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all-embracing compulsory system of Vercelli adopted, but it is most
likely that we shall find the French methods better suited to our needs.

NOTE.—I am indebted to the publishers of my _Underfed School
Children—The Problem and the Remedy_, Charles H. Kerr and Company,
of Chicago, for permission to reproduce the foregoing paper in this
volume.




APPENDIX B
LETTER TO THE ROYAL ITALIAN AMBASSADOR AT WASHINGTON FROM THE CHIEF OF
THE BOARD OF EDUCATION OF THE MUNICIPALITY OF VERCELLI, ITALY,
DESCRIBING THE SCHOOL-MEALS SYSTEM

NOTE.—I am indebted to the Italian Ambassador at Washington, his
Excellency Mayor des Planches, for permission to use the following
letter. The translation was made for me by Mr. Teofilo Petriella, of
Cleveland, Ohio, an Italian journalist.—J. S.


VERCELLI, September 13, 1905.

The school year, 1904–1905, just over, was the _fifth_ since the school
lunch (_refezione scolastica_) was introduced in our City Elementary
Schools, _at the complete expense of the Municipality_.

The school lunch is distributed every day during the whole school year.
Limited, at the beginning, only to the city schools, it has been
extended, since the school year 1901–1902, to the suburban and rural
schools.

To-day, therefore, all the male and female pupils of all the classes of
all the elementary schools, in both city and suburbs, take part in the
lunch. There are 65 schools with 91 classes, attended by an average of
2500 boys and girls.

The lunch consists of bread with another victual (_pane e companatico_).
Each pupil gets a very good loaf of first quality wheat bread, weighing
140 grammes for the IV and V classes;[K] 120 grammes for the III class;
and 100 grammes for the first two classes.

The victuals served with the bread are: On meat days, raw salt meat
(_salame crudo_) in rations of 14 grammes, alternated with cooked salt
meat (_salame cotto_) in rations of 20 grammes.[L] On fish days, cheese
(either Bernesa or Fontina alternated) in rations of 20 grammes. All is
of first quality, and this is daily ascertained by an inspection on the
part of the Steward and the Officer of the Board of Health.

Each ration costs from seven to eight cents of a franc.[M]

Every school morning each teacher, within 15 minutes of the commencement
of school (from 9 to 9.15), ascertains the number present by roll-call,
fills out an order in three copies, keeping for himself the one attached
to the stub and sending, by the ushers, the other two to the City
Steward.

The Steward keeps one of these duplicate copies for the office accounts
and registrations, while sending the other back to the teacher, along
with the requested rations in a closed basket.

The office of the Steward, after having received all the requests from
all the teachers, as above said, and after having classified same by
degree, locality, and number, sends the orders of purchase to the
different supply-contractors.

At 10 o’clock, in a suitable place, under the direction and supervision
of the City Steward, the baskets are made up, one for each class. The
baskets, once ready, are automatically padlocked—the teacher having the
necessary key—and forwarded by proper servants to the several suburbs,
while others take the rest, on pushcarts, to the city school buildings.

The School Trustees of the respective boroughs, the Principal and the
Steward in the City School, visit the different classes to make sure of
the regular and exact proceeding of the beneficent institutions.

So much, answering your favor of August 15th.

Truly yours,

The Mayor, per the Chief of the Board of Education, Cero Lucca.

- - -

Footnote K:

Twenty-eight grammes equal one ounce avoirdupois. The children in
classes IV and V get loaves, therefore, weighing five ounces each.

Footnote L:

_Salame_, here translated “salt meat,” is really the best kind of
salted dry sausage made of pork sirloin.

Footnote M:

One U. S. dollar equals about 492 francs; 100 Italian cents equal one
franc, so that one cent of a franc equals about one-fifth of an
American cent.




