Coordinating the Experts and the Masses: the Professions of Health and the Creation of American Community Health, 1915-1940 Philip L

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1999 Coordinating the experts and the masses: the professions of health and the creation of American community health, 1915-1940 Philip L. Frana Iowa State University

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Coordinating the experts and the masses: The professions of health

and the creation of American communit)' health, 1915-1940

Philip L. Frana

A dissertation submitted to the graduate faculty

in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

Major: Histor)' of Technolog}- and Science

Major Professor: Alan I Marcus

Iowa State University

Ames, Iowa

1999

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TABLE OF CONTENTS

CHAPTER L AN INTRODUCTION TO COMMUNIT\' HEALTH 1

CHAPTER II. BEFORE COMMUNITY HEALTH 27

CHAPTER III. TWO VIGNETTES ON SANITARY SCIENCE AND COMMUNITY HEALTH 67

CHAPTER IV. PUBLIC HEALTH NURSING 86

CHAPTER V. CHILD HYGIENE 129

CHAPTER VI. INDUSTRIAL HYGIENE 157

CHAPTER VII. MENTAL HYGIENE 198

CHAPTER VIII. SELLING HEALTH 232

CHAPTER IX. COMMUNITY HEALTH DEMONSTRATIONS 266

CHAPTER X. FAMILY HEALTH AND FAMILIAL EPIDEMIOLOGY 325

CHAPTER XI. THE PLACE OF THE INDIVIDUAL IN COMMUNTTY HEALTH 357

BIBLIOGRAPHY 367 1

CHAPTER I: AN INTRODUCTION TO COMMUNITY HEALTH

This dissertation reveals just how American public health professionals perceived themselves between 1915 and 1940, how they conceived of their expertise, and what they proposed to do with it. By examiiiing their own conclusions about the way things work or, alternately, do not work, the outlines of an entirely new way of practicing public health appear, described at the time as "community health." I wish to explore the process of invention and reinvention as it developed in the minds of the public health elite—those who by addressing particular problems in professional journals and books shaped the debate—and in the hands of those who implemented and lived with their decisions. This is not so much a dissertation revealing how public health professionals acted upon their professional debates (though illustrated in some detail in the chapters on health salesmanship and demonstrations). Rather, it emphasizes the debates themselves. It is essentially an intellecmal liistor)' of the re-professionalization of public health.'

The period sti'etching from around the time of the first World War through the 1930s witnessed the development of a new profession out of the old: so-called modern "communit)' health." The crj'stallization of community health as a unique field, sometimes called the "new public health," delimited a period in which the model of sanitary science and state medicine bore refinements and new ideological injections. These refmements and injections, taken together, took the professions of community health in new directions while preserving much of the usable knowledge and applications wrung from the older model for expertise, a model determined to

' For a comparable intellectual study of the professionalization of urban social reform see Don S. Kirschner, The Parados of Professionalism; Rsjorm and Public Service in Urban America (Westport, Conn.: Greenwood Press, 1986). 2 objectively identify a crying social need, initiate the process of self-identification, standardize new knowledge, create an organization with restrictive membership requirements, found journals, and establish universit)- departments and laboratories where ideas might be transferred from professionals to naifs. Health professionals did not discard the principles and practices of previous decades wholesale, but rather transformed them."

Many historians have noted a current of reform in American public healdi in the second decade of this centur\'. Often, these scholars point to die influence of Yale Professor of Public

Health Charles-Edward Amory Winslow—perhaps the most well-known public health philosopher of tlie time—in bringing popular health education to center stage.' Popular, or public, education is certainly one factor that contributed to the reinvigoration and transformation of public health, but there are also many others. Professional public health becamc by the 1920s an associational "field of social activity" populated by experts drawn from die newly "sciendfic" professions of psycholog)', psycliiatr)', sociolog}', and social work, as well as the traditional medical specialties of vital statistics, bacteriolog}', medical science, sanitation, and engineering.

"Teamwork," "team play," and "choreography," moreover, became tlie watchwords of effective and efficient professional acti^tity. Experts extolled the virtues of "cooperation," the universal glue, and "coordination," the universal solvent, of professional and lay interaction. Cooperation

" Athel Burnham Campbell, The Community Health Problem (New York: The Macmillan Company, 1920), 3, 29, 99; Charles Edward-Amorj' Winslow, The Rvoliition and Significance of the Modern Public Health Campaign (New Haven; Yale Universitj' Press, 1923), 49-65. On the matter of late-nineteenth-centur)- professionalization see Alan I Marcus, "Setting the Standard: Fertilizers, State Chemists, and Early National Commercial Regulation, 1880-1887," AgriculturalHistotj 61 (Winter 1987); 47-73. ^ See for example Elizabeth Fox, "Professional Education for Public Health in the United States," in A History of Ethuation in Public Health (New York, 1990): 230-3; many articles by .\rthur Jack Viseltear, including, "C.-E. A. Winslow and tlie Early Years of Public Health at Yale, 1915-1925," Yale journal of Biology and Medicine 55 (1982): 137-51; "C.-E. A. Winslow: His Era and His Contribution to Medical Care," in Healing and Histo^' (New York, 1979), 205-28; "The Emergence of Pioneering Public Health Education Programs in the United States," Yak Journal of Bio/og)' and Medicine 61 (1988); 519-48; and "Milton C. Winternitz and the Yale Institute ofHuman Relations: A Brief Chapter in the History^ of Social Medicine," Yale Journal ofBiolog}' and Medicine 57 (1984); 869-89. The role of nurses a.s popular healtli educators is described in Barbara Melosh, "More than 'The Physician's Hand'; Skill and Authority in Twentieth-Century Nursing," in IVomen and Health in America (Madison, 1984); 482-96. 3 and coordination paralleled professional desire for more generalized, general-purpose, or multipurpose principles and practices. Ideally, generalized principles and practices illuminated the apparent plasticit}' of human existence. Health, unlike traditional sanitarj' science, no longer simply consisted of a heaping up and winnowing out of expert knowledge and practice.

Communit)' health in the minds of early twentieth-centurj' professionals constituted an "ever changing" profession molded around and created out of everj'day life. Change in one principle or practice inexorabl)' transformed every other. Health, in other words, needed to be organic and dynamic, not artificial and static.

This smdy is broadly constructed to accurately reflect the encompassing nature of modern communit)' health itself •* The ancient Greeks had two words germane to the interwar professional conceptualization of communit)' health: synoikismos and agape. Synoikismos explained the gathering together of houses to make a polis, something greater than the sum of its constituent parts. Agape, a concept deployed often between the wars, referred to the unselfish caring and seeking for the greatest good within a closed circle of people engaged in mumal giving and taking. Like .ynoikismos and agape, communit}' health gathered together the strengths of specialized scientific experts and educated laypeople, arranging them into a whole stronger than

The organic, communin'-oriented, or associational interpretation of interwar medicine and heahh has not interested man;' contemporar)- historians. Most prefer to see all of rvventieth-cenrur)- medical and preventive science as simph' a linear continuation of late-nineteenth centur}- specialization or "reductionism." One recent work that helps to dispel such notions is GreaterThan the Paris: Holism in Biomedicim, 1920-1950, ed. Christopher Lawrence and George Weisz (New York: O.xford University' Press, 1998). See especially the thoughtful introductor)' essay "Medical Holism: The Context," written by the editors. "Holism" as an interwar theme is more widely accepted among urban historians. See for example Robert B. Fairbanks, Making Better Citi:^ns: Housing Refonti and the Community Development Strate^' in Cincinnati, 1890-1960 (Urbana: Universit)' of Illinois Press, 1988); Zane Miller, Suburb: Neighborhood and Community in Forest Park, Ohio, 1935-1976 (Knoxville: Tlie Universit)' of Tennessee Press, 1981); and Robert Fisher, "From Grass Roots Organizing to Communit)' Service: Communit)' Organization Practicc in the Communit)' Center Movement, 1907-1932," in Community Organit;alion for Urban Social Change, eds. Robert Fisher and Peter Romanofsky (Westport, Conn.: Greenwood Press, 1981), 33-58. On the political associationalism of the 1920s and 1930s see Ellis W. Hawley, The Great War and the Search for a Modem Order. A History of the American People and Their Institutions, 1917-1933 (New York: St. Martin's Press, 1979); and idem. The New Deal and the Problem of Monopoly: A Study in Economic Ambivalence (Princeton, N.J.: Princeton Universit)' Press, 1966); Joan Hoff Wilson, Herbert Hoover Forgotten Progressive (Boston: Little, Brown, and Company, 1975); and idem, American Business Foreign Polity, 1920-1935 (Lexington: University Press of Kentucky, 1971). 4 any individual. Community health tlius represented at the same time one profession and many professions acting (ideally) in concert. Thus, diis project concentrates on the many parts—public health nursing, child hygiene, industrial hygiene, mental hygiene, popular health educadon, philanthropic effort in health demonstrations, familial epidemiolog)'—as well as dieir shared, common ideas which permeated community healdi generally.'

Chapters III through VI are structured much the way community health professionals thought of themselves. They are organized latitudinally rather than longimdinally. That is, the core of my dissertation is composed of a cross-section of professional thought; it shows a set of distinguishable scenes locked in one particular period of time. It does not follow the exploits of individuals or organizations in continuous or linear fashion over immense spans of time. It does not trace die origins of community health back into distant past.

Nor does my dissertation seek to use the past as a fund to throw light on a present predicament, at least not in any conventional way. It seeks only to compare and contrast what modern twentieth-centur)' health professionals described as normal organization and practice with the tiomia! organization and practice of health professionals in the progressive late nineteenth century. But what is normal and what is mrviative? It should become clear that elements or parts of this normal organization and practice of the late-nineteenth-centur}' became in certain contexts in modern times what was abmnna! about the past. Each set of professionals locked in time related to one another using authoritative standards regulating proper or accepted wisdom about the "order of diings." But the authoritative standards changed around 1915, rendering the old

(progressive, hierarchical) order of things incompatible with the new (modern, associational) way of knowing about healdi.

^ On the problem of agape in this period start with Anders Nygren, Agape and Eros, 2 vols. (Philadelphia: The Westminster Press, 1932,1938-9). 5

Chapter II interprets what came immediately before communit)' health, something commonly called "sanitar)' science." It derived its authorit)' in large measure from the laborator)', sought to establish a uniform nomenclature and practice, and erected standards for professional expertise. In the process it specialized, ordered itself in hierarchical fashion, and systematically sorted out diseases and preventive regimens into classes. Chapter III presents brief vignettes of

William Thompson Sedgwick and Charles-Edward Amor)' Winslow, two individual health experts who knew each other intimately as teacher and student yet explicated very different professional imperatives. The chapter is used to bridge the gap between the older sanitar}- scientific way of describing and organizing health professionalism and the new communit)' or associational way. Chapter IV is given over to a discussion of "generalized" public health nurses as the preeminent middlepersons in communit}' health practice. Chapter V describes and interprets child hygiene in the age of association, and the growing Depression-era imperative to maintain the health of the "whole child." Chapter VI details new, more inclusive role of the industrial hygienist in promoting health wherever workers were found, that is, in factories, in department stores, in the home, and out in the communit)-. Chapter VII addresses communit)- mental h)-giene and its newfound preoccupation with the "normal" mind.

The next two chapters seek to split apart and separate out for independent analysis that wliich at the time would not have been spht-apartable. Chapter VIII is given over to so-called

"health salesmanship," a way of educating the public in modern communit}' health that would have appeared distincdy unprofessional in the late nineteendi century. Chapter IX deals with philanthropic health "demonstrations" designed by experts to create popular demand for communit}' health. Chapter X examines community health in microcosm, that is, as it operated in families, the most fundamental units of modern American life. It seeks to demonstrate how 6 this "natural" group informed and was informed by experts interested in "familial epidemiology," described at the time as employing eminendy useful, communit)'-oriented research methodologies. My dissertation concludes with an evaluation in chapter XI of the place of individuals, and pardcularly their physiolog)', in an age where definition is so often found through association. Here, late-nineteenth-centur)' perfect, special-purpose physiological functioning and health is compared with modern twentieth-century notions of relative, general-puipose physiological functioning and health.

The remainder of this preface defines communit)' health in die eyes of those who practiced it, and describes those administrative forms and institutional mechanisms designed to implement it.

In 1917 Donald Budd Armstrong, then Assistant Secretarj- of the National Association for the Study and Prevention of Tuberculosis, announced that "tlie communit)' is the logical social unit for disease prevention and control." But what did he mean by that, and how could it be so self-evident? Even C.-E. A. Winslow, once described as "one of the most widely quoted health leaders in the countr}'," had difficulty at times defining and describing his own profession on occasion. "It doesn't include anything that is peculiar to itself, as law and medicine and geolog)' do," he quipped in 1943. "If you tr)' to seek for that content of public health which is not present elsewhere, you can't find it." Communit)' health, he obfuscated further, dealt with

"the application of a whole galaxy of sciences in a particular field associated with social activities, and that is one of the things that makes our task so complex.'"'

^ Donald Budd Armstrong, "The Fratningham Health and Tuberculosis Demonstration," American Jotinial of Public Health 7 (March 1917): 318; Ira Hiscock, "Charles-Edward Amorj- Winslow, Februar\' 4th, 1877-Januar)' 8th, " journal of Bacteriok^' 73 (March 1957); 295; Charles-Edward Amor}- Winslow, "Tlie Training of Public Health Personnel for the Americas," in Inter-American Conference of Professors of Hygiene (Wasliington, D.C.: Pan American Sanitar)' Bureau, 1945), 39. 7

The ideological foundations of the professions of public health did become more associational in the late 1910s and 1920s. Experts continued to explore and build upon such traditional subjects as vital statistics, bacteriology, sanitation, and engineering, but built and broadened cross-connections to subjects created and refreshed by interest in the social sciences.

