance of 20 feet, th e average
n o rm al eye should re ad th e letters on the 20 foot line, an d if this is
d o n e correctly, o r w ith a m istake of one o r tw o letters, th e vision m ay
b e n o ted as 2 0 /2 0 o r norm al. In this fraction th e n u m erato r is th e
d istance in feet a t w hich th e letters are read, a n d th e d en o m in ato r is
th e n u m b er o v er th e sm allest line of letters read. If the sm allest letters
which can b e re ad are on th e 30 foot line, th e vision will b e n o ted as
2 0 /3 0 ; if th e letters on th e 40 foot line are th e sm allest th a t can b e
read , th e reco rd will b e 2 0 /4 0 . If th e letters on th e 50 foot line are
th e sm allest th a t can b e read, th e record will b e 2 0 /5 0 .
If the child can n o t see th e largest letters (th o se on th e 50 foot lin e ),
h av e him ap p ro ach slowly until th e distance is found from w hich they
can b e seen. If 5 is th e nearest distance from which th e 5 0 foot letters
can b e read, th e record will b e 5 /5 0 ( 1 /1 0 o f n o rm a l).
T est th e second eye, th e first being covered w ith th e card, a n d n o te
th e result as before. W ith th e second eye, h av e th e child re ad th e let­
ters from rig h t to left to avoid m em orizing. T o p re v en t reading from
m em ory, a hole, 1 / i inches square m ay b e cut in a piece of card b o ard ,
w hich m ay b e h eld against the test letters so as to show only one letter
a t a time, a n d w hich m ay b e m oved ab o u t so as to show th e letters in

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irreg u lar o rd er. A m istake of tw o letters on th e 20 o r 30 foot line
an d of one letter on th e 40 o r 50 fo o t line m ay b e allow ed.
P aren ts should b e notified if:
(a ) V ision in either eye is 2 0 /4 0 o r less;
( b ) C hild habitually h olds h ea d too n ea r b o o k (less th an 12
inches) ;
(c ) C hild frequently com plains of headache, especially in th e latte r
p o rtio n of school hours;
( d ) E ither eye deviates even tem porarily from norm al position.
In testing hearing, if it is possible, one person should m ake th e exam i­
n atio n fo r an entire school in o rd e r to insure an even m ethod. T h e
p erso n selected should b e one possessed of norm al hearing.
T h e exam ination should b e m ad e w ith th e w hispered voice; th e
child should re p eat w h at h e hears, an d th e distance a t w hich w ords
can b e h ea rd distinctly should b e noted. T h e tw o ears should be
tested separately. T h e test should consist of num bers, 1 to 100, an d
sh o rt sentences. T o avoid im itation, it is b est th a t b u t one pupil a t a
tim e b e allow ed in th e room . F o r v ery young children a fair id ea of
th e h earing m ay b e ob tain ed b y picking out th e back w ard or in atten ­
tiv e pupils an d those th a t seem to w atch th e teach er’s lips, placing them
w ith th eir back s to th e exam iner an d asking them to p erfo rm som e
unusual m o v em en t of th e h an d o r o th er act.
Physical defects should b e re p o rted to th e hom es, a n d all possible
efforts should b e m ad e b y teachers, superintendents, school nurses
a n d school d o cto rs to persu ad e th e p aren ts to obtain fo r th e child the
care necessary fo r correction of all defects th a t it is possible to rem edy.
Facilities should b e m ad e available for th e health reconstruction of
all th e school children.
It is vitally necessary th a t th e b est available efforts of official agen­
cies, national, state, an d local, shall b e supplem ented an d reinforced
b y the co o p eratio n of v o lu n tary service of individuals a n d organiza­
tions enlisted for this essential form of social service, expressing results
in th e conservation a n d im provem ent of th e n atio n ’s m ost vital a n d
m ost neglected assets, the health a n d w elfare o f th e children.
I w ould like to p ay trib u te to such organizations as the C hild H ealth
O rganization, w ith h ea d q u arters in New Y ork, which has given very
striking su p p o rt an d cooperation to this m ovem ent for th e correct
tion of m alnutrition, as a p a rt of th e general p ro g ram for th e health
o f th e school children of A m erica; to th e E lizabeth M cC orm ick M em o­
rial F u n d of C hicago, an d to the B ureau of E ducational E xperim ents
in New Y ork, as ty pes of volunteer organizations necessary to insure
th ese stan d ard s of health exam ination an d health care.
M agnificent provisions h av e b een m ad e for the health care of our
soldiers in w ar. Shall n o t th e children, d ra fte d b y com pulsory educa
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254

STANDARDS

OF

C H IL D

W ELFARE

tion into our schools, b e assured of as skillful an d satisfactory care as
th e soldiers in cam p an d trench? If health an d physical efficiency are
so im p o rtan t for th e country as a w hole, all of th e necessary forces,
b o th g o v ern m en tal an d voluntary, m ust b e m arshaled for th e task of
p ro tectin g an d developing th e physical fitness of the young. T h e p rin ­
ciple of universal training must, in a m an n er consonant w ith th e spirit
an d m eth o d s of dem ocracy, b e in terp reted an d applied in th e universal,
com pulsory h ealth an d physical care an d training of all th e children
of th e nation.
Physicians, surgeons, nurses, hospitals, d en tal an d general clinics,
a n d h ealth centers of requisite type m ust b e available to m eet th e needs
of the defective children in th e schools.
H e alth officers w ho supervise this p ro g ram m ust h av e special an d
th o ro u g h training in m o d ern educational principles an d practice, in
a d d itio n to m edical education an d experience, to qualify them for
th eir w ork. T eachers an d o th er school officials require ad eq u ate tra in ­
ing in h ealth principles an d m eth o d s to enable th em to co o p erate m ost
successfully. T h e curricula of training in all norm al schools an d in
o th er institutions for th e p re p ara tio n of teachers m ust b e b ro a d en ed
a n d m odified to include th e essential instruction in school health w ork
b efo re th e structure of national education can b e recognized as giving
evidence of rational w holeness or soundness. Special teachers a n d
supervisors of h ealth an d physical education, if p ro p erly trained, m ay
re n d e r invaluable service in th e health exam inations, supervision, an d
h ealth education of pupils.
R egistered nurses em ployed as district an d school nurses, o r giving
th eir tim e w hen necessary exclusively to the schools, h av e alread y
d em o n strate d th e ex trao rd in ary value of their professional services in
this p ro g ram of health exam ination an d care of the school children.
It is essential, how ever, th a t they should b e firm ly gro u n d ed in educa­
tio n al ideas an d in special teaching m ethods, an d possess th e skill
requisite for their highest usefulness.
It is ap p a re n t to careful students of this school health w ork th a t th e
teach er should h av e th e benefit of th e social an d com m unity m ethods
of th e b est hospitals, clinics, an d social w orkers; while it is equally
necessary th a t school physicians an d nurses should h av e th e benefit of
th e b est special training m ad e available for teachers in universities, col­
leges, an d norm al schools.
T h ere should b e a school nurse for every 1,000 to 3,000 school chil­
dren, according to geographical distribution an d th e presence or
absence of co operating agents for the health w ork.
T h e w o rk of th e school nurse m ay b e briefly outlined as follow s:
R outine class inspections to d etect cases to b e excluded from school
a n d referred to physicians-.

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F irst aid in em ergency cases.
A ssisting in h ealth exam inations an d keeping records.
Instructing pupils in various details of hygiene.
A dvising p aren ts of children found in health exam inations to require
rem edial treatm en t.
C onvincing p aren ts of necessity of treatm ent.
M aking ad ju stm ents for n eed ed treatm ent.
Instructing children an d p aren ts in personal an d hom e health.
M aking arran g em ents for treatm en t of n eedy children.
Securing m edicines, eye-glasses, etc., through philanthropic agencies.
T ak in g children to clinics an d persuading them to accept th e tre a t­
m en t a d v is e d ; obtaining necessary d a ta for the clinics.
T h e duties o f th e school nurse v ary w ith th e n eed s a n d resources
o f th e com m unity an d m ay include in ad d itio n to th e general activities
h ere in d icated special w ork with truants an d w ith classes o f physically
h an d ica p p ed children, such as th e cripples, tuberculous, anem ic, etc.
W ith o u t the nurse, the statistics show th a t corrective w ork is d o n e in
15 to 25 p e r cent of th e cases re p o rte d a n d recom m ended. W ith th e
nurse, it is show n th a t from 75 to 90 p e r cent of th e children receive
th e follow -up w ork an d atten tio n which has b een urged.
T h e possibilities of vital accom plishm ent w ith a stan d ard iz ed n a ­
tional p ro g ram of h ealth exam ination an d care o f school children seem
n o t only fu n d am ental fo r national safety b u t lim itless for national p ro g ­
ress. T h e significance an d necessity of th e w ork to b e d o n e m ake the
d em an d fo r constructive ad v an cem en t im perative. No facto r relating
to essentials in public education o r prom otion of national w elfare seem s
m ore im p o rtan t o r m ore prom ising.


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T H E N U T R IT IO N O F A D O LESC EN C E
By D R. G R A H A M LUSK
C o rn ell U niversity M ed ical C olleg e; N ew Y o rk C ity

A n ad eq u ate food supply is the requisite of national existence. If
to o little food is available the first to suffer are th e old people, an d
then th e children, though these are often fed w ith th e food designed
fo r th e m other, w ho sacrifices herself fo r th e w ell-being of h e r offspring.
B efore th e w ar g reat num bers of peo p le w ere habitually in a state
of u n d ernutrition. T his reduces th e w orking capacity an d dim inishes
the resistance to diseases, especially to tuberculosis. Such' a condition
grad u ally underm ining th e w elfare of a nation, m ay b e exem plified
b y a description of th e food conditions in G erm any, a know ledge of
which h as lately becom e available.
It is stated b y R u b n er1 th a t food difficulties first arose in th e m id d le
of 1916. O ne im p o rtan t article of food afte r an o th er disappeared'
from th e m ark et o r could b e o b tained .only in hom eopathic doses.
T hus, th e available am ounts of m eat, eggs, milk, an d b u tte r becam e
less afid less. D uring th e w inter of 1916-1 7, th e failure of th e p o ta to
crop o f 1916 led to th e substitution of turnips in th e diet, b o th in th e
cities an d in th e industrial centers. F rom th e effects of this d iet th e
p eo p le n ev e r recovered. T h ere w as insufficient m ilk fo r th e children.
T h e censorship of th e press p rev en ted th e tru e condition from being
generally know n, an d peo p le w ere tau g h t to congratulate them selves
upo n th eir loss in weight.
A secret inquiry, m ad e a t th e end of 191 7, led R u b n er to re p o rt to
th e Im perial M inistry of H ealth how w idespread th e evil effect of th e
w ar d iet h a d been u pon th e w elfare of th e people. T h e psychology
of th e nation h a d changed. T h e only th o u g h t w as to o btain a sufficient
q u an tity of food, albeit d evoid of flavor; th ere w as no initiative, only
u n p ro d u ctiv e depression. C hildren forgot how to laugh, to cry, o r to
play.
Inform ation reached L on d o n early in 191 $ th a t th e insurance com ­
panies of G erm any h a d secretly w arned th e governm ent as to the
failing h ealth of th e people, w hich was re p o rted to b e m ore disastrous
in loss o f life th an w ere th e m ilitary operations. T his now ap p ears
as an u n d o u b ted reflection from th e m eeting described b y R ubner.
1 R u bn er, M .,'B e rlin e r k lin ische W o ch e n s ch rift ( 1 9 1 9 ) , L V I

256


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T h e latte r states th a t certain high-placed individuals fo rb ad e a further
prosecution o f the inquiry.
K raus describes how h unger form s an excellent b ackground for
disease, an d th a t anti-bodies are n o t p ro d u ced as w hen ad e q u ate nutri­
tion is possible. H ence, th e tuberculosis d ea th ra te d o u b led during
th e w ar an d is now a t th e height prevailing tw enty-five years ago. H e
relates1 th a t th e fo o d conditions affected w om en in such a w ay as to
p ro d u ce cessation of th e m enses, sterility, an d a reduction in th e
qu an tity of m ilk of th e nursing m others, w hich m ilk w as also p o o r in
fat. T h e av erag e w eight of children a t b irth fell off. C ow s’ m ilk of
inferior quality w as given to children, for th ere w as no longer any
hygienic control. T h e evil effects of th e one-sided d iet on th e o ld er
children b ecam e m o re p ro nounced th e longer it w as continued. A
d iet m ad e up essentially of b re a d an d p o tato es p ro v e d injurious to
children. T h ere w as a deficiency in protein, fat, an d in vitam ines,
w hich led to scurvy, tuberculosis, rickets, an d anem ia. N ervous dis­
eases w ere ag g rav ated an d constitutional anom alies intensified.
R ep o rts h av e also com e out of G erm any show ing how an absence
of b u tte r fa t led to stu n ted grow th an d th e affliction of xerophthalm ia,
a disease of th e eye, b o th o f which sym ptom s can b e experim entally
p ro d u c ed in young rats in th e absence of th e fat soluble vitam ine con­
tain ed in b u tte r fat. T hese stories are n o t G erm an p ro p a g an d a. A n
A m erican m edical com m ission con d u cted an investigation into th e
condition of th e children o f T re v es afte r its occupation b y th e A m er­
ican arm y an d found a re ta rd a tio n in grow th of tw o years, children
of fourteen having th e physical dev elo p m en t o f those of tw elve.
In th e B ohem ian city of P rague a w idespread presence of infantile
scurvy as existing in th e early sum m er o f 1918 is b itterly described
by E pstein.2 A lm ost every p re p ara tio n for th e w elfare of th e sick
child h a d d isap p eared from th e m arket, th e rich buying a t high prices
th e “ last b o ttle ” of such m aterial from th e apothecary. M ilk w as
v ery scarce a t a tim e w hen th e farm ers w ere freely using h alf their
m ilk, a fo o d so necessary fo r sick children, in th e p re p ara tio n of butter.
It is well know n th a t this kind o f profiteering h a d long b een p re v en ted
in E ngland.
T h ese details are cited in o rd e r to em phasize th e necessity o f such
än organization of agriculture o r of food supply th a t th e national w el­
fare of a country b e m aintained. T h a t such an organization is incom ­
p atib le w ith industrial d iso rd er is a self-evident proposition.
B oth th e quality ä n d th e quantity o f fo o d should b e considered.
C hildren should receive a diet containing a sufficient quantity of
vitam ines. O f fu n d am ental im portance for grow th an d good health
1 K raus, B erliner klinische W o ch en sch rift ( 1 9 1 9 ) , I.VI, 3; C zerny, Ibid., p . 4.
2 E pstein, Ja h rb u c h fü r K in d erh eilk u n d e ( 1 9 1 8 ) , LXX XV III, 237.

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STANDARDS O F C H IL D W E L F A R E

is th e b u tte r fat contained in m ilk o r tak en separately in th e form of
cream o r bu tter. T his has b een set forth above. S tu n ted ra ts which
h av e b een long d ep riv e d of this substance grow to norm al size w hen
it is a d d e d to an otherw ise ad e q u ate diet, so th a t it m ay b e presum ed
th a t w ith th e adm inistration o f b u tte r fat to children w hose grow th
has b een re ta rd e d norm al grow th will b e obtained. V e g etab le oils,
like olive oil, an d p o rk fat d o n o t contain th e fa t soluble vitam ine an d
ca n n o t tak e the p lace of milk. B eef fat, eggs, liver, an d kidneys are,
how ever, quite rich in this m aterial, a n d it is present in spinach, lettuce,
b ee t tops, an d th e like. O live oil tak en w ith lettuce o r b e e t to p s
m ay tak e th e place of m ilk in th e d ie t of adults. T h ro u g h eating th e
green substances of th e field th e cow gains for h e r m ilk this grow thprom oting, life-preserving vitam ine. It follows from this th a t th e
m ilk of a cow nourished on clover from th e fields will b e of higher
nutritiv e v alu e th an th a t of one fed w ith corn ensilage. T h e cow s in
G re at B ritain h av e m ore vitam ines in their m ilk th an cow s in A m erica
because p astu rag e is b e tte r there.
If a fo o d b e given w hich consists m ainly o f highly polished rice, o r
highly m illed grains, beri-beri, a p ro fo u n d nervous disorder, results.
B eri-beri can b e cured b y adm inistering th e aqueous ex tract of p eas o r
of rice polishings o r of th e ev a p o rated salts of milk. T his disease has n o t
ap p e a re d in w ar tim e in th e E uropean nations because w heat has b een
m illed a t ab o u t 85 p e r cent o r m ore, so th a t a larg e p ro p o rtio n of th e
b ran, w hich contains th e w ater-soluble vitam ine, has rem ained in th e
b re ad . W h en a child can receive an o rd in ary m ixed d iet th ere is no
d an g e r in p artak in g of w hite b read .
S curvy ap p e ars w hen th e d iet contains no anti-scorbutic vitam ines,
such as are found in fruits, fresh vegetables, an d tubers such as p o ta ­
toes. T h e cure is found in lem on juice, orange juice, fresh vegetables,
p o tatoes, g erm inated peas, beans, an d lentils, a n d in canned tom atoes.
H ess finds th a t th e younger an d m ore te n d e r th e green vegetable, th e
g re ater its vitam ine content, hence an instinctive dietetic preference.
T h e question of vitam ines fo r th e w elfare of th e children is b o und
up in th e d ev elo p m en t of d airy farm ing, fruit culture, a n d th e p ro d u c ­
tion of fresh vegetables.
F u rth erm o re, m ilk contains salts for th e grow th a n d re p air of th e
bones, p ro tein fo r th e grow th an d rep air of th e m uscles a n d o th er
o rgans of th e body, to g eth er w ith fa t a n d sugar w hich give fuel for
th e m aintenance of th e hum an m achine. V e ry few p eo p le realize
th a t th e cost of m ilk p e r 1,000 calories is usually only one-half th e cost
of beef. T hus, in P aris on S ep tem b er 1 ,1 9 1 8 , 1,000 calories cost as
m ilk 98 centim es (equal to 1 7 c e n ts), as b eef 1 75 centim es (eq u al to
31 cents) ; a n d in New Y ork on Jan u a ry 1, 1919, as m ilk 24 cents a n d
as b ee f 45 cents. In P aris b e e f w as 82 p e r cent m o re costly th an m ilk

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a n d in N ew Y ork it w as 87 p e r cent m ore costly. T h e controlled
L o n d o n m ark e t does n o t lend itself for com parison. O n account of
th e g re at valu e an d lesser cost of m ilk th e w riter has urged th a t a
fam ily of five should n o t buy m eat until it has purchased th ree quarts
of m ilk daily.
M ilk is w anting in iron a n d hence children should b e given green
substances w hich contain this elem ent, especially spinach, w hich co n ­
tains a co n sid erable quantity. T h e yolks o f eggs also contain it, as
do, o f course, b ee f a n d b eef juice.
T h e curse of th e ign o ran t an d p o o re r classes is th e giving of te a
an d coffee to th eir children instead of m ilk.
T his is d o n e in
families in w hich m eat is regularly purchased. T h ere is n o t sufficient
education fo r th e p aren ts to realize th a t m ilk is a cheap a n d well-nigh
indispensable bo dy-building food. It is n o t d esirable to give to chil­
d ren o r to ad u lts the m inim al quantity of p rotein com patible with
existence, b u t it is safer to allow p rotein in a certain excess of the
actual need s in o rd e r th a t th e tissue cells b e filled w ith it. R ubner
has called such m aterial an “ im provem ent q u o ta” of protein, an d
th ere is evidence th a t this descriptive term inology is justified. This,
how ever, d o es n o t w a rran t th e eating b y an y m an of a p o u n d o r m ore
of beef a day, m eat w hich costs five tim es as m uch fo d d e r to p ro d u ce
as d o es a sim ilar fo o d value in m ilk.
W ith reg ard to a sufficiency in th e qu an tity of a diet th e question
becom es involved in th e n u m b er of calories necessary fo r th e m ain­
ten an ce o f th e living organism a t various ages. B elow are p resen ted
th e relative physiological n eed s o f food, in th e first colum n as estim ated
b y A tw ater, an d in th e second colum n as a d o p te d b y th e Inter-A llied
Scientific F o o d Com m ission of 1918.
.
.
A ge in y e ars

A tw a te r

In ter-A lh ed
Scientific
Food Com m ission

C hild ......................
C h i l d . -------. . ----C h ild ...................... .

Oto 2 .................... 0.3..................... 0.50
2 to 6 ............... . . 0 . 4 ......................0.50
6 to 10......................0.5......................0.70
B o y ............. .............10 to 12..................... 0.6. ....................0.83
G i r l ............................10 to 14..................... 0.6.....................0.83
B o y ............................12 to 14......................0.8......................0.83
B o y ............................14 to 16..........
0.9.......................1.00
G i r l ............................14 to 16..................... 0.7......................0.83
Men .................... ...................................... .1 .0 ......................1.00
Women .................. .................................. . , 0.8.................... 0.83

T h e British F o o d C om m ittee of th e R oyal Society h a d com puted
th a t an av erag e m an doing an averag e d a y ’s w o rk required 3,000
calories, as ingested, o r 3 ,300 w hen th e supply w as considered from
th e national stan d p o in t an d allow ed for w aste. W hen later it com ­
p u ted th e q u an tity of food available for their w hole population in the
five y e a r p rew ar period, 1909-1 3, dividing it am ong th e population in
acco rd an ce w ith the relative values ad o p te d b y th e Inter-A llied Scien
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STANDARDS O F C H IL D W E L F A R E

tific F o o d Com m ission, it w as found th a t 3,410 calories h a d been
available p e r m an p e r day. W ith increased care in th e use of fo o d
a national stock of 3 ,300 calories p e r "m a n ” p e r d a y ap p e ars am ple.
T h e earlier statem en t th a t a nation could live on w h at it w asted b efo re
th e w ar h as b een ab u n d a n tly refuted.
T h e stu d y o f sta n d a rd s of m etabolism h as occupied m uch tim e d u r­
ing recent years. A t th e tim e of the establishm ent of th e Russell S age
Institute respiration calorim eter in B ellevue H ospital satisfactory stan d ­
a rd s fo r th e d eterm ination of w h at constituted norm al m etabolism
w ere non-existent. F ro m th e w ork o f D u Bois a n d his associates it
h as b een firm ly established th a t th e w ell nourished, norm al a d u lt m an,
w hen resting in b e d b efo re breakfast, p ro d u ces 4 0 calories p e r h o u r
p e r square m eter o f surface w ithin an erro r lim it o f ab o u t ± 1 0 p e r
cent. T h is is know n as th e basal m etabolism . D u Bois found th a t
th e m etabolism of b oys betw een 12 a n d 1 3 years old w as 5 0 calories
p e r square m eter o f surface, o r 23 p e r cent higher th an in a d u lt m en.
A t this tim e, b efo re th e onset o f puberty, th e intensification of th e
grow th im pulse is accom panied b y a greatly increased m etabolism
w hen height an d w eight are reg ard ed . F urtherm ore, D u Bois investi­
g ated th e m etabolism o f these sam e boys tw o years later u n d e r identical
experim ental conditions. T h e m etabolism p e r square m e te r o f surface
h a d fallen so th a t it w as only 1 1 p e r cent ab o v e th e averag e fo r a d u lt
m en. In th e th ree youngest boys th e m etabolism w as actually g re ater
in calories p ro d u c ed during th e tw elfth y ea r th an during th e fourteenth
year, although the b oys show ed gains in w eight of betw een 35 a n d 50
p e r cent. It is w ell know n th a t a norm al b o y is extrem ely active a t
this p erio d of his life. Investigations b y G e p h a rt h av e show n th a t
A m erican bo y s in St. P aul’s School p a rto o k o f as m uch as 5 ,0 0 0
calories daily. Sir H en ry T hom pson, p rio r to his d ea th on an Irish
passenger steam er sunk b y a G erm an subm arine in th e sum m er o f 1918,
collected d a ta which show ed an average consum ption of 3,500 calories
daily b y English school boys, even in th e difficult day s of th e w inter
o f 1918. A t E ton an d H arro w th e spirit of p atriotism a t one tim e
certainly caused to o g reat a vo lu n tary restriction u pon th e qu an tity of
fo o d tak en a n d m an y boys lost in w eight, often to th e d etrim en t of their
health.
It h as been re p o rted from B erlin1 th at, in an asylum fo r foundlings
in th e th ird y ea r of th e w ar an a ttem p t w as m ad e to nourish th ree boys
betw een six an d eight years old w ith food containing 1,000 calories,
a n d fo u r o th e r bo y s betw een eleven an d fourteen w ith 1,334 calories.
T his m ay b e calculated as being less th an th e basal m etabolism of
th e children a n d th e result w as w h at w as to h av e b een an ticipated, a
1 F uhge, Ja h rb u c h fu r K in d erh eilk u n d e, ( 1 9 1 8 ) , LX X X V III, 43.

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Comparative Estimates of Physiological Needs for Food
(In Calories)

5000

S c h o o l B o y s (i. 1. S . A .)

CALS.
4500
■

—

**

^**
4000
_—•
eotf *.-■
3500

w

S c h o o 1 B o y s ( British)
\| 6 ^ '
-----

3000

—^ ^ 1
*»^

*
\

—

^ ^

V
H ';

r

G irls (i British)

_________
ßoV ■

Q uiet

Very

---- -

1500

y $
V

m%m*

**^
ater

\

------ ---Vyj Tiqerste d L _____

\
\

/

y

\

\ ------\

B a s a ^ _______d—
^ ^ —*

y✓

1000

500

Vl

/
............

\

w

\
\

è
<t\
\

2000

, /
/ __

Schoo

________

— *----- 1—
\
■,

^^^^’

2500

0

Seien tific

■■■■.■•1/. 1n « ¡r-allied

Food C o m m is sion
G.

1


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Federal Reserve Bank of St. Louis

2

3

4

5

9

10

11

12

13

F* Sod erstrom
14

15 YRS


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261

loss in w eight an d in b o d y p rotein of all these children, w ho w ere
n o t only u n d er height for their age b u t u n d er w eight for th eir height.
F ive th o u sand calories daily certainly ap p ears to b e an extravagant
q u an tity of fo od to furnish a boy. It is .20 p e r cent m o re th an th e
am o u n t consum ed b y a soldier a t h a rd drill. It w ould b e v ery in ter­
esting to investigate th e econom ic efficiency of th e m uscles o f th e grow ­
ing boy. Since his basal m etabolism is higher th an th a t of a m an, it is
n o t a t all unlikely th a t his m uscular efficiency is on a low er plane, th a t
is to say, th a t he m ay require m ore energy to w alk o r to m ove a bicycle
a given distance th an w ould an a d u lt of sim ilar height a n d w eight.
T his p o in t h as n ev er b een investigated.
T h e accom panying ch a rt show s th e food requirem ents o f b oys from
b irth to sixteen years of age, as calculated from all th e m aterial avail­
ab le a y ea r ag o .1 T o this h av e b een a d d e d :
(1 )
T h e requirem ents prescribed b y th e Inter-A llied Scientific
F o o d C om m ission (b lu e lin e).
(2 )
T h e requirem ents calculated b y A tw a te r (green lin e).
(3 )
T h e actual consum ption o f food b y ra th e r inactive school
boys, investigated b y C arl T ig erste d t in 1912, re p o rts of w hich h av e
ju st reach ed this country (re d d o tte d lin e).
(4 )
T h e re p o rte d food intake o f A m erican a n d English school
b oys a n d of English school girls (re d solid lines).
In ad d itio n to this it m ay b e n o ted th a t P fau n d ler’s 2 suggested cor­
rections of th e erratic, official d ietary fo r the children of M unich, as
o f Ja n u a ry 1, 1918, are in full accord w ith th e recom m endations of th e
In ter-A llied Scientific F o o d C om m ission from th e end of th e first y ear
to th e ten th y e a r o f age.
O n read in g th e evidence it ap p e ars th a t m uch know ledge is lacking,
m uch is n eed ed to fill in the picture. T h ere is now am ple fo o d in th e
country. T w elve th o u san d m illion d o llars p e r annum , o r on e-q u arter
of th e incom e of th e w orking population, is p aid for it b y o u r people.
H ousew ives are n o t organized politically, b u t th e tim e is com ing w hen
th e im p o rtan ce of a m o re thorough und erstan d in g of th e science o f
n u trition will b e realized in th e land.
1 L usk, G., Jo u rn a l o f th e A m erican M edical A ssociation, (1 9 1 8 ) , LX X , 821.
T h e lite ra tu re refe re n c e s a re given h ere.
2 P fau n d ler, M ü n ch en er M edizinische W o ch en sch rift ( 1 9 1 8 ) , LXV, 173.


