I

Having stated the problem of poverty, as it bears upon the child, as plainly and comprehensively as possible, I would fain leave it without further comment, feeling with Whewell that, “Rightly to propose a problem is no inconsiderable step towards its solution,” and believing that once the facts are known, and their significance understood, reform cannot be long delayed. Beyond the measures briefly suggested in the preceding pages, I would gladly leave the whole subject of remedial action untouched, regarding the purpose of this book as fulfilled in the statement of the problem itself. But when I have submitted the substance of the evidence herein presented to those whose knowledge and experience entitle them to be regarded as experts, or to popular audiences in the form of lectures, they have, with scarcely an exception, expressed the view that the statement of such a problem should be accompanied by some suggestions as to its solution; some indication of social and individual duty, lest the result be heaviness of heart and blackness of despair.

Whoever has seriously contemplated the misery and suffering which, like a poisonous cloud, encompasses modern society, must have experienced doubts and fears for the future, and, like the chastened patriarch of Uz, felt his hope “plucked up like a tree.” So many of the beacons that have shone out over the rough, perilous path of Humanity’s pilgrimage have turned out to be false lights, like the swinging lantern-lights of the old Cornubian wreckers, which lured trusting mariners to head their vessels to destruction upon the rocks, that we sometimes lose faith and despair of the visions of world-ecstasy, the “passionate prefigurings of a world revivified,” with which the seers of the race have beckoned us onward. And such despair blights and starves the soul of progress. When men cease to yearn for, and to believe in, justice, when they no longer aspire to social perfection, when old men cease to dream dreams, and young men to see visions of a nobler world than this economic anarchy, there can be no progress. Beautiful ideals seem to mock us at times, but it is doubtful if ever a beautiful ideal found lodgment in the heart of the humblest man without enriching the world.

If I were asked wherein the hope of the future lies, I should adopt for answer the message of a great rock. Travelling along the Yellowstone River, in the autumn of 1904, I saw an immense rock column, a veritable landmark for many miles, upon which some enthusiast had painted in large red letters, “Socialism is the Hope of the World.” Doubtless some ranchman, dreaming of a future world-righteousness, had conceived the idea of making that great natural obelisk a missionary for the faith he held, just as other enthusiasts had pasted the similar legends I had seen along the trails of the North Dakota prairies. I share that faith and hope, and believe that nothing short of the socialization of the means of life will ever fully and finally solve the problems inhering in our present industrial system, resulting in strife, bitterness, and the denial of human brotherhood. But long, weary years of suffering and struggle stretch between the present and that ideal state of the future. Socialism will, it is to be devoutly hoped, save the world from red ruin and anarchy and make possible a sweeter, nobler heritage for the generations yet unborn. But the most sanguine Socialist must see that it is little short of mockery to talk of the future triumph of his ideal in connection with the problem of relieving present misery and distress, to answer the hunger-cry of to-day with the promise of a coÖperative commonwealth in far-off years. All the Socialist parties of the world, with the exception of a few minor and unimportant factions, frankly recognize this and have formulated programmes of palliative measures for the amelioration of present evils. So far as I am aware, no non-Socialist political party has ever included in its programme demands for such measures as the abolition of child labor, the feeding of school children by the municipality, and the maintenance of municipal crÈches—demands which are included in practically all Socialist programmes. In suggesting only such remedial measures as may be taken by society or individuals within the present social state, and involving no fundamental change in the social structure, I do so, therefore, as one believing in the ultimate necessity of such change, and the right of every child born into the world to equal opportunity and equal share in all the gifts and resources of civilization.

II

In view of all the difficulties by which the problem is surrounded, the uncertain results which have attended some of the most intelligent and sincere efforts in that direction, he would be foolish indeed who ventured to dogmatize upon the reduction of the infantile death-rate, or the best methods to be adopted toward that end. There are, however, certain well-established facts, certain verities, upon which I would insist. It is perfectly obvious, for instance, that every child should be ushered into the world with loving tenderness, and with all the skill and care possible. The slightest blunder of an incompetent, unskilled midwife may involve fatal consequences to mother or child, or such injuries as are irreparable.^[153] So that the very first principle upon which everybody agrees, theoretically at least, involves the need of important legislative reform providing for the supervision of midwives, and the establishment of a system of training and education without which no midwife should be allowed to practise. That such a law would have the effect of materially lowering the rate of infant mortality, as well as that of mothers, no one who has ever given the matter serious consideration can doubt. From personal observation, and the testimony of gynecologists and obstetricians of large experience, I am satisfied that this reform alone would save many hundreds of lives each year, alike of mothers and infants. It is appalling to think of the large number of ignorant women who are practising as midwives. Many of them have no conception of the importance of their work; they are often dirty and careless, as well as ignorant of the first principles of obstetrical science. Knowing nothing of the need or value of antiseptic precautions, they are responsible for thousands of cases of blood-poisoning every year, and because they are ignorant of the methods of restoring asphyxiated infants they kill thousands of babes in the passage from the wombs of their suffering mothers.^[154]