Sociology, social work, psycholog}', psychiatry, and popular education all became crucial elements behind the efforts of public health experts. The new emphasis on the social sciences lessened professional self-identification in terms of a hard, quantifiable, laboratory-oriented discipline, while fLxing its gaze on larger social problems, that is, as more an applied "art" than as only a basic science. In sum, the "authentic experience" of public health had changed.'

Such inclusiveness stimulated professional desire for more generalized, multipurpose health practice. "While specialists are certain to remain and while they, without doubt, fill a distinct place in the public health program," advised Athel Campbell Burnham, director of the

Adantic Division of the American Red Cross, "the tendency of the recent graduates to specialize should be discouraged." Lewellys F. Barker of the York\'ille, New York, Medical Societ)' likened the specialist to the factor}^ "piece worker." Botli, he argued, were "exposed to a particular set of dangers," including narrowness, monotony, loss of adaptabilit}', objectionable aggressiveness, single-purposeness, stubborn opinionated-ness, boastful self-sufficiency, selfish materialism,

^'anit)', and arrogance. He recommended instead the "knitting together of specialists into a well-coordinated producing mechanism" by "diagnostic summarizers," "diagnostic integrators,"

"group managers," or "group organizers.""

' Winslow, The Eno/iition and Significance of the Modem Public Health Campaign, 1; Lloyd Ackerman, Health and Hygiene: A Comprehensive Stud}' of Disease Prevention and Health Promotion (Lancaster, Penn.: The Jacques Cattell Press, 1943), 5. ' Walter M. Dickie, "The Place of Medicine in Public Heahh" Journal of the American Medical Association 81 (October 13,1923); 1247-9; Campbell, The Community Health Problem, 44; Lewellys F. Barker, "The Specialist and the General Practitioner in Relation to Team-Work in Medical Pizcuce" Journal of the American Medical Association 78 (March 18, 1922); 776-9. 8

What appeared as grossly ovcrspecialized health research agendas came under especial scrutiny. "The word 'research' has fallen into some disrepute in certain quarters lately," noted

Milbank Fund board member Albert G. Milbank at the New York Health Conference in 1930.

"It has been referred to as a profidess search to learn more and more about less and less, a modern fad whose final goal will be to produce a super-scientist, an uhima tbuk of scholastic perfection who will know everything about nothing!"'^

Creating a profession representative of ordinarj' life led health experts, to an unprecedented degree, to enlist ever}'day Americans in the war against disease in everyday life.

Communit)- health demanded the application of the talents and abilities of experts to the whole community as well as die sendee of laypeople in achieving their goals. One of the central doctrines of this democratic public activit)' involved enlightened "salesmanship." Experts stressed not only the routinized and standardized teaching of physiolog)' and hygiene, a staple of schools and colleges as early as the 1870s,'" but the "seUing of health" hy persuasion rather than

' Edward \V. Sheldon and Albert G. Milbank, "Milbank Memorial Fund: Twenn'-Fifth Anniversar)-," in MUhank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversary (New York: Milbank Memorial Fund, 1930), 9. '"On the teaching of hygiene before 1915 see Alexander Crever .\bbott, "University' Teaching in Hygiene," Knports and Papers of the American Public Health Association 27 (1901): 94-9;John Shaw Billings, "Hygiene in University Education," Boston Medical and Surgical journal\?)\ (August 2,1894): 125-.'il; Emilio J. Bonillo, "Methods for Securing Greater Uniformity in the Instruction and Cooperation Toward Public Health by Means of the Teaching of Hygiene to the Cliildren in School" journal of Infectious Diseases 31 pt. 1 (1905): 161-8; Herbert Leslie Burrell, "A New View of the Medical Profession: The Education of the Public in Scientific Medicine," ycwwa/ of the American Medical Association 50 (June 6,1908): 1873-6; Lewis P. Bush, "The Importance of Educating Our Youth in the Principles of Hygiene," journal of the American Medical Association 14 (April 12, 1890): 540-1; Adrian De Garay, "Necessity and DesirabUit)' of Popularizing the Study of Hygiene," Reports and Papers of the American Public Health Association 21 (1896): 263-7; Oscar M. Dowhng, "Methods in Educational Hygiene," American journal of Public Health 2 (1912): 981; John Eaton, "Sanitation and Education," Reports am! Papers of the American Public Health Association 6 (1880): 248-65; Seneca Egbert, "The Teaching of Hygiene in Colleges and Normal Schools," Reports and Papers of the American Publicl-lealth Association 30 (1905): 143-52; Delos Fall, "A Plea for the Teacliing of Sanitary' Science in Our Schools," Education 17 (|anuar\' 1897): 266-75; idem, "The Teaching of Hygiene and Sanitar}' Science in the Secondary' Schools," School Review 6 (February' 1898): 65-74; Sarapliin Gauthier, "Teaching of Hygiene in Elementary Schools," Reports and Papers of the American Public Health Association 20 (1894): 259-62; j ane L. Greeley, "The Effect of Modern School Methods Upon the Health of the Teacher," Bulletin of the American AcadenQ' of Medicine 6 (February' 1905): 897-905; J.M. Gregory, "Hygiene and Higher Education," Reports and Papers of the American Public Health Association 4 (1877-8): 57-64; George G. Groff, "Physiology vs. Hygiene in Our Public Schools," Bulletin of the American Acaden^' of Medicine 6 (.August 1903): 370-4; Charles Nathaniel Hewitt, "The Work of Hygiene in the Education of Children in the Common Schools, and in the Families and Society in Which They Live," Reports and Papers of the American Public Health Association 4 (1877-8): 81-7; H.R. Hopkins, "Tlie Laws Compelling the Teaching of Physiology and Hygiene in the Public Schools," Buffalo Medical journal 215 (1895-6): 289-99; G. Hudson-Makuen, "The Teaching of Physiologic 9 pure reason. Invariably, however, health professionals remained the gatekeepers of their own expertise. Experts always remained more equal than laypeople in the American democratic experiment with communit)' health."

The community approach to health dovetailed nicely with a simultaneous desire to decentralize sen'ice. Public healdi professionals had tried many times to build a national, state, and local hierarchy for health administration since the end of the Civil War, and despite repeated frustrations and outright failure had clung tenaciously to the idea of some "national sanitan' bureau." By 1915, though, public health experts began shifting their attention to what they perceived as the great problem of wasteful "duplication and overlapping" of health ser\''ice and adminisuation. Many observers noted that the organization of local health units—districts for

Breathing," Bulletin of the American Academy of Medicine 6 (August 1903): 375-7; Isabel F. Hyams, "Tlie Improvement of Public Health Tlirough Teaching of Hygiene in the Elementary- Schools," Journal oj'Infections Diseases 35 pt. 1 (1909): 125-30; S.A. Knopf, "How May the Public School Be Helpful in the Prevention of Tuberculosis?" Bulletin of the American Academy of Medicine (> (April 1905): 913-22; A.W. Leighton, "Sanitar)' Training in Public Schools," New York Medical Journal 40 (1884): 527; G. Wilds Linn, "Higher Hygienic Education," Education 17 (September 1896): 30-6; James H. McBride, "Tlie Life and Health of Our Girls in Relation to Their Future," Bulletin of the American Academy of Medicine 6 (October 1903): 460-76; Charles O. Probst, "Instruction of Hygiene in Schools and Colleges," Reports and Papers of the American Public Health Association 20 (1894): 251-6; Helen C. Putnam, "The Desirable Organization for a Department of Hygiene in Public Schools," Bulletin of the American Academy of Medicine 6 (.August 1903): 378-86; Walter I.. Pyle, "The Teaching of Hygiene in the Public Schools," Bulletin oJ the American Academy of Medicine 6 (.\ugust 1903): 363-409; Ellen Henrietta Swallow Richards, "The Urgent Need of Sanitar\' Education in the Public Schools," Reports and Papers of the American Public Health Association 24 (1898): 100-2; J ohn W. Ritchie, "The Teaching of Hygiene and Sanitation in the Schools" Journal of Injections Diseases35 pt. 1 (1909): 131-7; A. Lapthorn Smith, "Are the -Modern School Methods in Keeping with Physiologic Knowledge?" Bulletin oJthe American Academy of Medicine 6 (February 1905): 871 -9; "Tlie Teaching of Phystolog)- and Hygiene in the Public Schools," Medical News 64 (March 31,1894): 357-9; \'ictor Clarence Vaughan, "The Michigan Method ofTeaching Sanitarj' Science or Hygiene in the Public Schools of the State," Bulletin of the American Acaden^ of Medicine (> (August 1903): 387-90; Thomas D. Wood, "The Training of Teachers of Hygiene for Public Schools," Bulletin of the American Acaderr^- of Medicine 6 (.August 1903): 391-409; H.P. Yeomans, "The Best Methods and Apparatus Necessary' for the Teaching of Hygiene in the Public Schools, as Well as the Means for Securing Uniformity in Such Instruction," Reports and Papers of the Public Health Association 12 (1886): 99-108. Helen C. Putnam, Edward Jackson, and George G. Groff survey of national and state laws regarding the teaching of hygiene in public schools in "Laws in the United States, A.D. 1903, Relating to Compulsorj' Instruction in Schools in Physiology and Hygiene with Special Reference to the Effects of Alcoholic Drinks and Narcotics on the Human System," Bulletin of the American Academy of Medicine 6 (April 1904): 635-67. An especially useful summary', complete with a list of common textbooks, is found in "Report of the Committee on the Teacliing of Hygiene in Public Schools," Bulletin of the American Academy of Medicine 1 Qune 1905): 1-64. "On the rising importance of advertising and consumer culture in the engineering of public demand sec James Har\'ev Young, "Food and Drug Enforcers in the 1920s: Restraining and Educating Business," Business and Economic Histor)' 21 (1992): 119-28; and Alan I Marcus and Howard P. Segal, Technology' in America: A Brief Histog, 2nd ed. (Fort Worth, Te\.: Harcourt Brace College Publishers, 1999), 207-60. 10 die cities and county health units in the countrj'side—naight reduce this waste. As historian Alan

I Marcus put it, "As a consequence of their growing acquaintance with the bacteriological view, which was bolstered by epidemiological determinations, and the socio-technological transformauon of America, many Americans saw disease prevention as a national problem and recognized that intercommunal action and cooperation were necessar}' facets of any public health campaign.'""

Only four county health units existed as late as 1912, in Jefferson County, Kentucky;

Yakima County, Washington; and Guilford and Robeson counties in Nordi Carolina.'-^ Jefferson

County, comprising the city limits of Louisville, organized a county department of health under its first full-time health officer B. W. Smock and several part-time sanitaty inspectors in 1908.

\'akima County hired Thomas Tetreau, a physician trained in sanitarj' science, along with a bacteriologist, a clerk, and several public health nurses and sanitaty inspectors during a raging typhoid fever epidemic in 1911. The last two, in Guilford and Robeson counties, were inspired in large measure by the short-li^'ed community efforts of the Rockefeller Sanitar}' Commission for die Eradication of Hookworm Disease. A county health department in Guilford County, with the city of Charlotte within its boundaries, came into existence under the full-time health officer G. F. Ross in 1911. The predominandy rural county of Robeson, North Carolina, organized its first county department the next year.'''

'"Donald Budd Armstrong, "Adequate Count)' Health Organization, Tuberculosis Control, and the Medical Profession," ]^eii> Riigland journal of Medicine 205 (September 17,1931); 570; Haven Emerson, Local Health Units for the Nation (New '^'ork: The Commonwealth Fund, 1945), v-w; Alan I Marcus, "Disease Prevention in America; From a Local to a National Outlook, 1880-1910," Bulletin of the Histor)' of Medicine 53 (1979); 195. '"^Not counting the parish health boards of Louisiana. See John Ettling, The Germ of harness: "Rockefeller'Philanthropy and Public Health in the New South (Cambridge, Mass.; Harvard Universit)' Press, 1981), 119-20. '''john A. Ferrell and Pauline A. Mead, comps., "Histoq- of Count}' Health Organizations in the United States, 1908-33," Public Health Bidletin 222 (March 1936): 3, 467-9; Ettling, The GermofL^t^ness, 221-2. The Rockefeller Sanitar\- Commission worked on many individual communit)' health education campaigns, but organized its servicc along state lines, reaving many of what the Commission described as moribund or ineffectual state boards of health in the South. See tlie Report of the Executive Secretary, publication no. 3 of the Rockefeller Sanitar)' Commission for the Eradication of Hookworm Disease (Washington, D.C.: Offices of tlie Commission, 1910), esp. pages 3-4. 11

Demonstrations projects, showcases for applied communit}' health, sponsored by the

National Tuberculosis Association, the American Child Health Association, the Milbank and

Commonwealth foundations, and the United States Public Health Sen-ice (USPHS) encouraged fu-st steps toward count}' or district health organization. By 1923, the number of full-time counts- health departments had grown to 214. In 1930, there were 505 count)' health units operating in the country, paid for mostly out of count)' revenue and supplemented with financial and professional assistance granted by state boards of health, the USPHS, the International Health

Board of the Rockefeller Foundation, the American Red Cross, and the Children's Bureau of the

U.S. Department of Labor.'^

Urban district health units also sprouted rapidly and profusely. In Boston Charles F.