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T H E N EED F O R S E X E D U C A TIO N
By ROBERT D. LEIGH
U n ited S tates P u b lic H e a lth Service

T h e inclusion of th e subject of sex education in a conference a d ­
dressing itself to the task of fixing m inim um stan d ard s for child w elfare
is som ething of a novelty. It m ay b e an indication th a t to som e extent
this v ery im p o rtan t phase of child w elfare is passing over from th e
p erio d of unregulated, unorganized experim entation into th a t of p artial
stan d ardization.
In dealing w ith either children o r adults it is difficult to get aw ay
from th e pro b lem s of sex education. T h e official agencies dealing
w ith th e h ealth an d m orale of th e soldiers an d sailors during th e w ar
started out w ith th e aim of reducing th e incidence of venereal diseases.
B efore going far they arrived a t sex education am ong civilians also,
as one of th e m ost im p o rtan t m eans to th e attain m en t of th e original,
single-m inded m ilitary aim. In organizing a com prehensive program
for prev en tio n an d control of th e venereal diseases am ong th e civilian
p o p u latio n of th e U nited S tates th e public health agencies o f nation,
state, an d city h av e com e to p lace em phasis on this sam e fundam ental
m eans of prevention.
W e k now th a t ven ereal diseases are sp re ad largely through p ro ­
m iscuous sex intercourse. If these contacts could b e elim inated syphilis
an d g o n o rrh ea w ould rap id ly dim inish as a com m unicable disease p ro b ­
lem . W e know , too, th a t these contacts through irregular sex in ter­
course are n o t outside th e control of th e individual o r personally u n ­
av o id ab le as are th e contacts w ith germ s of som e o th er com m unicable
diseases. W e know th a t th e individual exposes him self b y a conscious
act w hich serves no social purpose. It is, therefore, theoretically pos­
sible to elim inate these contacts b y th e p ro p e r education of th e indi­
vidual. E very rational anti-venereal-disease p ro g ram m ust include th e
p ro m o tio n of all k inds a n d types of training which will ed u cate m en
a n d w om en to refrain from prom iscuous sexual intercourse.
L et it b e m ad e clear th a t th e term sex education as a p re v en tiv e of
venereal diseases is m ean t here in its b ro a d est sense. It includes all
influences, all ty pes of training an d h ab it form ing, ¿11 k in d s of instruc­
tion an d activities w hich lead th e individual to set up for him self a
socially v alu ab le sex life.
M uch talk has b een w asted a t conferences in arguing th a t sex in-

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struction— th e im parting of facts concerning sex physiology, venereal
diseases, etc.— can n o t itself p re v en t venereal diseases o r lead th e in­
dividual into th e right sort of sex life. T his is setting up a straw m an
to knock it dow n. T hose who are to d ay advocating sex instruction are
extrem ely hum ble in their claims. T heir w ork is only an item of th e
large social p ro g ram of sex education an d prevention. T h ere is p ra c­
tical ag reem en t am ong them th a t sex instruction is only a sm all p a rt of
th e set o f influences w hich go to m ake up th e education of th e in­
dividual on m atters of sex.
A ll o f them w ould agree th a t m oral training o r ch aracter building
in th e hom e, b y p ersonal exam ple, b y religion, o r b y o th er agencies
is of g re at im p o rtan ce in th e individual p revention of venereal diseases
an d of sexual irregularity. A ll w ould agree th a t a rich recreational
life w ith w holesom e, o u t-d o o r exercise an d a b u n d a n t m o to r activity
is o f the greatest im portance in long-circuiting th e sex im pulse in a d o ­
lescence an d in pro m oting a norm al sex life. A ll w ould agree th a t
social intercourse betw een th e young peo p le o f b o th sexes u n d e r fa­
v o ra b le circum stances is a valu ab le m eans of sublim ating th e sex
im pulse an d directing it into right channels. A ll w ould agree th a t th e
p ersonal acquisition o f absorbing interests o r hobbies, com pelling en­
thusiasm s, an d am bitions are of g reat valu e in directing those sam e
im pulses along socially useful channels.
A ll w ould ag ree th a t th e reduction b y all m eans possible of the
stim uli leading to abnorm al sex thoughts, an d th e elim ination of direct
tem p tatio n s to com m ercialized vice are of value in prom oting a sound
sex life. E verything a d v o c ated a t this conference, fo r instance, which
will dev elo p th e recreational life o f ch ildhood a n d youth, o r w hich will
furnish b e tte r h o m e life, is helping to m eet th e n eed fo r sex education.
T h ere is, how ever, a n eed for th e giving of facts, for p ro p e r instruction
in m atters of sex. A n d its value is n o t inconsiderable.
O n e of th e m o st extensive cam paigns fo r sex instruction ever carried
on anyw here w as a d o p te d in the arm y a n d nav y during th e w ar
th ro u gh th e agency of the S urgeon G enerals’ offices, th e Com m issions
on T raining C am p Activities, th e Y. M. C. A ., a n d o th er cooperating
agencies. T h is w ork w as only p a rt o f a large schem e of prevention
by various m eans an d it w as em ergency w ork u n d e r the h andicaps of
lim ited tim e a n d rap id ly changing locations of troops. B ut it w as
surprisingly successful. A lthough it is im possible to gauge statistically
th e results of arm y social hygiene education on th e sex h ab its of th e
m en, it is d em o n strate d statistically th a t th e effects of law enforce­
m ent, instruction, an d recreation em ployed sim ultaneously w ith spe­
cific groups of m en m aterially reduced th e prophylaxis rate. A n d th e
p rophylaxis ra te is quite an accurate gauge of th e ra te o f irregular
sexual relations.

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B ut although statistics are n o t available for th e effect of sex instruc­
tion alone, case histories o b tain ed inform ally b y th e m any social
hygiene sergeants who h a d charge of th e instruction w ork in th e arm y
cam ps g av e unm istakable evidence of th e value of this m eth o d of
prev en tio n of venereal diseases. In case a fte r case th e simple, scientific
statem en ts concerning sex hygiene o r venereal diseases rem o v ed a
lo ad of w o rry which h a d b een w eighing a young m an dow n for years
a n d gave him am bition to lead a b e tte r sex life.
T h ese p ersonal testim onies reveal strikingly th a t sex education once
u n d ertak en h as effects m uch m ore inclusive th an th e prevention of
v enereal disease. It has a d irect bearing on th e p ro b lem of illegiti­
m acy an d on th e happiness ra te of m arriage relations. It also has a
distinct an d easily traceab le relation to th e happiness an d m ental
norm ality o f childhood a n d adolescence. F ro m no o th er cause so
m uch as ignorance of sim ple facts concerning sex d o th e fears, th e
worries, th e broodings, th e m isunderstandings, so com m on in ad o les­
cence arise. N othing, on th e o th er hand, can m ak e th e p erio d o f youth
so m uch a golden age of happiness an d pleasure in life as accurate
know ledge an d norm al attitu d e in m atters of sex.
If th ere w ere no o th er m atters involved, if it w ere possible to keep
th e child from p ro p e r instruction a t th e school ages an d re-educate
him o r h er later in college o r a d u lt life to norm al habits a n d points of
view, th e-w o rries an d d o u b ts a n d bro o d in g s im posed on b oys an d
girls o f th e adolescent p erio d as a result of lack o f sim ple know ledge
is a cruelty on th e p a rt of an y society th a t is ab le to furnish th a t in­
struction. F o r the im m ediate happiness of th e adolescent b o y a n d girl,
sex instruction is a clear duty. M odern psychological research, m o re­
over, is revealing th e destructive m ental an d physical consequences in
a d u lt life of th e neglect to give th e p ro p e r direction to th e adolescent
im pulse.
S tudies m ad e of childhood a n d adolescent sex experiences b ring out
clearly this n eed of early an d ad e q u ate sex instruction. A n u m b er of
y ears ago D r. M. J. E xner o f th e Y. M. C. A . o b tain ed answ ers to
questions concerning sex experience from 9 4 8 college m en in th e East,
C en tral W est, a n d F a r W est. T hese answ ers w ere o b tain ed u n d e r
circum stances fav o rab le to accuracy an d ten d in g to u n d erstatem en t
ra th e r th an to overstatem ent. T h e sum m ary of th e inform ation o b ­
tain ed h as b een in p rin t for som e tim e. T h e only criticism m a d e o f
its conclusions b y those fam iliar w ith A m erican boys a t first h a n d is
th a t th ey are too conservative. T h e conclusions are, in short, th a t th e
age a t w hich m ost boys receive their first p erm an en t sex im pressions
is m
y ears a n d th a t these im pressions, received from im p ro p er an d
un reliab le sources, usually h av e a b a d effect; th a t th e age a t w hich
m o st b oys are likely to begin som e form of sexual practice is b efo re


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p u b erty ; th a t th e age a t w hich m ost boys receive sex instruction from
well m eaning sources is 15 Yz years; an d th a t th e effects of this instruc­
tion, ho w ev er crude, are in alm ost every case good.
T h ese answ ers show vividly th a t th e recent generations o f school
bo y s com ing from hom es well ab o v e th e av erag e h av e b een getting
th e w rong so rt of sex education, th a t its effect is b ad , a n d th a t th e right
so rt of instruction com es six years too late.
No such extensive studies of th e sex life of girls h av e b een published.
It is p ro b a b le th a t w ithin a short tim e sim ilar studies of girls will b e
m ad e available. M ore lim ited investigations, how ever, p o in t to a
situation fully as serious as am ong boys. D r. R ichards, of P hiladel­
phia, questioning th e 36 girls of one of h e r high school classes, found
th a t m ost of them received their first sex inform ation a t the age of 1 1 \Zl
y ears from unreliable sources an d th a t they received their first reliable
in form ation a t th e age of 15.
A stu d y of 50 young w om en, 25 o f w hom w ere college graduates,
re p o rted in Social H ygiene, indicates th a t m any girls of th e m ore
p ro tec ted life received no ad e q u ate instruction regarding sex m atters
an d v enereal diseases until late adolescence a n d th a t th e effect on
those receiving a t a late d a te inform ation regarding th e abnorm al
m anifestations of sex was decid ed ly harm ful. O n th e o th er han d , it
indicates th a t those w ho received inform ation on norm al sex m atters
early in adolescence from m others o r teachers seem ed n o t to h av e ill
effects from hearin g ab o u t prostitution an d venereal diseases w hen it
w as given th em a t a later date.
F ro m these studies as well as from th e d ay -to -d ay experience of
lecturers, teachers, an d w orkers w ith boys an d girls, it seem s definitely .
established th a t sex instruction fo r boys an d girls a t th e school ages
is a crying n eed a n d th a t p ro p e r sex instruction has highly beneficial
effects.
V arious m eth o d s o f m eeting this n ee d fo r sex instruction o f th e
young are alre ad y d ev elo p ed an d m o re are developing.
T h e m eth o d s an d m a tte r fo r th e education of th e child b efo re p u ­
b erty are fairly well established. T h e child a t this p erio d is interested
in rep ro d u ctio n as in anything else going on ab o u t him an d questions
his p aren ts fo r th e satisfaction of his general curiosity. Sex instruction
d uring these y ears consists m ainly in giving truthful answ ers to these
questions an d in establishing confidence betw een p a re n t an d child.
A side from these questions an d answ ers certain elem entary instruc­
tion w ith re g ard to cleanliness o f th e sex organs is n eeded. T hese
questions an d this advice on hygiene belong to th e hom e. No school
m eth o d could b e d evised fo r tak in g o v er th e task from th e parents.
T h ere is practical agreem ent th a t all efforts should b e directed to w ard
encouraging th e p ro p e r education of p aren ts for this instruction.

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T h e chief p ro b lem is ju st a t this point. M others are n o t so easy to
reach as school children. It is necessary to devise m any w ays of
getting their atten tio n a n d interest an d of giving them th e p re p ara tio n
fo r im parting p ro p e r instruction. S everal p riv ate agencies in th e p ast
h av e d o n e g o od w ork along this line. R ecently th e task has been
tak en up b y th e health officials o f th e S tates an d b y th e P ublic H ealth
Service. P am phlets containing sta n d a rd inform ation fo r parents, is­
sued in larg e quantities b y these health agencies, are being w idely a d ­
vertised. Lectures, m otion pictures, exhibits, n ew sp ap er notices, p la ­
cards, a ll carry th e publicity to parents. T his y ea r th e P ublic H ealth
S ervice has distributed h u n d re d s of thousands of copies of its p a m ­
p h let en titled “T h e P are n ts’ P a rt” in response to individual requests
from parents.
T h e libraries h av e b een enlisted in the w o rk b y th e distribution of
an official selected b o o k list for th e use of parents. T h e so-called
L ib rary P lan of th e Public H ealth Service a d o p te d b y several libraries
p ro v id es fo r th e issuance of this b o o k list to th e addresses of all
m o th ers av ailable on school an d library lists on th e seventh an d fo u r­
teen th b irth d a y of th eir children. T his is accom panied w ith a sta te ­
m en t of th e n eed for th e instruction of their children, a n d th e fact th a t
th e b o o k s can b e o b tain ed from th e public library. It is possible that,
later, advisers on this subject will b e supplied an d teaching clinics d e ­
v elo p ed in connection w ith libraries.
It is im p o rtan t th a t all groups an d organizations dealing w ith m o th ­
ers carry this inform ation to them along w ith their o th er w ork. T h e
co o p eratio n of all health centers, an d of all persons in personal contact
w ith parents, is n ee d ed to extend this simple, valu ab le instruction
th ro u g h m o th ers to children.
A lth o u g h th e hom e can d o m uch in th e later education o f th e a d o ­
lescent b o y o r girl on sex m atters, th ere com es a t this p erio d a new
m eth o d a n d shift o f em phasis. T h e life of th e youth is cen tered m ore
in th e school. Its m any activities tak e m ost of*his tim e. H e turns
to his teach ers fo r th e answ ers to his questions ab o u t life. A t this
p erio d also th e sex im pulse ap p e ars to confuse an d bew ilder him . T h e
p ro b lem o f instruction becom es m o re p ro p e rly a p a rt of th e task of
th e school.
T h e necessary sex instruction during these years belongs in th e
curriculum . It is only b y running aw ay from th e facts concerning
hum an rep roduction, sex hygiene, a n d venereal diseases norm ally ris­
ing in connection w ith physiology, hygiene, biology, dom estic science,
an d physical education th a t teachers fail to give th e p ro p e r inform ation.
T h e p ro b lem of p utting sex instruction into th e high-school curriculum


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is n o t o ne of a d d in g an o th er course o r an o th er teacher. It consists
in rem oving deletions in several subjects.
R ealizing th e n eed for reorganization of th e high-school course
to include the sex facts in their p ro p e r places, th e B ureau of E ducation
an d th e Public H ealth Service h av e fo r th e last y ea r b een cooperating
in w ork am ong high-school teachers. A series of ten conferences of
high-school teachers has b een h eld in various eastern states. T h ey
will b e ex ten d ed in th e course of an o th er y e a r to all p a rts of th e coun­
try. In these conferences it has becom e ev id en t th a t th ere is general
agreem en t am ong teachers an d experts th a t sex instruction should b e
given an d given in connection w ith th e courses m entioned above. It
h as also becom e know n th a t such instruction is being given successfully
in several high schools.
T h ere are m any variations of m eth o d an d arran g em en t of such
courses. B ut alw ays th e facts w ith reg ard to reproduction, th e hygiene
of sex organs, th e venereal diseases, an d prostitution are given in their p ro p e r a n d n atu ral setting as a p a rt of all life, of general hygiene, a n d
of com m unicable diseases. It is n o t so im p o rtan t to h av e these m atters
p resen ted in any one of th e th ree o r four suitable courses as it is to h av e
th e course giving th e instruction com pulsory.
T h e training of teachers is also being tak en up b y these cooperating
go v ern m en tal agencies. T hro u g h th e In terd ep artm en tal Social H ygiene
B o ard colleges are being encouraged to train teachers in physical ed u ­
cation an d o th er subjects w ho will h av e th e back g ro u n d an d p erso n ­
ality fo r giving th e necessary instruction. T h e B ureau of E ducation an d
th e Public H ealth Service, through their jo in t organization, are trying
to centralize inform ation covering experim ents in teaching these sub­
jects a n d are now issuing a series of m o n o g rap h s to th ousands of high
school teachers, presenting re p o rts of successful experim ents. T ea ch ­
ers them selves d o n o t n eed to b e convinced of th e n eed of this sex
instruction; they are too close to individual boys a n d girls. T h ey d o
n eed training, how ever, an d they ask fo r guidance an d m ethods.
T h e fact th a t m any students are g raduating from high schools w ith­
o u t this necessary instruction, to g eth er w ith th e ignorance of m any
m o re w ho are n o t in school, constitutes an educational em ergency.
F o rtu n ately sex instruction can b e b ro u g h t to b o y s concisely a n d a ttra c ­
tively as a p a rt of a personal physical-fitness program . T h e P ublic
H ealth Service, in cooperation w ith the B ureau of E ducation, has p re ­
p a re d exhibits, lan tern slides, an d p am p h lets presenting th e m aterial
arran g ed in this form . T his y ea r in m o re th a n th irty S tates th e high
school b o y s of th e tw o u p p er years are being reached system atically
w ith this m aterial. S everal groups are presenting th e sam e m aterial
to out-of-school boys. M uch w ork is y et to b e d o n e in bringing these
facts to th e b o y w ho can n o t b e reached through th e norm al groupings

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of school, club, o r industry. T his instruction to out-of-school ad o les­
cents, th erefore, as well as to parents, n eed s fo r its success th e full
co operation of all public an d p riv ate agencies touching such groups.
T h e education of a d ra ft arm y reaching all groups an d kinds of
young m en h as given us a new conception fo r th e extension of sex
' instruction. W e h av e com e to see such instruction as th e right of every
young m an an d every young w om an in A m erica. W e h av e com e to
set stan d ard s. W e h av e com e to insist th a t every p a re n t shall answ er
his child’s questions truthfully a n d th a t every grow ing b o y a n d girl b e
p re p a re d w ith th e necessary facts, a t least, to help in m eeting th e p ro b ­
lem s th a t arise from th e existence of th e sex im pulse in its m any
m anifestations.


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EUROPEAN EXPERIENCE
B R ITISH O R G A N IZ A T IO N
By

SIR A R T H U R N E W SH O L M E , K .C .B ., M .D .

Late P rin cip a l M ed ica l O fficer, L o c a l G overn m en t B oard, E n gland

In th e follow ing pages an atte m p t is m a d e to sum m arize th e history
a n d p resen t ex ten t of official an d organized v o lu n tary w ork directed
to secure th e w elfare of m others an d th eir infants. F o r fuller particulars
it will b e necessary to consult th e re p o rts of m edical officers of health
of o ur chief tow ns during th e last th irty years, an d th e official rep o rts
issued b y th e M edical D ep artm en ts o f th e L ocal G o v ern m en t B oard
a n d o f th e B oard of E ducation.
T h e su b ject of child w elfare, in its chief developm ents, ca n n o t b e
se p a ra te d from th a t of public health, o f w hich it form s a constituent
p a rt. I d o n o t ignore th e fact th a t child w elfare is largely d ep e n d en t
also on th e ex ten t to w hich child lab o r is exploited, a n d to w hich ex­
p e c ta n t a n d nursing m others— as also o th er m others— ob tain ex tra­
dom estic em ploym ent, o r em ploym ent fo r gain w ithin th e hom e itself,
w hich involves neglect of young children.
Im p ro v em ent in child w elfare has occurred as th e sanitary progress-,
o f th e co u n try has ad v an ced . T his is n o t th e tim e fo r w riting th e
h istory o f sanitation in E ngland, b u t its effect— a n d th e effect of th e
co n cu rren t im provem ent in social conditions generally——is show n in
th e fact th a t w hereas in th e d ec ad e 1871-80, w hen m oney b eg an to
b e sp en t m o re freely on elem entary sanitary reform , th e expectation
of life o r m ean after-lifetim e a t b irth of m ales w as 4 1 .4 years an d of
fem ales w as 4 4 .6 y ears; in th e years 1910-12 these h a d increased to
51.5 an d 5 5 .4 years respectively. T h e g reater p a rt of th e saving of
life im plied in this ad d itio n of ten years to th e averag e d u ratio n o f
life w as th e result of red u ced m o rtality in children u n d e r 5 y ears of age.
T h e special influence o f sanitation m ay b e fu rth er illustrated b y th e
statem en t th a t in 1871, 12,709 d ea th s from enteric fever w ere regis­
tere d in a p o p u latio n of 22 4 /5 m illions, w hile in 1916, in a popu latio n
of 341/2 millions, th e d eath s from this disease only nu m b ered 1,137.
T h e first d irect steps to w ard s th e reduction of infant m o rtality w ere
p ro b a b ly d irected against epidem ic o r sum m er diarrhea. M edical
officers o f h ealth h av e alw ays b een required in their annual re p o rts to
sum m arize th e v ital statistics o f their districts; an d since 1905 a m ore
d etailed statem en t o f infant m ortality during each p a rt of infancy has
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b een required. A nnually, therefore, as well as w hen they received th e
w eekly returns of d eath s from the local registrars, th ere w as forced
u p o n th eir atten tio n th e fact th a t d eath s of infants u n d er one y ea r of
age fo rm ed a high p ro p o rtio n of to tal d ea th s a t all ages (1 2 .9 p e r
cen t in 1 9 1 7 ), a n d th a t o f these infantile d ea th s a larg e p ro p o rtio n
w ere caused b y d iarrhea, th e n u m b er varying w ith th e tem p eratu re
an d th e deficiency of rainfall in th e sum m er m onths. In 1912, a y ear
of relatively sm all m o rtality from diarrhea, it caused 8.1 p e r cen t of
all d eath s u n d e r one y ea r of age.
F o r m any y ears p a st it has b een custom ary for m edical officers of
h ealth to issue w arnings as to sum m er, diarrhea, to arran g e fo r th e
distribution of leaflets of advice concerning this disease, an d to urge
th e necessity of m ore thorough cleanliness, b o th m unicipal a n d d o ­
m estic, during th e sum m er m onths. E ven b efo re th e early notifica­
tion of b irth s becam e obligatory, in m an y areas th e addresses of in­
fan ts w ere o b tain ed from th e registrars of b irth s an d special visits
w ere m a d e to th e m o th ers o f infants during th e m onths of Ju n e an d
Ju ly an d especially to th e m o th ers o f those infants know n to b e a rti­
ficially fed.
T h e re p o rts o f m edical officers o f health of m an y of th e large tow ns
from 1890 o n w ard show th a t m uch valu ab le w ork w as being accom ­
plished, an d the w ay w as being p re p a re d for m o re general m easures
against in fant m ortality.
T h e im portance of m unicipal sanitation in th e elim ination of
d iarrh eal m o rtality is show n in th e experience o f m an y towns, an d
strikingly b y th e co m parative experience o f L eicester a n d N ottingham .
T h e chief difference betw een th e sanitary condition of th e tw o tow ns
w as th a t in N ottingham in 1909 pail closets still served m ore th an half
th e houses, while L eicester h a d ab a n d o n ed this system entirely, sub­
stituting w ater-closets. B etw een 1889-93 a n d 1909 th e diarrheal
m o rtality in L eicester h a d declined 52 p e r cen t; in N ottingham it h a d
d eclined only 4 p e r cent.
D iarrh ea is n o t th e only disease o f infancy w hich can b e greatly
dim inished b y im p roved public health adm inistration. T uberculosis
a n d w hooping cough a n d m easles figure largely in th e infantile d eath
returns. O v er 2 1 p e r cen t of th e to tal d ea th s in infancy are d u e to
these th ree diseases an d to diarrhea. T h e am ount of syphilis a p p e a r­
ing in the d eath -retu rn s is sm all; b u t its actual am o u n t is m uch g reater
th an this. If pneum onia an d bronchitis, w hich account fo r 19 p e r cent
o f th e d eath s in infancy b e re g ard e d — as they should b e— as infective
diseases, th en it m ay b e said th a t th e p ro b lem o f saving child life an d
o f securing th e co rrelative im provem ent in th e sta n d a rd of h ealth of
survivors to h igher ages, consists v ery largely in th e p revention of
infectious, including d iarrheal, diseases an d acute resp irato ry diseases.

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It follow s from this th a t even if th e lim ited a n d erroneous view b e
tak en th a t san itary authorities are concerned only w ith th e prevention
of infectious disease, th e reduction of infant m ortality is a d u ty d e ­
volving on these authorities, an d can n o t b e effectively carried out
failing th eir cooperation. V o lu n tary effort m ust th erefo re always, in
large m easure, b e directed to w ard s stim ulating local authorities to
p erfo rm th eir duties.
T h e influence of d iarrh eal sum m er m o rtality on th e progress of
child-w elfare w o rk is further show n b y th e fact th a t am ong th e earliest
efforts w ere those to p ro v id e p u re cows’ m ilk to infants. In E ngland,
official m ilk d ep o ts for this purpose n ev er w ere num erous; a n d b u t
little v o lu n tary effort w ent in this direction. T h ere now rem ain very
few such m ilk depots, b u t m any local authorities» p ro v id e m ilk, m ore
p articularly d ried m ilk, to infants for w hom it is specially prescribed a t
in fan t consultations. E arly investigations a t B righton a n d elsew here
show ed th a t th e m o rtality of infants fed on co ndensed m ilk— chiefly
of th e sw eetened v ariety— w as even g re ater th a n th a t of infants fed
o n fresh cow s’ m ilk; an d d irected atten tio n to th e suprem e im portance
o f dom estic cleanliness in th e prev en tio n o f sum m er diarrhea. T h e
m ilk d ep o ts a n d th e concurrent agitation fo r p u re r cow s’ m ilk served
a useful p u rp o se; though it can n o t y et b e said th a t th e cows’ m ilk o rd i­
narily supplied in E ngland is satisfactorily clean.
It becam e ev id en t ere long th a t th e b ro a d cast distribution of in-1
structions as to h o w cows* m ilk m ight safely b e sto red an d p re p are d
fo r in fan ts w as liable to b e m isinterpreted b y m others, as an encourage­
m en t to a b a n d o n breast-feeding; a n d th ere is reason to believe th a t
th ese instructions d id som etim es h av e this effect. H ence th e im portance
o f th e w o rk initiated b y th e late Dr. Sykes a t th e St. P aneras School
fo r M others, w hich b ro u g h t into, relief th e im portance o f encouraging
breast-feed in g b y every possible m eans. In tow ns in which the aided
supply of m ilk w as continued, advice as to its use w as also initiated ;
a n d thus g rad u ally infant consultations— in w hich th e m ain elem ent w as
th e giving of individual advice an d trea tm e n t as required— superseded
m ilk d epots, a n d w ere established in v ery larg e num bers w here m ilk
d ep o ts h a d n ev er b een started . T hese h a d educational value as well as
m edical an d hygienic activities; an d th e re n eed b e no dispute as to
th e relativ e v alu e o f these tw o aspects of th e w ork of infant consulta­
tions (also know n as schools for m others, child-w elfare centres, b a b y
weighings, mothers* welcomes, etc.) ; for w heth er advice a n d instruc­
tion are given to th e individual m o th er o r to m others collectively-—
o r as is advisable, in b o th ways— it should b e exactly th e advice which
a physician skilled in th e hygiene of infancy as well as in th e trea tm e n t
of infantile com plaints w ould give to his individual patient. In this
sense it rem ains true, as P ro fesso r B udin, th e distinguished fou n d er of

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in fan t consultations, said : “A n infant consultation is w orth precisely
as m uch as th e presiding physician.” T his is tru e w hether it is possible
to arran g e fo r a physician to b e p resen t a t each m eeting of a childw elfare cen tre; o r w hether, as has h ap p e n ed during th e G re a t W ar
in E ngland, nurses o r health visitors train ed u n d er such a physician
h av e given hygienic advice in his absence.
Notification of Births

F o r m any years b efo re th e N otification of B irths A c t w as passed,
it h a d been custom ary, especially in tow ns, to arran g e for inquiry by
a sanitary inspector o r fem ale visitor into d eath s occurring u n d e r one
y ea r of age, an d in m an y instances for th e giving of system atic advice
to m oth ers concerning their infants. M ore th an 20 years ago the
M anchester a n d S alford S anitary A ssociation h a d initiated a system of
h om e visitation b y v o lu n teer ladies a n d b y w om en w orkers p aid by
th e association, w ho w ent from house to house, gave elem entary
san itary advice, a n d re p o rte d serious defects to th e sanitary authority.
T h e city council, a t an early stage, show ed its appreciation of th e im ­
p o rtan c e o f this w o rk b y giving g ran ts to w ard s th e expenditure
incurred.
In o rd e r to enable early visits to b e m ade, th e tow n council of
S alfo rd h a d begun as e&rly as 1899 a system of v o lu n tary notification
o f b irth s b y m id wives.
It should b e m entioned a t this stage th a t p rio r to th e p erio d w hen
early notifications of birth s w ere obtained, th e m edical officer of
h ealth w as d ep e n d en t fo r his inform ation on th e registration of births,
fo r which an interval of six w eeks a fte r b irth w as p erm itted before
it b ecam e com pulsory. D uring this interval a larg e p ro p o rtio n of the
to ta l m o rtality of infancy h a d occurred— ap proxim ately one-fifth of
th e to tal d eath s in th e first y ea r afte r b irth occur in th e first week, an d
on e-th ird in th e first m o n th a fte r birth— an d th e possibility of success­
fully influencing th e m o th er to continue breast-feeding h a d gone. T h e
action of th e tow n of H uddersfield in 1906 in obtaining P arliam en tary
p o w er to secure th e com pulsory notification o f birth s w ithin 36 hours
of birth, rep resen ted a rap id grow th of opinion b ased on experience
in th a t an d o th er tow ns to th e effect that, in th e absence o f early in­
fo rm atio n of birth, th e necessary sanitary precautions a n d counsel as
to perso n al hygiene could n o t b e given w ith th e g reatest p ro sp ect of
success. T h is local pioneer w ork doubtless facilitated th e passing of
th e N otification of B irths A c t in 1907.
T his act w as “ a d o p tiv e,” each local au th o rity deciding w hether it
w ished to o b tain early inform ation as to birth s or not. A t th e m id d le
o f 1914, th e act h a d b een a d o p te d o r p u t into o peration in each m etro ­
p o litan b o ro u g h ; in 75 out of 80 county boroughs, representing 97.0,

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p e r cen t o f th eir to tal p o p u latio n ; in 104 out of 2 4 3 o th er boroughs,
representing 6 7 .0 p e r cent of their p o p u latio n ; an d for 35.7 p e r cent
o f th e rest of th e p o pulation of E ngland a n d W ales.
M uch im p o rtan t w ork follow ed th e notification o f births. H o m e
visits to th e m o th er w ere re g ard e d a n d continue to b e re g ard e d as
th e m o st im p o rtan t p a rt o f this w ork; b u t th ere also grew up rapidly
th e p resen t system of Infant C onsultations an d sim ilar organizations.
A s th e N otification o f B irths A cts form th e basis of child-w elfare
w ork, it is convenient to give here th e p u rp o rt o f th e N otification of
B irths (E x ten sion) A ct, 1915, w hich m ad e th e enforcem ent o f this
act universal, an d em pow ered each local au th o rity adm inistering th e
act to exercise an y pow ers which a sanitary au th o rity possesses u n d e r
th e P ublic H ealth A cts for th e pu rp o se o f th e care d f ex p ectan t
m others, nursing m others, an d young children.” In draw ing th e atte n ­
tion o f local authorities to th e term s of th e act th e Local G o v ern m en t
B oard, as earlier in th e w ar, d ep reca te d false econom y. T h ey said:
“A t a time like the present the urgent need for taking all possible steps to
secure the health of mothers and children and to diminish ante-natal and post­
natal infant mortality is obvious, and the Board are confident that they can rely
upon local authorities making the fullest use of the powers conferred on them .”