In most states there is very little supervision of midwives; in some cases practically none at all. New York, always rather prone to take pride in its record upon such matters, has regulations which are wofully inadequate. All that is necessary to enable a woman to practise as a midwife is: (1) a certificate or diploma from some school of midwifery, native or foreign, or (2) signed statements as to her fitness and character from two physicians. No inquiry whatever is made into the bona fides or character of the school granting the certificate, nor are the physicians held responsible in any way for the women they recommend.^[155] So long as the applicant meets either of the foregoing slight requirements, the authorities must issue her a permit to practise as a midwife. She becomes a “registered midwife,” and the title creates an altogether unwarranted confidence in the minds of the people. It is not only the poor, illiterate immigrants who are thus deceived, but many very intelligent citizens are under the impression that a “registered midwife” has had some sort of training. Immigrants coming from countries like Germany, where all midwives have to undergo a thorough training, are naturally unsuspicious of the fact that here we have nothing of the kind. It is impossible to present the evil results of the employment of untrained and incompetent midwives statistically, or even to estimate them. Some idea may be gathered from the fact that, while the physicians of the New York Lying-in Hospital, in 1904, attended over four thousand confinements, 2766 of them in the tenement districts among the very poor, with only three deaths,^[156] one midwife, in a very similar tenement district, showed me a list of sixty-two cases she had attended with five deaths. And she spoke proudly of her “good record”!

In Germany for some years midwives have had to pass a regular examination. In England, under the Midwife Act of 1902, they are placed under a much stricter supervision than ever before, and are made responsible for the cleanliness and care of mother and child during the lying-in period of ten days. While it is felt that this law is inadequate, it is believed that its enforcement tends to improve conditions materially. For years the New York County Medical Association and other medical societies of standing, supported by Boards of Health and the leaders of the medical profession, have tried to get legislation enacted providing for the establishment of a standard of education and training for midwives. In every state legislation of a uniform character should be enacted providing that no person shall practise as a midwife or accoucheur without having first undergone a thorough training and passed an examination set by the State Board of Regents or some similar authority. They should be held responsible for malpractice, incompetence, or neglect, just as physicians are held responsible. While it is true that such a reform would inflict a certain amount of hardship and suffering upon many women, on the other hand, it would raise midwifery to the dignity of a profession, and provide lucrative avocations for many other women. In any case, it is a most tragic folly to set the hardship involved against the enormous gain to society.

It is probable that such trained midwives would command a much higher rate of remuneration for their services than many of the incompetent women who now act in that capacity, and that many poor mothers would be unable to afford to employ them. Even now there are thousands of women who cannot afford attendance of any kind at their lying-in, and doctors tell of children, little girls ten years old,^[157] for instance, caring for their mothers through the pain and peril of parturition and for the newly born children. The remedy for such a condition lies, not in the employment of incompetent midwives licensed to destroy life because they are willing to do it “cheaply,” but in the extension of free medical service, maternity hospitals, and properly trained midwives as part of our district nursing services. This subject of the extension of our public medical service is a most important one. There is a tendency in some quarters to decry everything of this nature, and to magnify unduly the extent to which such services are abused. That they are sometimes abused, if by that term is understood their use by those who could afford to pay for such services, is undoubtedly true, though it would be easy to overestimate the extent of such abuses. On the other hand, it is certain that in many of our cities we have scarcely begun to make provision for the needs of the suffering poor. It is astonishing to find a manufacturing city of more than sixty thousand inhabitants, with a tenement-house problem as distressing as that of New York City, and with the most appalling poverty, having no city physician upon whom the suffering poor can call by right. I do not know if there are many other cities in the United States so utterly indifferent to the claims of the sick poor as Yonkers, the “city of beautiful homes and great industries” upon the Hudson, but I do know that there are many cities in which there is a sad and shameful failure to provide proper medical care and attention for the needy.