Wilinsky in 1916 opened the cooperative Blossom Street Health Unit, harboring in one building the Boston Cit)' Health Department, the Consumptives Hospital Department, Instructive District

Nursing Association, Milk and Baby Hygiene Association, the offices of a visiting physician of the Boston Dispensar)-, and the Hebrew Federated Charities. By 1923, with the assistance of public health nurse Marj' Beard, the Blossom Street Unit had expanded to include dental and nuuition sen'ices, tonsil and adenoid examination facilities, offices of the Boston Communit}'

Health Association and Boston Sanatorium, and a Habit-Forming Clinic operated by the State

Department of Mental Diseases. Donations in excess of six million dollars received from the

George Robert Wliite Fund allowed the city to create seven more district health units.

"Charles-Edward Amon- Winslow, Heahh on the Farm and in the Village (New York: The Macmillan Company, 1931), 96-7; Leslie Leon Lumsden, "Extent of Rural Health Service in the United States, 1922-1926," Public Health Reports 41 (Ma)- 7,1926): 870-81; Ferrell and Mead, comps., "History of Count)- Health Organizations in the United States," 9,11. '^Charles F. Wilinsky, "Tlie Blossom Street Health Unit," Nation's Health 6 Qune 15,1924): 397-8; George Rosen, "The First Neighborhood Health Center Movement: Its Rise and Fall," in Front Medical Police to Social Medicine: Essays on the Histoiy of Health Care (New York: Science Histon' Publications), 316; Charles-Edward Amor)- Winslow, et al., The Communi^' Health Association and Its Relation to Boston If Health Proffam (Boston, 1926). 12

The Milbank Memorial Fund along witli other public and private agencies contributed large sums in the late 1910s and 1920s to the Bowling Green, Mulberr}^ Greenwich Village, and

East Harlem districts of New York Cit}' to establish coordinated, comprehensive health ser\dces for their residents. District health centers replaced what health experts regarded as out-of-date or

"old-fashioned" charity dispensaries, gymnasia, and soup kitchens. New York district health units created health centers that did infant welfare work, carried out prenatal and infant health examinations, encouraged mouth hygiene prophylaxis, put on nutrition, posture, and habit clinics, performed minor surgeries, and treated minor wounds and diseases. The Milbank Fund staged a demonstration of new communit}- health principles and practices in the district of East Harlem to show that decentralized and generali2ed ser\'ice was superior both administratively and financially to specialized cit}' health department and voluntary' sendee. As proof demonstrators showed that the average cost of a home visit under the generalized plan was only eight)'-nine cents, compared with 51.25 under the specialized plan. At the same time the tuberculosis death rate tumbled twent)' percent. By 1940, New York Cit)''s Department of Health had organized thirt\-

"neighborhood" health districts complete with dieir own health centers or "health houses." Many other cides across the countr}' from Baltimore to New Haven and Cincinnati to Los Angeles adopted similar plans for administering and distributing health resources.'^

This decentralized yet generalized count)' and district focus became institutionalized ideals among professionals in modern America. The Committee on Administi'ative Practice of

the American Public Health Association established in 1920 by C.-E. A. Winslow and others

sun'eyed the health sen'ice of eighty-three large cities and laid plans for their division into more

"Milbank Memorial Fund, Milbank Memorial Fund: Thirty-Fine Years in Review (New York: Mibank Memorial Fund, 1940), 13-4, 36, 39-40; Michael M. Davis and Anna Mann Richardson, "Health Centers for New York," Smv^' 57 (March 15,1927): 786-8; Homer Folks, "Financial Aspects of Health Demonstrations," American Journal of Public Health Supplement 17 (Februan' 1927): 6; Haven Emerson, "Proof in the Public Healtli Pudding: East Harlem, New York Cit)'," Surv^ 59 (November 15,1927): 210-1; idem, "Toward Neighborhood Health," Surv^ 59 (March 15, 1928): 776. See also C.E. McCombs, City Health Administration (New York: Tlie Macmillan Company, 1927). 13

manageable district units. Health administrators also addressed the problem of constructing uniform, flexible, ideal plans for communit)' health administradon at the 1926 mecdng of the

American Health Congress in Adantic Cit}'. They used as grist for their mill surveys of citj- health semces done by Winslow, Yale professor of public health Ira V. Hiscock, and the American

Child Health Association. Administrators focused their efforts on applying communit)' health to three "average" American cit)' sizes, those with populations of about thirt}' thousand, fift)' thousand, and one hundred thousand.'"

The three communit}' plans to be applied nationwide that emerged from their deliberations bore essential similarities. Health administrators agreed that health departments had to be governed by five member health boards with litde or no direct involvement in daily public health work, and composed wherever possible of one physician, one businessman, a lawyer, an engineer, and a woman. The work of communit}- health also had to be lodged in a department of health, supenased by a health officer or commissioner of health. Departments were to perform administrative, statistical, communicable disease, child hygiene, sanitar}', public health nursing, and laboratoiy functions. Administrators at the 1926 American Health Congress meeting also agreed that generalized public health nursing sendee was better than specialized, single-purpose practice, that is, dividing nursing into three artificial groups: visiting nursing, institutional nursing, and private dut}' nursing. These recommendations were codified by the Committee on

Administtative Practice of the American Public Health Association into the four editions of

Communily Health Organi^tion (first edition, 1927), edited by Hiscock. "Regardless of the scope and extent of its powers and duties," he concluded in the 1932 edition, "ever}' health department

'^Sponsored by the Conference of State and Provincial Healtli Authorities of North America, American Cliild Health Association, National Organization for Public Health Nursing, and American Public Health Association. Sec Ira Hiscock, ed., Conmnmity Health Organit^alion: Revised Plansfor Communities of 100,000 and 50,000, and a New Plan for 30,000 Population (New York; American Public Health Association, 1927), vii. 14 is an integral part of the communit}' government, responsible to some central authorit) , and interrelated in its activities with the general conduct of municipal affairs.'"'^

The ideal "large cit)'" of one hundred thousand was constructed from a foundadon of modern municipal sanitar}' code consistent with state rules. The healdi board or the mayor appointed a full-time health officer or commissioner to run the department of health and its satellite health centers scattered throughout the cit}\ The department itself was ideally divided into eight separate bureaus and numerous subdivisions. These bureaus were diose for administration, vital stadstics, communicable disease control, child hygiene, public health nursing, sanitation, food inspection, and laboratories. The bureau of administration was to be split in two parts, the division of administration and the division of public health education. The bureau assigned to communicable disease control was to be divided into divisions dedicated to epidemiology, tuberculosis, and venereal diseases. The bureau for child hygiene was to be divided into divisions for infant and school hygiene. The bureau of food inspection was to be split into divisions for milk control and for food and drugs. The cit}' of one hundred thousand also required an advisor)' committee of "interested, public spirited citizens."-"

The ideal "small city" of fiftj' thousand also consisted of a super\dsor}' board of health, a full-time health officer overseeing the department of health, and an advisory committee. It did not necessarily include neighborhood health centers. Six bureaus were suggested for cities of about tliis size: administration and records, communicable disease control, child hygiene, public health nursing, inspection, and laboratories. Vital statistics became a responsibilit)' of the bureau

'''ira Hiscock, "The Oiganization and Budget of a Health Department in a Ciry of 20,000 Population," American Journal of Public Healti) 14 (March 1924): 203; George Truman Palmer, et -A., A Heahh Surv^

The ideal "rural community'" health plan for about thiitj' thousand residents was usually to be organized on a count)^vide basis. The plan demanded a count)' healdi board, this time with the full-time health officer or commissioner of health as a member. An advisor}' committee and close cooperation between the health department and voluntarj' agencies were also a necessit)'.

Six bureaus, like the small cit}' plan, made up count}' departments of healtli.""

As notable as what administrators agreed to include in health deparmient organization was what they did not. Health experts did not include among die plans for community health administration much of what had formerly formed a mainstay of sanitary science and practical hygiene work. Garbage collection and street cleaning were relegated to public works departments. Plumbing and housing inspection were given over to city inspectors. Water supply and sewerage control became functions of water departments. None of these activities were any longer considered part of communit)' health work. Ira V. Hiscock in the first administrative monograph to emerge from the newly formed American Health Congress put it succinctly:

"Many problems previously considered as functions of a sanitar}' division of the health department are recognized as duties of other official agencies, thereby conserving additional funds and resources for more productive public health work."~^

Districts and count}' health units, moreover, needed special physical infrastructure in order to function properly. That place was tlie health center. As C.-E. A. Winslow announced in

1919, "The most sttiking and t}'pical development of the public health movement of the present day is the health center." Ira V. Hiscock defined communit}' health centers as the anchors

-'ibid., 53-97. "Ibid., 98-122. -••'ibid., 5. 16 holding together count)' and district units and as the centerpiece of the whole communit}- health movement. They acted, ideally, as clearinghouses for administration, information, diagnosis, and supply. Hiscock argued that "the modern conception of a healdi center visualizes a communit)- agency engaged primarily in prevendve medicine and public health education, centering in an organizadon of physicians, nurses, and other health and social workers, and volunteers." Health centers coordinated the experts and the masses for communit}' health purposes. Frederick L.

Hoffman, then consulting statistician for the Prudential Insurance Company, claimed that "by combining the administrative health functions with other essential auxiliar}' duties and health-promoting efforts, the health center could be made the radiating source of all local health activities, both public and private." They also helped alleviate die gross inefficiencies of older administrative forms. Explained Charles f\ Wilinsky, chief health officer of Boston, in a progressive era refrain: "Duplication, and consequent waste, frequent inefficiencies and

misunderstandings, could not help but lead to the conclusion that there was a great need for

better coordination and correlation, more efficient organization, and more harmonious

understanding between those agencies concerned with the public health and with the

amelioration of human suffering."'"*

Two t)'pes of health centers existed in modern communit)' health practice. The first t)'pc,

the "major health center," consisted of a building or buildings containing all of the super\nsor)'

machiner)- necessai*)' for public health, and often welfare, in a given area. The "minor health

center" provided fewer sendees, or for the sake of efficiency served a single specialized function

or constituency. The minor health center in many ways remained a still viable artifact derived

"''ira N'aughan Hiscock, "Tlie Development of Neighborhood Health Services in the United States," Milhank MemorialFtmclQuarterly 13 Qanuar)- 1935): 30; Campbell, The Community Health Problem, 99,101,106; Charles Wilinsky, The Health Units of Boston, 1924-1933 (Boston: Cit)' of Boston Printing Department, 1933); Michael M. Davis, Clinics, Hospitals, and Health Centers (New York: Harper & Brothers, 1927), 341-63. Hoffman's comment quoted in Homer N. Calver, "Wliat is a Health Centei?" J^merican Journal of Public Health 10 (August 1920): 677. 17

from late-nineteenth centur}' practice. Some of the more numerous and popular minor health centers were found in milk stations, well-baby clinics, and settlement houses."'

Hiscock himself stated that setdement houses and infant welfare stations had been the direct precursors of modern health centers. The setdement house movement which spread from

England to America in the 1880s, he thought, had inspired public health pioneers like Stanton

Coit, Jane Addams, and Lillian D. Wald to situate setdement houses in the immigrant districts of large cities. There they designed the houses as refuges where the foreign-born might acquire skills necessar}' for productive living. Visiting nursing (attending to the sick poor in their tenement apartments) and first aid, Hiscock argued, became two of the major functions of the setdement house. Independendy, infant welfare stations popped up across the country' beginning in tlie 1890s. These stations distributed clean milk to mothers, distributed advice regarding infant feeding and hygiene, and organized outdoor camps for tuberculous children. Nathan Straus, a

New York businessman, fu'st advanced the idea of a systematized supply of pasteurized m'lk in

1893 as a central feature of infant welfare stations, but the teaching function of the infant welfare station occupied a greater and greater share of their activities after the turn of the centun'."^'

George Rosen, the proEfic twentieth-centur)' historian of public health, also ti-aced the idea of health centers back to infant welfare and milk stations. Other hygienists in the late 1910s found origins for, and sometimes confused, communit}' health centers with venereal disease clinics, visiting nurse's offices, outpatient hospital clinics, and g\'mnasia. Longtime legal expert to die National Health Counciljames A. Tobey in 1921 argued that health centers probably derived from an expansion of dispensary responsibilities. The modern health center, diough, he saw as essentially different, having a distinct advantage over dispensaries because "instead of caring only

"^Hiscock, "The Development of Neighborliood Health Services," 30; Richard A. Bolt, "Tlie Development of Infant Welfare Centers," ClevelandMcdka!journal \1 (Febniarj' 1918); 69-74. "^Hiscock, "The Development of Neighborhood Health Services," 31-4. 18 for those came for txeatment it reached out into a definite area and gave intensive health sen-ice to all diose whom its resources permitted it to handle.""'

Setdement houses, infant welfare stations, and dispensaries produced professionals and laypeoplc influential in later communit)- health centers, but the principles and practices undergirding these centers reveal a substantial shift in emphases. The most important difference between older t}'pes of health facilities and major modern health centers derived from their general-purpose orientation. Communit)' health centers by definition furnished multiple ser%''ices all under one roof. Among die responsibilities of the modern center were epidemiology, generaUzed nursing, medical examinations, school health, personal hygiene advice, mental hygiene clinics, well-baby meetings, health education classes, publicit}', vaccination, diphtheria immunization, dental hygiene, sanitarj' inspection, and organization of voluntary organizations and individual citizens. They did not specialize in one tj'pe of service or attack one particular disease. This work now fell to the minor health centers, who continued providing single-purpose health and welfare services only where more comprehensive centers proved unfeasible or uneconomical. Also important, communit)' health centers increasingly made the ser\''ices of professionals available to all residents, not just the poorer or immigrant classes. Health centers also functioned as a convenient way to "decentralize" health seivice. Neighborhood health centers in urban districts helped—both physically and cognitively—to bridge the gap between expert and layperson. In other words, the health center brought professionals out of cocooning institutions inaccessible to the public if only for a time, and distributed them in numerous, approachable oudets.""