T h e B o ard in th e sam e circular laid stress on “ th e im portance of
linking up this w ork w ith th e o th er m edical a n d sanitary services p ro ­
v id ed b y local authorities u n d e r th e P ublic H ealth an d o th er A cts.”
T h e a c t en joined th a t th e pow ers of th e act should b e exercised by
a com m ittee w hich shall include w om en an d m ay com prise, if it is
th o u g h t fit, persons w ho are n o t m em bers o f th e authority. T h e
passing of this act has b een follow ed, as will b e show n shortly, b y an
increasingly rap id dev elo p m en t of m atern ity an d child-w elfare w ork.
F o r E ngland th e N otification of B irths A c t h a d only em pow ered local
authorities to u n d erta k e such w ork as is authorized b y th e Public
H ealth A cts; w hereas, in S cotland, m o re general p o w er h a d b een given
to ca rry o u t an y w ork necessary for the w elfare of young children.
T h e technical d o u b t as to th eir legal pow ers h a d b een an excuse fo r
inaction on th e p a rt of som e local authorities; an d to rem ove this d o u b t
th e M atern ity an d C hild W elfare A c t w as passed in A ugust, 1918. T his
a c t m ad e it obligatory on each council exercising pow ers u n d e r th e
act to ap p o in t a m atern ity an d child w elfare com m ittee, w hich m ust
include a t least tw o w om en, a n d m ay include persons specially qual­
ified b y training o r experience in subjects relating to health a n d m a ­
tern ity w ho are n o t m em bers of th e council. In th e circular lette r sent
o u t to local authorities explaining th e new act, th e Local G o vernm ent
B o ard reem phasized its previously sta te d view s th a t child w elfare
w ork w as second only in im portance to direct w ar w ork, a n d w as
really a “m easure of w ar em ergency,” an d a d d e d ;


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“A lthough w e have enjoined upon local authorities the necessity o f the strictest
econom y in public expenditure, w e have urged increased activity in work w hich
has for its object the preservation of infant life and health. W e are glad to note
that the great majority of local authorities have realized the value o f continuing
and extending their efforts for child w elfare at the present time.*’

The Course of Child Mortality

It is con v en ien t a t this p o in t to give a b rief outline o f th e course of
in fan t m o rtality in E ngland an d W ales a n d to discuss h o w far th e
experienced reduction in this m ortality is ascribable to th e special w ork
u n d ertak en b y v o lu n tary agencies an d b y official authorities.
T h e g eneral course of m o rtality in th e first five years o f life during a
series of y ears is show n in th e follow ing figures: C om paring th e p erio d
191 1-15 w ith th e p erio d 1871-75, th e d e a th ra te in infants u n d er one
y ea r declined 39 p e r ce n t; in th e second y e a r o f life th e d e a th ra te d e ­
clined 41 p e r cen t; in th e th ird year, 50 p e r ce n t; in th e fourth year,
5 3 p e r cen t; an d in th e fifth year, 5 0 p e r cent.
N o consistent a n d continuous decline h a d tak en p lace in infant
m o rtality p rio r to 1900, although th ere h a d alre ad y b een m ark e d
reduction o f m o rtality in each of th e n ex t four y ears o f life. T his
difference co rresp o n d s in th e m ain w ith th e fact th a t g re ater success
h a d b een achieved in th e general m easures of sanitation a n d in th e
red uction of th e prevalence of a n d m o rtality from such infectious dis­
eases as scarlet fever, diphtheria, a n d enteric fever, th a n in respect of
th e special causes o f m ortality in infancy. T hese causes m ay b e placed
u n d e r th ree h ead in g s: First, infections— acu te resp irato ry diseases,
m easles, w hooping cough, syphilis, tuberculosis, a n d d iarrh ea; second,
errors of nutrition, d u e largely to poverty, to m ism anagem ent, a n d to
im perfect provision of facilities for health y fam ily life; a n d third, d e ­
velo pm en tal conditions p resen t a t th e b irth o f th e infant. U n d e r no n e
of these head in g s h a d m ark e d success b een achieved p rio r to 1900,
th ough th e stead y w ork d e v o te d to th e subject of d iarrh ea h a d already
begun to b e a r fruit.
T h e statistics of in fan t m ortality m ay b e stated as follow s:
Deaths o f Infants
Under 1 Year
Period
Per 1,000 Births
1 8 9 6 -1 9 0 0 ................................. ...................................
156
1 9 0 1 -1 9 0 5 ................................. . . ......................... ..
138
1 9 0 6 -1 9 1 0 .................................
1 9 1 1 ...........................................
1 9 1 2 ...........................................
1 9 1 3 ...........................................
1 9 1 4 ...........................................
1 9 1 5 ...........................................
1 9 1 6 ........ ..................................
1 9 1 7 ..........................................
1 9 1 8 ..........................................


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T h e foregoing are th e crude rates, w hen th e infantile d e a th ra te is
stated b y th e usual m eth o d p e r 1,000 birth s during th e sam e year.
O w ing to th e g re at decline o f birth s during th e w ar, this m eth o d over­
states th e in fan t m o rtality in recent years. In a tab le given in th e
R eg istrar G en eral’s annual re p o rt fo r 1917, this unusual source of
e rro r is co rrected. W hen this is done, a n d th e infantile d ea th s are
stated “p e r 1,000 t>f p o pulation aged 0-1,” th e ra te s fo r th e years
1912-17, inclusive, in successive y ears becom e respectively 104,
117, 113, 111, 98, an d 94. In o th er w ords, th ere has b een a stead y
a n d u n in terru p ted decline in th e d e a th ra te of infants during the
w ar.
T h is decline h as follow ed sim ilar declines in preceding years, an d it
is to b e n o ted th a t these declines occurred in p a r t during th e period
w hen th e hygienic w ork affecting child w elfare w as confined to general
public-health m easures, a n d th a t th e declines an ticip ated th e m o re
direct a n d active m easures a d o p te d b y v o lu n tary societies an d b y local
authorities for th e p rev en tio n of infant m ortality. C om paring th e fivey e a r p erio d s 18 9 6 -1 9 00 a n d 1901 -05, a decrease in th e infantile d ea th
ra te of 12 p e r cen t is seen; com paring 1901 -05 w ith 1906-10 a decline
of 15 p e r cent o ccu rred; com paring 1906-10 w ith th e average experi­
ence of th e th ree y ears 191 1-13 infantile m o rtality declined 5 p e r cent;
co m p arin g these th ree y ears w ith th e av erag e experience o f th e five
y ears 1914-18, d u rin g w hich w a r conditions prev ailed m o re o r less, a
red uction of 9 p e r cent w as experienced. T h e actual reduction during
w a r tim e is g re ater th an is indicated b y these percentages, w hen allow ­
ance is m a d e fo r th e statistical erro r indicated above. T h e experience
o f th e y e a r 1911 illustrates one of th e chief sources of e rro r in form ing
conclusions on th e experience o f a single year. In this y e a r th e sum ­
m e r w as excessively hot, a n d sum m er d iarrh ea p rev ailed to an ex­
ceptional extent. T h e illustration is im portant, as serving to rem ind
us o f th e lim itations of th e value of statistical tests an d of th e fact th a t
increase o f g o o d w o rk tending to im prove child life m ay b e associated
tem p o rarily w ith increase of to tal infant m ortality.
School Medical Inspection

In th e d ev elo p m en t of child-w elfare w ork in E ngland im p o rtan t
place m ust b e given to th e system o f m edical inspection of school chil­
d ren in itiated in 1907. T h e num erous physical defects found in school
children h av e led to th e beginning o f m easures fo r rem edial action,
confined in som e areas (in ad d itio n to advice given to consult p riv ate
d o cto rs o r to reso rt to hospitals) to m easures fo r securing g reater
cleanliness an d th e trea tm e n t of m in o r skin diseases; b u t extending
in o th er areas to such m easures as th e rem edial trea tm e n t of adenoids,

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th e cure o f ringw orm , th e correction of errors o f refraction* a n d th e
provision o f d en tal treatm ent. P erh a p s th e chief v alu e of th e system
of m edical inspection of school children h as b een th e fact th a t it has
d em o n strate d th e extent to w hich children, w hen they first com e to
school, are alre ad y suffering from physical disease which m ight have
b een p re v en ted o r m inim ized b y atten tio n in th e preschool period.
T h e inform ation thus accum ulated has h a d m uch influence in en­
couraging th e institution of infant consultations, w ith a view to the
early discovery o f disease o r o f ten d en cy to disease.
Statistical Studies

T h e intensive study o f o u r national a n d of local vital statistics has
also h a d a m ost im p o rtan t bearing o n th e fu rth e r dev elo p m en t of
m atern ity an d child-w elfare w ork. In successive official rep o rts it has
b een show n th a t infant m o rtality varies greatly in different p a rts of th e
country, irrespective of clim atic conditions; th a t it varies greatly in
d ifferent p a rts o f th e sam e tow n, in accordance w ith variations in
respect of industrial a n d housing conditions, of local sanitation, of
po v erty , a n d of alcoholism ; th a t th e v ariations ex ten d to different
p o rtio n s o f infant life, th e d ea th -rate in infants u n d e r a w eek, o r u n d er
a m o n th in age, for instance, being tw o o r th ree tim es as high in som e
areas as in o thers; an d th a t th e distribution of special diseases in infancy
sim ilarly varies greatly. Intensive studies o f in fan t m ortality on these
a n d o th er lines h av e p o in ted plainly th e direction in w hich preventive
w o rk is especially called for, a n d h av e incidentally d em o n strate d the
fu n d am en tal value o f accurate statistics o f b irth s an d of d eath s in the
child w elfare cam paign. S urveys of local conditions, b o th statistical
a n d b ased on actual local observations form an indispensable p re ­
lim inary to an d concom itant of g ood child-w elfare w ork, a n d it is such
w o rk w hich has re n d ere d possible th e im provem ent of recent years.
T o act helpfully w e m ust know thoroughly th e sum m ation of con­
d itio n s w hich form th e evil to b e attacked.
O n e im p o rtan t result of investigations such as those alre ad y m en­
tio n ed h as b een to b ring m o re clearly into relief th e fact— in th e p ast
p artially n eglected— th a t child-w elfare w ork can only succeed in so
fa r as d ie w elfare of th e m o th er is also m aintained. T his m ay im ply
extensions of w o rk m w hich serious econom ic considerations are in­
v o lv e d ; b u t a p a rt from such possibilities a n d a p a rt from questions of
housing, an d of provision o f ad d itio n al dom estic facilities fo r assisting
th e overw o rked m other, th ere is am ple evidence th a t m edical and
hygienic m easures b y them selves can d o m uch to relieve th e excessive
strain on th e m o th er which childbearing u n d er p resen t conditions
o ften involves.

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The Course of Mortality from Childbearing

T h e general course of m o rtality from childbearing (including deaths
ascribable to p reg n an cy ) in E ngland an d W ales is show n in th e follow ­
ing tab le:

5
5
3
2

A verage A nnual Death Rates Per 100,000
Births From
Puerperal
Other D iseases
Septic
of Pregnancy
Period
D iseases
and Childbirth
years, 1 9 0 2 -0 6 ..........................
185
228
years, 1907-1 1 ..........................
152
215
148
233
years, 1 9 1 2 -1 4 .......... . ............
years, 1 9 1 5 -1 6 ..........................
151
239

It will b e n o ted th a t although th ere has b een a m ark ed decline of
d ea th s from p u erp eral sepsis, th e d eath ra te from o th er com plications
of childbearing h as n o t declined. T h e decline in p uerperal sepsis is
general th ro u g h o u t th e country, an d evidences of g re ater care in m id ­
w ifery b o th on th e p a rt o f d o cto rs a n d of m idw ives. T h e adm inistra­
tion of th e M idw ives A ct, 1902, has doubtless d o n e m uch to secure
this. T h e d e a th ra te from conditions o th er th an p u erp eral fever con­
tinues to differ g reatly th roughout th e country. It is highest in W elsh
counties, W estm o relan d, Lancashire, an d C heshire com ing next in o rd e r
of u n fav o rab le p o rtio n ; in m any industrial, including textile, tow ns it
is also excessive. T h e general conclusion reach ed b y th e w riter in an
elab o rate official re p o rt on th e subject is th a t “ th e quality, a n d avail­
ability of skilled assistance before, during, a n d afte r childbirth are
p ro b a b ly th e m ost im p o rtan t factors in determ ining th e rem ark ab le
a n d serious differences in respect of m o rtality from childbearing show n
in th e rep o rt. T h e differences are caused in th e m ain b y differences in
availability of skilled assistance w hen n ee d ed in pregnancy, an d a t an d
afte r ch ild b irth ."
The Midwives Act, 1902

T his act fo rb ad e an y w om an a fte r A pril 1st, 1905, w ho w as n o t
certified u n d er th e act, from using th e title of m idw ife o r an y sim ilar
description of herself. It fo rb a d e afte r A pril 1st, 1910, an y such
w om an from “h ab itu ally an d fo r gain atten d in g w om en in childbirth,
except u n d e r th e direction of a qualified m edical p ra c titio n e r" ; a n d it
fo rb ad e any certified m idw ife to use an uncertified person as h e r sub­
stitute. T h e act defined th e lim its o f function of th e m idw ife b y
stating th a t it d id n o t confer u p o n h e r an y title to give certificates of
d e a th o r of stillbirth, o r to tak e charge o f an y abnorm ality o r disease
in connection w ith parturition.
T h e act set up th e C entral M idw ives B oard, giving it special discipli­
n ary p o w ers o v er m idw ives. It also im posed on county councils an d
th e councils of county boroughs th e d u ty of supervising th e w o rk of

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m idwives. F o r fu rth er details th e act itself an d th e rules of the
C entral M idw ives B oard m ad e u n d e r th e act should b e consulted.
T h e M idw ives A ct, 1918, gave fu rth er pow ers to th e C entral M id­
wives B o ard a n d to local supervising authorities, an d m ad e it th e d u ty
of th e la tte r to p ay th e fee of a d o c to r called in b y a m idw ife in any
o f th e em ergencies for w hich rules are m ad e b y th e C entral M idw ives
B oard. T h e fee p aid is to b e in accordance w ith a scale prescrib ed b y
th e Local G o v ern m en t B oard.
A s a t least three-fourths o f th e to tal b irth s in E ngland a n d W ales
are a tte n d e d b y m idw ives w ith o r w ithout th e assistance of doctors,
th eir w ork is o f g re at im portance in relation to th e reduction of m a ­
tern al d isab lem ent a n d m o rtality an d to th e prevention of early infant
m ortality, an d it is o f h a p p y au g u iy th a t th ey are being enlisted m ore
an d m o re in official w o rk fo r safeguarding th e h ealth o f th e m o th er
an d o f h e r u n b o rn o r recently delivered infant. A n im p o rtan t recent
a d d itio n has b een m a d e to th e rules of th e C entral M idw ives B oard,
w hich m akes it obligatory on th e m idw ife to notify th e m edical officer
o f h ea lth of an y instance, w hile th e p atien t is u n d e r h er charge, in w hich
for an y reason b reast feeding has b een discontinued.
L argely th rough th e m achinery p ro v id e d b y th e M idw ives A c t an d
th e N otification o f B irths A c t a system o f supervision o f m atern ity an d
child w elfare has b een organized in every county a n d county borough,
w hich h as b een responsible fo r a large share o f th e im provem ent ex­
p erien ced in recent years. T h e ch aracter a n d extent o f dev elo p m en t
of th e w ork varies greatly in different centres; an d as a rule th e w ork
is m o re fully d ev elo p ed in county boroughs th an in counties. In county
districts i t h as b een found possible a n d often desirable to unite th e
offices o f assistant inspector of m idw ives, in fan t visitor, a n d tuberculosis
visitor in on e ad e q u ately train e d health visitor, thus saving tim e in
travelling, b y enabling th e visitor to h av e a sm aller district allo tted to
h er th an if she u n d erto o k only o n e b ranch o f w ork. In som e counties
th e school nurse’s w ork is also u n d erta k en b y th e h ea lth visitor. In
som e co u n try areas arrangem ents h av e b een m ad e fo r in fan t visiting
to b e carried o ut b y district nurses w ho are also m idwives.
M uch of th e success so fa r achieved in im proving th e health con­
ditions of infancy an d childhood has b een secured b y cooperation
b etw een v o lu n tary a n d official health visitors. E xcellent w o rk has
been d o n e b y local an d o th e r societies, particularly during th e last ten
years, in educating public opinion a n d in d irect assistance to m others
an d th eir infants. It is essential th a t such v o lu n tary w ork should h av e a
nucleus of highly train e d an d w ell-paid w orkers; b u t given this Con­
dition, a larg e am o u n t o f g o o d w o rk can b e accom plished b y v o l­
u n tary aid.
T h e m ain w ork has b een th a t of health visiting. T h e details o f this

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w ork, th e conditions of qualification of w orkers, th e n u m ber of visits
w hich it is desirab le to m ake, a n d th e ch aracter of th e advice in ten d ed
to b e given a t these visits, are set out in an official m em orandum of the
M edical Officer of the Local G ov ern m en t B oard, a n d it is unnecessary
to re p e a t this inform ation in these pages.
A sim ilar rem ark applies to th e n ex t m ost im p o rtan t dev elo p m en t
of w ork, th e institution of m aternity an d child-w elfare centres. T h e
conditions of w ork of these institutions a re set o u t in th e sam e
docum ent.
T h e follow ing ad d itio n al facts are tak en from m y annual re p o rt to
th e L ocal G o v ern m ent B oard for 191 7-18 an d will serve to supplem ent
th e in form ation alre ad y given.
Up to the end of 1917, 542 centres for maternity and infant w elfare w ork had
been established by local authorities, and 551 by voluntary societies. A t the end
of June, 1918, the numbers w ere 700 and 578, respectively.
On June 1st, 1918, there w ere 751 w hole-tim e health visitors, 760 part-time
health visitors, and 1,044 district nurses, engaged by local authorities in maternal
and child w elfare work, in addition to 320 health visitors in the em ploym ent of
voluntary societies. T he district nurses em ployed as health visitors are almost
entirely engaged under county schem es. A n increasing number o f voluntary
societies suffer from deficiency of funds, and in many instances help has been
given to them by local authorities, either financial or in the form of staff. T he
Board repay half the approved expenditure for assistance granted in this way.
It is important that the same persons should act as health visitors and as in­
spectors under the Children A ct, 1908, and advice to this effect has been given
to boards of guardians and sanitary authorities.
'■
In many areas the work of inspection of midwives continues to be relatively
unsatisfactory. T his is the m ore regrettable as in som e of the m ost populous
counties and urban districts half or more than half of the midwives are bona
fide practitioners, having been placed on the roll because they w ere practising
before 1901. T he best inspector of midwives is a m edical practitioner, but under
present circum stances this is seldom practicable. T he appointm ent of the super­
intendent of the county nursing association to act under the control of the county
medical officer has proved satisfactory w hen she is qualified and experienced.
This arrangem ent is econom ical of traveling expenses and time, as she can also
supervise district nurse midwives, the number of w hich, w ho are also acting as
health visitors, is 1,044 at present.
"
V ery satisfactory progress has been made during the year in the provision of
midwives in districts in w hich there w ere none or the number w as insufficient.
T he urgency of this provision has increased, ow ing to the demands on the time
of m edical practitioners, m any o f whom cannot afford time to attend normal
confinements. T his provision has usually been made by county councils working
through the medium of county nursing associations.
T he provision o f additional trained midwives is a pressing problem. The
increased cost of living, longer training required, and the rapid developm ent of
less laborious and more lucrative occupations, have made it difficult to secure
wom en to train as midwives, or to continue to practise in this capacity after
qualification. In many industrial areas the older bona fide midwife is preferred,
although it is the alm ost universal experience that the trained midwife more
quickly detects conditions endangering the life of the mother or infant, and sends

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for medical help. In order to encourage further the supply of practising mid­
w ives, the Board are allow ing to rank for grant increased remuneration given to
midwives new ly appointed by local authorities, sufficient to recoup them in the
course of a few years’ service for the post of their training. T he Board have
also allowed the cost of providing outfits for midwives subsidized by local au­
thorities to rank for grant.
It remains the fact that at a recent date, of some 3 0 ,543 trained midwives on
the Roll, only 6,754 w ere returned as being in actual practise as such.
In order to make midwives available for all wom en needing them, the Board
repay to local authorities and voluntary associations half the cost of the pro­
vision of a midwife for necessitous w om en. In various forms a woman may
receive considerable assistance in her confinement; for in addition to the above__
( 1 ) If she is the w ife of an insured person, or if she herself is insured, she
received under the conditions of the National (H ealth) Insurance A ct 30s.
in cash, or if she is insured and the w ife of an insured person, 60s. in cash.
( 2 ) If she is the w ife of a soldier or sailor and not entitled to maternity
benefit she receives from 1Os. per w eek up to £2 from the Local Pensions
Committee.
( 3 ) If she is a munition w orker she may be aided under a schem e pro­
vided under the Ministry of Munitions.
(4 ) She also may obtain priority for the supply of milk, or obtain free
milk, or milk at cost price under the Board’s Food Control Order, No. I,
1918, em pow ering local authorities to supply milk and food and an extra
ration under the Food Controller’s Order. In addition, after confinement
she has available the ration apportioned to the infant and its allowance of
milk under the priority schem e.
There is evidently need for simplification and unification of effort in the above
cases.
In many instances maternity nursing is reqyired. T he midwife may have too
many patients to be able to give this during the ten days in w hich she is in charge
of the patient; and even when she carries out her duty in this respect in accord­
ance with the rules of the Central Midwives Board, additional help is required
in the feeding and care of the mother and infant and in the care of the household.
Often nursing is also required for both m other and infant for a considerable
period beyond the ten days. For these reasons the Board are now prepared to
give grants for maternity nursing and for “home helps.’*
Even when all the above requirem ents are or can be fulfilled, there remain a
br?® number of cases of pregnant and parturient w om en, and especially of unmarried w om en, w ho cannot be satisfactorily confined at home, either b ecau se.of
social or sanitary circum stances, or because abnormal or com plicated childbirth
is expected. For such cases hospital provision is needed. This is one of the most
urgent requirem ents of the present time. Most local authorities have not yet
appreciated the great need for institutional provision for com plicated midwifery
and for a certain number of normal cases, though som e are already taking steps
to m eet it. Other local authorities have been deterred by the doubtful position
of the law as to their pow ers to provide institutions for normal midwifery. This
doubt is now removed.
Present provision, as I pointed out in m y last annual report, is m uch more
adequate in the metropolis than in the rest of the country; and I connected with
this fact the exceptionally low mortality in childbearing in London due to causes
other than puerperal sepsis.


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Under present conditions, institutional lying-in provision is chiefly voluntary
in character; and the Board are advising local authorities to contract for its
use, rather than wait for the erection of special hospitals. In other instances
houses are being taken and adapted as maternity homes.
For som e years hospital provision for com plicated m idwifery has been made
by the local sanitary authority in Birmingham, St. Helens, and Bradford; and
at the present tim'e similar provision is being arranged at Batley, Bournemouth,
Burnley, Blackpool, Croydon, Dudley, Hull, Leeds, Nottingham, Rochdale, Sm eth­
wick, Southend-on-Sea, Stockton-on-Tees, Swindon, York, and other towns. In
nearly all these instances it is proposed to utilize existing hospitals or to convert
existing premises into hospitals. .
Official assistance for the provision of medical assistance has been greatly
developed during 1917, many county councils and county and m etropolitan
boroughs having made arrangements for this purpose. The Board have expressed
their w illingness to approve a scale of fees recomm ended by the British Medical
A ssociation in 1915. It is hoped that ere long the paym ent of such fees to
medical practitioners called in by midwives will be made obligatory on local
authorities.
T he progress made in the organization of antenatal work is slow for reasons
w hich are fairly obvious. There is difficulty in securing assistance from doctors
and midwives, and medical practitioners have no time for the work at the centres.
There is the well-known difficulty as to notification of pregnancy, w hich the
Board have not encouraged, except when the definite consent of the mother has
been previously obtained. The facilities for help provided at the centre have
in som e areas succeeded in attracting patients; and health visitors and midwives
have done much in other areas to persuade m others of the advisability o f safe­
guarding them selves against possible complications, as w ell as o f securing ade­
quate preparation for the lying-in period.
This subject is closely associated with that o f abortions, stillbirths, and deaths
in the first two w eeks after birth. One of the m ost prom ising methods for
securing the sound developm ent of antenatal work consists in the investigation
of stillbirths and early infant mortality. A t these inquiries mothers can be
induced to obtain medical advice not only at the time, but also in the event o f a
subsequent pregnancy. The investigation at the patient’s home of all such
cases and assistance in prevention of recurrence of unnecessary antenatal, natal,
and early postnatal deaths have as great an im portance as the building up o f a
successful antenatal clinic. The anti-syphilis work now being carried on will
help greatly in this direction.
There has been a large extension of dental assistance at centres, for expectant
and for nursing m others, and for children, especially in the metropolis and
its vicinity. T he Board has lately extended its grant to cover dentures for
mothers who are nursing or pregnant, if the medical officer of the centre is
satisfied that the wom an’s health will be materially improved by the denture,
and that she is unable to provide it for herself. ’
T he increased calling up of doctors for the Arm y and Navy has caused in­
creasing difficulty in obtaining medical advice at maternity and infant w elfare
centres, and without this the utility and popularity of the centre must necessarily
suffer. T he assistance of judicious voluntary workers, the promotion of social
clubs, the developm ent of self-constituted and self-regulated clubs or guilds,
with a social propaganda for the im provement of them selves ar^l their fellow
workers, friends, and neighbors, in som e instances are having marked effect.
It is notew orthy that at many centres the poorest wom en and those for whom

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O F C H IL D

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help is most needed are those least often in attendánce, and these wom en are also
the most skilled in avoiding visits of health visitors. T he formation of guilds
and institutes w ill do m uch to increase the scope of present work.
Creches and day nurseries m ay be expected to exercise influence in educating
m others in the care of their children. For this purpose it is very desirable to
have the creche attached to or near an infant w elfare centre. T he Locar Gov­
ernment Board, as w ell as the Ministry o f Munitions, are em powered to assist
creches by grants.
T hese creches, unless managed w ith the most rigid standard o f m edical and
general cleanliness, are very apt to spread infectious diseases; not m erely such
diseases as w hooping cough, measles, and chicken pox, but also catarrhal and
diarrheal diseases. In the prevention of all o f these the enforcem ent of the
strictest cleanliness is essential, especially during the summer months for the
last named diseases. For the prevention of catarrhal infections, it is essential
that the creche should be conducted, so far as practicable, on strict open-air
lines. Open-air creches give admirable occasional relief to m others, even when
these do not go out to w ork. T he “toddler’s playground’’ is a blessing to all
concerned, but the indoor creche m ay be, and often is, mischievous. T he risks
are greatly reduced by insisting on open-air conditions and by not allow ing
large groups of children to com e together. Smaller groups m ean greatly de­
creased possibility of cross-infection.
A t infant w elfare centres infants are not infrequently seen who fail to make
progress w hile living at home, and who yet are not ill enough to be sent to a
hospital. This especially applies to cases of defective nutrition. For these cases
beds in connection with centres have been found to be necessary for observation
purposes and to initiate further treatment. In som e instances, especially for
failure of breast feeding, it is advisable to admit the m other w ith the infant.
During the year, representatives of the chief children’s hospitals in London, of
general hospitals having children’s departments, and of infant w elfare centres,
conferred with the officers of the Board, and it was generally agreed that there
was need for further accom m odation in hospital beds as indicated above. . There
is no doubt that after the war such accom m odation will be provided to a greater
extent in the larger hospitals; m eanwhile, both in London and the provinces,
8üch beds are now being provided alm ost entirely at voluntary centres. The
Board have drawn up the follow ing rules for the guidance of those providing
such beds:
1. A cute cases of illness, such as w ould ordinarily be admitted to existing
hospitals, and cases of infectious disease should not be treated in cots at
a centre. T he centre should, if practicable, be associated with a general
hospital or a children’s hospital, w ith a view to prompt admission of acute
or serious cases of illness.
2. T he experim ent of providing cots at centres should be on a small
scale, w ith not m ore than two wards with four cots in each, and the fittings
and furniture should be as simple and inexpensive as possible.
3. A w hole-tim e nurse shpuld be in charge by day and one by night,
and the nursing staff should, as a rule, be distinct from the staff engaged in
the ordinary work of the centre.
4. If a medical officer is not resident on the premises, there should be
arrangem ents for securing his prompt attendance w hen required. The
Board w ould w elcom e arrangements of the treatment of m others, with their
infants, when breast feeding fails.'


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Nursing
A n increasing number of local authorities are now providing or arranging
to provide nurses at the patient s home for cases o f m easles, w hooping cough,
ophthalmia neonatorum, and acute diarrhea in children under five years of age;
also for wom en after confinement, and for cases of puerperal fever, especially
w here hospital accom m odation is unavailable.
New Work
T he Board have recently been authorized to assist by grants new work comprised
under the follow ing headings:
Hospital treatment for children up to five years of age;
Lying-in homes;
Hom e helps;
Creches and day nurseries.
A lso,
For the provision of food for expectant and nursing m others and for
children under five years of age;
For convalescent homes for nursing m others and for children under five
years of age;
For homes for children o f widowed and deserted m others and for illegiti­
mate children; and
For experim ental work for the health o f expectant and nursing mothers
and for children under' five years of age.
Government A id for Child W elfare W ork

A beginning in g ra n ts fo r child w elfare w ork w as m ad e b y th e
B o ard of E ducation fo r th e establishm ent of schools fo r m others a n d
sim ilar institutions in which collective instruction to m others w as given
an d som e d eg ree of regularity of atten d a n ce o f th e m o th ers w as
secured.
O n Ju ly 30th, 1914, th e Local G overnm ent B oard sent a circular
letter a n d covering m em orandum b y th eir M edical Officer w hich m ay
b e claim ed to h av e initiated m atern ity a n d child w elfare w o rk on a
larg er scale, m o re g enerally d istributed th ro u g h o u t th e country, a n d
m o re co m pletely covering th e w hole sphere of m edical an d hygienic
w ork fo r this p u rp o se th an h a d previously b een envisaged. A lthough
th e co u n try a t th a t tim e m ight b e said to b e alre ad y u n d e r th e shadow
of w ar, these d o cum ents h a d b een previously p re p are d , an d their
ap p earan ce fo u r d ay s b efo re th e declaration o f w ar w as a coincidence.
T h e chief b u rd e n o f th e ad d itio n al w o rk to w hich local authorities
w ere u rg ed w as th a t th ere should b e continuity in dealing w ith th e
w hole p erio d from b efo re b irth until th e tim e w hen th e child is entered
u p o n a school register; a n d th e m em orandum co n tem p lated th a t
m edical ad vice an d , w here necessary, trea tm e n t should b e continu­
ously an d system atically available for ex p ectan t m o th ers a n d for
children till th ey are en tered on a school register, an d th a t arran g e­
m ents should b e m ad e fo r hom e visitation th ro u g h o u t this p e rio d .”

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It w as a d d e d th a t * th e w ork of hom e visitation is one to which th e
B o ard attach v ery g re at im portance a n d in prom oting schem es laid
dow n in th e accom panying m em orandum th e first step should b e the
ap p o in tm en t o f an ad eq u ate staff of h ea lth visitors.”
T h e m em orandum w as as follow s:
Maternity and Child Welfare
A com plete schem e w ould comprise the follow ing elem ents, each of which
will, in this connection, be organized in its direct bearing on infantile health.
>•

Arrangem ents for the local supervision of midwives.
A rrangem ents for:
(1 )
(2 )
(3 )
cases of

A n antenatal clinic for expectant mothers.
The home visiting of expectant mothers.
A maternity hospital or beds at a hospital, in w hich complicated
pregnancy can receive treatment.