In order that the child may be surrounded at its birth with all possible care and skill, it must be born somewhere else than upon the floor of a factory. Notwithstanding all that may be said in its favor, it is little likely that the Jevonian proposal to forbid the employment of any mother within a period of three years from the date of the birth of her youngest child will be adopted for many years to come, if ever at all. Among the foremost opponents of such a proposal would be many of the advocates and defenders of “women’s rights,” begging the whole question of children’s rights, and ignoring the question whether it can ever be “right” for mothers to leave their babies and enter the factory, displacing men, or, what is finally the same thing, lowering their wages. It would be difficult, however, to imagine any such opposition to the proposal that the employment of women should be forbidden within a period of six weeks or two months prior to and following childbirth. Decency and humanity alike suggest that such a law should be embodied in the factory legislation of every industrial state, as is the case in most countries at the present time.

With our cosmopolitan population it is certain that the enforcement of such a law would be no easy matter.^[158] Little difficulty would seem to be necessarily involved in the enforcement of the period of rest after confinement; all that would be necessary would be to insist upon a copy of the birth certificate of the youngest child, accompanied by the sworn statement of the mother. If the whole onus of responsibility were placed upon the employer, and penalties were imposed in a few cases, there is no reason to suppose that the law in this respect would be less effective than other laws relating to employment. That it would not be perfectly successful is no more an argument against its enactment than the partial failure of child-labor laws, for example, is an argument for their repeal. But the period of exemption prior to childbirth is a much more delicate and difficult matter. It has not, I believe, been found possible in European countries to enforce the law in this direction with as much success as in the other, but the results have been sufficiently successful, nevertheless, to warrant continued effort. In actual practice such a law would have a tendency, doubtless, to discourage the employment of married women in factories, since employers as a rule would not care to take the trouble, or to assume the risks, thus involved in their employment.

But, as already noted, if working mothers are to be forced into prolonged periods of idleness, in the interests of their offspring and the future of society, some means must be provided whereby they may be maintained and secured against want. The philanthropic experiments noted in an earlier chapter owed all their success to such provisions. While it would perhaps be too Utopian to advocate as a measure for immediate adoption state pensions for childhood and youth as well as old age, as Mr. C. Hanford Henderson does in his wonderfully suggestive and stimulating book, Education and the Larger Life, it is not, it seems to me, too much to demand that the state shall (1) allow no mother to imperil her own life and that of her offspring by working too close to the period of parturition, nor (2) allow any mother to suffer want because she is prevented from, or of her own free will and intelligence avoids, such work. If the right of the child to be well born, to be ushered into the world with loving care and all the skill possible, is to be anything but a mere cant phrase, the safeguards thus briefly sketched cannot, it seems to me, be lightly denied. Recently I visited the stables of a friend interested in the breeding of horses. I saw that he had taken great care and pains to secure a well-trained veterinary surgeon, that the brood mares were patiently and lovingly cared for and tended, both before and after foaling. No humane and intelligent breeder of animals would deny them the protection and care here suggested for human beings. Until the state is willing to care for its children, at least as well as enlightened individuals care for their horses, or their dogs, it is mockery to speak of it as being “civilized”!

IV

The foregoing proposals relate only to the conditions surrounding the child at birth, but it is equally the duty of society to safeguard the whole period of childhood. In its own interest, no less than in the interest of the child, the state should protect every child from all that menaces its life and well-being. Before the British Interdepartmental Committee many witnesses, some of them factory surgeons of long experience, testified to the harm resulting from the employment of mothers and the leaving of infants in the care of children or old persons utterly incompetent to care for them. It was proposed that the employment of married women in factories should be forbidden, except in cases where there are children “absolutely dependent on their wages.” In all such cases “the municipality must make provision for the care of the child while the mother is at work.”^[159] As a minimum, this is a good and practicable proposal, though it falls far short of the ideal. Much more commendable for its humane good sense is the method adopted in some of the Socialist municipalities of France. In the case of widows and others with children absolutely dependent upon their earnings, these municipalities pay the mothers a weekly or monthly pension, thus enabling them to stay at home with their children.^[160] With characteristic good sense and courage, Mr. Homer Folks has proposed a similar system of pensions to widows and others dependent upon the wages of children, on the principle that the poverty of its parents ought not to be allowed to despoil a child’s life and rob it of opportunities of healthful physical and mental development.^[161] That is a perfectly sound principle, it seems to me, which applies with equal force to the working mother; for it is surely just as important to insist that poverty shall not be allowed to rob the child of its mother’s care.