"'Calver, "\Vliat is a Health Center?" 676; Rosen, "Tlie First Neighborhood Health Center Movement," 304-27; lames Alner Tobey, "Symposium on the Health Center: The Historical Development," American journal of Public 'Health 11 (March 1921): 212. •^Calver, "Wliat is a Health Center?" 677; Pliilip S. Piatt, "Symposium on the Health Center: Is the Health Center a Health Center? A Positive Health Ideal in the Health Center," American Journal of Public Health 10 (August 1920): 226; Tobey, "Symposium on the Health Center: The Historical Development," 212; Hiscock, "The Development of 19

Boston's health centers by the 1920s contained all the agcncies nccessan- for supervising tlae health and social welfare needs of the district. The first floor of each center held a tuberculosis and well-baby clinic, dispensaries, x-ray equipment, and a spacious auditorium. The second floor sheltered the Communit}' Health Association, Overseers of Public Welfare, Family

Welfare Societ)', Catholic Charitable Bureau, and Associated Jewish Philanthropies. Each health center also contained a cafeteria, solarium, locker rooms, and showers for the use of workers.

The buildings stood several stories in size, and were constructed substantially of durable brick.-'^

New York Citv also opened district health centers at an early date. Here, though, the construction of district health centers preceded the organization of comprehensive communit)- health centers like those found in Boston. The first health centers, in particular, chiefly recreated in microcosm the activities of the late-nineteenth-century cit)' health department. City health commissioner S.S. Goldwater opened the first health center on the lower east side of Manhattan in 1915. This "Health District No. 1" ser\'ed a population composed almost wholly of Austrian and Russian immigrants, not assimilated native wliite Americans. Haven Emerson, Goldwater's successor, opened four similar centers the next year in Queens. Each of these, again, operated as

miniature health departments, not as comprehensive neighborhood health centers.'"

By the time America went to war, only a handful of health centers existed.But when

pcace retvirned the American Red Cross made communit)' health centers its first priorit)'. The

Red Cross, a self-described "people's organization" founded by social relief worker Clara Barton

in 1888, wanted to enlist everyday citizens into its health vanguard without jeopardizing the

.Neighborhood Health Ser\'-ices," 30. "'l-Iiscock, "Tlie Development of Neighborhood Health Services," 36-7. ^"Charles-Edward .\mon' Winslovv and Savel Zimand, Health Under the "El": The Story of the Belleme-Yarkville Health Demonstration in Mid-Town New York (New York: Harper & Brothers Publishers, 1937), 33-4; Hiscock, "Tlie Development of Neighborhood Health Services," 38. "Tobev, "Symposium on the Health Center: Tlie Historical Development," 212. 20

scientific advances of modern public health. Healdi centers seemed to fit the bill perfecdy because they encouraged association between experts and laypeople and sen'ed as a practical oudet for that activit)'. "The Red Cross Health Center," the organization proclaimed, "is a place from which health influences of all kinds radiate into all phases of the communitj' life."^-

Red Cross health ccnters included among theii- functions, "in addition to its clinics, which are always directed by the local doctors, diose of a general informational, social, and educational character, which can be organized and conducted by laypeople, with technical advice and supenasion." They relied on local health center advisor}' councils to coordinate these activities and enlist public support. Members of each council included a local health officer, school superintendent, medical societ)' officer, dentist, and representatives of other local professional and charitable organizations. The Red Cross used health centers to distribute popular health literature, show slides and films relating to proper hygiene, conduct demonstrations and consttuct exhibits, and organize Mother's Clubs and Little Mother's Leagues (for girls). By 1921, 318 Red

Cross health centers existed in the United States, and 588 more were planned."

Probably no single indi^ndual contributed more to the institutionalization of communit}'-oriented health centers after the war than Hermann M. Biggs, commissioner of the

New York State Department of Health. Biggs for four years lobbied alongside the State

Deparmient of Healdi, State Medical Societ)', State Sanitary Officer's Association, and State

Charities Aid /Association for the state legislature to pass liis "New York Health Center Bill," first laid out in 1919. The bill, passed in 1923, allowed "a count)', cit)', or consolidated health district to create and maintain one or more health centers and providing state aid therefor."

'"Walter H. Brown, "Symposium on the Health Center: Present Status of the Health Center," American journal of Public Health 11 (March 1921): 220; American Red Cross, Department of Health Service, "Symposium on the Health Center: The American Red Cross Health Center," American journal of Public Health 11 (March 1921): 227-30. American Red Cross, "Symposium on the Health Center: The American Red Cross Health Center," 227-30. 21

County supemsors divided counties into district with centers staffed by health officers. Biggs also commissioned architectural drawings for bviildings especially suited for health center activity-.

J. D. Burt, architect on staff with the New York City Department of Health, envisioned in his drawings rooms for laboratories, cliild welfare, dendstr}', ophthalmolog}', tuberculosis diagnosis, treatment of venereal and skin diseases, and mental health. Space was allotted for a staff kitchen, lockers, bathing, and a "moving picture machine."'''

Some of the first health centers created in New York City under this law were placed in impoverished immigrant districts. The Milbank Memorial Fund organizers, for example, established the judson Health Center in an Italian tenement district of New York City in 1920.

They described the area as consisdng of families living in cramped quarters, packed on top of one another and "choked" with "screaming children" and street vendors. The Italians themselves were considered "poor, ignorant, in many cases superstitious, believing that health is a gift of kindly spirits." But immigrants and the poor, while continuing to derive benefits from community health centers after the world war, became less and less the focus of efforts.

Immigrant and poor districts demanded the earliest district healdi organization, for in these areas public health professionals found dieii* greatest problems. However, as health center activities became more inclusive, that is, as their mission broadened, their- target populations also became more heterogeneous. Rather than serving "special populations," community healtli centers provided ser\aces to everyone who needed or inquired after them.'^^

The only sei-\dces usually dissociated from the health center were the private physician's clinic and die hospital, though both stiU played a role in the proper functioning of community

'''Burr Ransom Rickards, "Symposium on the Health Center: What New York State Has Done in Health Centers," American journal of Vublic Health 11 (March 1921): 216-7; Armstrong, "Adequate Countj' Health Organization," 570. •^'Charles-Edward .^mon' Winslow, "The Li\'ing Hand: Elizabeth Milbank Anderson," in MUbank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anninersaiy (New York: Milbank Memorial Fund, 1930), 35-6; Tobey, "Symposium on the Health Center: Tlie Historical Development," 212. 22 health centers. Annual physicals and health habit in\'^entories might be done under the supervision of physicians working part-time or volunteering theii' labor in healdi centers. But the tnalmeni of more than minor health problems in all but charit)- cases was the province of the family pracdtioner, the surgeon, and the hospital specialist. Health center personnel might discover significant illness and chronic illness in routine evaluations, but these padents were uniformly referred to physicians in private practice or to hospitals. Local physicians could use communis,' health center equipment to diagnose health defects they otherwise might not identif}-, as in the use of x-ray machines for mberculosis finding. This, it was frequentiy argued, might bring them more business than they might otherwise see, not rob them of patients as die old free dispensaries seemed to do.'^''

Small community- hospitals sometimes assumed the responsibilities granted health centers in larger cities. Often the "rural hospital," as it was sometimes called, became for aO intents and purposes a "communit)' institution" representing the "merger of the charit}' institution and a private facilit}-" paid for by "communit}- expense" through local taxes. These rural hospitals ideally acted as "social agents" in the communit)', coordinating local welfare work by instituting social sei-vice departments to link public and private agencies to both admitted and newly discharged patients.^'

The district health center model developed across the country with amazing speed and

unit}' of purpose. Already in 1919, Los Angeles began dividing its territory to decentralize health

ser\'ice and built centers designed to correlate public and private agencies. Alameda and San

Joaquin counties of California soon followed, as did New Haven, Connecticut; Buffalo, New

''"Dean Franklin Smiley and Adrian Gordon Gould, Community Hygiene (New York; Tlie Macmillan Company, 1929), 293-306; Gerald Morgan, Pub/ic Relief of Sickness (New York: The Macmillan Company, 1922), 177-81. ^'Henr}- ]. Southmayd and Geddes Smith, Small Community Hospitals (New York; The Commonwealth Fund, 1944), 1-17; Lucy Cornelia Catlin, The Hospital as a Social Agent in the Community (Philadelpliia; W.B. Saunders Company, 1918), 19-31, 109. 23

York; Green Bay, Wisconsin; KnoxviUe, Tennessee; and Baltimore, Mar\'land. By 1930, constellations of major and minor communit)' health centers could be found as far away as

Hawaii and numbered over 1,500.'"

The new professions of community health also sought to integrate into their sen'icc one vast territory that nineteenth-centur)' public health had neglected in particular and that the decentralizadon impulse of communit)- health had revealed dramatically; rural health. "Onh- verj' recendy has there been growing a general appreciation of another side of country life, the dark side, a recognition of the fact that on the farm are to be found just the same evils that exist in die tenement: povert)', ill health, neglect, and the rest, with only the difference that in the countr}' these problems are unrecognized and uncared for," explained C.-E. A. Winslow.

Triumph against the grave crises of urban public health had "produced a change in the health balance sheet between cit)' and countr}^" So successful had public health been in the cities, that rural health appeared to modern communit)- health professionals as a languishing sphere ripe for coordination and integration into the nation's health program. As Allen W. Freeman of the

American Public Health Association's Subcommittee on Rural Health Work described the situation, "in rural areas ... a primitive organization still prevails.

Experts considered the health problems of the rural population severe. Two Universit)' of Minnesota medical researchers, William P. Shepard and Harold S. Diehl, lamented the fact that

"universit)- students who have been raised in villages and on farms show more physical defects and more multiple defects than those raised in large cities." Farm and village dwellers had

^'^Hiscock, "The Development of Neighborhood Health Senaces," 40-51; Tobey, "Symposium on the Health Center: The Historical Development," 213. "Smilev and Gould, Commtiiiilj Hygiene, 280-1; Winslow, "Tlie Living Hand; Elizabeth Milbank Anderson," 39; Hart)- H. Moote, AmericaH Medicine and /he People's Hea/th (New York: D. Appleton and Company, 1927), "71-5; 85-"', 89- 91, 102-6; Allen W. Freeman, Sludj of KtiralPublic l-leahh Service (New York: Tlie Commonwealth Fund, 1933), 19. See also Frederick D. Mott and Milton I. Roemer, Ktiral Health and Medical Care (New York: McGraw-Hill Book Company, 1948). 24 cavities, diseased tonsils, and poor nutridonal habits. Gertrude Bilhuber, associate professor of physical educadon at Purdue Universit}", reported that thirt}'-four percent of school children in rural Washtenaw Count}', Michigan, lacked any vegetables in their diet over the winter. Fully one-fourth of these same students drank no milk at any time of year, eleven percent never brushed their teeth, and fully one-third refused to open their windows for ventilation at night.

Further, noted Cornell Universit)' assistant professors of hygiene Dean F. Smiley and Adrian G.

Gould, few rural Americans ever considered seeking correcdon or remedy for their health defects.""'

As longtime Tennessee health officer American journal oj Pnblic \-\mlth editor Ham' S.

Mustard put it, rural areas had the peculiar advantage of "closeness" between the government and the governed. When fitted to the needs of the local community' and coordinated properly, rural health measures organized on a count)' basis could be as effecdve as urban health measures organized around districts. Here, in the backwoods, vast grasslands, and isolated mountainsides of the continent cooperation between laypeople and experts mattered most. With the supply of healdi professionals scarce, the interest and assistance of rural folk toward the mundane tasks of supplying loan closets witli medical supplies or forming transportation corps for patients was critical. Because of the scarcit)- of healtli and medical personnel, generalized service was also essential. Sometimes tlie scarcit}' of personnel or funds demanded the organization of multi-count\- health districts. Still, Mustard complained, superstitious customs, hidebound tradition, and individualism often hamstrung rural health efforts.""

'"'W.P. Shepard and H.S. Diehl, "Rural and Urban WcAxYi" jomm! of Ihe American Medical Association 83 (October 11, 1924): 1117; Gertrude Billiuber, "Health Habits of Rural Children Not of Highest Grade," Nation's Health 7 (November 1925): 748-9; Dean Franklin Smiley and Adrian Gordon Gould, "Health Inventor)' of Urban and Rural Smdents," JSation's Health 8 (]anuan' 1926); 21-2. •"j.W. Moundn, "Modern Trends in Public Health Administration: Counr\- Health American Journal of Public Health 24 (1934): 715; Harr)- Stoll Mustard, BjiralHealth Practice (New York: Tlie Commonwealth Fund, 1936), 7, 119-29; M.E. Barnes, "The Strengths and Weaknesses of Count)' Healtli Otgntiasuon" Amrican Journal of Public Health 19 (1929): 731; Wilson George SmiUie, Public Health Administration in the United States (New York: Tlie 25

The rural health movement reached its cliniax in 1945 when Haven Emerson as chaii' of the Committee on Local Health Units proposed that twelve hundred local health units be created to more evenly distribute health coverage over both rural and urban areas, tlius bringing together both rural and urban dwellers into a system delivering "full time health ser\'ices at the communit)' level."-'-

• • •

Like a spinning top, health experts almost universally recognized that haphazard centrifugal administrative motion over time might cause die whole movement for communit}' health to wobble out of control. Again, "cooperation," the universal glue, and "coordination," the universal solvent, were called into play as balancing cenuripetal forces. Experts also addressed the problem by reminding themselves of two fundamental questions of communit)' health;

"What was a natural communit)'?" and "How could public health ser\'ice integrate itself into that organic whole?" If public health professionals could tease out answers to these questions communit)' health would not need to worry about devolution overtaking decentralization. The natural communities they found in modern American health were the neighborhood district, the rural count)', and at the most fundamental level tiie family, and health professionals structured

their activities accordingly.