Arrangem ents for:
( 1 ) Such assistance as m ay be needed to ensure the mother having
skilled and prompt attendance during confinement at home.
( 2 ) The confinement of sick women, including wom en having contracted
pelvis or suffering from any other condition involving danger to the mother
or infant, at a hospital.
Arrangem ents for:
( 1) The treatm ent in a hospital of com plications arising after parturi­
tion, w hether in the mother or in the infant.
(2 )
The provision of system atic advice and treatm ent for infants at a
baby clinic or infant dispensary.
( 3 ) T he continuance of these clinics and dispensaries, so as to be avail­
able for children up to the age when they are entered on a school register,
i. e., the register of a public elem entary school, nursery school, creche, day
nursery, school for mothers, or other school.
( 4 ) T he system atic home visitation of infants and of children not on a
school register as above defined.

G ran ts w ere prom ised to local authorities o r to v o lu n tary agencies
fo r w o rk d o n e u n d e r th e schem e set out am ounting to one-half of th e
to tal ap p ro v ed expenditure. A b o u t the sam e tim e a circular w as sent
o u t b y th e B oard of E ducation prom ising sim ilar g ran ts for schools for
m others. T h e g ran ts to v o lu n tary agencies w ere m ad e conditional
on the w ork being co o rd in ated so far as practicable w ith th e public
h ealth w o rk o f th e local sanitary au th o rity a n d th e school m edical
service of th e local education authority.
T h e increased w ork since th a t d a te m ay b e g a th ered from th e fol­
low ing table, w hich show s th e increase each y ea r in th e g ran ts given
on th e 50 p e r cent basis b y th e Local G o v ern m en t B o ard a n d th e
B o ard of E ducation.

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AMOUNT OF GRANTS IN EACH FINANCIAL YEAR TO LOCAL AUTHORI­
TIES A ND VOLUNTARY AGENCIES, ON THE BASIS OF 50 PER
CENT OF TOTAL APPROVED LOCAL EXPENDITURE
Grants of
Local Government
Board
Financial Year
(Pounds Sterling)
1 9 1 4 - 15 ............................................ .
1 1,488
191516
....................
4 1 ,4 6 6
67,961
1 9 1 6 - 17 ...............................................
191718
..................
122,285
191 8 19
(e s tim a te d )...... 2 0 9 ,0 0 0

Grants of
Board of
Education
(Pounds Sterling)
10,830
15,334
‘ 19,023
24, 110
4 4 ,0 0 0

T h ese g ran ts d o n o t co v er th e entire scope of child-w elfare w ork
carried o u t th ro u g h o u t th e country, a n d th eir am o u n t m ust n o t b e
tak en as a com plete indication of th e extent of this w ork.
T h e increase d uring th e w ar p erio d has b een very great, a n d this can
b e attrib u te d to th e desire to d o everything practicab le for m others an d
children, especially fo r those belonging to soldiers an d sailors w ho
w ere risking their lives for th e country; an d to the increased realization
o f th e im p o rtan ce of preserving an d im proving our chief national
asset, w hich consists in a h ealthy population. D uring this p erio d th ere
w as a g re at increase in th e industrial em ploym ent of w om en, including
m arried w om en, in factories, including m unitions a n d o th er works.
T his increase it is b elieved am o u n ted to a m illion an d a h alf w orkers.
he M inistry o f M unitions to o k an active p a rt in arranging for w elfare
w ork in th e establishm ents fo r w hich it w as responsible; an d this w ork
included, in som e instances, special care for p re g n an t w om en an d fo r
nursing m others.
N o tw ithstanding th e m an y ad v erse influences, to w hich m ust b e
a d d e d g re at overcrow ding in m any industrial areas, especially those
in w hich new industries w ere h urriedly started, an d th e increasing cost
o f fo o d an d especially of m ilk w ith a scarcity of supply, it has b een
seen th a t in fan t m o rtality rem ained low a n d on th e w hole declined
durin g th e entire p erio d o f th e w ar.
T o w h at circum stances can this b e ascribed?
It is unnecessary to assum e th a t this result w as entirely d u e to th e
active m easures fav o rab le to m atern ity an d child w elfare w hich w ere
taken, on an unex am p led scale, though these m easures can claim an
im p o rtan t share in th e result.
A n u m b er of co n trib u to ry factors w ere a t w o rk :
(1 )
In n o n e of the years in question d id th e sum m er w eather
fa v o r an excess of d iarrh eal m ortality. W hen this factor, how ­
ever, is elim inated th e infant m ortality w as low er each y e a r th an
in previous years.
(2 )
A lth o u g h so m any hu sb an d s w ere aw ay from hom e, in a
larg e p ro p o rtio n o f cases th e wife, in. virtue of h e r separation

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allow ance, w as financially in a m o re favorable position them w hen
she w as d e p e n d e n t on h e r h u sb an d ’s w age o r such p o rtio n o f it as
h e allow ed h e r for th e su p p o rt of th e household.
(3 )
In addition, every soldier becam e an insured person,
a n d his wife w as th erefo re entitled to th e m atern ity benefit of
30 shillings on th e b irth of a child, an d an ad d itio n al 30 shillings if
she w as herself an em ployed person.
(4 )
T h ere can b e no reasonable d o u b t th a t th e restrictions
on th e consum ption of alcoholic drinks a n d th e lim itations of
h o u rs for opening public houses constituted a factor in im proving
dom estic welfare.
But, attaching full value to these an d o th er sim ilar factors which
u n d o u b ted ly w ere a t w ork, chief place m ust, 1 think, b e given to
th e aw akening of th e public conscience on th e subject, an d to the con­
cen tratio n on th e m o th er an d h er child w hich h a d b een urg ed in
season an d o ut of season, an d w hich now becam e a fact. A n indica­
tion o f th e public m ind is given b y th e advice issued b y th e Local
G o v ern m en t B oard in A ugust, 1918, which is q u oted on p ag e 274.
T h e special m easures carried o u t during th e w a r fo r w hich th e grants
are p ay ab le to local authorities o r local v o lu n tary agencies to th e ex­
te n t of h alf th e to tal a p p ro v ed expenditure are en u m erated in th e fol­
lowing ex tract from th e regulations issued b y th e Local G overnm ent
B oard in A ugust, 1918.
Regulations under w hich grants not exceeding one-half of approved net ex­
penditure will be payable by the Local Government Board to local authorities and
to voluntary agencies in respect of arrangem ents for attending to the health of
expectant m others and nursing mothers and of children under five years o f age.
I. .T he Local Government Board will pay grants during each financial year,
com m encing on A pril 1st, in respect to the follow ing services:
( 1 ) T he salaries and expenses of inspectors of midwives.
(2 )
T he salaries and expenses of health visitors and nurses engaged in
maternity and child w elfare work.
(3 )
T he provision of a midwife for necessitous w om en in confinement
and for areas w hich are insuificienctly supplied with this service.
(4 )
The provision, for necessitous w om en, of a doctor for illness con­
nected with pregnancy and for aid during the period o f confinem ent for
mother and child.
(5 )
The expenses of a centre, i. e., an institution providing any or all
of the follow ing activities: M edical supervision and advice for expectant
and nursing m others, and for children under five years of age, and medical
treatment at the centre for cases needing it.
( 6 ) Arrangem ents for instruction in the general h ygiene of maternity
and childhood.
( 7 ) Hospital treatment .provided or contracted for by local author­
ities for complicdtcd cases o f confinement or com plications arising after
parturition, or for cases in w hich a woman to be confined suffers from illness

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o r deform ity, o r fo r cases of w om en w ho, in th e opin io n of th e m edical officer
of h ealth, ca n n o t w ith safety be confined in th e ir hom es, o r su ch o th e r
provision fo r secu rin g p ro p e r conditions fo r th e confinem ent of necessitous
w om en as m ay be ap p ro v e d b y th e m edical officer of h ealth .
(8 )
H ospital tre a tm e n t pro v id ed o r c o n tra c te d fo r by lo cal a u th o ritie s
fo r children u n d e r five y e ars of a g e fo u n d to n e e d in -p a tie n t tre a tm e n t.
(9 )
T h e cost of food p ro v id ed fo r e x p e c ta n t m o th ers a n d n u rsin g
m o th ers an d fo r ch ild ren u n d e r five y e a rs of ag e, w h e re su ch p rovision is
certified by th e m edical officer of th e c e n tre o r b y th e m edical officer of
h e a lth to be n ecessary a n d w h ere th e case is necessitous.
(1 0 )
E xpenses of crech es a n d d ay n u rse rie s a n d of o th e r a rra n g e m e n ts
for a tten d in g to th e h e a lth of ch ild ren u n d e r five y e a rs of a g e w hose m o th ers
go o u t to w ork.
(1 1 ) T h e provision of accom m odation in convalescent hom es fo r n u rsin g
m o th ers a n d fo r ch ild ren u n d e r five y e a rs of ag e.
(1 2 ) T h e provision of hom es a n d o th e r a rra n g e m e n ts fo r a tte n d in g to
th e h ealth of child ren of w idow ed, d eserted, a n d u n m a rrie d m o th ers, u n d er
five y ears of age.
(1 3 )
E x p erim en tal w o rk fo r th e h e a lth of e x p e c ta n t a n d n u rsin g
m o th ers an d of in fan ts a n d ch ild ren u n d e r five y ea rs of a g e c a rrie d o u t
b y local a u th o ritie s o r v o lu n ta ry ag en cies w ith th e ap p ro v a l of th e Board.
( ] 4 ) C o n trib u tio n s by th e local a u th o rity to v o lu n ta ry institu tio n s
a n d agencies a p p ro v e d u n d e r th e schem e.
2. G ran ts will be p aid to v o lu n ta ry agen cies aid ed b y th e B oard on conditio n :
( 1) T h a t th e w o rk of th e ag en cy is a p p ro v e d b y th e B oard a n d c o o r­
d inated as far as p ra c tic a b le w ith th e pu b lic h e a lth w o rk of th e local
a u th o rity an d th e school m edical service of th e local ed u catio n a u th o rity .
(2 )
T h a t th e p rem ises a n d w o rk of th e in stitu tio n a re su b je c t to in­
spection by a n y of th e B oard’s officers of inspection.
(3 )
T h a t reco rd s of th e w o rk done by th e a g e n c y a re k e p t to th e
satisfaction of th e B oard.
3. A n ap p licatio n fo r a g ra n t m u st be m ade on a form supplied b y th e ^Board.
4. T h e B oard m ay ex clude a n y item s of ex p en d itu re w hich in th e ir opin io n
should b e d educted fo r th e p u rp o se of assessing th e g ra n t, a n d if a n y question
arises as to th e in te rp re ta tio n of th ese reg u latio n s th e decision of th e B oard
shall be final.
5. T h e g ra n t p aid in each financial y e a r will b e assessed on th e basis
of th e ex p en d itu re in c u rre d o n th e service re fe rre d to in A rtic le I in th e p re ­
ceding financial y ear, a n d will be, as a ru le, a t th e ra te of o ne-half of th a t ex­
p en d itu re w h ere th e services have b een p ro v id ed w ith th e B o a rd s a p p ro v a l a n d
a re ca rrie d on to th e ir satisfaction. T h e B oard m ay, a t th e ir discretion, reduce
o r w ithhold th e g ran t.

T h ese regulations w iden th e provisions m ad e for th e giving of grants
for m atern ity a n d child-w elfare w ork w hich h av e been in operation
since July, 1914, th e chief ad d itio n al services for w hich th e g ran t was
m ad e av ailable being:
H ospital trea tm e n t for children up to five y ears of age.
Lying-in hom es.
H o m e helps.

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T h e provision of food fo r expectant an d nursing m o th ers a n d
fo r children u n d er five years of age.
C reches an d d a y nurseries.
C onvalescent hom es.
H om es fo r children of w idow ed an d d eserted m others an d for
illegitim ate children.
E xperim ental w ork fo r th e health of ex p ectan t an d nursing
m o thers a n d of infants an d children u n d e r five years of age.
T h e circular published b y th e Local G o v ern m en t B oard on A ugust
9th, 1918 (M . & C. W . 4 ) , should b e consulted for fuller details.
T h e B o ard of E ducation has during th e w ar encouraged th e further
teaching o f m o th erc raft to girls o v er tw elve years of age in elem entary
schools, as well as th e establishm ent of d a y nurseries o r creches for
w hich g ran ts w ere p ay a b le as for institutions subsidized b y th e Local
G o v ern m en t B oard.
T h e provision of m ilk fo r infants an d young children becam e m ore
difficult during th e w ar, an d a prio rity schem e w as eventually p u t
fo rw ard w hich g av e priority to ex p ectan t an d nursing m others a n d to
children u n d e r five. T h e o rd e r m ad e in F ebruary, 1918, u n d e r th e
D efence of th e R ealm A ct, en ab led an y local au th o rity to arran g e for
th e supply o f fo o d an d m ilk for expectant m others a n d nursing m others
a n d of m ilk fo r children u n d e r five y ears of age, a n d required them
to p ro v id e such a su pply w hen instructed to d o so b y the Local G o v ­
ern m en t B oard. In necessitous cases on th e certificate of a m edical
officer th e provision o f food o r m ilk free o r below cost p rice w as
authorized. T h e se provisions w ere utilized to a considerable extent;
b u t th ere w as no evidence of w idespread suffering o f infants o r o f
th eir m o th ers th rough lack of m ilk o r o th er food. In a large n u m ber
of instances d ried m ilk w as utilized to supplem ent local deficiencies
of supply, a n d th e M inistry of Ffc>od m a d e itself responsible for the
distribution o f a large qu an tity o f full cream d ried m ilk. A consid­
erable n u m b er of authorities supplied free dinners fo r ex p ectan t an d
nursing m o th ers; b u t as th e w a r progressed th e ad d itio n al earnings
o f th e m ain m ass of th e p o pulation dim inished th e n eed for these. T h e
n eed w as still fu rth e r dim inished b y th e separation allow ances fo r
each soldier’s o r sailor’s wife. T hus a wife w ith fo u r children drew
in O ctober, 1914, 22 shillings a w eek; in M arch, 1915, this w as raised
to 25 shillings; in Jan uary, 191 7, to 31 shillings, a n d in O ctober, 1918,
to 35 shillings a week.


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B ELG IA N O R G A N IZ A T IO N
By DR. RENE SAND
U niversity of Brussels, Belgium

Y ou m ay b e a little puzzled to see a m edical m an w ho a few m onths
ag o w as a t a h ospital in th e front, stan d b efo re you a n d a tte m p t to speak
u p o n child w elfare, b u t it is p erh ap s n o t as p reposterous as it seem s a t
first sight.
It is quite tru e th a t I w as in a big hospital a t th e Belgian fro n t a few
Tnnnn
,b u t ^ ? r th f h ° Spital w as a L i l i a n population o f ab o u t
10,000 people. T h e m ilitary authorities h a d w an ted them to go b e ­
cause w e w ere only eight m iles from th e G erm an trenches, b u t th ey retu sed to go. T h e civilian authorities h a d also w an ted them to go, a n d
p ro b a b ly th e G erm ans w an ted them to go also— a t least th ey bom a rd e d them , w hich w as equal to m anifesting their desire— b u t th e p eo ­
p le d id n o t w an t to go. A n d so as th ere w ere m o th ers am ong them ,
a n d as b ab ies w ere b orn, th e m ilitary hospital started a m aternity a n d
babies clinic. W e considered it quite an unusual thing to do, b u t w ar
n as d o n e aw ay w ith m any prejudices.
\Y/lWeII,i tKo n; k KaS been ?h ° Wn w h at a goo d teac h er is adversity.
W hen th e B elgian governm ent h a d to leave the country th e n eed fo r
som e unofficial organization w as felt. So a few business m en an d p o ­
litical m en o f high standing cam e to g eth er a n d form ed a national
com m ittee. ■ T his com m ittee h a d no judges, no police, a n d no arm y to
enforce its decisions. N evertheless th ey w ere obeyed as the decisions of
an y reg u lar g o v ern m ent h a d n ev er been. T his com m ittee h a d to
care fo r every n eed w hich could b e helped, an d h a d of course a t first
to d istrib u te the fo o d a n d supplies w hich you so generously sent to
us; B ut it started a benefit relief organization, a n d in doing so it d e ­
velo p ed a p lan of w hich every g o v ernm ent could h av e b een p ro u d .

It included many things.

F irst o f all th ere w ere so m any unem ployed in Belgium. A lm ost
everyone was u n em ployed because to h av e w orked w ould h av e b een to
w ork fo r the G erm ans. So th e national com m ittee decid ed th a t courses
w ould b e o p en n o t o nly fo r general education b u t also fo r vocational
training o f ail unem ployed, b u t th a t th ey could n o t enforce because
th e G erm an s flatly o pp o sed it. T h e G erm ans d id n o t w an t us to
em erge from th e w ar m ore o r less p rep ared .
So th ey started an o th er scheme, a m edical scheme. O f course a
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STANDARDS O F C H IL D W E L F A R E

g reat m ajo rity of th e po p u latio n w as m ore or less ruined it is now
alm ost co m pletely; a n d th ey could no m o re p ay for their d o cto rs o r for
th eir m edicines. So th e national com m ittee d ecid ed th a t every citizen
w ith a lim ited incom e w ould b e entitled to free m edical service. S pe­
cialists a n d m aternity a n d hospital care w ere p ro v id ed in th e sam e way,
an d fo r th e first tim e a national m edical service w as instituted. E very­
on e h a d a right to choose his ow n doctor, a n d th e d o cto r w as p aid a t
th e p e r cap ita ra te b y th e national com m ission.
T h e n ational com m ittee started also a w ar-orphan schem e a n d a
crip pled-soldier schem e, an d finally a child-w elfare scheme.
W e h a d b efo re th e w ar a child-w elfare league in Belgium. It w as
u n d e r th e presidency of our Q ueen w hom you are alw ays sure to find
w h erev er th ere is a n eed to p lacate o r a sufferer to help. B ut th e activity
o f th a t league w as like a d ro p in th e cup of infantile m ortality. Now,
w ar b reak s out. T h e future of th e race is im perilled. T h e necessity
of caring for th e children becom es evident, a n d th ere springs u p a
child-w elfare organization w hich alm ost a t once reaches th e tiniest
villages in th e country. B efore th e w ar w e h a d only 60 babies clinics
in Belgium. T h e re are now m o re th an 700, an d they h av e d istribute
o v er one billion gallons of m ilk— m ostly y o u r milk.
In 1914 tw o cities only h a d dinners for m others; th ere are n o w 600
m unicipalities w hich h av e follow ed this exam ple. T h e result cam e
v ery quickly. Infantile m ortality, instead of increasing, decreased
in Belgium during th e w ar.
: ;3
.,
W e h av e n o t b ee n an d w e could n o t b e as h a p p y in o u r results w ith
th e o ld er children. V e ry precise figures h av e b een com m unicated to
th e Belgian A cad em y of M edicine, a n d th ey show th a t th e average
Belgian child is, on account of th e w ar, one full y e a r b eh in d his norm al
d ev elopm ent. T h e average Brussels schoolboy has lost th ree p o u n d s
in four years, a n d th e averag e Brussels school girl seven pounds, a n d
this applies to alm ost all classes of th e population. '
^
H ow ever, m an y m eans w ere em ployed in o rd e r th a t this evil should
n o t b e g reater. E very d a y tw o ounces of special b re a d m a d e w ith
th e b e st av ailable w heat w as d istributed to every school child, an d
this b re a d which w as b a k e d in individual lum ps w as such a tre a t com ­
p a re d to w ar b re a d th a t it becam e v ery soon know n as school cakes.
O n e m illion tw o h u n d re d th o u san d of such cakes w ere d istributed daily
in th e w hole of Belgium, to g eth er w ith cocoa o r m ilk. T h o se lunches
h a d to b e tak en in th e schools u n d e r th e supervision of th e teachers,
because experience show ed th a t m any children w ere so self-sacrificing
th a t th ey to o k th e cakes h o m e in o rd e r to share them w ith o ld er
b ro th ers an d sisters w ho w ere n o t entitled to receive them . Special
d inners w ere p ro v id ed for anem ic children, a n d d a y cam ps an d colonies
were started for them. The children remained there for three weeks,


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a n d u n d e r th e influence of fresh air an d g o o d d iet th ey generally gained
fo u r p o u n d s an d som etim es as m uch as ten o r tw elve p o u n d s in th a t
v ery sh o rt time.
Besides this official w ork, girls a n d w om en organized through th e
w hole o f Belgium dinners a n d luncheons for th e children betw een the
ages of 3 an d 18. T hose girls an d m o th ers w ere quickly know n u n d er
th e charm ing nam e o f “L ittle Bees.”
Now, all th ose activities, w hich are really d u e to th e w ar, will b e
m aintained a n d dev eloped. A bill has b een passed through th e B elgian
P arliam en t in o rd e r to create a national children’s bureau, which will
tak e care o f th e w hole w ork of child w elfare in Belgium. It will b e
a semi-official organization. It will w ork u n d er th e p a tro n a g e an d su­
pervision of th e S tate, b u t it will b e free from to o m uch red ta p e an d
from political intervention. It will h av e to see to it th a t in every city,
in every village, th e re will b e organized a t least one babies* clinic u n d e r
th e care of a local com m ittee, to which will also b e en tru sted th e care
of th e b abies an d of th e children b o a rd e d out b y th eir p aren ts an d
guardians. Besides this com pulsory w ork th e national children’s b u ­
reau will h av e also to p ro v id e fo r every kind of v o lu n teer w ork.
T h is organization ca n n o t stan d quite alone. W e ca n n o t in the
hygiene, o r in an y social w ork, m aintain a policy o f enclosed fields.
C hild w elfare has to go h an d in h an d w ith m others’ w elfare an d
fath ers’ w elfare an d ev ery b o d y ’s w elfare. T his w e m ust y et p lan an d
d ev elo p . W e h av e y e t n o p ro g ram fo r th a t w ork, b u t w e h av e a
slogan, an d the slogan has been given to us this aftern o o n b y Miss
L ath ro p . S he said “cooperation a n d education.” It sounds quite
A m erican, d o es it n o t? It is given u n d e r y o u r guidance, a n d I feel
certain it will lead us to success.


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A P H Y S IC A L C LA SSIFIC A T IO N O F C H IL D R E N
s.
By PR O FESSO R FABIO FR A SSETTO , D. S M M. D.
D irector, A n th ro p o lo g ical In stitu te, U niv ersity of B ologna, Italy

T h e preserv ation of th e child in p erfect h ea lth a n d in equilibrium
w ith th e n atu ral an d social environm ent during its grow th is th e su­
p rem e p u rp o se to w ard w hich should b e d irected all th e efforts of
child-w elfare w orkers.
T h e essential requirem ent fo r p erfect h ealth is p erfect balan ce of
functions (w h e th er d irect o r p rim ary b alan ce d ep e n d in g on perfect
p ro p o rtio n am ong th e organs a n d th e p a rts of th e b ody, o r secondary
o r in d irect balance, dep en d in g on th e m utual reaction b y w hich those
functions m ay b e co m pensated fo r a longer o r sh o rter p erio d for
m odifications in re la ted fu n c tio n s). B ut this ideal condition of equi­
librium is rarely found in th e hum an b o d y . M ost of th e individuals
p resen t an u n stab le lack o f p ro p o rtio n in th e d ev elo p m en t of their
organs, resulting in disturbances of functions, perm anent, continuous,
o r tem p o rary , w hich disturbances are th e first step to w ard disease.
T h e lack of p ro p o rtio n am ong th e organs w hich is called in m edical
language predisposition h as its n atu ra l origin in th a t com bination of
organic a n d functional characteristics term e d in m edical language con­
stitution. T h e less th e functions, in th eir anom alies, are .susceptible to
disturbances, th e sm aller is th e predisposition a n d th e g re ater the
resistance o f th e b o d y to disease; and, vice versa, th e m o re th e func­
tions are susceptible to disturbances, th e g re ater is th e predisposition
a n d th e low er th e resistance of th e b o d y . In th e first case it is said
th a t th e constitution is strong; in th e second case th a t it is w eak ; an d
these adjectiv es strong an d w eak d o n o t refer to m uscular force, as it
is generally thought, b u t to th e h arm o n y am ong th e organs a n d to
equilibrium am ong th e functions. It is necessary to clarify these con­
ceptions o f predisposition an d constitution because of th e uncertainty
in reg ard to this m a tte r prevailing even am ong m edical m en. T o this
should also b e a d d e d th a t a g o o d o r b a d constitution o f an organ
o r of a b o d y is th e m ain foundation fo r its h ea lth o r its illness.
O u r n ex t step will b e th e discussion o f th e m eth o d s to follow in
th e stu d y of th e constitution. A ccording to th e b rillian t anatom ical
investigations b y M orgagni in Italy, continued b y T h eo p h ile B orden
a n d B ishat in France, th e conception o f constitution w as b ase d on
anatom y, w hile a t p resen t its bases are considered an ato m y an d
physiology co m bined; th a t is, m orphology. T h e stu d y o f constitutions
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on th e basis of m o rphology w as first in tro d u ced b y D e G iovanni in Italy,
w hose w ritings on th e subject w ere first published ab o u t 1880,' an d
w ho fo u n d ed th e School of Italian Clinical M orphology. T his school
has show n v ery clearly on th e basis of th e biological law of correlations
of d ev elo p m en t th a t th e exterior constitution of th e b o d y reflects its
inner constitution; an d th a t any defect in th e m orphology of th e b ody,
w hether external o r internal, will result in a functional d efect; the
school h as also show n th a t th e deg ree o f this defect represents th e
d eg ree of the predisposition to disease.1
L et us see now w hat kin d s o f constitutions th ere are in existence.
E ven a v ery superficial a n d hasty exam ination allow s us to distinguish
in th e ap p a re n t kaleidoscope o f varieties of size an d form tw o types of
constitutions, well defined, w ith distinct contrasting characteristics, th e
h eav y physique an d th e slen d er constitution p resen t in all tim es a n d
am ong all races, as illustrated b y th e accom panying plates.2
If w e exam ine carefully these tw o extrem e types show n in figures
I an d 2, P la te I, w e can easily see th a t th ey are in com plete co n trast
to each other, n o t only anthropom etrically, b u t also functionally an d
pathologically, since, as w e stated previously, th ere usually exists a
co n stan t relation betw een th e external m orphology o f the individual
an d his internal visceral organs a n d betw een th e condition o f these
latte r an d disease.
T h e principal anthropological, physiological, an d pathological ch a r­
acteristics of these tw o types are listed below :
I.

H EA V Y PH YSIQ UE (w ith p red isp o sitio n to a p o p lex y ) 8
H ab itu s a p o p lec ticu s (m a c ro sp la n c h n ia )

A.

Principal A nthropological C haracteristics

1. Body ( so m a ). L a rg e r th a n n o rm a l (m a c ro so m ia ).
2. M orphological ty p e. B revilinear (b ra c h y m o rp h o u s) w ith th e p ro p o rtio n
of th e p a rts of th e body like th o se of a n infant.
iA chille D e G iovanni, fo r instan ce, h as show n th a t w hen th e h an d le of th e
b reast-b o n e is considerab ly too long in p ro p o rtio n to th e body, it is acco m p an ied
by congenital a tro p h y of th e left v en tricle a n d o f th e a o rta . G iacinto V iola has
show n by clinical ex p erim en ts a n d a n ato m ical o b serv atio n s th a t a co nsiderably
insufficient developm en t of th e w hole m ed u llary system a n d a v e ry g re a t sh o rte n ­
ing of th a t system a fte r its rem o v al from th e v e rte b ra l can al a re alw ays acco m ­
p an ied b y considerable n erv o u s sufferings in th e spinal region, an d th e stre tc h o f
th e arm s is in such cases sh o rte r th a n th e le n g th of th e body. D r. M essedaglia
has show n a d irect relatio n betw een th e e x te rn a l size of th e ab d o m en a n d th e
developm ent of th e liver, th e stom ach, a n d th e intestin e. T h e localization of
P o tt s disease is confined to th o se p laces w h e re th e re is a lack of p ro p o rtio n
am o n g th e p a rts of th e v e rte b ra l colu m n ; a n d sim ilarly m an y o th e r diseases a re
caused by th e lack of p ro p o rtio n betw een th e abdo m in al cavity a n d th a t of th e
th o rax , betw een th e h e a rt a n d th e v ascu lar system , betw een th e e x te n t of th e
su rface of th e a rte rie s a n d th a t of th e veins, betw een th e size of th e tru n k a n d
th a t of th e limbs. (C f. A . De G iovanni, L av o ri dell’ Istituto di C linica m edica
di Padova, M ilano, H oepli, 1907—19 1 4 .)
2See p p. 2 9 9 -302.
8See figure I, P late I, p . 299,

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STANDARDS OF C HILD W ELFA RE

3. H eig h t. Less o r e q u al to th e stre tc h of arm s.
4.
' T ru n k . L a rg e r w ith sag ittal diam eters ex ceeding th e tra n sv e rse d iam eters;
abdom en la rg e r a n d ro u n d e r th a n th e th o ra x ; th o ra x relativ ely deficient, h aving
th e shape of th e in sp ira to ry th o rax , as in children, w ith slight inclin atio n of th e
ribs in relatio n to th e v e rte b ra l colum n, a n d th e sh o u ld er line horizontal.
5. Lim bs. S h o rt in relatio n to th e tru n k (b ra c h y sc e lia ). U p p e r lim b lo n g er
th a n low er one.
6. Skull. S h o rt a n te ro -p o ste rio r d iam eter, w ith te n d en c y to th e b rach y cephalia (la rg e sk u ll).
7. N eck. S h o rt, w ith circu m feren ce, b o th ab so lu te a n d relative, exceeding
th e norm al.
8. T h y ro id cartila g e (p o m u m A d am i) slightly p ro m in en t.

B.