Wherever possible, then, I believe that the effort of society should be to keep the mother in the home with her children, and where pensions are necessary in order that this result may be attained, they should be given, not as a charity, but as a right. It would be a very good investment for society, much more profitable than many things upon which immense sums are lavished year by year. In the meantime, much good might be accomplished by the establishment of municipal crÈches or day nurseries in all our industrial centres, so that babies and young children could be properly cared for during the absence of their mothers at work. Something is already being done in this direction by private philanthropy in many cities, but it is exceedingly little when compared with the magnitude of the need. In saying that these institutions should be provided by the municipality, or by the state, I do not mean that any attempt should be made to prohibit private philanthropic effort in this direction, nor that such effort should be in any way lessened; but that the municipality or the state should accept final responsibility in the matter, and provide them wherever the failure of philanthropy makes such a course necessary. In all our great cities, as well as in many of the smaller manufacturing towns, there should be such a crÈche or nursery in the neighborhood of almost every primary school, until it is found possible to enable the mothers to remain with their little ones instead of going to work. With trained nurses in charge of such institutions, it would be easy to control the dietary of the infants and to see that they were not given pickles, candy, or other unwholesome things. Yet such a system, no matter how perfected, can only be regarded as a makeshift, a rather uneconomical substitute for the humane system of keeping the mother with her child.

The heavy death-rate in most foundling hospitals, despite all scientific care and the most elaborate equipment, have been accounted for by the lack of maternal interest and affection. In the splendidly appointed Infants’ Hospital on Randall’s Island New York City, little lonely, mother-sick foundlings pined away at an alarming rate and died like flies until the Joint Committee of the Association for Improving the Condition of the Poor, and the State Charity Aid Association, investigated the matter. The Joint Committee wisely decided that every one of the bits of human driftwood was entitled to one pair of mother’s arms, and that no institutional ingenuity could ever take the place of the maternal instinct. They instituted a system of placing-out the children with foster mothers, and the results have been highly gratifying.^[162] That is the human way, answering to the universal child-instinct for a mother’s love and presence. The same objection applies to crÈches as to foundling hospitals; the difference is only one of degree. These institutions are far better for the children than the neglect or the ignorant handling of “little mothers” from which they now suffer, but they can never compare in efficiency with the personal attention of the mother. There are few mothers, be they ever so ignorant, who would not attend their own children with greater efficiency than any institution nurses could do. In the ultimate result I am convinced that the pensioning of mothers to care for their children adopted by the French municipalities where the Socialists have obtained control is much more economical and effective.

The importance of impure milk as a contributing cause of infant mortality is now pretty generally recognized. The splendid work of Mr. Nathan Straus has done much more, perhaps, than anything else, to emphasize this fact. In view of some rather caustic criticisms of charity in the preceding pages, it may be well if I embrace this opportunity to explain my position somewhat more fully. No one, I think, recognizes more fully than I do the important experimental work which has been done by philanthropic enterprise. Such work, of which that of Mr. Straus is a conspicuous example, has blazed the path for much municipal and state enterprise. It would be impossible to overestimate the value of the work done by social settlements and such bodies. For the charity which denies justice and seeks to fill its place, I have no sympathy, but for the charity which adopts as its motto the fine phrase adopted by the ablest journal of philanthropy in America,^[H]—“Charity to-day may be Justice to-morrow,”—I have nothing but praise.

I have long held the opinion that the milk supply of every city should be made a matter of municipal responsibility. Some ten years ago, while residing in England, where the subject was then beginning to be discussed and agitated, I devoted a good deal of time to the propaganda of the movement for the municipalization of the milk supply. In view of the splendid achievement of the gouttes de lait in France, it was natural that we should have attached much importance to the sterilization of the milk, and I remember with what enthusiasm some of us hailed the introduction of the system into St. Helen’s, Lancashire, the first English city to adopt it. I am convinced now that sterilization is unnecessary and a grave mistake. Undoubtedly it is well that dirty or impure milk should be sterilized, but it would be still better to have clean, pure milk which needed no sterilization. The testimony of Dr. Ralph M. Vincent before the British Interdepartmental Committee^[163] and, more emphatically still, the splendid results of the Rochester experiment under the leadership of Dr. Goler^[164] show that this can be attained. Every municipality in America could adopt, and should adopt, the plan. “Now that the way has been shown, upon ‘city fathers’ indifferent to the childhood of their cities, upon health officers and departments warped into unbudgeable routine, upon near-sighted charity workers and unknowing givers who care for the suffering, but do not get at causes, will rest the responsibility for the continuance of a part of that fearful tally of dead babies which each summer’s week jots down on a town’s death-roll—your town and ours.” In these direct, unequivocal words Charities sums up the whole question of responsibility.