Communit)' health experts struggled less over unit)' of purpose than over their boundaries

and aspirations. The professions of communit)' health purported to have a right to some share of

the work of nearly ever)' other professional group, and a voice in the proper running of the daily

lives of all Americans. But how could one profession do everything necessar)' to investigate,

regulate, and promote healthy individual and group living?

Macmillan Company, 1935), 313-35. ''"Emerson, et al.. Local Health Um/sfor the Nation, v-vi, 1-6. 26

The answer was twofold. First, community' health was composed of several professions,

not just one. It took public health nurses and mental hygienists, familial epidemiologists and industrial health experts, nutritionists and family practitioners, illumination engineers and health

educators. Second, ever}' other recognized profession potentially had a hand in the proper

functioning of communit)' health, as did ever}' interested layperson. Communit)' health, in sum,

as a cooperative, coordinating venture, depended at least as much on the efforts of other

professions and the public's acceptance and willingness to participate as upon its own expertise.

This essential fact engendered not only great respect for and admiration of public health experts

into the 1950s, but also threatened at ever}' turn to unlock for others the door to their own

authentic experience. It should not surprise us, then, that the current crisis in communit}' health

expertise—derived from our contemporar}' notions of the "professionalization of ever)'one," of

the perceived need for deinstitutionalization, personal responsibilit}', and empowerment in

matters of health—came to pass, but that it took so long in coming. 27

CHAPTER 11. BEFORE COMMUNITY HEALTH

The emergence of the public health "professional" in the nineteenth centurj^ should not be assumed to be only the obvious extension of the "Sanitar)' Ideal" of the "great men" of nineteenth-centur)' public health, men like Edwin Chadwick, Lemuel Shattuck, and John

Griscom. In fact, they were anything but "ideal" public health practitioners as defined under late-nineteenth-centur)' esthetics. Chadwick came to sewerage as a solution to the problems of his native England by way of Benthamite utilitarianism. Griscom spent a career with New York's medical police rooting out public nuisances like garbage and overflowing privies, as well as disease-producing atmospheric disturbances. Shattuck car\'ed out his living mainly by binding and selling books."''^

''"^On Edwin Chadwick see especially his "Centralization: Public Charities in France," LMICIOII ^view 2 (1829): 536-65; Repor/ to Her Majesty j' Principle Secretary of State for the Home Department, from the Poor Law Commissioners on an E nqitiry into the Sanitaiy Condition of the Labouring Population of Great Britain (London: Clowes, 1842); "The Requisite Attributions of a Minister of Health, and the Principles of Central and Local Administrative Organization and Action .\ccording to British Experiences," Sanitarian 7 (1879): 59-67; Sanitaiy Progress: Progress in Prenentive, as Compared with That of Curative. Science: Including Results, in the Saving of Sickness and Death (I^ondon: Spottiswoode, 1881); "Progress of Sanitation: Prevention as Compared with that of Curative Science," Transactions of the National Association of Social Science (1881): 625-49; The Health of Nations (London: Longmans, Green, and Co., 1887); and Benjamin Ward, ed.. The Health of Nations: A Review of the Works of Edwin Chadwick, 2 vols. (London: Longmans, Green & Co., 1887; reprint, London: Dawsons of Pall Mall, 1965); as well as secondar)' studies by Anthony England Brundage, England's "Prussian Minister": Edwin Chadwick and the Politics of Government Growth, 1832-1854 (University' Park: Pennsylvania State Universin- Press, 1988); Samuel Edward Finer, The Life and Tims of Sir Edwin Chadwick (London: Methuen, 1952; reprint. New York: Barnes & Noble, 1970); idem, "The Transmission of Benthamite Ideas, 1820-1850," in Stiulies in the Gmwth ofNiiieteenth-Ceniiiiy Government, ed. Gillian Sutherland (London: Routledge and Kegan Paul, 1972), 11 -32; Christopher Hamlin, "Could You Stat\'e to Death in England in 1839? The Chadwick-Farr Controversy and the Loss of the 'Social' in Public American fournal of Public Health ?>5 (June 1995): 856; idem. Public Health and Social justice in the Age of Chadwick: Britain, 1800-1854 (New York: Cambridge University Press, 1998); Dorsey D. Jones, "Edwin Chadwick and the Early Public Health Movement in England," Ph.D. diss., Universit)- of Iowa, 1929; Ann Elizabeth Fowler La Berge, "Edwin Chadwick and the French Connection," Bulletin of the Histoiy of Medicine 62 (1988): 23-41; Richard A. Lewis, "Edwin Chadwick and the Public Health Movement, 1832-54," Ph.D. diss., Universirv' of Birmingham, 1949; idem, Edwin Chadwick and the Public Health Movement, 1832-1854 (London: Longmans and Green, and Co., 1952; reprint. New York: Augustus M. Kelley, Publishers, 1970); ImiuI Ringen, "Edwin Chadwick, the Market Ideology, and Sanitary Reform: On the Nature of the 19th-Centur\' Public Health Movement," International Journal of Health Services 9 (1979): 107-120; Roger Watson, Edwin Chadwick, Poor Law, and Public Health (London: Longman, 1969); and Huntington Williams, "The Influence of Edwin Chadwick on American Public Healtli," Medical Officer')5 (1956): 273-9. On Lemuel Shattuck see especially liis "On the \'ital Statistics of Boston," American Journal of the Medical Sciences 1 (April 1841): 369-401; Report of a General Plan for the Promotion of Public 28

Rather, the idea of the professional public health worker demanded an expansion in the

definition of "profession" itself, a word generally rescr\'ed for priests, physicians, niilitar)- officers,

and attorneys in the nineteendi centuiy. The idea also demanded, in the last few decades of the

centur}' at least, public submission to the whims of an elite constructed of sciendfically-tiained

and insdtutionally-educated experts who discovered, guarded, and dispensed judicious facts and

concrete truths about prevenuon. That such a process did indeed take place is itself remarkable.

But that the profession of public health evolved so quickly, as the historical record reveals, and

with such apparent integrit)' as a legitimate field withoul much initial agreement as to its principles, even

cmjong /be professionals themselves is uialy astonishing.

In his The Sanitarians: y\ Histoiy of.American Public Health (1992), historian of medicine

John Duff)' remarked that the founding of the American Public Health Association (APHA) in

1872 clearly indicated that the period of the professionalizadon of public healdi was at hand.

Indeed, it is true that those individuals who gathered at 301 Mott Street in New York Cit)' on

and Personal Heahh, Devised, Prepared, and Recommended fy the Commissioners Appointed Under a Resohe of the Legislature of the State (Boston: Dutton & Wentworth, 1850; reprint, Cambridge: Har\'ard Universit)' Press, 1948); and Bills of Mortality, 1SW-1849, City of Boston (Boston: Registry Department, 1893); as well as secondar)' studies by John Ballard Blake, "Lemuel Shattuck and the Boston Water Supply," Bulletin of the Histoij of Medicine 2') (1955): 554-62; Hugo Muench, "Lemuel Shattuck, Still a Prophet; The \'italit)' of ^•'ital Statistics," American journal of Public Health 39 (1949): 151-5; Robert G. Piiterson, "Lemuel Shattuck and Public Health: A Letter to the Editor," journal of the HistoQ' of Medicine 7 (1952): 187-9; Wilson George Smillie, "Lemuel Shattuck: Still a Prophet," American Journal of Public Health 39 (Februan- 1949): 135-44; George Rosen, "William H. Welch and the Myth of Lemuel ShwXXncV." journal of the Histoiy of Medicine 6 (1951): 127-8; Charles-Edward Amorj- Winslow, "Lemuel Shattuck, Still a Prophet: The Message of Lemuel Shattuck for American journal of Public Health 39 (1949): 156-62; Abel Wolman, "Lemuel Shattuck, Still a Prophet: Sanitation of Yesterday, But VCIiat of Tomorrow?" American journal of Public Health 39 (1949): 145-50. On John Griscom see especially his Survival Mechanisms and Phjsiolo^' (New York, 1839); Annual Report of the Interments in the City and County of New 5 'ork for the ^ 'ear 1S42, with Remarks Therein, And a Brief I 'iew of the Sanitary Condition of the City (reprint. New York, 1943); 'The Sanitaiy Condition of the Laboring Population of New York with Suggestions for Its Improvement (New York: Harper & Bros., 1845); Tije Uses and Abuses of Air. Showing Its Influence in Sustaining Life, and Producing Disease (New \'ork: Red field, 1850); "Improvements of the Public Health and the Establishment of a Sanitar)- Police in the Cir\' of New York," Transactions of the Medical Society of the State of New York (1857); A History, Chronological and Circumstantial of the Visitations of Yellow Fever at New York (New York, 1858); and Sanitary Legislation, Past and Future: The Value of Sanitary Reform and the True Principlesfor its Attainment (New York, 1861); as well as James Higgins Cassedy, "The Roots of American Sanitar}' Reform, 1843-7: Seven Letters from John H. Griscom to Lemuel Shattuck," journal of the History of Medicine 30 (April 1975): 136-47; Duncan Robert J amieson, "Towards a Cleaner New York: John H. Griscom and New York's Public Health, 1830-1870," Ph.D. diss., Michigan State Universit)', 1972; Carroll Smith Rosenberg and Charles E. Rosenberg, "Pietism and the Origins of the American Public Health Movement: A Note onjohn H. Griscom and Robert H. Harriey," yo/zrW of the History of Medicine 23 (Spring 1968): 16-35. 29

April 18, 1872, to informally usher into existence the APHA agreed that they had formed an exclusive league of public health professionals. Still, the furst several decades of the APHA should not be characterized in terms of inevitable or inexorable advances in public health.

Despite claims by the early leadership to the contrary', tlie APHA in its infancy was no

"harmonious" assemblage of individuals united by well-defined, common principles or practices.

The organization, rather, tliough held together by a mission to advance scientific public health,

was divided over such basic issues as administrative control, necessary' character among members,

nomenclature, etiolog)^ and proper registration and reporting. In fact, the early reports and

papers of the APHA reflect, in part, a concerted effort by members from the Northeast to attack

and control diseases threatened by those considered to be "outsiders" or "strangers," especially

blacks, immigrants, and Southerners.'"'

The founders of the APHA—seven physicians, one attorney, an architect, and two

medical statisticians—^were all deeply united in their desire to apply scientific sanitar)' principles

and promote state and national health laws. "The gready increased interest in sanitary knowledge

and its manifold applications," wrote the first secretar)' Elisha Harris in 1874, "with an enlarged

spirit of scientific inquiry which has begun to apply itself to the economical and social interests of

mankind, already insure a numerous membership and harmonious working of the Association."

Harris' vision of healthy growth materialized almost immediately. From a core of eight)'

members on the rolls at the time of the first national convention at Cincinnati in 1873, the

organization grew rapidly. By 1900, APHA membership stood at over 560."*^

''''lohn Duff\-, The Sanitarians: A Histoiy of American Public Health (Urbana: University of Illinois Press, 1990): 130; Mazyck Porcher Ravenel, "The American Public Health Association: Past, Present, and Future," in A Half Centrny of Public Health: Jubilee Historical Volume of the American Public Health Association, ed. Alazyck Porchcr Ravenel (New York: American Public Health Association, 1921), 13. ''^"Meeting at Long Branch," Bjports and Papers of the American Public Health Association 2 (1874-5): 533; "Revised List of Members," Reports and Papers of the American Public Health Association 15 (1890): 335-46; "Revised List of Members," journal of the American Public Health Association (1900): wd-xxviii. For more on the formation and forerunners of the American Public Health Association see Gert H. Brieger, "Sanitar)' Reform in New York City: Stephen Smith and 30

But Harris' notion of a "harmonious" host of like-minded members did not materialize.