P rincipal Physiological an d P athological C haracteristics

T h e system of veg etativ e life, re p re se n te d by th e o rg an s of th e tru n k , prev ails
o v er th e system of life of relatio n , re p re se n te d by th e lim bs; w h ich fa c t is ex­
p ressed b y less agility a n d a ctio n (v elo city ) of th e o rg an ism ; h en ce th e ten d en c y
to se d en tary life.
T h e h e a rt is in a v e ry o blique position, alm o st h o rizo n tal. G en erally th e re is
a n excess of developm ent of th e rig h t h e a rt a n d a deficient d evelopm ent of th e
left h e a rt, w h ich is fre q u e n tly acco m p an ied b y a g re a te r developm ent o f veins
a n d a relatively deficient d evelopm ent of a rte rie s. A s a re su lt th e re is a p e r­
m an en t state of slow circu latio n , a n d a te n d en c y to v enous stasis, a n d g en erally
to diseases of th e circ u la to ry system a n d especially to ap oplexy.
T h e excessive dev elopm ent o f th e abdo m in al o rg a n s re q u ire s a b u n d a n t n u tr i­
tio n , b u t, b ecause o f relativ e deficiency o f th e th o ra x a n d relativ ely sm all size
of th e lungs a n d h e a rt, th e re is less p o w er o f o x idation a n d less h e a rt actio n .
B ecause of th ese ch a racteristics, a n d of th e ten d e n c y to se d e n ta ry life, th e re is a
red u ctio n of th e m etabolism of carb o h y d ra te s, a n d h en ce th e p red isp o sitio n of
th e organism to p o ly sarcia (c o rp u le n c y ) w h en th e re is a deficient b u rn in g u p
of fats, a n d to glycosuria in case of deficient m etabolism , o r com bustion of su g ar.
M oreover, such d isp ro p o rtio n b etw een th e sto rin g u p of th e e n e rg y a n d its ex­
p en d itu re explains m orpho lo g ically th e co n stitu tio n al ab n o rm alities o f m e ta b ­
olism a n d th e p ath o lo g y of a rth ritism (g o u t, diabetes, u rin a ry c a lc u li).
B ecause of th e excessive developm ent of th e ly m p h atic system a n d of th e les­
sened h e a rt actio n due to th e u n d erd ev elo p m en t o f th e left h e a rt, th e re is a lack
of equilibrium w hich p ro d u ces stag n atio n of ly m p h atic secretio n s follow ed by
g lan d u lar tum ors, th e fo rm atio n o f w h ich is also aid ed b y th e te n d en c y to v enous
stasis.
T h e skin is oily, th a t is, rich in sebaceous secretio n s w ith ten d en c y to seb o rrh ea,
a n d su ch condition causes p re m a tu re baldness. T h e su b cu tan eo u s fa t is a b u n d an t.
T h e nerv o u s system is inactive, w ith to rp o r of p h y sical a n d psychic life.
II.

SLENDER C O N STITU TIO N (w ith pred isp o sitio n to tu b e rc u lo sis)1
H ab itu s p h th isicu s (m icro sp lan ch n ia)

A.

Principal A nthropological C haracteristics

1. B ody (s o m a ). S m aller th a n n o rm a l (m ic ro so m ia ).
2. M orphological ty p e. L on g ilin ear (d o lic h o m o rp h o u s) w ith th e p ro p o rtio n
of th e p a rts of th e b o d y fa r d ifferent from th o se of a n infant.
^ e e figure 2, P la te I, p . 299.

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3. H eig h t. G re a te r in le n g th th a n th e stre tc h o f a rm s.
4. T ru n k . Sm all w ith tran sv erse d iam eters exceeding th e sa g itta l d iam eters;
abdom en p o o r a n d flat; th o ra x relatively larg er, h av in g th e sh ap e of th e e x p ir­
a to ry th o rax , w ith m a rk e d in clination of th e ribs in relatio n to th e v e rte b ra l
colum n, an d th e sh o u ld er line drooping.
5. Lim bs. L ong in relatio n to th e tru n k (m a c ro sc e lia ). L ow er lim b lo n g er
th a n th e u p p e r one.
6. Skull. L ong an te ro -p o ste rio r diam eter, w ith ten d en c y to th e dolichocephalis
(n a rro w sk u ll).
7. N eck. L ong, w ith circu m feren ce, b o th ab so lu te a n d relative, less th a n
norm al.
8. L ary n x (p o m u m A d am i) v ery p ro m in en t.

B.

P rincipal Physiological a n d P athological C haracteristics

T h e system of life of relatio n , re p re se n te d b y th e limbs, p rev ails o ver th e system
of vegetative life, rep re se n te d by th e o rg a n s of th e tru n k , w hich fa c t is expressed
by g re a t agility a n d a c tio n (v elo city ) of th e organism , h en ce th e ten d e n c y to
active life.
T h e h e a rt is in a m o re v ertical p osition a n d a lto g e th e r sm all.
T h e lungs a re relativ ely large.
T h e stom ach has a ten d en c y to a v ertical position.
B ecause of th e deficient d ev elopm ent of th e abdo m in al o rg an s, wliftch causes
a p o o r g én éral n u tritio n , a n d of relativ ely larg e m etab o lic forces, th ese c h a ra c ­
teristics, w ith a ten d en c y to a n active life, p ro d u c e a lack o f eq uilibrium b etw een
th e ingestion a n d elim ination, w ith p rev alen ce of th e la tte r. A s a re su lt th e re
is a ten d en cy of th e org an ism to be of a d elicate build, o ften v e ry e x trem e o rg a n ic
p o v erty , w ith v ery p o o r disease resistance.
T h e ly m phatic system is ch ro n ically u n d ern o u rish ed , th e re fo re , fo r this reason
also th e re is a n insufficient n u tritio n of tissues, w ith inflam m ation a n d m ark ed
v u lnerability to w ard p ath o g e n ic a g en ts o f w h a te v e r n a tu re , su c h as chlorosis,
n eu rasth en ia, d eran g em e n t of fem ale genitals. G en erally th e re is a m ark ed
predisposition to diseases of ly m p h atic ty p e, o r to diseases w h ich v e ry easily
develop ow ing to such ly m p h atic su b stratu m , fo r instance, scrofulosis, p u lm o n ary
tuberculosis, lupus, cold abscesses, tu m o r alb u s o f th e joints, etc.
T h e skin is thin, tra n sp a re n t, a n d dry, w ith p o o r su b cu tan eo u s fat.
T h e nerv o u s system show s m o rbid excitability, p h y sical a n d psychic, a n d is
easily exhaustible.

In o rd e r to av o id incorrect ideas ab o u t these tw o ty p es I m ust state
th a t n o t all th e characteristics specified belong to th e tw o types exclu­
sively an d constantly, as n o n e of th e diseases specified are lim ited to
one o r the o th er constitution. W e are m erely speaking o f th e m ajo rity
of cases. In reality factors of h ered ity an d çrossbreeding often m odify
these tw o ty p es in such a w ay th a t th e n u m b er of th e kin d s o f con­
stitutions is considerably increased, b u t n o t indefinitely, because th e
laws o f interorganic correlations p ro d u c e a lim iting effect on th a t
num ber. A fte r having com bined am ong them selves th e th ree kinds,
small, m edium , an d large size of head, trunk, an d limbs, I w as ab le to

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ascertain th rough m athem atical calculations th e possibility of tw entyseven m o rp h o lo gical types distinctly different from each o th er.1
T o retu rn now to o u r tw o fundam ental types, w e m ust a d d th a t
th ey can b e recognized n o t only am ong m en as show n on P la te II, b u t
also am ong w om en (P la te III), an d n o t only am ong adults, b u t in all
ages; fo r instance, according to V iola, th e y h av e b een recognized
am ong children eight an d five y ears o ld (P la te IV ) ; an d I m aintain
th a t th ey can b e recognized also am ong th e new ly bo rn . It w ould
b e of th e highest scientific interest a n d th e g reatest practical use to
follow th e course o f th e various d ev elopm ents w hich m ay ta k e place
in th e cases of th e individuals of th e tw o types during th e p erio d of
grow th, arid w hich are connected w ith th e p articu lar phases of grow th.
F o r exam ple, it is n o t infrequent to find individuals o f th e slender ty p e
w ho in th eir early childhood h a d slow d entition com bined w ith sym p­
to m s o f rickets; in their second p erio d of childhood syffiptom s of
scrofula co m bined w ith irritability of th e resp irato ry passages (b ro n ­
chial c a ta rrh ) ; during p u b erty hem orrhages from th e nose, b lo o d
expectoration, a n d palp itatio n o f th e heart, an d finally la te r pulm onary
tuberculosis.
H av in g th en established th e possibility of classifying m orphologi­
cally th e child a n d of tracing through the p erio d of its grow th various
kind s of predisposition to definite m o rb id conditions, th e Italian School
o f Clinical M orphology p roposes through ap p ro p riate artificial m eans
to resto re th e p ro p e r b alance of functions in th e b o d y . M odifying
m o re o r less, th ro u g h food a n d exercise prescribed in accordance w ith
individual p rev entive hygiene— an d n o t general, as is now com m only
d o n e— those functions w hich are in close relation w ith th e organs an d
p a rts th rea ten ed b y disturbances in their developm ent, w e will b e
ab le to check, o r a t least to re ta rd th e beginning disturbance, w hich
if left to itself, w ould inevitably lead to disease. T his p ro g ram applied
to a grow ing b o d y ten d s to re-establish th e p ro p o rtio n am ong th e p arts
so th a t th ey m ay regain th eir b alance in th e course of time; W hen th e
efforts ex erted on an individual, first in his childhood a n d then in his
adolescence, d o n o t succeed in rem oving th e d an g e r an d d o n o t restore
th e m orphologic equilibrium of th e b ody, an d th e tendencies to w ard
disease increase w ith m aturity, preventive individual hygiene should
b e adv ised to th e person; h e should b e w arn ed to .ta k e g o o d care of
th ose organs of his b o d y w hich are especially vulnerable.
CONCLUSIONS A ND PR O PO SIT IO N

B ut in o rd e r to obtain these results, th e organizations available, a l­
though v ery useful, are n o t sufficient. T h e w ork now d o n e b y th em
m ust b e com bined an d co o rd in ated in one harm onic w hole b y a new
^ e e A ppendix, p. 297.

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office, which I w ould nam e th e International C hild Survey, because of
th e presence in A m erica of m any children belonging to different n a­
tionalities an d because of th e scientific an d practical necessity of a d o p t­
ing an in ternational p lan o f w ork, w hich w ould facilitate th e col­
lection, coordination, a n d com parison of d a ta collected in th e various
countries of A m erica, E urope, an d Asia. T hese d a ta w ould allow us
to determ in e th e general law s governing th e norm al an d pathological
grow th. T h is new office m ust h av e as its m ain purposes to study
th e child m orphologically, to distinguish th e norm al children from
those th a t are defective o r delinquent, to w atch their health during
th e principal phases of their grow th, an d to o rd e r th eir physical an d
m ental w ork in such a w ay as to enable them in their m aturity to use
th eir pow ers in th e best w ay for their ow n benefit an d th a t of society.
T his office m ust contain a staff able to com pute w ith th e greatest ac­
curacy th ose m easurem ents of th e b o d y which, as we believe w e h av e
d em o n strated , are indispensable fo r a good m orphological classification
of individuals.
A PPEN D IX

A chille D e G iovanni, on the basis of relative p ro p o rtio n am ong th e
principal p a rts of the body, distinguishes th ree types of constitutions
w hich h e calls “m orphologic com binations.”
G iacinto V iola, besides th e d a ta furnished b y relative proportions,
considers, as do es D e G iovanni, his teacher, in ad d itio n also the to tal
bo d ily size of the individual; he has established a relation betw een th e
volum e of the tru n k an d the length of the extrem ities an d on th e basis
of this distinguishes five types.
In th e follow ing tab le 1 we give th e tw o classifications:
TABLE I
DE GIOVANNI
1. M orphologic com bination.
2. N orm al type.
3. M orphologic com bination.
4. M orphologic com bination.
5. N ot given in De G iovanni’s classi­
fication.

V IO L A
1. M icrosplanchnic individuals (sm all
tru n k , long lim b s).
2. N o rm osplanchnic individuals (w ell
p ro p o rtio n e d ).
3. M e g a l o s p l a n c h n i c individuals
(la rg e tru n k an d sh o rt lim b s).
4. M icrosplanchnic individuals (w ell
p ro p o rtio n e d ).
5. M egalosplanchnic individuals (w ell
p ro p o rtio n e d ).

B ut in this classification we notice th e absence of an elem ent of
p rim ary anthropological im portance— the head. C onsidering th e sizes
of th e h ead, sm all, m edium , an d large, an d th e corresponding sizes of
th e tru n k a n d limbs, w e succeed b y m eans of m athem atical calcula­
tions in establishing tw enty-seven m orphological types, as given in th e
1P rof. F. F rassetto, “ Di u n a n uova classificazione a n tro p o m e tric a delle indi­
vidualità.” D er anatom isch e A nzeiger, X X X V Band, 1910, p. 468.


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STANDARDS O F C H IL D W E L F A R E

tab le below , clearly distinct from each other, all equally p ro b ab le, b u t
h o t all equally frequent.
TABLE II i
T h e G reek letters in th e tab le ind icate sm all sizes: ft fo r a m icro cep h alo u s h ea d ;
j3 fo r a m icrosplanch n ic tr u n k ; fo r m icrom elous limbs.
T h e sm all le tte rs designate m edium sizes': a fo r a n o rm o cep h alo u s h e a d ; b fo r
a n orm osplanchnic tr u n k ; m fo r norm om elous limbs.
L arge letters indicate larg e sizes: A fo r a m acro cep h alo u s h e a d ; B for a
m acrosplanchnic tru n k ; M fo r m icrom elous limbs.

I“
aY
m

m icrom elic
n o rm om elic
m acrom elic

m icro cep h alo u s

[M

j*

asm
(M

M icrosplanchnic

n o rm o cep h alo u s

f m icrom elic
s n o rm om elic
l m acrom elic
m icrom elic
n o rm om elic
m acrom elic

m acro p h alo u s
M

I“

as m

[M

f*
asm

(M

N orm osplanchnic

■, (>
As m
(M

J>

i

n o rm o cep h alo u s

f m icrom elic
s norm om elic
[ m acrom elic

m acro cep h alo u s

m icrom elic
n o rm om elic
m acrom elic

m icro p h alo u s

fts m

[m

K

asm
|M

m icrom elic
n orm om elic
l m acrom elic

m icrocephalous

m icrom elic
norm om elic
m acrom elic

M acrosplanchnic - n o rm o cep h alo u s

m icrom elic
n orm om elic
m acrom elic

m acro cep h alo u s

f m icrom elic
s n o -m om elic
[ m acrom elic

l>

As m
[M

1F. F rassetto, “ Di u n a n uova classificazione a n tro p o m e tric a delle indiv id u alità.”
D er anatom ische A nzeiger, X X X V Band, 1910, p. 472.


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299

F igure 2

predisposition to ap o p lex y
(M acro sp lan ch n ia)

S lender physiq u e, w ith
predisposition to tub ercu lo sis
(M icro sp lan ch n ia)

F ig u re im itate da V iola e Fici (cf. A . D e G iovanni, L av o ri dell Istituto^
di C linica M edica di P adova, M ilano, H oepli, 1 9 1 4 ).


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STANDARDS OF CHILD W ELFARE

Slender physique
(L o n g ilin ear ty p e )

F igure a

F igure 3

N orm al o rd in a ry
ty p e

H eav y phy siq u e
(B revilinear ty p e )

F ig u re im itate da V iola (cf. A. D e G iovanni, L av o ri dell’ Istitu to di C linica
M edica di P adova, M ilano, H oepli, 1 9 1 4 ).


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P L A T E III


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F igure 1

F igure 2

S len d er ph y siq u e
(L o n g ilin ear ty p e )

N orm al b eau tifu l ty p e
(N o rm al p ro p o rtio n s )

F igure 3

H eav y p h y siq u e
(B rev ilin ear ty p e )
F ig u re im itate da V iola (cf. A. D e G iovanni, L a v o ri dell* Istitu to di C linica M edica di P adova,
M ilano, H oepli, 1 9 1 4 ).

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STANDARDS OF CHILD W ELFARE

GIRLS EIG H T YEARS O LD
F igure

i

S lender p hy siq u e
(L o n g ilin ear ty p e )

F igure

F igure 3

z

N o rm al ty p e
(N o rm al p ro p o rtio n s )

H eavy p h y siq u e
(B revilinear ty p e )

Figure im itate da V iola (cf. A . D e G iovanni, L av o ri dell* Istituto di C linica
M edica di Padova, M ilano, H oepli, 1 9 1 4 ).


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\

T H E IN T E R N A T IO N A L R E D C RO SS A N D C H IL D W E L F A R E
By LIVINGSTON FA RRA ND
C hairm an o f 't h e C e n tra l C om m ittee of th e A m erican R ed C ross

O n e thing p articularly im pressed m e a t th e conference a t C annes,
w here m edical experts from th e five g reat allied nations w ere b ro u g h t
to g eth er to form ulate th e b ro a d principles u pon w hich an international
organization of th e R ed C ross m ight b e basied an d to advise th e R ed
C ross organizations of th e w orld as to w h at p articu lar fields of p re ­
ven tiv e m edicine a n d public h ea lth such an organization m ight a d v a n ­
tageously u n d ertak e. T his w as th e fact th a t a fte r th e tuberculosis
ex p erts a n d th e m alaria experts a n d th e venereal disease experts an d
th e general public health experts an d th e 'infant m o rtality ex p erts h a d
held th eir conferences an d h a d reached unanim ity u p o n certain general
principles, an d h a d begun to unite u pon general recom m endations to
m ak e as to th e In ternational R ed Cross, they- all ag reed th a t th e first
an d m ost im p o rtan t field to b e a ttac k ed an d th e one w hich offered
th e g reatest prom ise of im m ediately successful results, w as th e field
o f th e child an d child w elfare; th a t w e could w ell afford to p o stp o n e
if necessary action in th e o th er fields in o rd e r to a ttac k p ro m p tly this
g reat p ro b lem of infant m ortality an d to increase th e w elfare of child­
h o o d th ro u g h o u t th e w orld. N ow th a t is exactly th e history of every
public h ealth m o vem ent in th e w orld. T h o se of us w ho h av e h a d
years of experience in this field, w ho h av e b een in terested personally
in this o r th a t p articu lar phase, alw ays com e b a c k to th e child as th e
essential feature.
A n o th e r conclusion w hich all those o f us w ho h a v e w o rk ed in
public h ealth h av e reached v ery soon is th a t th e responsibility for
public health, th e responsibility for th e w elfare of m ankind, is an offi­
cial responsibility. It is n o t a m a tte r for p riv ate ph ilan th ro p y . P ri­
v a te p h ilan th ro p y only takes it up because it has to. It m ust som etim es
tak e th e first step a n d m ak e th e first dem onstration. It m ust educate
th e people. It m ust create a public sentim ent. B ut th e responsibility
afte r all is a public an d an official responsibility. A n d consequently we
are d em an d in g th a t S ta te a n d m unicipal h ea lth d ep a rtm en ts shall co n ­
cern them selves n o t only w ith certain obvious things, b u t shall accept
th e entire responsibility for th e p ro tectio n o f th e public health. In
o rd e r th a t they m ay accept it an d carry it thro u g h w e m ust p ro v id e
fo r them th e su p p o rt of a public sentim ent. H ere, as I conceive it, is
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on e of th e chief functions o f a g re at organization like th e R ed Cross.
W e are faced in th e R ed C ross to d a y w ith a v ery g rav e responsi­
bility. W e h av e to effect th e transition from a tim e of w ar to a tim e of
peace. W e h av e to m ak e certain very far-reaching decisions. So
far as 1 am co n cerned som e of those decisions w ere n o t difficult to
m ake. I am certain th a t th e R ed C ross is to b e an active organization
in tim e o f peace. It seem s obvious to m e th a t this g re at sentim ent
w hich h as b een bu ilt up in tim e of w ar fo r th e w elfare of m ankind,
fo r th e relief o f suffering a n d distress, for th e im provem ent of condi­
tions generally, should b e preserv ed so far as possible to solve th e g reat
p ro b lem s o f peace, w hich a fte r all are m uch m o re serious th a n the
pro b lem s of w ar. H o w m uch of it can b e p reserved depends, of course,
u p o n th e w isdom an d effectiveness of th e peace p ro g ram a d o p te d an d
carried out.
T h e beginnings of th a t transition h av e alread y tak en place. T h e
in tern atio n al m ovem ent th a t I h av e spoken of has given th e stam p
o f ap p ro v al to such activity n o t only for A m erica b u t for th e entire
w orld, a n d th e p lan is now included am ong th e covenants of the League
of N ations a n d will h av e th e force w hich th a t L eague will have, w h at­
ev er th a t m ay be.
T h ere is no difference of opinion as to th e fact th a t th e g re at factor
in th e p eace p ro g ram of th e R ed C ross is going to b e public health.
B ut I d o n o t see th e A m erican R ed C ross as a g re at o perating concern
to tak e th e responsibility for carrying through th e child w elfare p ro ­
gram of th e U n ited States, o r th e tuberculosis program , o r th e venereal
disease p rogram , o r any other. I d o see it as th e g re at cooperating
b o d y in th e U nited S tates th a t will enable you, th e child w elfare
w orkers, to g et th e results w hich you know are legitim ate, an d which
can b e o b tain ed if you h av e th e p ro p e r audience an d th e p ro p e r aid.
W e will give you th a t audience, b u t w e will n o t a tte m p t to absorb
y o u a n d a tte m p t to o p erate y o u r different activities. A n d w hat is
tru e in th e field o f child w elfare will b e tru e in th e field of tu b e r­
culosis a n d in th e field of th e o th er public h ea lth questions. W e shall
d em an d th a t th e responsibility fo r all o f these problem s shall b e
assum ed b y th e public authorities; w e shall e n d e av o r to coo p erate
w ith th e public authorities an d w ith all o th er legitim ate agencies in
furthering th eir p articu lar aims. A n d thus w e shall b e ab le in various
w ays to b rin g ab o u t certain very necessary coordinations, a n d to
give an im petus to w a rd this g reat en d of th e prev en tio n of disease an d
th e p ro tectio n of public health, in w hich field nothing rivals th e p ro b ­
lem of th e child in im portance.


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Section IV
Children in Need o f Special Care
(T h e m inim um sta n d a rd s for th e protection of chil­
d re n in n ee d o f special care a d o p te d b y th e W ashing­
to n C onference will b e found on pages 4 4 0 -4 4 4 .)


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THE FUNCTION OF THE STATE
T H E R ESPO N SIB IL ITY O F T H E S T A T E
By R O B ERT W . KELSO
E xecutive D irecto r, M assachusetts S tate B oard of C h arity

|

I wish a t th e outset to offer th ree fundam ental points reg ard in g th e
n atu re o f hu m an society; a n d to follow them b y som e considerations
touching th e responsibility of th e S ta te for children who stan d in n eed
o f special care.
F irst; It is necessary to th e ad v an cem en t of an y com m unity th a t
th e forthcom ing g eneration b e superior physically a n d m entally to th e
g en eration o u t o f w hich it springs.
S eco n d : C onsequently, organized society ow es to th e grow ing
ch ild w ho is in n eed o f special care sufficient p ro tectio n to re n d er
reaso n ab ly p ro b a b le his upgrow th to th e age of self-support w ith physi­
cal h ealth a n d intelfectual attain m en t equal to th a t o f th e average child
in th e com m unity.
T h ird : T h e h istory o f m an k in d show s th a t th e m onogam ous union
of o ne m an a n d one w om an for th e p urpose o f pro creatio n a n d th e
rearing o f their offspring is a n atu ral evolution extending o v er a
geologic age; th a t it stands, u n d e r th e short nam e of th e “ family*” as
th è vehicle a n d th e basis o f o u r social order. H ence it is th e p ro p e r
channel th ro u g h w hich th e av erag e o p p o rtu n ity fo r dev elo p m en t w hich
I h av e ju st m en tioned is to b e sought.
T h e various course of history— th e grow th of early com m unities,
th e rise an d fall of em pires, th e up-spring an d decline of com m unistic
experim ents— shows these th ree fundam entals to b e sound.
W h a t then, in specific form , is th e responsibility of organized so­
ciety—-the state— to w ard those of its children w ho n eed special care, -7—
th e d ep en d en t, th e neglected, th e delinquent, an d th e defective.
Successful com m unity life presupposes th a t th e individual will sup­
p o rt him self afte r reaching th e age w hen h e is physically ab le to d o so;
a n d th a t p aren ts will su p p o rt th eir offspring through infancy an d ch ild ­
h o o d until th ey can becom e self-supporting.. T h e first b o u n d ary m ark
of this responsibility o f th e state, then, is n egative; nam ely, th a t no
policy should b e inau g u rated o r practice carried o u t w hich deprives
th e child o f th e care, com fort, a n d affection of his p aren ts; o r w hich
ten d s unnecessarily to relieve th e p a re n t of th e natu ral b u rd e n of sup­
p o rtin g a n d fostering his child.
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W ith these p o ints in m ind, I wish to discuss this state responsibility
® th e light o f th e experience of M assachusetts. T h e prim ary unit of
govern m en t in th a t S tate is th e Tow n, w ith its selectm en an d its tow n
m eeting. C ity g overnm ent is an elaboration of this ancient tow n sys­
tem , subject to th e principles of tow n law. C ounty governm ent exists,
b u t its functions are so far circum scribed th a t it m ay b e term ed for
th e m ost p a rt a judicial unit m erely. A ll p o o r relief is adm inistered
locally, in th e first instance, alw ays b y cities an d tow ns. T h e overseer
of th e p oor, a local officer, is th e agency through w hich the govern­
m en t takes notice of dependency. T h e S ta te treasury is called u pon fo r
reim bursem ent of aid ren d ere d w here th e child is w ithout legal settle­
m ent. T h e S ta te has an elab o rate an d com plicated settlem ent law.
T H E D EPEN D E N T C H IL D

In M assachusetts, public aid to children w hose only han d icap is a
failure of su p p o rt is given alm ost exclusively in th e child’s ow n hom e.
Since S ep tem b er 1, 1913, w hen th e M others’ A id L aw becam e o p era­
tive, assistance in th e home? given m ostly in cash an d totalling
$ 3 ,8 8 6 ,6 7 8 .5 8 , exclusive o f adm inistrative expenses, has b een given to
7,65 1 m others, in order, as the law states, to enable them to bring up
th eir 2 4 ,4 6 4 d ep e n d en t children u n d e r 14 years of age in their ow n
hom es. U n d e r o th er relief laws, overseers of the p o o r re n d er tem ­
p o ra ry aid in the hom e to m any children w here sickness, accident, o r
o th e r cause h as cut off natu ral support. A ccording to law, th e S tate
b o a rd of ch arity m ay receive d ep e n d en t children for support, b u t they
are n o t now tak en w here d ep en d en cy is the only cause. T h e d e p e n d ­
en t children now in th e b o a rd ’s custody are those w ho h av e been
o rphaned, neglected, ab an d o n ed , o r abused.
T h e illegitim ate child falls w ithin th e group o f dependents. F o r
him th e fam ily h as failed. It is th e obligation of th e S tate to guarantee
to th e illegitim ate as m uch of its fam ily rights as can b e preserved.
T hus, it has a right to its m o th er s affection a n d personal care. H ence,
m o th er an d child should n o t b e sep a rated in cases w here th e m o th er
h as a passab le d egree of intelligence. T h e illegitim acy statu te of
M assachusetts m akes illegitim ate p atern ity a crim e. It p ro tec ts th e m an
b y requiring p ro o f bey o n d a reasonable doubt, as in an y o th er crim e.
It im poses u p o n th e fath er as m uch responsibility for th e su p p o rt of his
offspring as is required óf th è legitim ate p aren t. T h e parties in interest
a re th e public an d th e child.
C onsidering th e responsibility of th e S ta te for th e d e p e n d e n t child,
I subm it th a t w hen th e norm al child, through th e loss of p aren ts o r for
o th e r reason n o t d u e to its ow n conduct, is d ep riv ed of its natural hom e
a n d th e su p p o rt necessary to its grow th, th e S tate ow es th e positive
obligation of tran splanting it to a foster fam ily h om e as th e b est sub
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S P E C IA L C A R E — T H E

stitute for th e h om e th a t has b een lost.
hom es are readily found.