APPENDIX C


I
THE QUESTION OF HEREDITY

In his testimony before the British Interdepartmental Committee on
Physical Deterioration, Dr. Alfred Eichholz, one of H. M. Inspectors of
Schools, a Doctor of Medicine, and formerly Fellow and Lecturer of
Emmanuel College, Cambridge, said:—

“I have drawn a broad distinction between physical degeneracy and
hereditary deterioration. The object of my evidence is to demonstrate
the range and the depth of degeneracy among the poorer population, and
to show that it is capable of great improvement—I say improvement
purposely even within the areas of the towns—and to show that there is
_a lack of any real evidence of any hereditary taint or strain of
deterioration even among the poor populations of our cities_. The point
which I desire to emphasize is that our physical degeneracy is produced
afresh by each generation, and that there is every chance under
reasonable measures of amelioration of restoring our poorest population
to a condition of normal physique.

“I draw a clear distinction between physical degeneracy on the one hand
and inherited retrogressive deterioration on the other. With regard to
physical degeneracy, the children frequenting the poorer schools of
London and the large towns betray a most serious condition of affairs,
calling for ameliorative and arrestive measures, the most impressive
features being the apathy of parents as regards the school, the lack of
parental care of children, the poor physique, powers of endurance, and
educational attainments of the children.... _While there are,
unfortunately, very abundant signs of physical defect traceable to
neglect, poverty, and ignorance, it is not possible to obtain any
satisfactory or conclusive evidence of hereditary physical
deterioration_—that is to say, deterioration of a gradual retrogressive
permanent nature, affecting one generation more acutely than the
previous. There is little, if anything, in fact, to justify the
conclusion that neglect, poverty, and parental ignorance, serious as
their results are, possess any marked hereditary effect, or that
heredity plays any significant part in establishing the physical
degeneracy of the poorer population. In every case of alleged
progressive hereditary deterioration among the children frequenting an
elementary school, it is found that the neighborhood has suffered by the
migration of the better artisan class, or by the influx of worse
population from elsewhere. _Other than the well-known specifically
hereditary diseases which affect poor and well-to-do alike_, there
appears to be very little real evidence on the prenatal side to account
for the widespread physical degeneracy among the poorer population.
There is, accordingly, every reason to anticipate RAPID amelioration of
physique so soon as improvement occurs in external conditions,
particularly as regards food, clothing, overcrowding, cleanliness,
drunkenness, and the spread of common practical knowledge of home
management. In fact, all evidence points to _active, rapid improvement,
bodily and mental, in the worst districts_, so soon as they are exposed
to better circumstances, even the weaker children recovering at a later
age from the evil effects of infant life. (P. 20.)

“To discuss more closely the question of heredity may I in the first
instance recall a medical factor of the greatest importance: the small
percentage of unhealthy births among the poor—even down to the very
poorest. The number of children born healthy is even in the worst
districts very great. The exact number has never been the subject of
investigation, owing largely to the certainty which exists on the point
in the minds of medical men—but it would seem to be not less than 90 per
cent.

“I have sought confirmation of my view with medical colleagues in public
work, _e.g._ public health, poor law, factory acts, education, and in
private practice in poor areas, and I have also consulted large
maternity charities and have always been strengthened in this view. _In
no single case has it ever been asserted that ill-nourished or unhealthy
babies are more frequent at the time of birth among the poor than among
the rich, or that hereditary diseases affect the new-born of the rich
and the poor unequally._ The poorest and most ill-nurtured women bring
forth as hale and strong-looking babies as those in the very best
conditions. In fact, it almost appears as though the unborn child fights
strenuously for its own health at the expense of the mother, and arrives
in the world with a full chance of living a normal physical
existence.... The interpretation would seem to be that Nature gives
every generation a fresh start.”

[Q. 558. There is a fresh chance of getting rid of rickets with every
generation?]

“Yes; rickets, malnutrition, low height, poor weight, anæmia, and all
the other circumstances of neglected existence. It is from the moment of
birth that the sad history begins,—the large infant mortality, the
systematic neglect, the impoverishment of the constitution,—the
resulting puny material which is handed over to the school to be
educated.