The purely experimental work of such philanthropic efforts as that of Mr. Straus has been done. The practicability and value of municipal control of the milk supply has been abundantly proven, and there is no longer need of private charitable effort and experiment. There lurks a danger in leaving this important public service to philanthropy, a danger well-nigh as great as in leaving it to private commercial enterprise. The dangers arising from the amateurish meddling of “near-sighted charity workers and unknowing givers” is much greater than is generally recognized. Many of these charitable societies drag out a precarious existence, their usefulness and success depending upon the measure of success attending the efforts of the “begging committees.” Generally speaking, they are less economical, and, what is more important, less effective, than municipal enterprises, besides being based upon a fatally unsound and demoralizing principle. I know of one large city in which a number of public-spirited citizens have for some years interested themselves in the supply of sterilized milk for infants. Notwithstanding that they receive each year in subscriptions a much larger amount of money, in proportion to the milk supplied, than Rochester’s deficit, they charge the parents more than twice as much as the latter city for the milk.

Nor is this all; there are other, weightier objections than this. There are no regular depots for the distribution of the milk, under the direct supervision of the Committee, but it is handled by drug-store keepers and others. No sort of control is exercised over the sale. Any child can go into the store and buy a bottle of milk. This is what happens: small children, sometimes not more than four or five years old, are sent by their parents to buy the milk. These little children are, naturally, ignorant of the importance which the medical advisers of the charity attach to the subject of modifications of the milk to suit the age of the child to whom it is to be given, with the result that babies less than three months old are given milk intended for babies eighteen months old, while the latter are half starved upon the modified milk intended for the former. Another evil, not, I am told, peculiar to this particular charitable society, is the selling of milk irregularly and in single bottles. When the mothers have the money, or when they are not too busy to go for the Pasteurized milk, they buy a single bottle, but at other times they send out to the grocery store for cheaper milk, or else feed the babies upon ordinary table foods. Of course, there should be a system of registration adopted; every child’s name should be enrolled, together with the date of its birth, and no less than a full day’s supply should be sold. That is the custom where the matter has been taken up by the municipal authorities. The result is that the children can be weighed and examined more or less regularly; facilities are offered for the periodical visiting of the homes of the infants and their inspection; mothers can be taught how to care for their little ones; and, instead of leaving it to chance, or depending upon the word of an ignorant mother, or a child, the attendants in charge are able to regulate the supply so that at the proper time each child gets milk of the proper strength and richness. How far the abuses I have named are prevalent in philanthropic experiments of this kind, I do not know, but I am convinced that there should be no room for such well-intentioned but disastrous muddling. The whole milk supply of every city should be the subject of municipal management and control, and special arrangements should be made for dealing with the milk intended for infant consumption. Personally, I should like to see the principles of the Rochester system extended to cover the entire milk supply of the city, and, in some one of our great cities, the further experiment of a municipal farm dairy for the supply of all milk necessary for hospitals and similar institutions upon the most hygienic principles possible. This has been done to some extent in Europe with success.

It is a delightful and scientifically correct principle which those Utopia builders have embodied in their schemes of world-making who have advocated the restriction of matrimony to those women who have undergone a thorough course of education and training in eugenics and household economy. Most persons will agree that such a system of education for maternal and wifely duties would be a great boon, if practicable. But so long as hearts are swayed by passion, and the subtle currents of human love remain uncontrolled by law, such proposals must remain dreams. Even the modest suggestion of Mrs. Parsons that a “matrimonial white list” be created by establishing continuation schools for training young women in the domestic arts and the principles of child-rearing and giving them certificates or diplomas, as well as certificates of health,^[165] is so far in advance of anything yet attempted that it sounds almost Utopian. Still, there is nothing fanciful or impossible in the proposal itself.