The early years of the APHA instead witnessed significant divisions emerging from wrangling over control and professional identity. The strong constitutional powers granted to the organization's Executive Committee constantly irritated newer members who referred to it confidentially as the "star chamber." These irritations exploded into public dispute over two repressive policies at the 1882 Indianapolis meeting. First, many members attacked the

"gentlemanly" absence of debate following paper presentations. Members resented the enforcement of silence during and after sessions, a rule deliberately designed by the Executive

Committee to encourage pleasant proceedings among members presumably of unimpeachable character.'"^'

Second, then-secretan' Azel Ames' proposal at Indianapobs to divide members into

"active" and "associate" members threw the whole question of membersliip into question. Who was "active" enough to be identified as "active"? Did one have to attend national meetings? Pay dues? Be a physician of good standing? Have a state license to practice, or merely a medical school diploma? What was an "associate"? Was the APHA a voluntar}' organization (as the charter indicated), soliciting and accepting aU who applied (save women)? Was it constituted merely to educate the public, or only the practitioners? And were those practitioners to be solely physicians, or did they include (as were currently accepted) plumbers, architects, meteorologists, the Passage of the Metropolitan Health Bill," Bttlklin of the Histor)' ofMedicine 40 (Seprember-Octobcr 1966): 407-29; Harold M. Gavins, "The National Quarantine and Sanitarj- Conventions of 1857 to 1860 and the Beginnings of the American Public Health Association," Biilktiii of the His/or)' ofMedicine 13 (April 1943): 419-25; Lec Kaufer Frankel, "The Plans and Purposes of the American Public Health Association," American Journal of Public Health 61 (July 1971): 1443-4; and Richard Harrison Shn'Ock, "The Origins and Significance of the Public Health Movement in the United States," Annals of Medical Histoiy 1 (1929): 645-65. For primar)- material see especially the Minutes and Proceedings and Debates o( the pre-Civil War National Quarantine and Sanitarj' Conventions; the Sanitary Condition of the City: B^por! of the Council of Hygiene and Public Health of the Citi^n 's Association of New York (reprint, New York: Arno Press, 1970); as well as the collected Reports and Papers of the American Public Health Association. ""^Stephen Smith, "On the Limitations and Modifj-ing Conditions of Human Longe\nt)', the Basis of Sanitar)' Work," Reports and Papers of the American Public Health Association 1 (1873): 7,12,' Howard Lynn Bodily, "Tlie First Section: Laboraton'," American Journal of Public Health 63 (August 1973): 667-8; 31 and sanitaty engineers? Was the organization to remain a debating club for refined gendemen, or a space dedicated to inculcating public health experdse among sciendfic pracudoners?''^

Members in the end reached a tense, uneasy compromise over these issues. The

Execudve Committee approved limited open debate, but did not encourage it. The Committee retained its powers to circumscribe debate where it deemed appropriate, and to select all members according to the quite open qualifications that they have an "acknowledged interest in, or devotion to, sanitar)' studies, and allied sciences." Still, a fractious minorit)' remained concerned that too much power, especially to select or reject members rested in the hands of an

Execudve Committee armed with only fuzzy guidelines.''"

Many among that fu-st generation of APHA members felt uneasy given the fluid nature of professional character maintained by public health professionals within the organization. In his account of the first attempt to form the APHA, founding member Stephen Smith noted the genteel refinement of the men he himself selected for membership. Other members spoke of

Smith in a similar vein. Smith was "straight, erect, and self-disciplined as an army officer, yet with a genial, humorous 'twinkle,'" noted his close friend the medical historian Fielding Garrison.

"No one could clasp liis hand and look into liis face without feeling impressed with his

'''"Proceedings and Discussions at the Tenth Annual Meeting," Reports and Papers of the American Public Health .Association 8 (1882): 191 -209; Stephen Smidi, "Remarks," Reports a/iH Papers of the American PuiiHc Health Association 22 (1896): 20-4; "Meeting at Long Branch," 533; "Revised List of Members," xvi-xxviii; Milton Terris, "Evolution of Public Health and Preventive Medicine in the United States," American journal of Public Health 65 (Februar)' 1975): 162; John Shaw Billings, "The Rights, Duties, and Privileges of the Communit)' in Relation to Those of the Indiwdual in Regard to Health," Reports and Papers of the American Public Health Association 3 (1875-6): 51; A.Nelson Bell, "Tlie Relation of the Mechanical Arts to Preventive Medicine, Particularly Illustrated by the Artesian Wells and Tidal Drains of Charleston, B.C.," Reports and Papers of the American Public Health Association 16 (1890): 229; Andrew Young, "The Relation of the Plumbers and the Physicians," Reports and Papers of the American Public Health Association 17 (1891): 48-9, 52; "American Public Health Association," Science 4 (1884): 440; "American Public Health Association," Science 10 (1887): 258-89; "Meeting of the American Public Health Association, 1885," Science 6 (1885): 511, 531; The Plumber and Sanitar)' Engineer?) (May 1,1880): 1; Mark W. Harrington, "The Relations of the Official Weather Ser\'ice to Sanitary' Science," Reports and Papers of the American Public Health Association 18 (1893): 37-42. Sec also Henn- C. Meyer, The Stoiy of the Sanitary Engineer, Later the Engineering Record (New "i'ork: Jacques & Company, Inc., 1928). ''""Proceedings and Discussions at the Tenth Annual Meeting," 191-209; Srrtith, "Remarks," 20-4. 32 astonishing vitality' and virility." Smith and other early members resisted the deterioration of this classic definition of the public health official, and helped achieve a sanitar)' expertise that was not only objective and sciendfically rigorous, but also reserved and well-groomed.'*'^

Massachusetts law'er and APHA member Emory Washburn, however, responded to

Smidi's faith in gendemanly professional trappings with dismay. "For faith [without science]," he concluded in his speech at the 1875 Baltimore national meeting, "is too often but the substance of things hoped for, but not seen." Resisting the gentrification of sanitarj' science, Washburn and a younger generation of APHA members instead preferred to advance a set of common, and presumably objective sanitarj' principles to replace die old-fashioned mores of their elder statesmen. The cultivation of expertise, they argued, conferred its own respectability. Sanitaty science relied not so much on civility or any ritual, lectured the physician and Sanilarian editor

Nathan Allen at the 1886 Toronto national meeting of the APHA. There was, he explained, "no mystery in it; no visitation of Divine Providence; no curse inflicted by some evil spirit." It was just science; pure, objective science. Earnestness and temperance were, of course, still admirable and worthy achievements in their own right, but could be pursued by laypeople as easily as by professionals.^"

The American Public Health Association membership also struggled to develop a standard vocabularj', a common language that befitted its standing as professional public health.

""Emon' Washburn, "Expert Testimony and the Public Service of Experts," Reports and Papers of the American Piih/ic Heahh Association 3 (1875-6): 38; Smith, "Remarks," 20-4. '"Nathan .-Mien, "The Relations Between Sanitan' Science and the Medical Profession," Reports anil Papers of the American Piih/ic Hea/th Association 12 (1886): 85, 97; Rebecca J. Tannenbaum, "Earnestness, Tcmpcrancc, Industn': The Definition and Uses of Professional Character .^mong Nincteenth-Cenfur)- American Physicians,"»J ll'e Histoij' of Medicine 49 (1994): 251 -9, 2''0-7, 282; Nancy R. Bernstein, The First One Hundred Years: Essays on the History of the American Public Health Association (Washington, D.C.: American Public Health Association, 1972), 2,12. See also John Duffy, "The American Medical Profession and Public Health: From Support to Ambivalence," Bulletin of the HistOQ' of Medicine 53 (1979): 1-22; Barbara Gutmann Rosenkrantz, "Cart Before the Horse: Tlieor)-, Practice, and Professional Image in American Public Health, \S10-\'!)2Q" Journal of the His/oiy of Medicine 29 (1974): 55-73; and Peter Wright and Andrew Treacher, eds.. The Problem of Medical Knowledge: Examining the Social Construction of Medicine (Edinburgh: Edinburgh Universit)- Press, 1982). 33

This sticky problem began with self-identification itself In the 1870s and 1880s, members could not even agree what to call dieir experdse. Pardcipants in these debates advanced such appellations as "public hygiene," "hygieine," "hygiology," "sanitar}' science," "practical hygiene," and "state medicine." They could not even agree on a proper spelling for "hygiolog}'."^'

Beyond this rather disconcerting lack of immediate agreement, were the more immediate problems creating uniform taxonomies for the classification of diseases (or nomenclature) and systematically collecting mortalit)' and morbidit)- data (vital statistics). Members viewed valid schemes for registering deaths as of the utmost importance, but did not clear this basic hurdle in all of the nineteentli-centuiy activities of the APHA. Congress had passed legislation inaugurating a National Death Registration System in response to an 1879 resolution sponsored by the APHA Committee on Vital Statistics. Yet, despite this great achievement, it quickly became apparent that the statistics being collected by states under the Death Registration System were notoriously incomplete, erroneous in the determination of cause of death, defied uniform categorization, and suffered manipulation by local physicians who withheld information they deemed private or embarrassing. Moreover, many in the public had no idea that deaths needed

to be reported to anyone other than family, friends, the priest or the pastor. Fears of local economic ruin in die reporting of epidemics also reduced official reporting. Inadequate

mechanisms for communicating statistics to count)' clerks and state departments of health

contributed to poor vital statistics collection. In Iowa, for instance, it took three painstaking years

''Ezra M. Hunt, "Sanitan' Nomenclature," Reports and Papers of the American Public Health Association 11 (1885): 31-7; "Report of Committee on Nomenclature and Forms of Statistics," Reports and Papers of the American Public Health Association 21 (1895): 517-35; Henr)- B. Baker, "Remarks on the Classification of Diseases," Reports and Papers of the American Public Health Association 14 (1888): 30-2; J.E. Monjaras, "Necessit}' of Uniformity' in the Meaning of the Term journal of the American Public Health Association 22 (1896): 128-9; Cressy L. Wilbur, et al., "Report of the Committee on the Nomenclature of Diseases and Forms oiStatisdcs" jomtal of the American Public Health Association 21) (1897): 337. 34 just to collect all the county mortalitj' schedules into one state mortalit}' report for the single year ended October 1, 1881."

Many APHA members resisted attempts by the Committee on Nomenclature to hammer out a single system for naming diseases and classifying them. Michigan physician Henr)- B.

Baker, mirroring the statements of many others, argued that "until these diseases are all more thoroughly studied and their causes better understood, any classification must necessarily be artificial, incomplete, and subject to change. ... In this generation, every investigator must use his own classification" and compile and present them in the least misleading way, that is, simply by "alphabetical arrangement.""

The nomenclature controversy within the American Public Health Association manifested itself because of deep controversies surrounding the cause of disease itself. Between

1872 and 1900, and for some as late as the 1910s, APHA members remained divided by several different, though by no means always mutually exclusive, conceptions of disease etiology. Put another way, the successes of Pasteur and Koch's bacteriological investigations on the Continent did not translate into easy acceptance of the "germ theor)'" of disease among members of the

APHA. In fact other loci for disease, particularly in "miasma" and "contagion" were both more popular theories among pubEc health experts than the germ theon' until late in the 1890s.''*

^"Elisha Harri.s, "Report on Plans for Complete and Authentic Records of Death and the Causes of Deaths in the United States," Reports and Papers of the American Public Heal/h Associalioii 4 (1879): 143; "Report of the Committee on N'ital Statistics," Reports and Papers of the American Public Health Association 7 (1881): 429-31; O.W. Wright, "Laws Requiring Medical Men to Report Deaths and Cases of Infectious Disease to the Public Authorities," Reports am! Papers of the American Public Health Association 8 (1882): 17-22; Samuel Warren Abbott, "National Registration a N'eccssir\'," Reports anil Papers of the American Public Health Association 19 (1894): 63-4; John S. Billings, "Methods of Tabulating and Publisliing Records of Death," Reports and Papers of the American Public Health Association 11 (1885): 62-3; Cres.sy L. Wilbur, "The Outlook for a General System of Registration of Vital Statistics in the United States," journal of ti)e American Public Health Association 21 (1895): 231, 235-41. "" "Report of the Committee on Nomenclature and Forms of Statistics," 517-35; Baker, "Remarks on the Classit'icauon of Diseases," 30-2. '""R.C. Kedzie, "The President's Address," Reports and Papers of the American Public Health Association 8 (1882): 2-3, 10; Bela Cogshall, "Is Tubercular Consumption a Contagious and Parasitic Disease?" Reports and Papers of the American Public Health Association 8 (1882): 164,173; William Thornton Parker, "Tlie Overshading of Our Homes," Reports and Papers of the American Public Health Association 15 (1889): 41; C.A. Lindsley, "An Epidemic of T)'phoid Fever," Reports 35

The miasma or "filth" theon' of disease located the source of many illnesses in invisible, noxious emanations from rotting garbage and other effluvia. Pools of stagnant water and newh' disturbed soils were also potential sources of miasma. Poor climate or peculiar meteorological events could contribute to the production of the miasmic atmosphere ripe for disease production.