“... It seems clear that every generation receives its chance of living
a good physical life, and when to the fact of the large proportion of
healthy new births we couple the evidence of improving health and
physique in children who pass up the poorer elementary schools, _it
seems clear that we are not dealing with a hereditary condition at all,
but with a systematic postnatal neglect by ignorant parents, and that
heredity, if it makes for anything, makes for recuperation, and so do
the other social forces which are brought into play in dealing with the
poorer population_.” (P. 31.)—Report of the Committee, Vol. II.

Dr. Edward Malins, M.D., President of the Obstetrical Society of London
and Professor of Midwifery in the University of Birmingham, was examined
upon the same subject. From the Report of the Committee (Vol. II, p.
136), the following extracts are taken:—

“3124. You have been good enough to attend here in consequence of
certain evidence that we received the other day in which it was stated
by Dr. Eichholz, on the authority of other medical men, that if people
are going to have children, they will have healthy children as though
Nature were giving every generation a fresh start, and he went on to say
that healthy births were about 90 per cent in the poor neighborhoods,
and he suggested that we should go to the London Obstetrical Societies
to ascertain how far their experience bore out this statement. What are
you able to say on this point?—What I have to say at the present time is
more a matter of observation and of opinion. _We have not the figures at
present to prove the accuracy of it, but I think the testimony of
experienced observers would be in accordance with the views expressed by
Dr. Eichholz_, though perhaps not to such a large extent. I should say
that from 80 to 85 per cent of children are born physically healthy.

“3125. Whatever the condition of the parents may be? Whatever the
condition of the mother may be antecedently.

“3126. And you think the deterioration sets in later?—I do, materially
so. _The weight of children at birth as far as I know—and I have weighed
a great many—is generally not below the average; the average keeps up
very much no matter what the physical condition of the mother may be for
the time._ Since receiving this information we have instituted at the
Obstetrical Society of London, in connection with Lying-in Charities and
Hospitals in London, a tabulated form for ascertaining these facts—what
the weight of children is at birth; their physical condition, and
whether there is an increase or otherwise during the time a woman is
under observation. That time is not very long, not more than 10 days or
a fortnight generally.

“3127. Will you be able to furnish us with these facts when
collected?—Certainly. I will give the information later on, but I think
there is a general consensus of opinion, at all events irrespective of
figures, which I am not able to give, that the average is kept up no
matter what the condition of the mother may be.

“3128. That proves what you say in your _précis_,—that Nature intends
all to have a fair start?—Yes.”


II
MALNUTRITION

“One of the most striking things about children suffering from
malnutrition is their vulnerability. They ‘take’ everything. Catarrhal
processes in the nose (adenoids), pharynx, and bronchi are readily
excited, and, once begun, tend to run a protracted course. There is but
little resistance to any acute infectious disease which the child may
contract. One illness often follows another, so that these children are
frequently sick for almost an entire season. Their muscular development
is poor, they tire readily, are able to take but little exercise, and
their circulation is sluggish. Mentally, they are usually bright, often
precocious. Many would be called nervous children.”—_The Diseases of
Infancy and Childhood_, by L. Emmet Holt, M.D., LL.D., p. 231.

“General malnutrition is the commonest pathological feature of infant
life. Probably 50 per cent of all infants in this country (England)
suffer from a greater or less degree, and this large proportion is
caused undoubtedly by the extremely unsatisfactory methods of substitute
feeding at present in vogue. Illness, in the usually accepted sense of
the word, is not present. No specific disease can be diagnosed, and
unless the indications are realized, the degeneration is allowed to
proceed until marasmus or some acute disorder supervenes....

“Marasmus represents the extreme result of gradual and long-continued
malnutrition. Extreme wasting is the cardinal, and indeed only, specific
symptom. The term is not applicable to those cases where the wasting is
the result of exhaustion due to the incidence of specific disease, such,
for instance, as tuberculosis....

“The most striking and perhaps the commonest result of impaired
nutrition is the disease generally known by the name of rickets. Though
some of its most obvious features are those associated with changes in
the osseous system, those are by no means the only effects of the
disease. Rachitis is the expression of profound pathological changes
occurring in practically all the tissues of the body.