The preservation of child life must depend largely upon the dissipation of maternal ignorance. Until mothers are enlightened, the infantile death-rate must remain needlessly and unnaturally heavy. And so long as industrial occupations absorb our young girls in the very years which should be spent at home in practical training for the responsibilities of wifehood and motherhood, there must continue to be a very large number of marriages productive of poverty, misery, and disease, because of the ignorance and inefficiency of the wives. So the fight against maternal ignorance, the ignorance which breeds disease and poverty, appears as an almost Sisyphean task. So long as such industrial conditions prevail, ignorance will continue to sap the foundations of family life and mock our efforts at reform. In such important matters of domestic economy as knowledge of food values and how to spend the family income to the best advantage, what but failure can be expected when a young woman worker graduates from mill labor to wifehood? Even where such a young woman, or girl growing into womanhood, feels the need of training in these important matters of domestic economy, she is prevented by the fact that the family cooking and buying are necessarily done during the hours she is at work. By the time she returns home after her day’s labor, little or nothing remains to be done except washing the dishes. Even were it otherwise, she would in most cases be too tired to help. After confinement in a shop or factory for ten or twelve hours, at monotonous tasks entirely devoid of interest or attractiveness, it is natural and right that she should seek recreation and pleasure. Further confinement, either in the home or a school, is extremely liable to prove injurious.

For these reasons, and others obvious to the reader, I am not very sanguine that much can ever be accomplished by evening classes for working girls. The British Interdepartmental Committee suggests that “continuation classes for domestic instruction” should be formed, and attendance at them, twice each week during certain months of the year, made obligatory, only those employed in domestic service being exempted from compulsory attendance. Realizing that it would be an injury to the girls to impose this attendance and study upon them in addition to their already too long hours of employment, the committee very properly suggests that some modification of the hours of work would have to be introduced, so that in fact the hours of instruction would have to be taken out of their ordinary working time.^[166] With such a provision as this, a system of compulsory instruction in domestic science might very well be adopted. It is probable, however, that the principal effect would be a considerable diminishing of the employment of girls and young women within the ages prescribed for compulsory attendance at the continuation classes.

The suggested curriculum for such classes is interesting. “The courses of instruction at such classes should cover every branch of domestic hygiene, including the preparation of food, the practice of household cleanliness, the tendance and feeding of young children, the proper requirements of a family as to clothing—everything, in short, that would equip a young girl for the duties of a housewife.”^[167] The further suggestion is made that the members of these continuation classes should visit from time to time the municipal crÈches—the establishment of which is strongly recommended—and receive there practical instruction in the management of infants. This is such a comprehensive and courageous proposal that one would like to see it given a fair trial.

VII

The efficient work done by the school nurses in New York City, and elsewhere, though sadly restricted in its scope, suggests far wider possibilities. If nurses were appointed in far greater numbers, at least one to each large school, their functions might be enlarged. If, as has been suggested, they were to receive special social training, possibly at the expense of part of their present medical training, they might attend to the needs of those below school age as well as of those enrolled at school. Above all, they might be made a potent means of educating the mothers. It has been found that visiting nurses attached to the schools receive cordial welcome as a rule, are not viewed with suspicion as other officials or philanthropic visitors are, and have a correspondingly greater influence. The weak point in such a proposal lies in the fact that the school nurse would not, if her work was based upon the school registration, reach those families not represented in the schools. Thus the most important cases of all, educationally, young mothers with their first babies, would not be reached.

Elsewhere I have referred to the efforts made in some cities to educate mothers by the distribution of leaflets and pamphlets upon the subject of infant feeding and general care. Some of these leaflets and pamphlets which I have seen are models of concise lucidity, and their wide distribution among mothers intelligent enough to profit by them would be of great value. One of the first difficulties presented when this plan is attempted upon a large scale is the efficient distribution of the literature. To accomplish anything at all, the literature must be printed in the various languages represented in the city’s industrial population, and it is no easy matter to see that each mother gets literature in her own language. Quite recently, I heard of a tenement in which there were families representing no less than fourteen nationalities, and in which lived Mrs. O’Hara, a German, speaking little English! Added to this difficulty is the expense of distribution. If sent by mail,—and in large cities no other method seems possible,—the cost is enormous. To send a single circular to the registered voters of New York City, for instance, requires an expenditure of upwards of $60,000 for postage alone.^[168] There would seem to be no good reason why the Federal Government should not authorize the Health Boards to send all such educational matter through the mails free of cost. Why should the Health Department of a city not have the privilege of a local frank? Nothing could well be more foolish than the system under which the city, while performing a national service, must pay the national post-office for doing its share of the work.