One participant in the debate over antiseptic tlieories, the mining engineer and APHA member

EKv)'n Waller, concluded on the basis of miasmic theor)' that "removal of odor" was the central test of antiseptic efficiency. Waller sun^eyed many commercial preparations, including those containing chlorides, sulphates, and various acids. Carbolic acid, a staple in the deodorizing of sewage for almost four decades, was also tried. Putrid blood was the odoriferous substance against which each product was tested. On tliis basis, Waller anointed carbolic as "by far tlie best disinfectant of all."" and Papers of the American Public Heahb Association 11 (1885): 39-40. See also Phyllis Allen Richmond, "American .•\rdmdes Toward the Germ Theon' of Disease, \860-1880," joimia/ of /he His/oi^' of Medici/ie 9 (1954); 428-30; idem, "Some N'ariant Theories in Opposition to the Germ Theorj' of D'istasc," Journal of the Histoty of Medicine 9 Quly 1954): 290-303. Differences over disease etiologi' had enormous implications for the single most intrusive activity- of public health workers in the late-nineteenth centur)': quarantine restrictions. If, for example, miasma were to blame for diseases, it might be argued that quarantine was a useless measure since particular diseases emanated from an infected, inanimate localit)' and could not possibly be passed serially from person to person. For a careful examination of this problem see the paper presented to the APHA national convention by Oakley van der Poel, health officer of the Port of New York, "General Principles Affecting the Organization and Practice of Quarantine," Reports and Papers of the American Public Health Association 1 (1873): 402-26; and a practical example in .•\lfrcd W'oodhull's paper, "May Not Yellow Fever Originate in the United States? .^n Etiological Study of the Epidemic at Savannah in 1876," Reports and Papers qftlje American Public Health Association 5 (1879): 89-107. See also the secondan' study by Les M. Benedict, "Contagion and the Constitution: Quarantine Agitation from 1859 to Journal of the History of Medicine 2b (1970): 177-93, ^^Samuel Warren Abbott, "Wliat Constitutes a Filth Disease," Reports and Papers of the American Public Health Association 16 (1890): 30-49; Bell, "The Relation of the Mechanical Arts to Preventive Medicine," 2227-35; idem, "The Relations of Certain Filth Diseases to Cold Weather," Reports and Papers of the American Public Health Association 6 (1880): 154-7; William Clendenin, "Tlie General Causes of Disease," Reports and Papers of the American Public Health Association 1 (1873): 49, 52-3; Felix Formento, "The President's Address," Reports and Papers of the American Public Health Association 18 (1892): 1-14; S.S. Herrick, "The Relation Between Underground Sewerage and Filth Diseases," Reports and Papers of the American Public Health Association 10 (1884): 180-3; Alberto Noriega, "Miasmatic Fevers in the State of Sonora," Reports and Papers of the American Public Health Association 22 (1896): 294-6; Max von Pettenkofer, "Wliat We Can Do Against Cholera," Reports and Papers of the American Public Health Association 1 (1873): 335; Elw)'n Waller, "Report on Disinfection and Disinfectants," Reports and Papers of the American Public Health Association 1 (1873): 459-71. See also T.H. Barker, On Malaria and Miasmata (1863); Charles Caldwell, An Essay Upon the Nature and Sources of the Malaria or Noxious Miasma, From Which Originate tiie Family of Diseases Usually Knomi by the Denomination of RiHous Diseases; Together with the Best Means of Preventing the Formation of Malaria (Philadelpliia: Carey & Lea, 1831); idem. Thoughts on Febrile Miasms, Intended as an Answer to the Boyhton Medical Pri::y Question, for the Year 1830, 'Wljetljer Fever is Produced by the Decomposition of Animal or Vegetable Substances, and y By Both, Their Comparative Influence?" 36

"Contagion," often resented for chemical conceptions of disease like that of Justus von

Liebig, likened the propagation of disease in the human body to the fermentation of organic poisons in otherwise innocuous substances. These decaying substances, often gaseous agents, could then be transferred to others through the air or by personal contact."^'

Henr)- M. Lyman of Rush Medical College at the 1877 Chicago meedng of the American

Public Health Association argued for contagion theory' and against animalcules. "We know ven- well how [infectious diseases] prevail sporadically at certain times; and again as a pandemic pestilence. But what was the original source of theii-infection.^" he queried. "We can never account for the furst case of such disease" since "its causation must have been dependent upon the reaction between the human organism and the physical forces which impinge on it," rather than "a direct transmission of infecting matters from one generation of patients to another."

Lyman complained that

When Pasteur clears the blood of its parasites, the residuum is stiU confessedly infectious. . . . Now we know that all die different kinds of viiTJS and the various digestive ferments, are the products of organized bodies, to wit, the cells which help to make up the tissues of animals in which diey exist. Consequentiy, we must believe that a substance which responds in the same way to chemical reagents, and which Uke them can be separated as a soluble glycerole, must be a kindred substance, and must be the product of organized cells. And since it has been shown that bacteria do

(Lexington, Ky., 1830); Charles \'alue Chapin, "Ate Diphtheria and Typhoid Fever Filth Diseases?" Medical News 60 (March 19,1892): 312-6; idem, "The End of the Filth Theor)' of Disease," Vopuiar Science MonMy (Xi Qanuan' 1902): 234-9; John H. Ellis, Yellow Fever and Public Health in tbeNew South (Lexington: The Universirj' Press of Kentucky, 1992), esp. p. 168; and Sylvia N. Tesh, "Miasma and 'Social Factors' in Disease Causalit)-: Lessons from the Nineteenth Century" Journal of Health Politics, PoUg, and Law 20 (Winter 1995): 1001-24. '''Manuel Carmona y N'alle, "Can Syphilitic Contagion Form the \'ehicle for the Transmission of Tuberculosis as Well?" Reports and Papers of the American Public Health Association 19 (1893): 204-9; Grcgorio Mendizabal, "Dermatosis as Commonly Transmitted to the Pupils of Public Schools by Contagion, and Means of Prevention," Reports and Papers of the American Public Health Association 24 (1898): 234-6; Tomas Noriega, "Tlie Contagion of \'enereal Diseases on Railroads," Reports and Papers of the American Public Health Association 21 (1895): 303-8; Edwin Miller Snow, "Does Small-pox Become Epidemic, or Spread Only by Its Own Contagion?" Reports and Papers of the American Public Health Association 2 (1874-5): ?; Thaddeus M. Stevens, "The True N'alue of Chemical Analysis in Determining the Hygienic Purity of Potable Water," Reports and Papers of the Awerican Public Health Association 10 (1884): 96-9; Orlando W. Wight, "Tlie Management of Contagious and Infectious Diseases in Milwaukee," Reports and Papers of the American Public Health Association 6 (1880): 86-92. Tlie theor)' of contagion is often interpreted as being swallowed up by miasma etiolog}' in tlie nineteentli century. This combining of the two separate theories into one can be explained mainly because both cleave to atmospheric explanations, albeit by chemical agency for contagion and noxious vapour by the other. 37

not liberate any such substance, the only remaining cells by which it can be produced are the cells of the animal itself. It is a product of morbid cell acdon.^'

In his estimation, the 1873 cholera epidemic that besieged the United States was

"autochthonous," arising spontaneously from the diseased condition of the individual, rather than "exotic" in origin. Lyman suggested that the disease, radier than arriving by a circuitous path from the "crowded" and "defiled" valley of the Ganges in India, may have originated in a sailor who "immediately after gorging liimself with cabbage . . . was taken sick, and died the next day."^"

Controversy swirled around the germ theor}-, largeh' because the origin of Pasteur's germs was uncertain. Indeed, the germ theor)' itself existed not as a single entit)-, but rather in a multitude of forms strange to us today. Various germ theories ascribed disease production to infection from microscopic bacteria, parasitic vermin, algae growths, or fungi. Some advocates supposed that parasitic "vegetative forms" invaded the body from witliout. Others posited the germs, or morbid "gemmules," were produced inside the unnaturally excited human body out of otherwise "normal bioplasm." Consider the novel system for naiTiing microscopic diseases of

"parasitic" origin crafted by Vermont physician and first hygiene instructor at the Trenton (N.J.)

State Normal School Ezra M. Hunt;

Micro-organisms, .... litde organized particles Microbes or microbia.... litde living things Microzoa ..... Utdeanimals Microphytes ..... litdeplants Microzvmes ..... litde ferments''^

The notion of the "carrier state," that is, obser\'ably healthy persons testing positive for infectious

bacteria, also cast considerable doubt on the germ theory. One observer noted that, "A simple

^'Henn- M. Lyman, "A Review of the Present State of Exact Knowledge Regarding the Causation of Epidemic Infectious Diseases," Reports and Papers of the American Public Health Association 4 (1879): 97. '®Ibid.,93,101-2. ^'Hunt, "Sanitan- Nomenclature," 31-7. 38 form of fungus, called the Sarcinia ventriculi, is often found in matters thrown up by persons laboring under disorder of tlie stomach. But it is likewise found ... in the stomachs of persons in perfect health." Many permutations of tliese three basic categories of etiology

(miasma, contagion, germs) were articulated by APHA members. Heterogeneous mixes formed from the basic precepts of each were standard practice in explaining the machinadons of elusive diseases.'^'"

So what did public healtli experts agree upon? Though the rank and file of the American

Public Health Association remained divided over etiological matters, members generally agreed that certain classes of the population bred miasma, contagion, or germs all out of proportion to their numbers. Francis Amasa Walker, superintendent of the ninth U.S. Census (and later

^"Henn,- Frazer Campbell, "The Yellow Fever Quarantine of the Future, as Organized Upon the Portabilit}' of Atmospheric Germs and Upon the Non-Contagiousness of the Disease," Reports and Papers of the American Puh/ic Health Association 5 (1879): 131-44; W.T. Councilman, "The Malarial Germ of Lavcran," Reports and Papers oj the American Public Health Association 13 (1887): 224-32; George Miller Sternberg, "Disease Germs," Reports and Papers of the American Public Health Association 10 (1884): 69-78; F..\.P. Barnard, "The Germ Theor\' of Disease and its Relation to Mvgiene," Reports and Papers of the American Public Health Association 1 (1873): 73-4. Sec also Robert P. Hudson, Disease am! Us Controh The Shaping of Modern Thought (Westport, Conn.: Greenwood Press, 1983): 153-4; Phyllis .-Mien, ".Americans and the Germ Tlieon- of Disease," (Ph.D. diss., Universit)- of Pennsylvania, 1949); John Shaw BilUngs, "Germs and Epidemics," Sanitary En^ineerl (March 15, 1883): 341-2; idem. Sanitary Engineer! (NIarch 29,1883): 387-90; Charles N'alue Chapin, The Present State of the Germ Theory of Disease (Providence: Kellogg Printing Company, 1885); idem. What Changs Has the Acceptance of the Germ Theory Made for Measures for the Prevention and Treatment of Consumption? (Providence: Providence Press Company, 1888); J.K. Crellin, ".Airborne Particles and the Germ Theon-, 1860-1880," Annals of Science 22 (March 1966): 49-60; idem, "The Dawn of the Germ Theor}-: Particles, Parasites, Infection, and Biolog\'," in Medicine and Science in the 1S60s, ed. F.N.L. Poynter (I^ondon: Wellcome Institute of the Histor)' of Medicine, 1968); A. Scott Eatle, "The Germ Theon' in .America: Antisepsis and Asepsis, 1867-1900," Surgey 65 (March 1969); 508-22; Henr}' Gradle,J3df/f/7fl and the Germ Theory of Disease (Chicago: W.T. Keener, 1883); "The Gerni-Theon- of Disease," Popular Science Monthly 23 (1883): 579; Jon M. Harkness, "The Reception of Pasteur's Rabies ^'accine in America: An Episode in the Application of the Germ Theor)- of Disease," (M..A. thesis, Universit)' of Wisconsin, 1987); E.P. Hurd, "On the Germ Theorj' of Disease," Boston Medical and Surgical Journal 91 (1874): 97-110; Howard D. Kramer, "The Germ Tlieor)- and the Early Public Health Program in the United States," Bulletin of the Histoy of Medicine 22 (May-June 1948): 233-47; Alan M. Kraut, "Silent Travelers; Germ, Genes, and American Efficiency, 1890-1924," Social Science Histor}' 12 (Winter 1988): 377-94; idem, Silent Travelers: Germs. Genes, and the 'Immigrant Merrace" (New York: BasicBooks, 1994); Benjamin H. Landing, "Rollin R. Gregg of Buffalo, a 19 th Centvin- Opponent of Pasteur and the Germ Theory- of Disease," Bulletin of the Histoy of Medicine hb (1962): 524-8; Regina Markell Morantz-Sanchez, "Feminism, Professionalism, and Germs: The Thought ofMar)' Putnamjacobi and Elizabeth American Quarterly 1)^ (Winter 1982): 459-78; J.G. Richardson, "Tlie Germ Theory of Disease, and its Present Bearing Upon Public and Personal Hygiene," American Journal of Microscopy and Popu/ar Science 3 (1878): 241-6; Phyllis Allen Richmond, "American Attitudes Toward the Germ Tlieon' o( Disease" Journal of the History ofMedicine (October 1954): 428-54; George Miller Sternberg, "Preface," to The Bacteria by Antoine Magnin (Boston: Litde, Brown, and Company, 1880), 4-5; Nancy Tomes, "American Attitudes Toward the Germ Theor)' of Disease: Ph)'llis Allen Richmond Revisi red,"Journal of the Histoy ofMedicine 52 (] anuar)- 1997): 17-50. 39 president of MIT), carefully laid out this problem in liis 1873 paper delivered to APHA members.

Walker in his well-received report contrasted the "uniformit)' with which tlie native wliite population contributes to the mortalit)' from each specified cause in each section of the countr)- by turns" and the corresponding "fluctuations among the colored and the foreign elements of the population." These fluctuations, in his estimation, contributed fuUy one-third more deaths each year dian otherwise expected among the native population. Walker specifically noted the particular "liabilit}-" of blacks to malaria, lung disease, yellow fever, venereal disease, and premature births.'^'

Further, Walker continued, while white Northerners did not grow sickly while living in the South, foreigners were increasingly felled by disease the furdier they moved southward. The

South, he deemed, had a particularly insalubrious climate, and demanded the careful quarantine of southern ports whenever necessar}\ The South, moreover, had made both native blacks and whites weak, debilitated, and disease-prone. Southerners, it might be added, had litde voice with wliich to refute Walker's conclusions, comprising as they did less than thirteen percent of total

APHA membersliip before 1900.

Immigrants stood as the greatest threat to American public health. "With the immigrant came r\-phus and t)'phoid fevers, which resisdessly swept through the tenement houses, decimadng the povert\'-su:icken tenants," remembered Stephen Smith on the occasion of the

fiftieth anniversar}' of die APHA. He considered the Scotch and Irish the most sickly. The

Scotch were particularly susceptible to nen^ous system failure, locomotive difficulties, smallpox,

"Proceedings and Debates of the Seventeenth .-Annual Meeting," Reports and Papers of the American Public Health Association 15 (1889): 297; G.B. Tliornton, "The Negro Mortalit)' of Memphis," Rsports and Papers of the American Public Health Association 8 (1882): 178-9; Francis A. Walker, "The Relation of Race and Nationalit)* to Mortalitj' in the United States," Reports and Papers of the American Public Health Association 1 (1873): 30-1. For cogcnt accounts of "strangers" as public health problems, see Alan I Marcus, Plague of Strangers: Social Groups and the Origins of City Semices in Cincinnati (Columbus: Ohio State University' Press, 1991); John Mgham, Strangers in the hand: Patterns of American Kativism, 1860-1925 (New Brunswick, N.J.: Rutgers Universit)' Press, 1955); and Alan M. Kraut, Silent Travelers: GertMs, Genes, and the 'Immigrant Menace" Basic Books, 1994). 40 scrofula, cancers, paralysis, er^'sipelas, measles, and whooping cough. The Irish confounded the public health officials by their tenacious consumption, rheumatism, and "extraordinar)- mortalit)'" from kidney disorders. Even the foreign-born English and Scandinavian immigrants suffered greater mortalit)' than the native American population. The English were considered harbingers of dysenter)% diarrhea, enteritis, t}'phus fever, bronchitis, and smallpox. Swedes, Norwegians, and

Danes bore the brunt of diseases of the spine, circulatory problems, measles, scarlet fever, and diphtheria. Only the industrious and cleanly Germans exhibited an "evenness" in deaths comparable to that of native whites."