STATE

309

Experience show s th a t such

T H E N E G LE C TE D C H IL D

T h e neglected child is d ep e n d en t an d should b e trea ted according
to th a t stan d ard . B ut the family, of w hich it is th e m ost v aluable part,
is an offender against society. T h e p aren ts are delinquent. T h e State,
obliged as it is to safeguard th e institution of th e family, owes a posi­
tive d u ty to punish an d to correct p aren tal neglect of children.
O nly as a last resort should th e fam ily b e b ro k en up. C om pulsion
u n d er no n -su p p o rt an d desertion law s can d o m uch. T h e 155 p ro b a ­
tion officers of o ur 88 M assachusetts courts of first instance collected in
1918 from n o n -supporting h usbands an d fathers a n d from persons w ho
failed to su p p o rt their aged p aren ts a to tal of o v er $ 4 8 5 ,0 0 0 a n d
tu rn ed it o v er to th e d ep en d en ts of those backsliders. T h e item for
th e su p p o rt of aged p aren ts is p ro b a b ly less th an ten p e r cent of the
w hole. T h e S tate b o a rd of charity collected $ 2 5 ,9 3 6 .0 2 in th e sam e
p erio d from p aren ts of children w ho b y court o rd e r o r through o th er
provisions of the law h a d been p laced in th e custody of th a t b o ard .
W h en th e child is rem oved because o f neglect, th a t act of sever­
ance should b e accom panied b y all p racticab le com pulsion of the
p aren tal responsibility fo r support. T h e U niform D esertions A c t
should b e in force in every S ta te in th e U nion. It declares wilful failure
to su p p o rt to b e an offense. It m akes th a t offense extraditable. It
m akes it possible to com m it th e offending p a re n t to h a rd labor, th e
g o v ern m en t repaying to th e d ep e n d en ts a sum p e r d a y fo r his labor. A
charge o f neglect should lie against th e offending p arties only. It
should not, as in M assachusetts, b e b ro u g h t as though it w ere a charge
against th e child. T h e little fellow, innocent as y o u r child o r mine,
stan d s w ide-eyed b efo re th e court w ondering w hy h e is so accused.
S een through his eyes, p o v erty is a g reat sorrow , b u t neglect is tragedy.
'

T H E D E L IN Q U E N T C H IL D

D elinquency am ong children arises, as I ap p reh en d , from tw o chief
sources: (a ) b a d environm ent; an d (b ) abnorm al m ental d ev e lo p ­
m en t o r m en tal defect. Its trea tm e n t m ust follow w idely divergent
channels in accordance w ith th e one cause o r th e other. If th e cause is
environm ent, th e child should n o t b e rem oved from th e fam ily until
th e full possibilities of court p ro b a tio n h av e b een exhausted an d every
effort m ad e to correct the hom e conditions. T his effort m ay tak e th e
form o f m oving th e fam ily b o d ily to a n o th e r district. In these en ­
vironm ental problem s, th e child is found often to d o w ell w hen placed
in a foster fam ily hom e. V e ry m any w ayw ard children com ing o u t
of w rong h om e conditions do w ell a fte r p ro b a tio n w hen p laced out


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in families. T h e S ta te B oard in M assachusetts has 304 such children
in fam ily hom es u n d e r th e supervision o f field visitors. A ll o f them
cam e to th e b o a rd as delinquents a n d none of them has b een in an in­
stitution fo r delinquents.
W h ere th e child’s conduct is such as to d em an d custodial care, h e
should b e sent to an industrial training school w hich is d ev elo p ed on
th e co ttag e p lan an d to which is attac h ed an effective p aro le system —
so th a t th e child m ay b e p laced out as soon as his conduct ap p e ars to
w a rran t so m uch confidence. T h ere are th ree such schools in M assa­
chusetts, tw o fo r boys an d one fo r girls. T h ey contain 1,145 inm ates,
a n d th ere are 2,831 o th er children w ho h av e b een in these schools a n d
w ho are now p laced out in fam ily hom es o r w ho are w ith th eir p aren ts
on p arole. T h ese rem ain still u n d e r th e custody of th e trustees o f th e
schools.
T H E D E F E C T IV E C H IL D

T h e defective child is alm ost alw ays a d ep en d en t. H e is often
neglected, an d h e is in v ery m any cases a delinquent. H is defective
m ind indicates a t th e outset sm all likelihood th a t h e will b e ab le to a d ­
ju st him self to his surroundings to th e satisfaction of society. T h e in­
san e an d th e feeble-m inded in M assachusetts are cared fo r b y th e
S ta te G overnm ent. A feeble-m inded person is com m itted to institu­
tional care in m uch th e sam e m an n er th a t an insane person is com m itted.
T h ere are tw o schools for th e feeble-m inded, now housing 2 ,8 0 6 . A
th ird has b een authorized, b u t is n o t y et ready. T h ere are o v er 1,000
persons on th e w aiting list for ad m ittan ce to these schools. O v e r 100
o f these rem ain constantly a t th e State. Infirm ary, w hich is th e S ta te’s
alm shouse, w here they d o n o t belong.
T h e defective child does n o t necessarily n eed institutional care in all
cases. E stim ating ap proxim ately 15,000 feeble-m inded persons in
M assachusetts, th ere is a strong likelihood th a t alm ost h alf of these will
n o t n eed restrain t in an institution. T his p ro p o rtio n will readily obtain
am ong th e children. E ither th ey are found to h av e w atchful a n d h elp ­
ful relatives; o r th ey are o f such low g ra d e th a t th ey d o n o t com e
within th e dan g ero us class of breeders. F o r w h atev er reason m ay a p ­
pear, th ey are n o t a m enace to th e public w elfare. A ll these should b e
supervised in th eir ow n hom es b y th e S ta te G overnm ent.
R esearch discovers th a t feeble-m indedness is tran sm itted b y in­
heritan ce in ab o u t three-fourths of all cases. C onsequently, th e g re at
m enace caused b y this group is th a t of procreation. T h e S ta te ow es
th e positive obligation o f pro tectin g itself against th e transm ission o f
d em o n strate d h e red itary m ental defect. T his d u ty it will carry out in
th e w ay th a t is m ost hum ane. O u r p re sen t m eth o d is segregation of
th e sexes.


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S P E C IA L C A R E — T H E

STATE

311

F o r th é defective child w ho is n o t feeble-m inded, institutional train ­
ing can d o m uch, an d so long as th ere is reasonable h o p e o f returning
him to th e com m unity w ith enough capacity o r sufficient m ental h ab it
to g et along w ith out endangering society, his ca re in th e institution
should include v ocational training.
- T h e condition of feeble-m indedness is n o t curable, though it is im ­
p ro v ab le, w ithin n arro w limits, in th e direction of self-support. It
m ust follow th a t institutional care o f feeble-m inded children should
seek to fit them for such occupation as their capacity will ad m it ; a n d for
th e rest, should m ake them as nearly self-supporting in th e institution as
hu m an e trea tm e n t will perm it. W h ere facilities for care are inadequate
to m eet th e need, preference should b e given in th e ad m ittan ce of
cases to th e institution to th e feeble-m inded girl w ith sex tendencies,
as shq rep resen ts th e g reatest th rea t to society.
R esearch discovers an o th e r vital fact ab o u t feeble-m indedness,
nam ely, th a t it n ev er dev elo p s in a d u lt life. W h ere present, it m ust
h av e existed eith er from b irth o r from early childhood. T his fact,
to g eth er w ith th a t o th er finding on heredity, should po in t th e line o f re­
sponsibility for the S tate. A m erican childhood has a right to b e p ro ­
tected in adolescence. M ore th an this, it has a right to b e well b o m .
T h e S ta te will n o t h âv e p ro te c te d itself in an y tru e sense until it shall
h av e ap p ro ach ed its child problem s w ith a view to preventing th em —
until in th e case of th e feeble-m inded, it shall h av e sought o u t th e d e ­
fective in th e days of his childhood, a t the outset of his career, a n d b e ­
fore h e h as created pro b lem s of illegitim acy, of venereal disease, of
crim e, a n d of trag e d y for every h e a rt along his trail of anti-social con­
duct.
I h av e m en tio n ed here an d th ere th e experience of M assachusetts in
these problem s. L ast y ea r th e G overnm ent, S ta te an d local, exclusive
of th e m aintenance of th e 5 county training schools, ex p en d ed a p ­
p roxim ately $ 3 ,2 3 0 ,2 8 9 in the care, custody, an d trea tm e n t o f the
children of these several classifications. Y et th a t w as n o t th e only co n ­
tribution. L arge sum s w ere ex p en d ed b y p riv ate in co rp o rated child­
caring agencies. T h ere are 1 10 of these corporations in M assachusetts.
F orty-five are co ngregate hom es fo r children, som e of them w ith
placing-out system s attach ed . F o u rteen d o only placing-out. T w entyseven are d a y nurseries, an d nine are special hospitals fo r sick children.
T h e to tal capital funds o f th e 9 0 o f these societies th a t re p o rte d are
$ 1 5 ,9 0 6 ,8 8 2 . L ast y e a r th ey re n d ere d child care in 106,71 7 instances
a t a to tal ex p en d iture of $1,833,1 70. T h ey received from o r on ac­
count of beneficiaries $42 8 ,4 5 5 a n d from investm ents a n d all o th er
sources $ 1 ,4 9 6 ,1 2 1 , m aking a g ran d to tal of $ 1 ,9 2 4 ,5 7 6 received.,
T h e S ta te b o a rd of charity has 6 ,4 4 0 children in its custody, a n d of
these 5,531 are in foster fam ily hom es. T h e to tal exp en d itu re last


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STANDARDS

O F C H IL D

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y e a r fo r th e care of these children, including adm inistration an d tuition
in th é public schools, w as $ 9 2 5 ,0 1 0 .
O n e m ay rightly inquire in view of m y insistence u pon a positive re­
sponsibility in G o v ern m en t itself, w h at is .the function a n d th e re­
sponsibility o f th e p riv ate ch aritab le agency in child care. T h a t tru e
relationship I tak e to b e this: T h e prim ary obligation rests u p o n o r­
ganized society— th e state itself. • T h e ca re of children needing special
care is th erefo re a function of th e S tate. T h e p riv ate agency, in fact
as well as in law, is a public trust, perform ing a function o f G overnm ent.
T o b o rro w th e w ords of our g reatest judicial definition o f charity, th e
p riv ate agency in its operation is “ relieving th e b u rd e n s o f G o v ern ­
m en t.“ 1 H en ce th e process of child care, w heth er it b e public o r private,
is b ased u p o n those sam e fundam ental elem ents of responsibility which
rest u p o n organized society, an d m ust th erefo re conform to identical
stan d ard s.
’ G ray, J „ in J a ck son vs. Phillips, 14 A lle n , 5 3 9 , at p . 5 5 6 .


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S T A T E SU PE R V ISIO N O F A G EN C IES A N D IN STITU TIO N S
By C . V . W IL L IA M S
D ire cto r, C h ildren ’ s W e lfa re D epartm en t, B oa rd o f State C harities, O h io

T h e hu m an itarian im pulses m anifested b y th e m ajo rity of th e p eople
of th e co u n try h av e b een responsible to a larg e degree for th e co m ­
m ercializing of physically h an d ica p p ed o r u n fo rtu n ate children b y u n ­
scrupulous individuals. In S tates w here th ere is no regulation of ch ild ­
caring agencies, persons utterly unfit are p erm itted to exploit these d e ­
fenseless children fo r th eir ow n gain. In som e such S tates a fearful
traffic in infants is carried on through so-called m atern ity hospitals or
lying-in hom es w here ad o p tio n s o r ab o rtio n s m ay b e h a d fo r a co n ­
sideration.
E v ery b o d y recognizes th e necessity o f securing th e elim ination of
these hum an p arasites from th e com m unity, b u t I am of th e opinion th a t
of even g reater h arm is th e o peration of institutions b y w ell-m eaning b u t
in com petent m en a n d w om en w ho retain th e stan d ard s of a generation
ago. S om e of these institutions are well sup p o rted , a n d are to lera te d
in th e com m unity because n o b o d y w ants to h u rt th e m anager s feel­
ings. T h e h ealth a n d happiness of thousands of children is sacrificed
because of th e failure of th e S ta te to secure th e p ro tectio n of these chil­
d re n th ro u g h a system of S ta te regulation w hich will d em an d m inim um
stan d ard s of efficiency from every child-caring agency.
T o b e specific I will cite a few conditions com m on to S tates w here
th ere is no provision fo r th e supervision of child-caring agencies. O nly
th e greatest care will p re v en t the best-m anaged institutions ih th e land
from becom ing a “ dum ping g ro u n d ” for p aren ts w ho d o n o t care to
su p p o rt th eir children o r for agencies th a t sum m arily an d unnecessarily
sep arate children from their parents. A large n u m b er of so-called d e ­
p en d e n t o r d elinquent children h av e b een sep a rated from p aren ts b e ­
cause of th eir delinquency w hich has b een d u e to conditions for w hich
th e com m unity is responsible. W ith th e develo p m en t of a p ro g ram of
service fo r th e family, a large n u m b er of these hom es can b e reclaim ed
an d th e children retu rn ed to their parents. O nly constructive S tate
supervision can p re v en t th e needless d e ten tio n of children in institu­
tions.
A p ractice com m on to d a y in m any institutions sm acks of conditions
existing a generation ago. R espectable an d w o rth y m o th ers are com ­
p elled to relinquish all right, an d claim, an d title to their children in
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o rd e r th a t th ey m ay receive th e care of som e of o u r public a n d p riv ate
child-caring institutions. T h e social crim e of this p ro ced u re is o ver­
lo o k ed b y th e enterprising, am bitious ag en t of th e H om e, w ho is m ore
interested in finding an attra ctiv e child for a prospective foster p aren t
th an in recognizing th e G od-given rights of an unfo rtu n ate w om an who
a t th e m o m en t is neither physically n o r m entally responsible fo r h er
conduct.
S ta te regulation is necessary to hum anize som e institutions to which
these children are com m itted a n d w here children are practically b uried
fo r m an y of th e m ost im p o rtan t years o f their lives. T h eir tim idity,
th eir rat-like faces, their undernourished bodies, th eir closely cro p p ed
heads, th eir frightened though eager an d hungry look, reveal som e­
thing of th a t g re at though unsatisfied longing for p aren tal care, which
of course institutions can n o t give. T h ey becom e a p a rt of a system ;
th eir individuality is consequently dw arfed, an d though m aintained a t
g reat expense, a large n u m b er of these children can never overcom e th e
baneful influences incident to this early training.
M any of these children still ea t their m eals w hile sitting upo n b ac k ­
less benches. T h e use of th e oilcloth tab le cover, of ironw are o r tin
dishes, a n d of spoons instead of knives a n d forks, does n o t con­
trib u te to th eir training in p ro p e r tab le m anners.
T o o th brushes in som e of these institutions a re unknow n. Infectious
diseases are com m unicated through th e use of a com m on tow el. T h ree
o r fo u r children frequently sleep to g eth er in one b ed . M uch im m or­
ality prevails, as d o rm ito ry supervision is lacking an d th e m ingling of
th e sexes is frequent. In m any w ell-supported children’s institutions,
th a t invention of th e devil, th e “silent regim e,” still prevails. H e re th e
children e a t th eir m eals in silence, m arch from one room to an o th er in
silence w ith h a n d s b eh in d their backs, an d sit in th eir playroom s in
silence, doing nothing. In m any institutions th ere is no atten tio n w h at­
ev er given to rem ediable physical defects o f children w ho rem ain
w ard s for long p erio d s of tim e. Som e institutions b o ast th a t th e physi­
cian rarely com es— th a t it is n o t necessary.
O n e o f th e g reatest problem s requiring stan d ard izatio n is th e sys­
tem em ployed b y agencies engaged in th e placing of children in foster
families. 1 h av e personal know ledge of th e ease w ith w hich persons
physically an d m orally unfit h av e secured even from so-called substan­
tial organizations th e custody of hom eless children. I know th a t m any
o f these ch ild ren h av e n o t only b een placed in unfit hom es, b u t th a t
th ey h av e subsequently b een literally ab a n d o n ed b y th e officials w ho
w ere en tru sted w ith th eir care an d guardianship. I also know th a t
th e lives of g re at num bers o f these children h av e b een irrep arab ly
b lig h ted because of th e failure of the S ta te to secure their protection
th ro u g h a co m p etent system of S ta te supervision.

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In m an y of th esein stitu tio n s the records concerning th e children an d
th eir an teced en ts h av e b een m islaid o r lost; n o r is th ere inform ation
av ailab le concerning th e m an n er in w hich som e of th e children h av e
b een d isposed of. N ob o d y know s w here they h av e b een placed, an d
supervision is re n d ere d im possible. T h e futile efforts of children w ho
h av e reached their m ajority, w ho seek to ascertain som ething concerning
th eir fam ily h istory o r their relatives, is sufficient com m entary on th e
seriousness of this neglect.
It is highly significant th a t nearly every S tate has d ev e lo p e d som e
system for th e p ro tectio n of neglected children. P rovision has b een
m ad e fo r courts of certain jurisdiction to rem ove neglected children
from th e cu sto d y of th eir ow n p aren ts an d to aw ard their guardianship
either to public o r to p riv ate child-caring agencies during th eir m inority.
H ow ever, it so h ap p en s th a t som etim es th e children thus legally a n d
p ro p e rly rem o v ed from their ow n p aren ts are legally p laced in th e care
of an institution o r agency even less co m p eten t to care for th em th a n
are th eir parents.
In outlining th e scope of supervision, I w ould consider th a t th e re ­
sponsibility of th e S ta te fo r th e stan d ard izin g of child-caring agencies
should ap p ly to th e sam e extent to p riv ate as to public institutions. T h e
S ta te is m o re interested in the natu re of th e trea tm e n t afforded these
Ymfortunate children th an in th e auditing of financial accounts to ascer­
tain w h eth er o r n o t th e funds of public agencies h av e b een w isely ex­
p en d ed .
T h e O hio law p rovides for th e supervision b y th e B o ard o f S tate
C harities of all institutions o r associations, public o r private, incor­
p o ra te d o r otherw ise, th a t receive children or th a t place children in
foster hom es. A ll of these institutions are subject to inspection an d en ­
d o rsem en t b y the S ta te d ep a rtm en t an d a p en alty is p ro v id ed for th e
no n -ob serv an ce of this statute. T h e B oard of S ta te C harities is re ­
quired to pass u p o n th e m an n er in w hich th e w ard s of these institu­
tions are cared fo r an d also to exam ine into th e system s em ployed in
th e adm ission a n d discharge of children an d their placem ent in foster
hom es. It is req u ired to visit such children as h av e b een p laced out
in foster hom es b y th e agencies u n d er supervision as, in th e ju d g m en t
of th e b o ard , m ay b e necessary to determ ine th e actual ch aracter o f th e
w o rk accom plished b y th e agency.
T h e p resen t legislature has also p ro v id ed fo r th e licensing o f all
b o ard in g hom es in th e S ta te w here p riv ate fam ilies care fo r children n o t
related b y b lo o d o r m arriage fo r “hire, gain o r re w ard .” T his law will
m ake it possible n o t only to reach th e “ b a b y farm s,” b u t also to regu­
late th e activities of individuals, w ho in th e past, w ithout any b o a rd of
m anagers, h av e b een exploiting children. T h e O hio law also p ro v id es
th a t th e B o ard of S ta te C harities shall pass u pon th e m erits of all in
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stitutions o r associations desiring to incorporate, w hose o bjects m ay in­
clu d e th e care of children or their placem ent in foster hom es. T his
provision h as en ab led th e b o a rd to p rev en t th e incorporation of use­
less an d even vicious organizations.
T h e O hio law is weak, how ever, in th a t it m akes no provision fo r th e
supervision o f children w ho are placed out in foster hom es b y juvenile
co u rt judges. N or has it jurisdiction over th e o peration of th e hum ane
societies w hich engage exclusively in th e enforcem ent of th e anti-cruelty
laws. T hese agencies are just as greatly in n eed of stan d ard izatio n a n d
regulation as th e recognized child-caring associations, an d should b e
included in th e dev elo p m en t of a S tate supervisory program .
S ta te supervision, to b e constructive, m ust b e sym pathetically exer­
cised. A n y investigator can find a b u n d a n t o p p o rtu n ity fo r criticism in
th e best o rd e red institutions. It becom es therefore a task necessitating
unusual tact an d discretion to secure needful corrections w ithout dissi­
p atin g th e altruistic activities of th e trustees. T h e S tate is as greatly
concerned in th e conservation an d the develo p m en t of th e initiative of
m anagers a n d trustees as it is in th e correction of th e abuses of their
institutions. It is therefore necessary to em ploy in this service only
such persons as are ab le to m aintain a p ro p erly balan ced perspective,
w ho h av e an u n d erstan d in g of children, an d w ho u n d ersta n d th e tech­
nique of case w ork a n d fam ily rehabilitation an d a t least th e fu n d a­
m entals of institutional adm inistration. T h e investigators m ust h av e a
p ro fo u n d sym pathy for th e children concerned, an d a vision as to the
possibilities of their future. Such investigators will readily im press th e
officials in charge of th e institutions of their desire to b e of real service in
th e solving of the institution’s problem s. T h ey will b e ab le to adyise
w ith the su p erin tendent sensibly concerning th e creating of a norm al
atm o sp h ere in the institution. T h ey will b e ab le to secure fo r th e chil­
d re n th e recreational, th e vocational, th e physical, th e social, th e educa­
tional, an d the religious opportunities so frequently denied. If th e low
stan d ard s of th e institution h av e been due to ignorance, th e investigator
should rem ain in th e institution long enough to w ork out a program
consistent w ith available resources. If th e institution’s stan d ard s are
sacrificed because of th e necessity of keeping w ithin a low p e r capita,
it becom es th e privilege of th e investigator, through the dev elo p m en t
o f educational p ro p ag an d a, to secure fo r th e institution needful finan­
cial support. T h e S tate will m ake a serious m istake if in th e exercise of
its police function, in th e elim ination o f b a d agencies, it forgets its
g re ater o p p o rtu n ity in rendering helpful an d constructive service to th e
w eak er agencies u n d er its supervision.
^
T h e S tate should establish a uniform reco rd an d b lan k system , an d
w hen desired, should assist in its installation. It should secure the regis­
tratio n o f all o f th e w ards of th e public an d p riv ate child-caring institu
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tions in the S tate. T his can b e readily accom plished through a system
of m o nthly rep o rtin g on th e m ovem ents of children, which can b e
readily p o sted on a card index. T h e supervision b y th e S ta te of chil­
d ren w ho are p laced in foster hom es b y child-caring institutions, is a
task necessitating th e exercise of unusual tact. T h e S ta te is prim arily in­
terested in determ ining th e fitness of th e en d o rsed agency to engage in
this w ork, an d unnecessary duplication of effort should b e avoided.
Irrep arab le h arm can com e through the unnecessary visit of a tactless
field agent. It is of fa r g reater im portance to th e S ta te th a t it secure th e
m aintenance of th e necessary stan d ard s incident to investigations,
supervision, an d records, from th e supervised agencies, th an it is to
p erfo rm th a t function itself. W hen th ere is any indication of th e failure
o f th e agency ad eq u ately to p erfo rm this function, each of its w ards
should b e visited, such as are found in im p ro p er hom es rem oved, a n d a
definite p ro g ram created b y th e S tate w hich m ust b e accepted b y th e
institution as a m inim um w hich will justify subsequent endorsem ent.
Each institution should b e required to d evelop a reco rd system suf­
ficiently intensive to satisfy th e S tate investigator as to th e ty p e of w ork
accom plished. T his record k e p t on file in th e office of th e institution
a n d av ailable to p ro p e rly accredited agents of th e S ta te supervisory
b o ard , should o rdinarily furnish sufficient d a ta fo r a determ ination as
to th e agency’s fitness fo r endorsem ent.
T h e exercise of a supervisory p rero g ativ e unaccom panied b y a
p en a lty fo r violation is w ithout g reat value. T h e O hio law p ro v id es
th a t an y perso n w ho receives a child o r solicits m oney on b eh alf of
an u n en d o rsed institution o r association, u pon conviction thereof, is
sub ject to a fine. It has b een th e experience of th e O hio b o a rd th a t
th e civic p rid e of a com m unity is in itself generally sufficient to, accom ­
plish certain reform s w hen th e official fam ily refuse to m aintain p ro p e r
stan d ard s. A n d I am of th e opinion th a t b e tte r results are ultim ately
accom plished b y confining th e po w er of th e S ta te to its function of
licensing o r refusing to license than in actually giving to th e S tate the
co n tro l o v er th e w ard s of th e institution except w here it is im possible
otherw ise to secure them p ro p e r care. T h e O hio B oard of S ta te C hari­
ties has m et w ith certain difficulties w hich are local in their nature, in
securing the p ro tection of th e w ards of u n en d o rsed agencies w ho have
been p laced o u t in unfit hom es. T h e S tate, having refused o r revoked
th e license of an institution, can go no further, an d th e indifferent
trustees p erm it th e continuance of th e neglect of these children. A
rem ed y fo r this condition m ay ordinarily b e found through th e ju v e ­
nile co u rt ju d g es o r th e courts exercising th a t jurisdiction in the counties
w here th e children are neglected. T h e strongest possible pressure th a t
can b e b ro u g h t to b e a r upon th e officials is through local public opinion,
an d w isely d irected sym pathetic an d constructive S ta te p ro p a g a n d a


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locally d iiected will in m ost instances accom plish th e necessary re­
form s. It is a p rim ary d u ty o f the S ta te to m ake th e com m unity see
its problem s, a n d then to tre a t them .
A supervisory b o a rd will early m ake a survey o f the children’s needs
o f th e entire S tate. It will inform itself concerning th e conditions p re ­
vailing in localities w here th ere is a p rep o n d eran ce of child dep en d en cy
a n d child delinquency a n d will develop com m unity initiative to th e
en d th a t th e conditions producing these conditions will b e changed.
It will n o t only stan d ard ize an d intensify th e activities of th e existing
organizations u n d e r its supervision, b u t will assist in bringing into ex­
istence necessary agencies to m eet th e n eed s of children in neglected
com m unities, an d it will u n d erta k e to secure a coordination of all th e
agencies interested in hum an w elfare. It will o p erate as a clearing house
to w hich all p ro b lem s concerning children m ay b e referred. It will
co n d u ct com m unity conferences, circulate educational literature, a n d
ta k e ,the initiative in th e dev elo p m en t of legislative program s. It
will b e a trem en d ous facto r in th e d evelopm ent of th e thought th a t in
th e care o f neg lected children th e S tate n eed s th e service of every
individual. It will u n d erta k e to dissipate th e com placency of individ­
uals b ased u p o n accom plishm ents for som e of th e children of th e S tate,
b y directing th eir atten tio n to th e unfinished task; to th e g reat m ultitude
o f children who, su rro u n d ed b y vicious influences, will b e driven into
lives of delinquency unless p ro tected , an d to th a t large group of chil­
d ren fo u n d in every S ta te w ho, because of physical o r m ental handicaps,
are in special a n d im perative need. T h e S tate has an unquestioned re ­
sponsibility n o t only in securing th e protection of those w ho are cared
fo r b y existing agencies, b u t also in th e dev elo p m en t of a S tate-w ide
p ro g ram which will recognize as its m inim um of responsibility, th e
ad e q u ate p ro tectio n of every child.
H o w long will th e S tate rem ain indifferent to th e n eed s of these d e ­
fenseless children w ho deserve a t least a chance to becom e useful citi­
zens?
D ISCU SSIO N
M iss H . Ida C u rry (S ta te C harities A id A s s o cia tio n , N ew Y o r k C ity ) : I am
g rea tly in terested in som e o f the su ggestion s M r. ^Villiams has m ad e in reg a rd to
State su p ervision a nd State licen sin g, w h ich is som eth in g in w h ich I stron g ly b e ­
lieve, a n d w h ich I sh ou ld like to see exten d ed v e ry grea tly in all o f th e States.
W e have e very th in g in N ew Y o r k , fro m the v e ry best institution to the v e ry
b a ck w a rd in stitu tion; and I think that, in som e o f the tow n s w h ere th e b a ck w a rd
orga n iza tion s exist, w e a re som etim es in the p osition o f w a itin g fo r s o m e b o d y to
die. A s M r. W illia m s has suggested, w e fail to im p rov e o u r m eth od s b eca u se
w e d o n o t w an t to h urt s o m e b o d y ’ s feelin gs— som e p erson that h elp ed to org a n ize
th e institution.
A n d y e t it w as o n ly a fe w years a g o , that o n e little institution in N ew Y o r k
State h ad a pu nish m en t clo s e t built fo r the ch ildren , a n d had it pain ted b la ck inside.


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W h en th e S tate B oard of C h arities o b je c te d to this, th e b o a rd of th e institu tio n
held a m eeting an d solem nly decided th a t th e y could n o t do aw ay w ith th e p u n ish ­
m en t closet, b ecause th e y could th in k of no o th e r m ode of p u n ish m e n t fo r dis­
o b edient children. T h a t w as only a b o u t five y e a rs ag o . B ut th e o th e r d ay a
young w om an, a m em ber of th a t b o a rd of m an ag e rs, cam e to o u r office a n d ta lk e d
over a p la n fo r selling th a t old-fashioned little building, in w h ich th ey k e p t alm ost
as p riso n ers a b o u t fo rty little child ren , a n d doing aw ay w ith it in its p re s e n t form .
Shp discussed w ith us a p lan fo r o rg an izin g a receiving hom e, w h ich w o u ld receive
th e children a c cep ted as p u b lic charges, find o u t w h a t th ey really needed, a n d pass
them on to a b o ard in g hom e o r to a special in stitu tio n if th ey n eed ed special c a re
— in fact give each child w h a t e a c h needed.
~
, .
P ro g ress is b ein g m ade, even in th e m o re, b a c k w a rd in stitu tio n s. C ertain ly
w e do need, in m ost of th e States, m u ch m o re c arefu l inspection of th e placingo u t w o rk . T h e b e tte r o rg an ized p la cin g -o u t ag en cies a re p ro b a b ly doing as
good w o rk as can b e done. B ut th e re a re v e ry m an y u n su p erv ised agencies.
In a little m a te rn ity h o m e of w h ich I know , th e p hysician is p lacin g o u t chil­
d ren all th e tim e. In o n e in stan ce— w e laid th e facts b efo re th e a u th o ritie s in
this case— h e p lace d o u t a child giving a false d ate of b irth , m ak in g a false sta te ­
m en t of th e circu m stan ces of th e b irth ; th e only n a m e re co rd ed on th e ad o p tio n
p a p e rs is th e nam e of th e fo ster p a re n ts; th e re a re no nam es a t all of th e real
p a re n ts of th e child. S uch in stan ces still p rev ail in o u r old E a ste rn S tates, a n d
1 suppose in o th e r S tates as w ell. W e n eed m o re S tate sup erv isio n ; w e n eed
S tate supervision in all w o rk done fo r th e children, b o th b y p riv a te a n d b y pu b lic
agencies.
M r. C . C . C a rsten s (G e n e ra l S e c re ta ry , M assachusetts S ociety fo r th e P re v e n ­
tion of C ru elty to C h ild re n ): T h e re is a questio n w hich, it seem s to m e. is
com ing into th e social w o rk fo r ch ild ren a n d n eed s o u r v ery c arefu l consid eratio n
d u rin g th e n e x t few y ears. T h e re a re S tates of th e U nion w h e re th e p riv ate
agencies a re p ractically doing all, o r a t least 75 p e r c en t of th e w o rk . T h e re a re
o th e r S tates in th e U nion w h ere p u b lic ag en cies a re p rac tic a lly doing all, o r, w e
will say, 75 p e r cen t of th e w o rk . I know of S tate agen cies th a t a re in ev ery w ay
d iscouraging p riv ate agen cies to g et u n d e r w ay a n d to assist in doing th e w ork,
I know S tates w h ere th e re a re p riv a te agencies th a t in a good m an y w ays a re
blocking th e public w o rk . I th in k it is tim e fo r u s to find o u t w h e re w e stan d o n
th a t question. W h a t shall b e th e relatio n of th e p riv a te ag en cy to th e p ublic
agency? T h e re is a fu n d am en tal service th a t b o th can re n d e r. I do n o t m ean
th a t a t this m o m en t I am re a d y to give a n y o u tlin e of w h at it shall be. B ut I
believe th a t w e have g o t to do som e th in k in g a b o u t it, a n d have som e considerable
discussion of it, so th a t w e m ay h av e b o th , fo r 1 do n o t believe th e d ev elopm ent of
an y S tate, w h e th e r it is in th e M iddle W est, th e F a r W est, o r th e E ast, w ill b e
rig h t unless th e re is a relatio n sh ip grow ing u p b etw een pub lic a n d p riv a te services
so th'at th e y m ay su p p lem en t e a c h o th e r, a n d th a t n e ith e r sh a ll th in k it its d u ty to
kill off th e o th er.
M rs A d a E. Sheffield (D ire c to r, B u reau o n Illegitim acy, B oston, M assachu­
setts) •’ I have w o rk e d o n a pu b lic b o ard , a n d I have h a d co n n ectio n s w ith quite
a few p riv ate agencies. It h as im pressed m e th a t b o ard s of p riv a te agen cies are,
w ith few exceptions, lo o k in g fo r th e pro m isin g cases; th e y like to see resu lts; a n d
of course, as th e ju d g e of th e c o u rt of special sessions in New Y o rk once said to
m e, one can m ake w o rk 100 p e r c e n t successful b y ta k in g u p o nly th e b e st cases.
It h as b een m y opinion th a t, as betw een th e tw o kinds of w o rk , w o rk fo r p ro m ­
ising children an d w o rk fo r ch ild ren th a t do n o t show p ro m ise on th e face o f
things, th e pu b lic ag en c y is fairly w ell e q u ip p ed to ta k e c a re of th e p ro m isin g child.