Many of the mothers, especially of our immigrant population, are quite unable to read, and literature is wasted upon them. It will be seen, therefore, that the propaganda of health by literature is subject to several important restrictions. While admirably adapted to simple, homogeneous communities in which there is a small percentage of illiteracy, it fails to meet the needs of our great cosmopolitan cities. If it were possible to have all births reported at once to the Health Department by telephone, in order that each case might be visited by special maternity nurses, it would be comparatively easy to give special, personal attention to those cases in which literature would be worthless. This plan has been adopted in Australia with conspicuous success. The State Children’s Department appoints women inspectors to visit the children of the poor. These nurse inspectors have to report, not only upon the condition of the homes, but of the children. The mothers are furnished with printed instructions as to the kind of food to be given, the proper quantities, methods of preparation, and times of feeding. If the child does not thrive satisfactorily, the nurse inspector calls in one of the physicians of the department. If milk cannot be properly assimilated, something else is tried. In short, all that skill and care can do to protect the lives of the infants is done, with the result that the infantile death-rate has been reduced from 15 per cent to 8 per cent.^[169]

I would not leave this subject without insisting upon the urgent need of State or Federal supervision of the manufacture and sale of patent infant foods. The mortality from this one cause alone is enormous. There has been no satisfactory or comprehensive inquiry into this important matter in this country, and it is therefore impossible to get reliable figures. In Germany, where the law requires that the death certificate of an infant under one year of age must state what the mode of feeding has been as well as the cause of death,—a wise provision which might with advantage be adopted in this country,—it is possible to ascertain approximately the extent of the evil. The records show that of children fed on artificial food 51 per cent die during the first year, while only 8 per cent of the children exclusively nursed by their mothers die during the same period.^[170] No one familiar with the work of our infants’ hospitals can fail to be impressed by the large number of cases of illness and death in which artificial feeding appears as a primary or contributing cause. I have gone over the record books of many such hospitals in different parts of the country, with the almost invariable result that artificial foods appeared to be the source of trouble in many cases. Most of the patent foods, one might almost go farther and say all of them,^[171] are unhealthful because of the starch they contain, which the little infant stomachs cannot digest. Many of the cheaper kinds of patent infant foods upon the market are, as previously stated, little better than poisons. The testimony of the greatest authorities upon the subject of infant feeding, backed by the grim eloquence of hospital records and the death-rates, points irresistibly to the need of some strict supervision of the production and sale of artificial foods for children. Whether this should be done by the establishment of certain standard formulÆ, or by compelling the makers to submit certified samples for official analysis, is a question which only a body of experts should decide.

The question of reducing the rate of infant mortality is, it will be seen from the foregoing, most complicated. It is not without reluctance and misgiving that I have ventured upon this detailed discussion of measures to that end, and in doing so I have kept from speculation and theory, confining myself almost entirely to those measures which have been tested by experience and found beneficial. If Berlin has been able to reduce its infantile death-rate from 200 per thousand to 80 per thousand, Australia to reduce its rate from 15 per cent to 8 per cent; if Rochester can reduce its summer death-rate of infants by 50 per cent, it is surely evident that, given the determination to do so, we can at least hope to save one-half of the babies who, under present conditions, are perishing each year. In other words, it is possible to save almost 100,000 babies annually from perishing in the first year of life. No greater, worthier task than this ever challenged the attention of a great nation.

IX

When all the evidence is piled up, we are irresistibly driven to the conclusion that no attempt to educate hungry, ill-fed children can be successful or ought to be attempted. Danton’s fine phrase rings eternally true, “After bread, education is the first need of a people.” That education is a social necessity is no longer seriously questioned. But the other idea of Danton’s saying, that education must come after bread,—that it is alike foolish and cruel to attempt to educate a hungry child,—is often lost sight of. In the early days of the public agitation for free and compulsory education, it was not infrequently urged that before the state should undertake to compel a child to attend its schools and receive its instruction, it ought to provide for the adequate feeding of the child. That argument, happily, did not prevent the establishment and development of public education, but now that the latter system has been firmly rooted in the soil of our social system, there is an increasing belief in the inherent wisdom and justice of the claim that the state has no right to attempt to educate an unfed or underfed child.^[172]

There is something attractive about such elemental simplicity as that of the Czar who drew a straight line across the map from St. Petersburg to Moscow, when his counsellors asked him what course he wished a railroad between the two cities to follow, and said, “Let it be straight, like that.” I suppose that every worker for social improvement has felt oppressed at times by the complexity of our social problems, and wished that they could be solved in some such simple and direct manner. But social progress is not made along straight lines in general. What seems to the agitator axiomatic, simple, and easy, appears to the constructive statesman doubtful, complex, and difficult. There is at least one European municipality, however, which has solved this problem of the feeding of school children in a delightfully direct and simple way. The city of Vercelli, Italy, has made feeding as compulsory as education!^[I] Every child, rich or poor, is compelled to attend the school dinners provided by the municipality, just as it is compelled to attend the school lessons. Not only food, but medical care and attention, are provided for every child, as a right, on the principle that it is absurd and wrong to attempt to develop the mind of a child while neglecting its body. It is a mocking judgment of our civilization that such a natural, intelligent solution of a pressing problem should be impossible for our greatest and richest cities, though attained by a little Italian city like Vercelli.