“No other disease illustrates so completely the effects of inadequate
nutrition. An infant nursed by its mother and receiving from her a
sufficient supply of adequate food, never contracts the disease, however
disadvantageous its environment may be in other respects.

“Defect in the diet is the prime and essential cause of rachitis; while,
as might be expected, the most advanced forms of the disease are to be
seen when the effects of inadequate food are intensified by unhygienic
environment....

“The effects of rachitis on the general constitution are extremely
severe. The relationship between the nutrition of the infant and the
condition of the child and adult has received but little attention. But
there can be no doubt that the defects of nutrition occurring in infancy
are of paramount importance in regard to the development of the adult.
The cases of retarded physical and mental development in the child and
the adult are numerous at the present time, and it is probable that
their chief cause lies in defective nutrition during the period of
infancy.

“Rachitis is a disease attended with a high mortality with which it is
never credited, for the disease itself is seldom, if ever, fatal. In
consequence of the cachectic condition and the extreme debility
associated with advanced rachitis, the specific infectious diseases,
such as measles, pertussis, and others, are associated with a much
higher mortality in these cases than in others. Associated more or less
closely with rachitis is a large class of disorders, such as bronchitis,
diarrhœa, laryngismus stridulous, convulsions; these are attended with
many fatal issues.”—_The Nutrition of the Infant_, by Ralph M. Vincent,
M.D., pp. 226 _et seq._


III
MIDWIFERY AND DEATH

Dr. Thomas Darlington, President of the New York Board of Health, says:
Any movement for a proper regulation of midwives has my earnest support.
Under the laws of New York as they now exist there is no adequate
regulation. It is very easy for a woman to become a midwife in this
city. She is required, it is true, to come to the department of health
with a certificate from some school of midwifery, here or abroad, or to
present statements from two physicians as to her fitness and character,
but the _status_ of the school does not enter into the consideration,
and that it is not difficult to obtain the indorsement from the two
doctors is indicated by the great degree of incompetency and
carelessness to be found in the ranks of the 800 midwives of New York
City. Under the laws now existing we have no right to demand further
proof of qualification. If the applicant meets the slight requirements,
we must put her down as a “registered midwife.” She brings this phrase
prominently into use in her solicitations for business in her
neighborhood, and it inspires confidence—a good deal more confidence
than it should. Thus are the people deceived by the laxity of the law. A
measure was introduced in the legislature, providing for a much stricter
supervision of midwives than is now the case. The bill had the support
of this department and of the medical societies of standing, and yet,
because of ignorance and indifference concerning the evils of the
practice, it failed to reach a place on the statute books. My own
opinion is that the midwife should, before being allowed to practise,
undergo a schooling at least as long and as careful as that of the
trained nurse.

Dr. Henry C. Coe, Professor of Gynecology at Bellevue Hospital, New
York, and Chief Surgeon of Gynecology and Obstetrics at the General
Memorial Hospital, New York, says: Midwives are responsible for the
majority of cases sent to public hospitals. It is a sad commentary on
the mediæval customs of obstetrics that such facts, known to all
doctors, should be ignored by coroners. The remedy is plain,—to have
educated midwives, as in Germany.

Dr. J. Clarence Webster, of the Rush Medical College, Chicago, says: The
midwives are, as a class, uneducated and untrained. They are responsible
for the great majority of maternal deaths. Every gynecologist who works
in a large charity hospital can give evidence of the morbidity among
poor women resulting from infection where the attendant was a midwife.
The splendid results obtained by the lying-in hospitals and
dispensaries, where women are attended by skilled physicians and trained
nurses, are chiefly due to a rigid technique, the essential feature of
which is cleanliness. It is a disgrace to every city that the benefits
of such institutions cannot be extended to all poor women. Any surgeon
who would dare to operate under the conditions observed by midwives
would be denounced not only by the medical profession, but also by the
enlightened laity. Yet the latter are apparently indifferent to the work
of the midwife, and allow her to carry on her dangerous career
uncensured. The extension of the benefits of scientific obstetrics is
chiefly due to the persistence and self-sacrifice of the medical
profession, but the doctors are unable, unaided, to do what remains to
be done.