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It is n o t w ell eq u ip p ed to ta k e c a re of th e difficult child, w ho n eed s close intensive
stu d y a n d experim en tin g — try in g -o u t of m eth o d s th a t th e S ta te h as n o t y e t ta k e n
over. T h a t seem s to m e to be th e o n ly excuse fo r h av in g p riv a te ag en cies. A t
p resen t, th e b o ard s of p riv a te ag encies a re n o t in tere ste d in th a t k in d of w o rk ;
b u t it is m y ow n opinion th a t th e y could be b ro u g h t to b e in te re ste d in it. T h a t
w ould give th e excuse fo r h av in g p riv a te agencies. T h e la tte r a re going to be
asked, before a g re a t w hile, w h a t th e ir fu n ctio n is. W h y sh o u ld w e give m o n ey
to those agencies, w hen w e p a y tax es to m ain tain th e p u b lic ag en cies? U n d e r
such a division of functions, p riv a te ag encies w ould fill a g en u in e n eed.
D r. H astings H . H a rt (R ussell Sage F ound atio n , New Y o rk C it y ) : 1 a m co n ­
vinced n o t only th a t w e n eed pu b lic supervision, b u t th a t w e n eed supervision o f
som e of o u r superviso rs. T h e tr u th is th a t a good m an y p eo p le w ho h av e th a t
responsibility laid u p o n th em have n o t y e t g o t a co n cep tio n of w h a t is m ean t.
W h a t w e n eed is to g et su p erv iso rs in th ese in stitu tio n s to stu d y th e ir jobs.


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C H IL D W E L F A R E W O R K IN JA P A N
By TA K AY UK I NAMAYE
D ep a rtm e n t of In terio r, Ja p an

Ellen K ey said th a t th e tw entieth century w as th e century of th e
child. It is well said, for th e w orld is beginning to realize th e im p o rt­
ance of children’s w elfare as never before. T h e protection of children
is d em an d e d n o t only from th e consideration of hum anity, b u t also from
th e self-evident tru th th a t th e future w elfare of society a n d n ation a t
large d ep e n d s u p o n th e h ealthy m inds an d bodies of the present chil­
dren. It is the realization of this fact th a t has m ad e th e question of
ch ild ren ’s w elfare a social an d national pro b lem from th e la tte r half
of th e n ineteenth century up to th e p resen t tim e. T h e fact th a t a
bu reau fo r ch ild ren’s w elfare w as organized in th e A m erican L ab o r
D ep artm en t ab o u t six years ago, although m any S tates a t th a t tim e
h a d highly efficient organizations fo r children’s w elfare w ork, m ust
h av e b een d u e to th e sam e consideration.
J a p a n is n o t b eh ind o th e r nations in appreciating th e im portance of
ch ild ren ’s w elfare; b u t our m eans fo r prom oting it are far inferior to
those of A m erica an d th e nations of E urope. V arious circum stances,
custom s, an d hab its are responsible for th e p o o r accom m odations; b u t
it is b ey o n d th e scope of this p a p e r to discuss them . I shall confine
m yself chiefly to stating w h at regulations an d provisions different d e ­
p artm en ts h av e in reg ard to child w elfare, a n d give explanations an d
personal view s only occasionally. T h e d ep a rtm en ts th a t supervise chil­
d re n ’s w elfare are th e D ep artm en t of Interior an d th e D ep artm en ts of
E ducation, of Justice, an d of A griculture an d C om m erce. In discussing
children’s w elfare w ork, it is convenient, therefore, to divide it as it is
d iv id ed b y th e d ep artm ents.
T H E D EPA R TM EN T O F INTERIOR

C hildren’s w elfare w ork u n d er th e D ep artm en t of Interior m ay be
d iv id ed into tw o classes; nam ely, th a t w hich is regulated b y law and
th a t w hich is not.
U n d e r th e first class w e h av e ( 1 ) th e provisions of th e P o o r Law
concerning th e children of th e poor, (2 ) the F oundling A ct, an d
( 3 ) th e R efo rm ato ry A ct.
( I ) T h e P o o r Law w as enacted in Ja p a n in 1874, an d th e provision
in question states th a t th e forlorn children u n d e r thirteen years of age
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shall b e given rice a t th e ra te of th ree bushels an d a half p e r year, a n d
states also th a t th e children w ho, although n o t strictly forlorn, h av e
no relatives u n d e r seventy an d ab o v e fifteen years of age, an d are in
distressing condition, shall receive the sam e am ount of rice as th a t
allow ed to th e forlorn children. It is h ard ly necessary to say th a t this
m eth o d of relief is v ery prim itive an d the recipients necessarily v ery
few.
T h e expenses are to b e p aid b y the national treasury; b u t as
a m a tte r of fact th e local public corporations supply the deficiency,
w hich am ounts to a considerable sum, although their legal responsi­
bility in th e m a tte r ends w ith th e actual carrying o u t of th e relief
m easures.
T h e latest statistics, w hich are those of 1917, will give a general
id ea ab o u t th e am ount o f expenses an d th e n u m ber of recipients, as
they h av e n o t increased or decreased to any g reat extent in late years.
G overnm ent e x p e n s e ................................................................................................. ip§ 3,070
Local expense su p p le m e n ta ry to th e go v ern m en t e x p e n se ........................... Y 8,452
L o c a l e x p e n s e ..............................................'................... • . . . . . . . ................... .. Y 23.630
T o tal ............................................................ .............. ............................................ Y 35.152
T h e to tal n u m b er of child ren cared fo r w as 1,203, of w hom 213 w ere c a red
for a t g overnm ent expense an d 990 a t local expense o r a t local expense su p p le­
m e n tary to g overn m en t expense.

It should b e noticed that, although th e local public co rporations are
n o t required b y law to p ro v id e m oney fo r th e relief of th e p o o r chil­
dren, th e actual financial assistance given b y them to th e relief w ork is
com p arativ ely large, as the governm ent allow ance is insufficient, its
policy being to let them tak e th e m atter as m uch as possible into th eir
ow n hands.
(2 )
T h e F oundling A c t w as passed in 1871, a n d is th e oldest
of th e relief enactm ents now in force in Jap a n . T h e original act en ­
jo in ed th a t th ree bushels an d a h alf of rice p e r y e a r should b e given to
each foundling until h e reached his fifteenth y ear; b u t in 1873 th e age
lim it w as red u ced from fifteen to thirteen, an d has rem ained so ever
since.
T h e n u m b er of foundlings found in Ja p a n in a y ea r is very sm all com ­
p ared to those found in any of the E uropean countries w ithin th e sam e
length of tim e,— a fact of which Ja p a n can b e proud. F o r illustration
th e n u m b er of foundlings for several recent years m ay b e given:
Y ear

F oundlings

191 1 i ........................................................
1 9 1 2 .......... .............. .. . ....................................................... ..........274
1 9 1 3 . . . . ...............................................................

1914 ...............................................
1 9 1 5 .......... .... ......................... . . . . . .............. • . ............... 301
A v erag e fo r th e five years.*.................... ................... « . . . .2 4 6
1A yen is w o rth ap p ro x im a te ly fifty cents.


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323

In a country possessing a population of m ore th an sixty millions,
only tw o h u n d re d an d forty-six foundlings a y ear is in d eed a very
sm all p ro p o rtio n . O ne m ight suspect th a t this scarcity o f foundlings
m ay b e d u e to th e strangling of infants or to ab o rtio n ; b u t now such
crim es are seldom p e rp e tra te d in Japan, though in the p ast they seem to
h av e b een quite frequent. In 1916, th e to tal n um ber of the foundlings
u n d er th e p ro tectio n of this law w as 1,733, an d the to tal expense for
them Y 6 6 ,8 2 6 . T h e foundlings being so few, it is scarcely necessary
to h av e sep arate asylum s for th e m ; so th e public corporations p u t them
u n d er th e care of o rp h an asylums.
It will b e seen th a t th e to tal num ber of th e children u n d er th e p ro tec­
tion of th e P o o r L aw a n d th e F oundling A ct is ab o u t 2 ,9 3 0 for a year,
an d th e ag g reg ate sum of expenses for them only ab o u t Y 101,970.
E uro p ean an d A m erican specialists m ay, no doubt, w o n d er a t these
sm all figures; b u t I believe th a t th e chief causes are th e following
fa c ts:
(a )
(b )
has n o t
(c )
(d )
(e )
of th eir
(f )
(g )
poor.

T h e Jap a n ese P o o r Law is extrem ely retrenching.
Social consciousness of th e necessity of supporting th e p o o r
y et daw ned.
T h e spirit of m utual help is quite strong.
T h e strong solidarity of th e fam ily system .
T h e strictness of legal responsibility of p aren ts to tak e care
children.
T h e n atu ral kindness of Jap a n ese people tow ards children.
T h e com paratively sm all disparity betw een th e rich a n d the

(3 )
T h e R efo rm ato ry A ct w as first enacted in 1900 an d was
am en d ed in 1908. T h e act requires each prefecture to establish re­
form schools to tak e in delinquent children u n d e r eighteen years of age,
th e u p p er age-lim it of th e inm ate being tw enty. T h e-b u lk of th e ex­
pense is to b e p aid b y th e prefecture; b u t one-half of th e expenses
required in founding reform schools an d one-sixth of running expenses
are to b e g ran ted from th e N ational treasury.
T h ere are 54 local reform schools in Ja p a n a t present. T h ey are d i­
v id ed into tw o kinds, public a n d private. T h e public reform schools
are 28 in num ber, th e p riv ate ones 26. T h e to tal n u m ber of inm ates
of all these refo rm schools a t th e end of 1917 w as ab o u t 2,100, of
which ab o u t 5 0 0 w ere tak en in during th a t sam e year. T h ey are m ostly
trea ted u n d er th e fam ily system o r u n d er a system which is a com bina­
tion of th e fam ily system a n d th e do rm ito ry system . O ne h u n d re d an d
fifty is th e largest n u m ber of inm ates th a t a reform school has a t present,
an d 9 o r 10 is th e sm allest. U n d e r th e fam ily system , ab o u t 10 inm ates
are tak en in as a rule an d th e m aster an d m istress o r nurses look afte r

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them . T hey are given som e elem entary school lessons in th e m orning
an d som e practical lessons in th e afternoon, m ostly in agriculture an d
m anual labor. W e h av e no accurate statistics as y et on th e results of
these efforts; b u t w e can say th a t 70 p e r cent of th e inm ates com e out
of the reform schools m uch im p ro v ed . T h e to tal expense in 1917 was
Y 2 4 6 ,8 8 6 , of which Y 4 4 ,0 0 0 was G overnm ent subsidy.
Besides the local reform schools, th ere is one national reform school
which w as o p en ed in M arch of this year. T h e num ber of inm ates is
lim ited to 100. A training school for officers an d staffs for reform
schools in general is to b e established in this institution.
T h e special feature of our R eform atory A ct is th a t th e executive d e ­
p artm en t, an d n o t the judicial, is the one th a t places th e delinquent chil­
d ren in th e reform schools. T his is because w e believe th a t th e purpose
of placing delinquent children in reform schools is n o t to punish o r im ­
prison them , b u t to ed ucate an d im prove them , an d to m ake them
d ecen t m em bers of society. It is, therefore, th e prefectural governor
w ho issues the o rd ers to b e served upon those w hom he thinks it to b e
ad v isab le to p u t u n d er th e care of a reform school. T his is a pro ced u re
which is seldom seen in o th er countries.
T h e reasons w hy th ere are only ab o u t 2 ,0 0 0 delinquent children
in m ore th an 50 reform schools are (1 ) th e scarcity of delinquent
children in Jap a n , an d (2 ) th e inadequacy of th e R efo rm ato ry A ct.
T h e G o v ern m en t is contem plating a revision of the act to m ak e it m ore
effective.
U n d er th e w elfare w ork n o t regulated b y th e law, we h av e ( 1) o r­
p h a n asylums, (2 ) d ay nurseries, (3 ) the C om m ittee on Social A ffairs
fo r w ork on th e B ureau of Local Affairs, (4 ) the C om m ittee on Inves­
tigation of H ealth an d S anitation, an d (5 ) the Lectures on S anitation
fo r W om en.
(1 )
O rp h an Asylum s.-—T h e origin of orphanages in Ja p a n was
m o re th an ten*centuries ag o ; b u t it is unnecessary to dw ell u pon its
long an d obscure history. I shall speak only of th e orp h an ag e w ork
since th e R esto ration of 1868. T h e first orp h an asylum b uilt in Ja p a n
in th e M eiji era w as started by a F rench C atholic nun in 1874. This
o rph an ag e has b een m aking g reat efforts for p o o r an d o rp h a n girls for
th e p ast 45 y ears an d takes th e first ran k am ong th e orp h an asylum s
in J a p a n in the n u m ber of children taken in, w hich is o ver 4 ,1 0 0 . B e­
sides this, one of the best know n asylum s in Ja p a n is th e O kayam a
O rp h an A sylum , w hich w as started b y the late Ju ji Ishii, who’’h a d been
g reatly inspired b y G eorge M uller. T his is w idely know n as th e m odel
o rp h an ag e in Jap an .
T h ere are a t present 138 orp h an asylum s w ith 6 ,5 0 0 inm ates.
T h eir ag g reg ate expense for a y ear is ab o u t Y 4 2 0 ,0 0 0 . T heir p ro p e r­
ties are estim ated a t m ore than Y 2 ,0 0 0 ,0 0 0 . T h ey are, w ith v ery few

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S P E C IA L C A R E— T H E ST A T E

325

exceptions, p riv ate enterprises founded b y som e ben ev o len t person;
an d in financial m atters they are alw ays h a rd pressed because th ere are
n o t enough of public orp h an asylum s to relieve th e p riv ate ones of their
burdens. It is true th a t th e D ep artm en t of Interior subsidizes, to som e
extent, such institutions as are doing excellent w ork, an d each p refec­
tu re gives som e financial aid to those th a t are w ithin its jurisdiction, out
o f the interest on the com m on fund of Y 5 ,0 0 0 ,0 0 0 , w hich w as gran ted
b y th e Im perial H o u seh o ld ; an d th e m oney th a t com es from public
co rp o ratio n s w hen they give the charge of foundlings to orphan^ asy­
lum s is of som e help. But all these aids are far from being sufficient to
enable o rp h an ag e w orkers to carry on their w ork as th ey wish.
T h ere are now ab o u t 700 ch aritable institutions in Jap a n , an d th ere
are indications th a t they will increase y ear afte r year. It seem s th a t
C hristianity is responsible for this stirring tip of the public consciênce.
T h ere are m o re th an 70 charitable institutions u n d e r th e m anagem ent
of Christians, an d 30 of these are for orphan children, B ut charitable
institutions are n o t m onopolized b y C hristians b y an y m eans. In fact,
B uddhists h av e m ore th an 80 of them u n d er th eir m anagem ent, an d
their institutions fo r orphan children also outnum ber those conducted
by Christians. It should b e m entioned here as a tribute of praise to b o th
C hristians an d B uddhists that, though they differ in their religion, they
are w orking h an d in h an d for the cause of charity.
T h e u n w eaned o rphans are m ostly p laced u n d er th e care of farm ers’
fam ilies an d w hen they reach school age they are, as a rule, tak en into
th e regular orphanage. • In Ja p a n th e farm ing p o pulation is v ery large
as co m p ared w ith th e city population, an d th ere is n o t m uch difficulty,
therefore, in finding suitable fam ilies am ong farm ers to w hom to entrust
these children, an d the result has been excellent. T hose w ho can not
b e p laced in fam ilies are tak en into the regular o rp h an asylum s w here
th ey are now m ostly trea ted u n d er th e fam ily system , though in the past
th ey used to b e tre a te d u n d er th e do rm ito ry system . T h e o rp h an asy­
lum s co n d u cted u n d e r th e fam ily system h av e from ten to fifteen in­
m ates w ith a nurse o r a m aster an d m istress to look a fte r them .
(2 )
D ay N urseries.— T h e first d a y nursery in Ja p a n w as estab ­
lished b y th e K obe W om en’s Public Service A ssociation during the
R usso-Japanese w ar. A t th a t tim e w hen it w as necessary to support
the p o o r fam ilies of soldiers w ho w ent to the fro n t b y giving them som e
w ork, an d to en able m pthers w ith sm all children to w ork th ey hit upon
th e id ea of th e d a y nursery an d im m ediately som e h u n d re d d ay
nurseries sprang up in different p arts of Ja p a n ; b u t soon a fte r the
w ar all except one o r tw o closed. Lately, how ever, their necessity was
felt again owing to the dem an d s of th e times, an d as a m a tte r of fact
they are increasing rapidly in num ber com pared w ith o th er charitable
institutions. A lm o st all the d a y nurseries in Ja p a n are priv ate establish
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m ents. T h ey are div id ed into creche an d infant schools. T h e form er
tak e b o th th e unw eaned an d infants, th e la tte r th e infants only. T h e
fo u r d ay nurseries m anaged by the W a r M em orial D ay N ursery A sso­
ciation o f K obe, an d the Sam egahashi Infant School of T okyo are
am ong th e best know n in Jap an . T h ere are o v er fifty d a y nurseries
now an d o v er th ree thousand infants tak en care of b y them . T h e to tal
expense is m ore th an Y 5 0 ,0 0 0 . In every d a y nursery great care is
tak en ab o u t the h ealth of th e children.
In J a p a n th ere is v ery little settlem ent w ork; b u t in th e d a y nurseries
th ey h av e fam ily m eetings from tim e to time, an d they even visit th e
p o o r fam ilies an d encourage them to save m oney an d give o th er a d ­
vice. In this w ay they are doing a sort of settlem ent w ork to th e g reat
benefit of the p oor. T hough th e d a y nurseries have b een only recently
organized, th eir g ood w ork is alre ad y ap p reciated b y th e public.
(3 )
C om m ittee on Social A ffairs.— T h e Jap an ese G overnm ent,
in view of the ten d en cy of th e times, deem ed it advisable to m ake
investigations ab o u t th e social conditions, b o th a t hom e an d ab ro ad ,
w ith th e pu rp o se of availing itself of th e suggestions o b tain ed from th e
investigations in coping w ith problem s th a t m ay arise in th e future,
a n d organized a com m ittee on social affairs, consisting of tw enty m em ­
bers, p artly selected high officials of th e G o v ern m en t an d p a rtly ex­
p e rts w ho h av e special know ledge an d experience on such m atters. T h e
com m ittee m akes investigations ab o u t such m atters as are requested by
th e M inister of th e D ep artm en t of Interior, an d m akes rep o rts giving its
view s on them . T h e scope of investigation is quite extensive. A t th e
last y e a r’s m eeting th e subjects b ro u g h t for discussion w ere th e public
m arket, th e housing problem , th e em ploym ent bureau, th e ad ju stm en t
o f capital an d labor, an d others. T h e com m ittee is to m ake a thorough
investigation of children’s w elfare w ork in th e n e a r future w ith th e
p u rp o se of aiding those institutions alread y in existence an d of es­
tablishing new ones.
F ro m tim e im m em orial th e Jap an ese h av e h a d th e custom of an ­
cestor w orship an d even now they attach a peculiar im portance to the
notion of “ fam ily,” an d children as future successors to th e “ fam ily”
are trea ted w ith g reat care. T h ey are re g ard e d literally as fam ily
treasures. A w ell-know n old Jap an ese poem says:
Silver, gold a n d p recio u s stone,
W h at a re th ey in com parison
W ith a d a u g h te r an d son?

T rav elin g th rough any p a rt of Ja p a n you will see im ages of G ods an d
G o d d esses w hich are reg ard e d as p ro tecto rs of children. F rom this
superstition also you can see how solicitous th ey are for children’s w el­
fare. A t any rate, th e birth ra te is alw ays on th e increase, an d Ja p a n
do es n o t h av e to resort to a prem ium system for the encouragem ent of

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childbirth as in o th er countries. T h e following statistics show th a t not
only d o es th e b irth ra te exceed the d ea th rate, b u t it is also steadily
increasing every y ear— a phenom enon seldom seen in any o th er
country.
Y ear
1885
1895
1905
1910

B irth R ate
1,058,137
1,335,125
1,614,472
1,737,674

R ate of In crease of Pop>
D eath R ate
latio n p e r 1,000
753,456
7.8
8 76,837
10.9
1,016,798
12.8
1,037,016
13.4

T h e statistics for 1910 show th at the num ber of births exceeded th at
of d eath s b y o v er 700,000.
B ut though w e are v ery optim istic ab o u t the birth rate we are som e­
w h at alarm ed ab o u t th e d eath rate of b ab es an d infants, for it has
b een increasing in the p ast except in very recent years, as can b e seen
in th e follow ing statistics on the d ea th ra te of the unw eaned less than
one year old.
T h e follow ing figures show th e yearly average ratio of thes6 deaths
for every h u n d re d births:
1886-1890
1891-1895
1896-1900
1901-1905
1906-1910
1912
1913

..........................................................
. . .............................................
.
.........................................................
.......... ....................................... .. ; .
.................................................................
............................................................

117
14 7
15 3
15 4
15.7
15.4
15.2

T h e slight decrease in the d ea th ra te as show n in th e last tw o figures
m a y b e d u e to th e efforts w hich the G overnm ent has been m aking of
late years.
T h e av erag e d ea th ra te p e r hun d red children over one y ear an d
below five years of age is as follow s:
P eriod
1889-1893 , .
1894-1898 . .
1899-1903 . .
1904-1908 . .

A ge I -2 Y ears
.................. 4.51
.................. 4.29
.................. 3.38
................. 4.37

A ge 2-5 Y ears
2.24
2.07
1.70
1.98

A ge 0-5 Yea:
5.82
5.92
5.65
6.13

T h e ab o v e figures show th a t the d eath rate of children u n d er five
y ears of age has n o t m aterially decreased, b u t is still ab o u t tw ice as
high as th a t of som e E uropean countries. It is a re g rettab le fact th a t
n o tw ithstanding this enorm ous d ea th ra te of children th e re are very
few p riv ate enterprises to co m b at this problem . A t p resen t th ere is
only one m o th ers’ consultation society in T okyo a n d a n o th e r in O saka.
T h ere are hospitals for children, th e circuit hospitals, visiting nurses,
an d such organizations, w hich m ay b e available in giving m edical tre a t­
m ent to sick children, b u t these accom m odations are b u t a few d ro p s
in a bucket. T his state of things m ay look strange in a country which
has b een called b y som e “ th e parad ise for children,” b u t the fact is

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th a t th e social consciousness has n o t been aw akened to the actual
state of affairs, the public a t large having no know ledge of it.
(4 )
T h e C om m ittee on Investigation of H ealth an d Sanitation.
— T w o v ery prom ising organizations h av e b een started lately to p ro b e
this pro b lem — nam ely, th e C om m ittee on Investigation of H ealth an d
S anitation an d the Lectures on S anitation for W om en. T h e form er,
which w as started b y Im perial D ecree in 191 6, is u n d er th e supervision
of th e D ep artm en t of Interior an d a t present has thirty-six m em bers,
p a rt g o v ernm ent officials, p a rt non-official experts. T h e V ice M in­
ister of the D ep artm en t of Interior is th e p resid en t of th e com m ittee.
T h e w ork of the com m ittee is divided into eight divisions, an d one of
them is th e investigation of th e health of infants, school children, and
youth. T h e m atter which has alread y b een investigated an d published
is the d eath ra te of children u n d e r five years for th e last ten years.
O th er m atters now u n d er investigation are th e sickness of school chil­
dren, physical d ev elo p m en t of babies, th e health conditions in th e day
nurseries an d o rp h an asylums, an d th e condition of ab o u t 2 0 ,0 0 0 sick
infants in the pediatric d ep artm en ts of th e m edical school. T h e com ­
pletion of statistics on those m atters will facilitate in ascertaining the
causes, w h eth er this higher d eath ra te is d u e to p o o r nutrition o r to the
m o th er’s lack of know ledge in rearing children o r to endem ics. T hen
th e com m ittee will b e in a position to devise som e suitable m eans to
check th e w idespread death s an d diseases.
(5 )
T h e L ectures on S anitation fo r W o m en.— In prefectures and
public co rp o rations in our country, lectures on sanitation are held
fo r w om en. A lthough these w ere fi^st started scarcely ten years ago
th ey are now held th ro u g h o u t m ost of th e country. T h e aim of
these lectures is to diffuse am ong w om en know ledge in th e rearing
an d care of children. T h e regular m eetings continue several days a t a
place an d som etim es they h av e exhibitions of things w hich are of in­
terest to th e w ork, som ething like th e B aby W eek M ovem ent.
It is possible th a t b y these m eans, the d ea th ra te of infants in Ja p a n
will b e red u ced as low as in o th er countries.
T H E D EPA RTM EN T O F ED U C A TIO N

•

T h e P rim a ry S chool E d u catio n

( 1 ) H istory.— C om pulsory education is th e m ost im p o rtan t m eans
of building up a h ealthy nation by inculcating a w holesom e national
spirit an d diffusing general know ledge am ong th e children of school
age. . A ll n ations of E urope arid A m erica h av e a d o p te d it long ago.
In J a p a n it w as in 1886 th a t com pulsory education was ad o p ted .
T h e p resen t school regulation requires six years’ course of instruction
an d as a rule does n o t charge an y school fee.
(2 ) M atriculation an d A tten d an c e.— T h ough it is only thirty years

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since school education becam e com pulsory, school houses have been
built all o v er th e country. T h e following tab le shows th e percentages
of m atriculations an d atte n d a n c e from 1911 to 1915:
Year
1911
1912
1913
1914
1915

Percentage of
Matriculation
....................................... i t _____ 98.23
.................... ........................ .. 9 8 .1 6
.......... .............................................. 9 8.26
................................... ; .................... 98.47
.............................. . . ...................... 98.61

Percentage of
A ttendance
92.47
92.78
93.36
9*3.69
94.25

(3 )
T h e N um ber of Schools an d School C hildren.— T h e num ber
of schools in 1914 w as: public, 2 0 ,4 4 0 ; private, 1 36. In 1915 it w as:
public, 20,5 18; private, 150. T h e num ber of school children in 1914,
6 ,7 0 0 ,0 0 0 ; 1915, 6 ,9 0 0 ,0 0 0 .
(4 )
Finances.— Expenses are p aid by public corporations. T hey
am o u n ted in 1914 to Y 5 6 ,7 2 0 ,0 0 0 an d in 1915 to Y 6 0 ,0 0 0 ,0 0 0 .
T his ra p id increase o f expenditure is due to th e fact th a t th e population
of J a p a n increases b y 6 0 0 ,0 0 0 or 700,000 every y ea r an d conse­
qu en tly m an y new school houses m ust b e built. Such being th e case,
th e b u rd e n of th e self-governing com m unities becom es h eavier yearly,
a n d in som e tow ns an d villages th e school expenses am o u n t to one-half
of th eir w hole expenditure. L ast y ea r th e G o v ern m en t decid ed to
g ran t ten m illion yen annually to relieve the self-governing com m unities
to som e extent.
(5 ) E xem ptions.— C hildren of school age afflicted w ith lunacy,
idiocy, o r serious illness m ay b e excused from m atriculation. G u a r­
dians too p o o r to send their children to school m ay p o stp o n e their
m atriculation. It is to b e reg retted th at th e nation an d self-governing
com m unities h av e no legal responsibility fo r educating these p o o r
children. B ut th e G overnm ent is contem plating m aking their ed u ca­
tion com pulsory, though it is n o t know n y et w hen this provision will
b e p u t in force. T h ere are som e public an d p riv ate schools, how ever,
w hich tak e in these p o o r children. So, in fact, this defect in our school
regulations is n o t so b a d as it appears. A s those special schools have
th e d o u b le aspect of being institutions of education an d of relief, they
are u n d e r th e jo in t supervision of the D ep artm en t of Interior an d the
D ep artm en t of E ducation.
(6 )
Institutions of R elief for th e D efective an d D estitute C hil­
d re n .— In 1917 th ere w ere tw enty-nine schools for the blind an d
d u m b (b o th p riv ate an d public) ; th ree schools for the deaf, and
thirty-eight schools for th e blind. T h e n u m b er of children taken
in b y these institutions w as 3,326. T h ey are given four or six years
of com m on education an d practical training, in m ost cases free of
charge. Som e of these special schools have dorm itories w here the
stu d en ts can b o ard with little expense. M ost of the blind students be
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com e m asseurs afte r their g ra d u atio n ; b u t as th e d eaf an d du m b can­
n o t easily earn a living, em ploym ent offices are established especially
for th eir benefit. T h e to tal expense of these 7 0 institutions was
Y 176,000 in 1916. T h e N ational treasury, th e self-governing com ­
m unities, th e educational associations, an d som e individual volunteers
co n trib u te to d efray th e expense.
In 1916 th e num ber of th e blin d children o f school age w as 3 ,2 4 0 ;
th a t of th e du m b children o f th e sam e age, 6,039. T hese num bers are
ra th e r large in p ro p o rtio n to th e n um ber of th e children taken in b y
these institutions for defective children. B ut as they are building new
schools an d enlarging som e of th e old ones, they will b e able to tak e
in a larg er p ercen tag e in th e future.
T o com e b ack to th e education of th e p o o r children, although th e
self-governing com m unities are n o t legally responsible for the educa­
tion of th e p o o r children w hose m atriculation is delay ed fo r reasons
sta te d 'b e fo re , som e of them h av e voluntarily established schools for
th e p o o r children. Besides these th ere are som e conducted b y in­
dividual benefactors. In 1915 th e re w ere 6 7 schools of this kind, of
w hich 52 w ere d ay schools an d 15 w ere night schools. T h e to tal num ­
b e r of th e pupils in these schools w as 14,1 76. T h e expenses for th e
sam e y e a r am o u n ted to ab o u t Y 142,000. M oreover, alm ost every
tow n an d village has societies for th e protection of the children of
school age. T ex tb o o k s an d lunches are distributed b y th em am ong th e
p o o r children. In this way, th e inadequacy of th e school regulations
is sup p lem en ted to som e extent.
(7 )
T h e School Physicians.— In 1898 an Im perial D ecree w as
issued to th e effect th a t all p rim ary schools except those in sm all
tow ns an d villages having less th a n 5 ,0 0 0 inhabitants should hire p h y ­
sicians to im prove th eir sanitary conditions, th e physicians to b e a p ­
p o in ted b y th e local m agistrates. Now m ost schools are too p o o r to
hire p riv ate physicians exclusively attac h ed to them — only those in
larg e cities can do that. C onsequently they hire o rd in ary practitioners.
T hus, nearly 5 7 p e r cent of the entire p rim ary schools, th a t is, 15,300
o u t of 2 7 ,0 0 0 , h av e th eir physicians. T hose physicians inspect the
sanitary conditions of th e schools from tim e to time, an d once a y ear
th ey m ak e physical exam inations of all th e pupils an d re p o rt to th e
D e p artm en t of E ducation an d also to th e g uardian of th e students.
T h e results of the physical exam inations of th e school children for
ten y ears (1 9 0 6 -1 9 1 5 ) show th a t their height, w eight, a n d lung ca­
p acity are getting m ore satisfactory.
A lth o u g h co nsiderable efforts are thus being m ad e for th e im ­
p ro v em en t of th e sanitary condition of schools, som etim es th e im ­
p ro v em en t d o es n o t com e up to th e expectation, because m ost of th e
school physicians, being p o o rly paid, can n o t give sufficient atten tio n

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ST A T E

to th e schools. T herefore, in th e large cities the schools are trying to
h av e their ow n physicians if possible. U n d e r th e p resen t regulation th e
school physician does n o t exam ine the m ental condition of the chil­
dren, b u t som ething will h av e to b e d o n e to rem edy this defect.
(8 )
T h e C entral O rgan.— F or b etter supervision of th e sanitation
of schools, th e D ep artm en t of E ducation established the School S ani­
ta ry Office in th e D ep artm en t in 1915, an d in ad d itio n to this org an ­
ized the School S anitary A ssociation as th e consulting organ of the
M inister of E ducation, an d also ho ld s a lecture class in th e d e p a rt­
m en t for th e benefit of th e school physicians from all over th e country.
A p art from this supervision of the D ep artm en t of E ducation som e p re ­
fectures h av e th eir ow n supervisors.
The Supplementary Industrial Schools

In J a p a n as elsew here th ere are m any g rad u ates of p rim ary schools
w ho desire to engage in som e industry. T o m eet this d em an d the
Jap an ese G o v ern m ent issued th e Industrial School O rder, encouraging
th e establishm ent of such institutions as are necessary to give p ro p e r
training to these graduates. * T hose institutions are technical, agricul­
tural, com m ercial, m ercantile, m arine, an d supplem entary industrial
schools. I shall speak here only of th e last.
T h e supp lem en tary schools are div id ed into technical, agricultural,
fisheries, com m ercial, an d o th er schools. T h ey m atriculate prim aryschool g rad u ates an d those w ho h av e an equivalent education. T h e
length of the course an d th e n u m b er of stu d y hours v ary according to
th e season, locality, an d th e like; fo r instance, th e supplem entary agri­
cultural schools are op en ed during the w inter season w hen th ere is little
agricultural work*to b e done. T h e supplem entary schools are of very
recen t origin in Jap a n , b u t they are m aking ra p id progress. O f these,
th e agricultural schools are m ost num erous, which is quite natural,
Ja p a n being essentially an agricultural country. T h e lessons taught in
com m on th ro u g h o ut th e various kinds of supplem entary schools are
m orality, th e vernacular, an d arithm etic. O th er lessons v ary according
to the kind of school.
In 1916 th e n u m ber of th e public an d p riv ate supplem entary schools
w as 7,063 an d th at of the students 369,000. T h e follow ing are th e
statistics for all kinds of supplem entary schools for th e ^ a m e y ear:
Public
N um ber of S chools. . 9,344
N um ber of P u p ils. . . 5 65,899
E x p en d itu re ........... Y 931.134

P riv ate
3,021
11,868
U nknow n

T o tal
3,697
577,747
U nknow n

*

T h e su p p lem entary school education is n o t yet com pulsory, b u t th e
w onderful grow th of this kind of school in a short p erio d shows th a t it
is alm ost as g ood as com pulsory, an d it is believed th a t the G overn/


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STANDARDS OF CHILD WELFARE

m en t will extend this course of instruction b y tw o years a n d then re­
quire those who do n o t receive high-school education to a tte n d one
of th e su p p lem entary schools.
.