I do not suppose that it will be found possible to apply such a principle generally until many years have passed and our social system has been modified considerably. In the meantime, some less thorough and comprehensive system, like that of the French Cantines Scolaires, for instance, will probably be adopted. It is not, however, my intention here to advocate any particular scheme. I can only reiterate that the feeding of school children is an imperative, urgent, and vital necessity, and emphasize certain principles. Elsewhere I have given a rÉsumÉ of the methods adopted in several other countries,^[J] and I need not, therefore, go over that ground. Whatever is done should be free from the taint of charity. There must be no resorting to the pernicious principle, sometimes advocated by our so-called “practical reformers,” of subsidizing charitable societies to undertake the work. There must be no discrimination against the child whose parents have failed to do their duty. The child of the inebriate, the idler, or the criminal must not be made to suffer for his parent’s sin. The state has no right to join with the sins of the fathers in a conspiracy to damn the children’s lives, and only a perverted sense of the relation of the child to the state could have made it possible for such a proposal to be made. Upon the principle that every child born into the world has a right to a full and free supply of the necessities of life during the whole period of its helplessness and training for the work of the world, so far as the resources of the world make that possible, the state should proceed until in all schools where children attend compulsorily, free, wholesome, and nutritious meals are provided for all children as a common right.

Of course, the cry will be raised that such a system would result in wholesale pauperization. I am not afraid of that cry—it has become too familiar. When I first went to school in the West of England, I used to carry my school fees—six cents a week—each Monday morning. Under that system it was necessary for the school authorities to employ officers to see that the fees were paid, and frequently defaulting parents were summoned. The children of poor parents were exempted from paying the school fees, but they had to present big cards to be marked by the teacher, and were thus made conspicuous. I remember very well that when it was proposed to make the schools free to all, the same bogey of pauperization was raised.^[173] The school fees were abolished, however, and the objection was heard no more. In the early days of the Free Libraries movement, a similar outcry was heard, but one never hears it nowadays, nor does anybody consider that he is pauperized when he takes home a book from the city library to read. And so one might go on, through a long list of things which were opposed upon the same grounds by many earnest people, but are now commonly enjoyed. If, moreover, the alternative to pauperization is slow starvation and suffering, I unhesitatingly prefer pauperization.

X

Next to the feeding of school children in importance is the need of a much more efficient and thorough system of medical inspections in all our schools. In most of our cities something is already done in this direction, but it is very little. As a rule, the medical inspections now made are most perfunctory and superficial. With a few honorable exceptions, the practice is to look only for cases of contagious and infectious disease or verminous heads. The excessive prevalence of “granular lids,” or trachoma, which is an acquired disease,^[174] has led to a good deal of attention being given of late to the whole subject of defective vision. But practically no effort at all has been made to combine remedial treatment with inspection. Children suffering from infectious diseases are simply excluded from the schools, and those found to be suffering from defective vision are given notes asking their parents to provide them with suitable glasses. In a very large proportion of cases, probably a majority, the requests are ignored. I have had children pointed out to me who were suffering from such serious defects of vision as materially to handicap them in their school work, whose parents had taken no notice whatever of repeated notices and warnings from the school doctors. Many parents are too poor to buy glasses, many more are too ignorant to understand the importance of complying with the request. I know many parents of this type. On the other hand, I know many cases in which it would be just as reasonable to ask the parents to make glasses for their children as to buy them. For instance, I know of one public school in which the teachers have repeatedly reported upon the number of children with defective vision, but without appreciable effect. I spoke to the priest to whose church a majority of the children’s parents belong about it, and he replied: “What can they do? They cannot afford to buy glasses. Of the 300 families belonging to my church, I am in a position to say that there are not more than 10 in which the father earns more than $9 a week. Many of them earn only six or seven. They have all they can do to get food; glasses are impossible.” Now, while it is true that in many of these families there will be supplementary wages from the children or the mothers, it is perfectly obvious that there must be many unable to procure glasses for their children.

INTERIOR OF THE COMMUNAL SCHOOL KITCHEN, CHRISTIANIA, NORWAY