Dr. Francis Quinlin, President of the New York County Medical
Association, says: All reputable physicians who have given the matter
the slightest consideration are of one mind in regard to the menace to
life in the ignorant work of the great majority of midwives. The New
York County Medical Association has let slip no opportunity to throw the
weight of its influence on the side of remedial measures. That little
has been accomplished so far is due to the fact that the midwife, as she
exists to-day, is a time-honored institution, difficult to uproot. Most
midwives have apparently no conception of the scientific cleanliness
which is rightly regarded by physicians as being of prime importance.
The most ordinary antiseptic precautions are ignored, with the result
that, every day, women who have been attended by midwives are brought to
hospitals suffering from blood-poisoning. In their habits of
carelessness the midwives also carry from one house to another the germs
of infectious diseases. In the interest of a host of poor mothers and of
children whose lives are valuable to the nation, I say that the practice
of midwifery should come under a much closer scrutiny of the law than is
now the case.

Dr. Eleanor B. Kilham, Head of the Maternity Department of the Women’s
Infirmary, New York City, says: That much injury results to mothers and
children from the unrestrained practice of midwives there can be no
doubt in the mind of any physician who has been brought in contact with
the conditions. There is an opportunity here for an important reform,
and I am very glad to know that something is being done in this
direction.

(These letters are quoted from _Success_, April, 1905.)


IV
MUNICIPALIZATION OF THE MILK SUPPLY AND THE DANGERS OF STERILIZATION

“The real solution of the milk problem is not the supply of sterilized
milk of doubtful purity, but rather the supply of clean milk from
sources above all suspicion. The transport of milk from long distances
under present conditions, as to cooling, transit, etc., may render
sterilization all important, but the necessity for sterilization
indicates the presence of avoidable organic impurity, and to obtain a
naturally pure milk supply is the really important thing....

“If we municipalize water because the public health aspect is of such
vital importance, then from the same standpoint we should municipalize
the milk supply. We nearly all need milk—many live on it exclusively;
its supply is as regular as the water supply, and its distribution
demands even greater care for a longer time. The milkman calls more
regularly than the postman and the milk bill comes in as regularly as
the rate card. Like the liquor trade, the milk trade is a simple one,
and the dividends of modern dairy companies show that it is
profitable....

“We should bear in mind that, although under present conditions of
supply any stringent enforcement of the most thorough sanitary
regulations on farmers, or any distinct raising of the legal minimum of
fat in milk, would certainly tend to raise the price of milk to the
consumer, and any rise in price would be most unfortunate, yet a high
standard of production and distribution is essential. The only way to
get both low price and a better article is by means of the enormous
economies in distribution, cartage, etc., which would at once result
from municipal ownership....

“Finally, it has been shown that all successful attempts to solve the
question have been those in which the aim has been other than the
ordinary commercial one, and those organizing the supply have been
interested in the public health, and in which there has been thorough
organization on a large scale both in supply and distribution. These
facts alone show that the only solution possible under modern conditions
is that suggested by the municipal ownership and control of the milk
supply.”—F. Lawson Dodd, M.R.C.S., L.R.C.P., L.D.S., Eng., D.P.H.,
London, in _The Problem of the Milk Supply_.

Sir Richard Douglas Powell, in his lecture to the Congress of the
Sanitary Institute at Glasgow, in July, 1904, said: “There can be no
doubt that scientifically conducted dairy farms on a large scale, with
urban depots for the reception and dispensing of pure milk in clean
bottles at a fair price to the poor, would pay, and would be a most
laudable employment of the municipal enterprise that is often devoted to
matters of much less urgent public interest and importance. Apart from
the primary benefit of affording a pure milk supply at a fair price, the
object lesson to mothers and families in food cleanliness would be


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