The Religious Education

C atholicism was intro d u ced into Ja p a n several h u n d re d years ago;
b u t P ro testantism cam e in only a t the beginning of th e M eiji era
( 1 8 6 8 ) . In th e fifth y ear of Meiji, th a t is in 1872, th e first S unday
School w as opened, b u t for som e tim e th e grow th w as v ery slow. A b o u t
tw elve years ago, how ever, Mr. Brown, general secretary of th e W orld
S u n d ay School A ssociation, cam e to Ja p a n an d organized th e N a­
tional S u nday School A ssociation of Jap a n , an d from th a t tim e the
S u n d ay School w ork has m ad e a rap id progress, until in 1917 the
n u m b er of S u n d ay Schools reached 2 ,4 7 3 an d th a t of th e S unday
School children 160,000.
T h e follow ing tab le will show how rapidly the S unday School w ork
is grow ing:
Year
1907
1912
1917

No. of Schools
1 ...............
857
.............................................. 1,588
........
2,773

No. of Attendants
64,910
106,599
156,245

P rom inent m en like M arquis O kum a, B aron Shibusaw a, an d others
w ere ap p o in ted as the prom oting com m ittee of the W o rld S unday
S chool A ssociation C onvention, to b e held in Ja p a n in O cto b er of next
year, a n d p re p ara tio n for it is alread y on foot. T h e expenditure, it is
said, will b e Y 150,000. It is believed th a t th e com ing convention will
bring a new epoch to th e S unday Schosol w ork in Ja p a n an d will m ake
a g re at contribution to th e general education of th e Jap a n ese children.
S u n d ay schools w ere a t first all C hristian institutions, b u t of late
B uddhists also began to feel the n eed of them an d established their
own, an d it shoüld n o t b e overlooked th a t they h av e m ad e a rem ark ­
ab le progress w ith them .
T h e Y oung M en’s A ssociation is an institution w herein th e boys,
w ho, though g rad u ates of p rim ary schools, can n o t receive higher ed u ­
cation, g et to g eth er an d learn ab o u t ¡supplem entary studies, industrial
w ork, an d citizenship. T h e m anagem ent of the institution is left to the
self-governing com m unities, th e governm ent only giving instructions
on p ro p e r occasions. M ost of these associations w ere organized after
th e C h in o-Japanese W a r an d again afte r th e R usso-Japanese W ar.
T h ey h a d alre ad y d o n e m uch goo d for social im provem ent, an d in
1915, in view of th e G re at E uropean W a r an d for th e future w elfare
of Jap a n , the M inisters of the E ducation an d the Interior D epartm ents
gave jo in t instruction to th e prefectural G o v ern o rs for th e im prove
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m en t of th e Y oung M en’s A ssociations, which b ro u g h t them u n d er a
system an d m ad e them dou b ly efficient.
In m o st cases each city, tow n, an d village constitutes a Y. M. A .
district a n d h as its h ea d q u arters; b u t w ithin a district branches are es­
tablished to facilitate th e w ork an d to bring th e m em bers into close
touch. In som e counties an d prefectures they h av e h ea d q u arters to
supervise Y. M. A . w ork w ithin th eir districts. T h e age lim it is n o t
quite uniform th ro ughout th e country, b u t in m ost places tw enty, an d
in som e, tw enty-five years of age is the limit. A ccording to th e last
y e a r s re p o rt of th e D ep artm en t of Interior th ere are 18,482 associa­
tions an d 2,932,1 13 m em bers.
A m ong th e various w orks carried on b y th e Y. M. A ., th e m ost gen­
eral are th e sup p lem entary education, circulating library, keiro kai
(v en eratio n of aged p e o p le ), tem perance w ork, physical training, imp ro v em en t of am usem ent, p o p u lar education, an d the m oral training
of young m en. Instruction is m ostly given from tim e to tim e b y lec­
tures by school teachers, local officials, religious leaders an d som etim es
b y business m en.
T h e expenses of th e associations a re p a id : ( 1) out of m oney earned
an d co n trib u ted b y the m em bers of th e associations; ( 2 ) b y subsidies
from the cities, towns, an d villages; (3 ). b y individual subscriptions;
(4 ) b y incom e from th e capital; (5 ) the proceeds from cooperative
enterprises of th e associations. T h e to tal expenditure of all th e associa­
tions in th e co u n try fo r 1916 w as Y 736,750. T h eir p ro p e rty in th e
sam e y e a r w as estim ated a t Y 1,000,000.
T h e aim of th e Y oung W o m en ’s A ssociation is practically th e sam e as
th a t o f th e Y oung M en’s A ssociation, nam ely, to m ake m ore efficient
those girls an d young w om en w ho are graduates of p rim ary schools, b u t
w ho can n o t g et higher education. T h e w ork of this association is
n atu rally different from th a t of th e Y. M. A. It includes dom estic
work, hygiene, rearing of children, cooking, sewing, fam ily nursing,
m orality, a n d so on.' T h e instruction is given b y lectures of experts
in these lines. T hese associations are all of v ery recent o rig in ; b u t they
alread y n u m b er 8 ,852 an d h av e 1,049,652 m em bers. T h e age lim it
of th e m em bership varies from tw enty to thirty years.
O n e v ery n o tew o rth y feature of these tw o organizations is th a t they
som etim es h av e jo in t m eetings. T h e occasions fo r these jo in t m eet­
ings are w hen th ey h av e school exhibits, pictures, lectures on m oral
culture, ch aritab le w ork, an d so forth. I say it is no tew o rth y b e ­
cause in J a p a n com m ingling o f young m en a n d w om en in this w ay is
v ery rare, an d th ose jo in t m eetings, though hum bly started , m ay if
wisely co n d u cted on a large scale h av e a great significance for th e social
w elfare of Jap an .


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T H E D EPA RTM EN T O F JU STICE
T re a tm e n t of Juvenile C rim inals

T h e trea tm e n t of crim inals, especially young crim inals, is an im ­
p o rta n t question for crim inology. In 1907 th e crim inal co d e of Ja p a n
w as revised an d th e age of discretion w as fixed a t 14. T h e act says
“ th e acts of persons u n d er 14 years of age are n o t punishable.” Y oung
offenders ab o v e th a t age are punished b y ordinary crim inal law, th ere
being no special laws for them .
W h en a police officer ap p reh en d s a young offender, h e tak es him
into a police station an d th ere an d then th ey exam ine him. If the
offense is only slight they let him off w ith an adm onition; an d if it is
n o t so slight o r so serious th ey keep him in th e house of deten tio n for
n o t m o re th an 30 d ays; if it is serious they send him to th e public p ro ­
cu rato r’s office an d th e p ro c u rato r exam ines th e case an d decides
w h eth er th e offender should b e prosecuted o r not. T h e average num ­
b e r of young offenders w ho w ere subjected to judicial exam ination in
five recen t y ears w as ab o u t 3 0 ,0 0 0 ; of these only 10,000 w ere p ro se­
cu ted according to th e regular law — som e of them w ere fined, som e
p u t in jail, an d o thers im prisoned. T h e averag e n um ber of those w ho
w ere im prisoned during th e p erio d of th e five years 1913-1917 w as
2 ,2 4 8 . T h e statistics, how ever, reveal an annual decrease in th e num ­
b e r o f juvenile offenders in prison beginning w ith th e y ea r 1914, as
show n in th e accom panying tab le:
Y ear
1913
1914
1915
1916
1917

Male
2,156
2,684
2,092
2,021
1,828

Fem ale
183
189
172
163
148

T o ta l
2,339
2,873
2,264
2,184
1,976

T h e form of trial of young offenders is n o t uniform th ro u g h o u t th e
country, b u t in large cities like T okyo, O saka, a n d others, th e courts
h av e a juvenile d ep a rtm en t w ith a special judge. * T h ey usually segre­
g ate th e young offenders from ad u lt crim inals an d h av e a sep arate room
fo r them . T h e trials are n o t open to th e public. In these m atters th e
spirit a n d th e m eth o d closely resem ble those of th e juvenile courts in
A m erica an d E urope. B ut as th ere are no special law s fo r children
th e y are ju d g ed according to o rd in ary crim inal law.
T h e prison regulations p ro v id e th a t th e offenders u n d e r 18 years
o f age w ho are subjected to m ore th an tw o m onths of penal servitude
m a y b e p u t into special prisons o r special d ep a rtm en ts of regular
prisons, an d th a t they b e k e p t in them until they reach their tw entieth
year. T h u s th e juvenile offenders are trea ted in a different w ay from
th a t in w hich o rd in ary crim inals are trea ted , th e o b ject being their p ro ­
tection an d refo rm ation m ore th an punishm ent. M oreover, they are

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obliged to a tte n d school a given n u m ber of hours every day, a n d even
th e lab o r th ey are required to d o is ra th e r fo r their training th an for sup­
plem enting th e funds b y w hich th e prisons are m aintained. A t present
th ere are nine such juvenile prisons in principal places of Jap a n , an d
several m o re will b e established in th e n ea r future. In th e trea tm e n t
of juvenile offenders b o th th e g ra d e system an d th e m ark system h av e
b een a d o p te d an d th e choice betw een them is left to each prison.
W h eth er they use th e g ra d e system o r th e m ark system , they keep each
p riso n er in a sep arate cell for th e first th ree o r four m onths of his im ­
p riso n m en t in entire seclusion from th e outside w orld, an d if he show s
signs o f im p ro v em en t h e is p ro m o ted to a higher g ra d e an d trea tm e n t
becom es m o re lenient.
T h e result of this trea tm e n t is show n in the accom panying tab le:
Y ear
1913
1914
1915
1916

F irst O ffenses
2 ,220
1,903
1,851
1,787

Second a n d L ater
O ffenses
585
470
413
397

T h u s it m ay b e seen th a t th e num ber of offenses is decreasing every
year, b u t th e n u m b er of second an d later offenses has n o t m aterially
changed. T h e la tte r fact m ay b e due p artly to n o t im posing an indefi­
nite sentence an d p a rtly to th e lack of social sym pathy w ith th e dis­
ch arg ed prisoner.
It can easily b e im agined th a t m any of those w ho are set free w ithout
trial will re p eat the offense if ad eq u ate protection is n o t given to them .
T h erefo re w h eth er the juvenile offenders are hom eless o r not, som e
fu rth e r m eans of p ro tection is absolutely necessary. In this re g ard w e
reg ret th ere is no p ro b a tio n system in Ja p a n as yet. N ot th a t th ere is
nothing d o n e in th e w ay of their protection, for th ere are tw o hom es
for bo y s an d one fo r girls in T okyo. In those tw o places fo r b o y s they
look afte r m o re th an a thousand boys every year, a n d their w ork in
seven cases o u t o f ten is successful. T h ere are m o re of these societies
outside of T okyo, b u t they are n o t so active in their w ork as those in
T okyo. It is to b e h o p ed th a t m any m o re such societies will b e o rg an ­
ized in th e future to give ad e q u ate p rotection to th e m isguided youth.
The Children's Act

T h ough various a ttem p ts h av e b een m a d e a t devising m eans o f p re ­
vention of juvenile crimes, they h av e n o t accom plished th e desired re ­
sults; b u t it h as b een th o u g h t th a t th e establishm ent of juvenile courts
w ould b e b est suited for th e accom plishm ent of this object. T h e law
investigating com m ittee h av e b een w orking a t a bill fo r som e years, an d
the bill is n early co m pleted. It is n o t tim e y et for its p u b licatio n ; b u t—
generally speaking— it seeks to ap p ly a sort of p ro b atio n system to
those u n d e r 18 y ears of age w ho h av e com m itted som e crim inal

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STANDARDS O F C H IL D W E L F A R E

offense or are inclined to d o so.
as follow s:
(1 )
(2 )
(3 )
(4 )
(5 )
(6 )
(7 )
(8 )

W h a t th e bill seeks to accom plish is

To
To
To
To

give adm onitions from the court.
obtain adm onitions from th e principal of th e school.
d em an d a w ritten prom ise for repentance.
h an d delinquents o v er to som e p ro tecto r on certain co n ­
ditions.
T o place them u n d er th e care of som e religious organiza­
tion or pro tectiv e society.
T o place them u n d er p ro b atio n officers’ care.
T o send them to industrial schools.
T o send them to reform schools.

T h e re are also features n o t seen in th e law s of o th er countries, b u t
on th e w hole the provisions are practically th e sam e as the juvenile
court regulations of A m erica an d of Europe. If th e bill passes, afte r
som e am endm ents, it will d o a g reat deal of good in th e w ay of recti­
fying th e d efects of the present law.
T H E D EPA RTM EN T O F A GRICULTURE AND COM M ERCE

T h e d ev elo p m en t of factories in Ja p a n is of v ery recent origin. In
fact it is n o t fifty years old yet. T h erefo re th e capitalists an d factory
ow ners of J a p a n h av e n o t h a d experience in th e m anagem ent of such
enterprises. B efore th e introduction of the factory system , th e various
industries of J a p a n carried on their business b y m eans of h an d icraft
an d h om e industry. In those days, w hen international tra d e w as for­
b id d en an d th e principal of “ self-supply” h a d to b e enforced, no g reat
inconvenience w as felt from those old-fashioned m ethods, an d the
h an dicraftsm en an d those w ho w ere engaged in hom e industries d ra g ­
ged along in th eir w ork from m orning till late a t night in a m ost lax
m an n er w ithout an y definite restriction o f time. T h e relation of th e
em ployer an d em ployee was, of course, th a t of m aster an d servant.
But w hen C o m m odore P erry cam e an d b ro k e th e spell of a long dream ,
all of a su d d en the policy of isolation w as a b a n d o n e d ; international
com m erce w as allow ed, an d in fact everything changed in a v ery short
tim e. T h e social, political, an d business conditions u n d erw en t a com ­
p lete change an d left no trace to rem ind us of form er conditions. In
th e industrial circle also the factory w ork to o k th e place of h o m e in­
d u stry an d a g re at m any operatives b egan to w o rk w ith w onderful
m achinery an d to h av e definite hours of w ork. B ut even w hen such
violent change h a d b een accom plished, th e relation of th e capitalist an d
th e facto ry w orkers rem ained th a t of m aster an d servant. A s to th e
long h o urs of labor, too, em ployers, em ployees, a n d th e public a t large,
being accustom ed to it, n ever thought anything w as amiss.

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337

The Factory Act

Such being th e conditions u n d e r which th e factory system h a d d e ­
velo p ed , th e G o v ernm ent perceived the necessity of taking som e p ro ­
tective'm easures an d in 1882 organized a com m ittee to investigate th e
actual conditions an d custom s of th e factories th roughout the country.
In 1897 a bill w as d ra fte d b ased on the results of th e investigation by
this com m ittee. • But v ery unfortunately the P arliam ent dissolved a t
th a t tim e an d th e bill w as n o t even presented. A fte r m any years of
h a rd lab o r in overcom ing obstacles throw n in its way, the bill finally
passed th rough b o th H ouses in 1911 for th e first tim e; b u t it w as n o t
until 1916 th a t it becam e operative, owing to th e fact th a t deciding
on th e rules of enforcing th e law to o k a long time.
A s a result of this law, an Im perial D ecree w as issued ordering th e
D ep artm en t of A griculture an d C om m erce to establish a factory sec­
tion in th e D ep artm ent. In pursuance of this decree th e D epartm ent
ap p o in ted th e V ice M inister as th e sectional chief w ith four factory
supervisors an d five sub-supervisors to assist him . M oreover it has
b een d ecid ed to h av e local supervisors p laced in several im p o rtan t
places, an d in fact th ere are now ab o u t tw o h u n d re d of them distributed
in v arious p arts of th e country. T h e expenditure required in this w ork
is ab o u t Y 2 0 0 ,0 0 0 . A lthough we h av e now this F acto ry Law for th e
protection of child laborers, no special law has b een enacted as to th e
restriction o f th e w ork hours of ad u lt laborers, it being left entirely to
the ag reem ent betw een th e em ployers an d th e em ployes.
T h e restrictions placed u pon child la b o r are as follow s:
(1 )
T H E A GE O F T H E CHILD LABORER. "T h e fa c to ry o w n ers (e m ­
p lo y ers) a re n o t allow ed to h ire ch ild ren u n d e r tw elve y e ars of a g e ex cep t
u n d er special ad m in istrativ e perm issio n ."
(2 )
T H E PRO H IBITIO N O F N IG H T W O RK . "A ll child ren u n d e r
fifteen years of a g e a re n o t allow ed to be em ployed in a n y w o rk a fte r 10
P. M. a n d before 4 A . M. But fo r fifteen yedrs a fte r th e e n fo rcem en t o f this
law, those special in d u stries w hich re q u ire n ig h t w o rk o r co n tin u al day-andn ig h t w o rk m ay be exem pted from th e ap p licatio n of th is law b y th e p e r ­
m ission of th e M inister of th e D e p a rtm e n t.”
(3 )
HOLID AY S AND RECESS PERIOD S. "T o child ren u n d e r fifteen
y ears of age, tw o holidays should be allow ed in a m o n th a n d to child ren
of th e sam e age w ho a re em ployed in a business re q u irin g d ay -and-night
w ork, fo u r holidays should be allow ed in«, a m o n th , a n d if th e w o rk in g tim e
should exceed six h o u rs a day, a recess of a t least h alf a n h o u r should be
given to them , if te n ho u rs, a recess o f a t lea st o n e h o u r.”
(4 )
CASES W H ER E A SSISTAN CE IS T O BE GIVEN. “W h en a facto ry
o p erativ e m eets accid en t, falls sick, o r dies w ith o u t a n y serio u s fau lt o f his
own, th e em ployer is re q u ire d to give financial assistance to him o r to his
surviving fam ily.”


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STANDARDS O F C H IL D W E L F A R E
The Number of Child Laborers in Japan

T h e n u m b er of child w orkers in factories in 191 6 is show n in th e
accom panying ta b le :
A ge
10-12
12-15

T o ta l
. . . . . . . . . . 10,914
____ _____ .1 3 3 ,5 7 0

Boys
1,938
29,853

G irls ,0
8,976
103,717

31,791

112,693

A ll a g e s .......... . .1 4 4 ,4 8 4

T h e to tal n u m b er of th e ad u lt operatives an d th e child lab o rers in
factories being ab o u t a million, children form nearly fifteen p e r cent.
Welfare Work

Special arran g em ents m ad e for th e prom otion of the lab o re r’s w el­
fare are n o t few. Since th e o peration of th e F acto ry Law, th ey h av e
rap id ly increased, although their exact num ber is n o t y et ascertained.
In th e P refectu re of T okyo th ere are ab o u t 1,600 factories of all sizes
a n d ab o u t 2 3 0 ,0 0 0 operatives. T h ere are ab o u t 500 factories th a t
em ploy m o re th an 50 w orkers. S ixty-three out of these 500 factories
h av e m utual aid societies, som e of which, in case of sickness o r retire­
m en t o f th e m em bers, give financial aid out of the fund p a id -u p b y
operativ es exclusively, an d others of which give aid out of th e fund
co n trib u ted to b y th e operatives an d the em ployers. T h e la tte r usually
co n trib u te as m uch as o r h alf as m uch as th e to tal sum of th e con trib u ­
tion b y th e em ployees. T h ere are also d ay nurseries, rent-free houses,
dorm itories, bath-houses, places of am usem ent an d so on, alto g eth er
num bering 21 0. A n d for th e education of the em ployees th ere are
fifty-six institutions w here th ey train apprentices a n d give supple­
m en tary instruction o r p rim ary school education, an d th e p ro sp ect is
th a t these institutions will gradually increase.
I m ust confess th a t w h at has b een said ab o v e is a v ery im perfect
p resen tatio n of th e subject. A n d tim e does n o t allow m e to discuss
fully th e advisability o r inadvisability of th e long hours o f lab o r to
w hich Jap a n ese children are subjected. I should only say th a t lab o r
in J a p a n h as a peculiar history an d circum stances, an d now to a d o p t
th e A m erican o r E uropean system bo d ily in entire disregard of th a t
h istory a n d circum stances w ould b e only to bring on unnecessary dis­
tu rb an ce if n o t disaster. A s principles, th e propositions m ad e b y th e
C om m ittee on th e International L ab o r A lliance m eet o u r approval,
b u t J a p a n is u n d e r th e necessity of steering h e r course in this m a tte r
w ith d u e re g ard to h er peculiar internal conditions as well as external
circum stances, an d for this reason Ja p a n m ay h av e to b e trea ted as an
exception. W e are not, of course, satisfied w ith th e p re sen t condition of
th e F acto ry A c t; b u t w e m ust b e patient. P erseverance has accom ­
plished w onders. R om e w as n o t b uilt in a day. Jap an , though n o t very
slow in m aking progress, requires tim e to bring ab o u t such fundam ental
changes as suggested b y th e com m ittee now m eeting in Paris.

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CARE OF DEPENDENT CHILDREN
T H E C O NCLUSION S O F T H E W H IT E H O U SE C O N F E R E N C E TEN YEARS A FTER
By DR. HASTINGS H. H A R T
D irector, D ep a rtm e n t of C hild H elping, R ussell Sage F oun d atio n
New Y o rk City

O n e of th e last official acts o f P resid en t T h eo d o re R oosevelt w as th e
calling of th e W hite H ouse C onference w hich m et a t W ashington
Jan u a ry 25 a n d 26, 1909. T h e id ea of this very rem arkable conference
w as conceived an d its details w ere executed b y Jam es E. W est, now
C hief S cout E xecutive of th e national organization of th e A m erican Boy
Scouts. A b o u t 2 0 0 delegates w ere invited, representing every S tate
in th e U nion, a n d every kind of agency for d e p e n d e n t a n d neglected
child ren : S ta te b o a rd s of charities, b o a rd s of children’s guardians,
charity organization societies, associated charities, children’s hom e
societies, ch ild ren ’s aid societies, societies for th e prevention of cruelty
to children, juvenile p rotective associations, juvenile re fo rm a to rie s,%
orphanages, ch ild ren’s hom es, an d institutions for m others an d chil­
d ren. T h e deleg ates represented all form s o f religious belief, in­
cluding Catholics, P rotestants, Jew s, an d th e S alvation A rm y.
It w as felt th a t the conference ought to form ulate som e k ind of a
statem en t em bodying those principles u pon w hich these delegates
could agree, w hich m ight contribute to a b e tte r un d erstan d in g b e ­
tw een them , p av e the w ay for a g reater degree of cooperation an d
serve as a p o in t of d e p a rtu re for future progress an d for th e s ta n d a rd ­
ization of child-w elfare w ork. O n th e night b efo re th e opening of th e
conference, a sm all representative group of ab o u t 30 p eo p le m et in
th e New W illard H o tel to consider th e possibility of agreeing upon
such a statem ent. T h ere a p p e are d such a w ide diversity of opinion,
especially betw een th e representatives of the child-placing societies
a n d th ose of th e orphanages, th a t it seem ed as if it w ould b e im possible
to agree u p o n an y com prehensive p latfo rm ; b u t th e subject was
am icably discussed, an d it w as agreed th a t th e atte m p t should b e m ade.
O n th e follow ing d a y th e conference convened a t th e W hite H ouse,
w ith P resid en t R oosevelt in th e chair. A com m ittee on resolutions
w as ap p o in ted , of w hich I h ad th e h o n o r to b e chairm an. T h e other
m em bers w ere E d m o n d J. Butler, H o m er Folks, Julian W . M ack, an d
Jam es E. W est. A ll of th e m em bers of th e com m ittee w orked earnestly
339

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STANDARDS O F C H IL D W E L F A R E

a n d harm oniously. It is only fair to say, how ever, th a t th e cred it for
th e g re at re p o rt of th a t com m ittee belongs chiefly to Col. H o m er Folks,
w ho w as its author, to g eth er w ith th e late T hom as M. M ulry an d Ju d g e
Julian W . M ack, through w hose wise an d farseeing cooperation a sur­
prising an d h a p p y result was attained.
T h e conference sat fo r tw o days, during w hich the com m ittee on
resolutions w as h a rd a t w ork. A t tim es they sat in the conference to
catch th e spirit of its deliberations; a t o th er tim es they consulted w ith
m em bers of th e b o d y as to w hat should b e included in o r o m itted from
th e docum ent.
T h e re p o rt of th e com m ittee on resolutifins contained fourteen a rti­
cles, covering hom e care, preventive work, hom e-finding, th e cottage
system , incorporation, S tate inspection, inspection of educational w ork,
facts an d records, physical care, cooperation, undesirable legislation,
p erm an en t organization, a F ed eral C hildren’s Bureau, an d a sum m ary.
It is im possible, in 15 m inutes, to discuss in detail this g re at p latfo rm of
3,000 w ords. It included such vital propositions as th e follow ing:
1. T h e creation of a N ational C hildren’s Bureau, accom plished b y
th e p ro m p t action of P resid en t R oosevelt an d seconded b y his successor
P resid en t T aft, which resulted in the splendid b u reau w hose guests we
are to day.
2. T h e conservation of fam ily hom e life as “ th e highest a n d finest
p ro d u c t of civilization,” “ n o t to b e bro k en for reasons of poverty, b u t
only fo r considerations of inefficiency o r im m orality,” an d to b e p re ­
served b y “ such aid . . .
as m ay b e necessary to m aintain suitable
hom es fo r th e rearing of the children . . .
to b e given b y such
m eth o d s an d from such sources as m ay b e d eterm ined b y th e general
relief policy of each com m unity.” T his proposition has been realized:
first, th rough an increasing recognition of th e im portance of preserving
h om e life, b y th e courts, b y children’s aid societies an d children’s hom e
societies, an d b y th e constructive w ork of such agencies as th e societies
for th e prev en tion o f cruelty to children in B oston, B rooklyn, an d
P hiladelphia, a n d the C leveland H um ane Society; second, b y th e d e ­
v elo p m en t in m o st of th e S tates o f th e U nion of th e p lan of “m o th ers’
pensions,” “m o th ers’ assistance,” an d so forth. T his plan h as d e ­
v elo p ed w ith such rap id ity th a t it has n o t h a d tim e to crystallize into
fixed an d definite policies. It is clear, how ever, th a t it h as com e to stay,
an d th a t it involves a new realization of th e value of h om e life a n d th e
com m unity’s responsibility therefor.
3. A n em phatic en d orsem ent of th e do ctrin e th a t “ th e carefully
selected foster hom e is fo r th e norm al child th e b est substitute for th e
natu ral h o m e,” w ith th e proviso th a t “such hom es should b e selected
b y a m o st careful process of investigation, carried on b y skilled agents
th ro u g h personal investigation an d w ith due reg ard to th e religious

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341

faith of th e ch ild,” an d that, even for tem p o rary care, “co n tact with
fam ily life is p referab le for these children, as well as for o th er norm al
ch ild ren .” T h e use of b o ard in g hom es w as suggested, b u t the difficulty
of finding such hom es w as recognized b y th e stat