Thus, immigration restriction and quarantine efforts perennially dominated discussion. In

1883, for instance, the APHA passed resolutions directing Congress to take action to "prevent, so far as possible, the coming of these foreign defective and criminal people to burden our resources, and to deprave, by the transmission of their defects to their children, the mental, moral, and physical qualities of our present and future people." Several members bemoaned the immigrant threat in their own jurisdictions in debate prior to passage of tliis 1883 resolution. "In

New Orleans you cannot go one block without coming upon a pauper making a living from begging by exhibiting his deforrruties," exclaimed Executive Committee member Gustavus

Devron. "He is brought from Europe; and that class of people I see every day in New Orleans; and if the laws were enforced, they would remain objects of charit}' in their own countr)'."

Physician Hemy Pickering Walcott of Massachusetts, head of local charit)' groups dealing with the problem of "lunacy" agreed, noting that he had seen penitentiaries full of criminals haUing from European ports. Dr. Miliar)' Ryan expressed himself all too plainly in his support of the

'"Nathan Allen, "Perfection of Structure in the Human Body, as a Leading Element of Hygiene," ¥jporls anil Papers of the American Public Health Association 1 (1873); 38-40; Stephen Smith, "Tlie Histoiy of Public Health, 1871-1921," in A Half Century of Public Health: jubilee Historical Volume of the American Public Health Association (New York: American Public Health Association, 1921), 4-7. 41 resolutions. "Mr. President," he announced, "in Texas, the emigrants, Bohemians especially, are fearfully dishonest. Nothing can come in their way that they wiU not steal. ... It is painfully true that the Germans and Bohemians are Germanizing and Bohemianizing Texas instead of

Texas Americanizing them.""

Not all members were so violend)' xenophobic, but the restricdon of immigrants was without exception a common aim. Colonel George Waring, die sanitary "White Wing" of New

York City, standing alone during the 1883 debate pleaded that the resolution "not pass, not because we do not appreciate, as we all do, the importance of the subject, but because it seems to me it is going beyond the range of our duties. It is like the question on intemperance, and I think we had better leave it alone." To which Walcott replied, widi a peal of laughter and applause following, "If the insane population of the United States is not a concern of public health, in the name of heaven what is?""''

The American Public Health Association did not stand alone as guardian of public health expertise in the late nineteenth centur}-. The American Medical Association constituted a Section on State Medicine and Public Hygiene almost simultaneously with the founding of the American

Public Health Association. The AK'L^ and APHA both encouraged many of the same aims, like

the formation of state boards of health and preventive health legislation. Indeed, many (though

not all) of the members of the two organizations were the same. Henry I. Bowditch, for instance,

was a founding member of the American Public Healtli Association in 1872 and president of the

American Medical Association in 1877. Both organizations benefited from the atmosphere of

public urgency attending several severe epidemics of tj'phus, tj'phoid, and yellow fever. Yet the

Durgin, "Report of Committee on Sanitarj' and Medical Senrice on Emigrant Ships," Reports and Papers of the American Public Health Association 16 (1890): 43-9; W.W. Daniels, "Report of the Committee on Car Sanitation," Reports and Papers of the American Public Health Association 17 (1891): (sl-llf, "Proceedings and Discussions at the Eleventh Annual Meeting," 412-4. ''"'"Proceedings and Discussions at the Eleventh Annual Meeting," 413-4. 42

AMA Section on State Medicine saw its influence gradually wane between 1874 and 1900, while the American Public Health Association rapidly grew in membership. Bowditch, who initially man^eled at the "frequent intermingling of men" in the Section on State Medicine had already becomc disenchanted by 1876. "It must be confessed," he wrote, "that [this] subject seems to afford less interest than any others [at the AM\ national convention]."^"

To understand how the profession of public health became lodged in the American

Public Health Association rather than the American Medical Association, both of which by 1915 were populated almost entirely by medical school graduates, it is crucial that we examine the aims of die Section on State Medicine. Close scrutiny of tlie core assumptions behind state medicine revealed in published papers reveals no fundamental break in plans or purposes, and no opposition to positions argued or held by the APHA. State medicine encapsulated the greatest advance in scientific knowledge in human histor)' in the minds of its adherents. The selfish interests of elected officials and businessmen were considered its greatest enemies. And as in the

APHA, urban immigrant groups remained the greatest direat to a healthy order of things, and cleanliness and objectivit)' were the watchwords of the profession. These ideas remained remarkably consistent.

The most striking common theme revealed by close scrutiny of the papers of the AMA

Section on State Medicine is the enduring conflict over theory and practice. Wliile confident of dieir science, delegates were unsure of its most efficient application in practice. Fear of falling into a political morass, uncertainty about the distinct role of state medicine within general medical practice, and competition from the more diverse American Public Health Association signaled a fundamental weakness of the Section. The medical historian John Duffy has already obsen'ed

^^Pnceeeliiigs of the House of Delegates of the American Medical Association 73 (May 1922): 2; Henrj' I. Bowditch, ".-Vddress on Hygiene and Preventive Medicine," Transactions of the Inteniational Medical Confess of Philadelphia, 1876. 43 the growing ambivalence toward public health by the AMA. What he did not comment upon is that this conspicuous ambivalence in matters of public health extended beyond the body of AMA practitioners as a whole to the verj' section given the opportunit\' to legitimate public health efforts among physicians/'^'

The purpose of state medicine as described by the Section's first chairman A. Nelson

Bell, an active early member of the APHA, was to apply medical science and engineering to public hygiene problems. Delegates to the Section agreed upon a number of other key purposes:

(1) institution of some sort of "National Sanitarj' Bureau," (2) collection of vital statistics, and (3) publication of warnings against the self-administration of alcohol as a medicinal. An unresolved problem delegates confronted at the ver}' fu'st meeting mirrored exacdy that facing the APHA: what exacdy was "state medicine"? Stanford E. Chaillc of the Louisiana State Board of Health pleased many when he articulated the definition of state medicine as "the application by the State of medical knowledge to the common weal; and embraces ever\' subject for the comprehension of which medical knowledge, and for the execution of which State authorit}', are indispensable."

Still, throughout the late nineteenth centurj' and into the early decades of the twentieth great confusion surrounded use of the term. "State Medicine is not an attractive designation," complained U.S. Na\^- Medical Director Albert L. Gihon in 1882, "though the difficult)' is at once apparent of suggesting any other that expresses so distinctly the relationship of the State to the great ends the science of medicine aims to accomplish, the exhibition of the legislative will and executive authorit)- of the body politic to the enforcement of what medical science has demonstrated to be essential to the pubUc health." Gihon recommended that the Section

^''Duffy, "Tlie American Medical Profession and Public Health," 1-22. 44 embrace single-mindedly the goal of assisting, in a "neutral" rather than political way, government campaigns to prevent disease/"

Science formed the bedrock of state medicinc, and practidoners increasingly fell to calling their experdse "sanitar}' science" to separate it from the wider administradve goal of public hygiene. Science, it was widely held, was liberadng the professions from supersddons perpetrated by generations before. Public health loiowledge would inevitably be transmuted into a purer, more valuable form with the advance of science. A. N. Bell mar\'^eled at both the advance of science and the economic progress of the nation, but he also noted that sanitar)- science had borne the fu'st fruits of both. Even the millionaire industrialist turned to the physician for scientific expertise during an epidemic. The physician who practices state medicine for public benefit, he noted, stands as one of "the Scientific class" working outside the daily grind of business. The uncorrupted scientific class represented the great equalizer in societ}'. The progress of medicine and public health from "esoteric" to "exoteric" was thought to be winning out over resisting secular and mystical ideas.'^'*

Disinterested professionalism stood as the goal of the practitioner of sanitarj' science.

"Efficient and economical sanitar)' administration depends upon the dignit)', qualifications.

^'Minutes of the Committee on a National Health Council, Scction on Medical Jurisprudence, Hygiene, and Physiology-, Transaclions of the American Medical Assodalionli (1872): 155-9; Franklin Staples, "Minutes of the Scction on State Medicine and Public Hygiene," Transactions of the American Medico/ Association 25 (1874); 351-2; R.C. Kcdzic, "Chairman's Report to the Section on State Medicine and Public Hygiene," Transactions of the American Medical Association 27 (1876); 353; Stanford E. Chaille, "State Medicine and State Medical Societies," Transactions of the American Medical Association 30 (1879): 299-300; Albert L. Gihon, "Address in State Medicine," Transactions of ti)e American Medical Association 33 (1882); 290, 293, 302-3; L.D. Waterman, "Minutes of the Section on State Medicinc and Public Hygiene," Transactions of the American Medical Association 28 (1877); 376; John Shaw Billings, "Address in State Medicine and Public Hygiene," Transactions of the American Medical Association IXi (1879): 277; J.T. Reeve, "Minutes of the Section on Stare Medicine and Public H)-giene," Transactions of the American Medical Association 30 (1879): 269; james F. Hibberd, "Address in Medical J urisprudence. Psychology, Chemistrj', State Medicine, and Public Hygiene," Transaction of the American Medical Association 31 (1880): 419; Morris Fishbein, A History of the American Medical Association, 1S47 to 1947 (Philadelphia; W.B. Saunders Company, 1947). 1092-6. ''^Frank Seaver Billings, "State journal of the American Medical Association 5 (September 19,1885): 312-4; Alfred L. Carroll, "Address on State Journal of the American Medical Association 14 (May 24, 1890); 756;J. Berrien Lindsley, "Address on State Medicine; The People and the Public Health Movement,"of the American Medical Association 19 (j uly 2,1892): 2. 45 powers, and responsibilities of the officers who are appointed to execute it," announced Bell.

State medicine, noted another Section delegate, like other areas of medicine was "honorable and profitable as well as pure." Physicians working in the dispensar)\ the public hospital, or in the health department rather than the private clinic were doubly blessed with human and charitable virtues. Puritj* required the physician to remain politic yet nonpartisan. Patrons of science were enjoined to proceed slowly where the patrons of men were concerned, for those who governed were easily confused. Purity did not preclude a paternalistic attitude toward those ignorant of sanitai-)- scjencc. M

Even'where, the role of "fact" seeming))' replaced "guesswork" in the pursuit of perfect knowledge of sanitar)' science. What separated this new dawning of a science of public health from a former dark age of superstition involved the assembly and classification of empii'ical facts.

Fact was the weapon by wliich the practitioner of state medicine would validate his effort. At all times delegates to the Section on State Medicine, and the APHA for that matter, appealed for more data to support theii' claims.^"

"Truth" as derived in tliis process of perfecting knowledge, to be worthy of that appellation, needed to be equivalent to the great truths found in the exact sciences of chemistr)', physics, and mathematics. Exact truth, Ezra Hunt thought, "speaks out for itself as lustily as ever a born cliild cries for itself that life has taken possession of this sanitan' science." Nature had

Nelson Bell, "The Waste of Life," Transactions of the American Medical Association 25 (1874): 370; Ezra M. Hunt, "Annual Address in State Medicine and Public Hygiene," Transactions of the American Medical Association 28 (1877): 386, 392, 397, 407; Billings, "Address in State Medicine and Public Hygiene," 278-9; J.E.D. McDaniel, "Prevention of War and Protection of Peace, in Relation to State Jonrnal oj the American Medical Association 27 (.\ugust 29,1896): 455-6; "Progress of State Medicine," of the American Medical Association 1 (September 1883): 313. "Purit\'" absolutely required that physicians abstain from immoral "weak-kneed" abortion procedures. See also James F. Hibberd, "Minutes of the Secuon of State Medicine," Transactions of the American Medical Association 31 (1880): 412. ™Ezra M. Hunt, "Minutes of the Section on Public Hygiene," 335; idem, "Chairman's Report to the Section on State Medicine and Public Hygiene," Transactions of the American Medical Association 28 (1877): 378; idem, "Annual Address in State Medicine and Public Hygiene," 392; Foster Pratt, "Address of the Chairman of the Section on State Medicine, cK.," Jonrnal of the American Medical Association 1 (August 18, 1883): 163. 46 now offered up its greatest secrets to expertise, and the sanitarian literally wallowed in a newly rendered objective world that his sense hoped to master. The massing up of these revealed secret forms, said Hunt, provided the raw "material which the builders of the temple |of science] can use." The worst state medicine could do was "claiming for it results that are not yet warranted," explained physician Foster Pratt of Kalamazoo, Michigan. "Have we not urged as facts in sanitar)' science, what in truth was nothing more than theorj'," and thereby "crippled sanitar}' work." Only by objective knowledge witliout recourse to imperfect theorj' or "undigested dogmatism" could the lifetime of man be increased.^'

The greatest hindrance to the authorit)' of the professional and scientific class of public healtli practitioners could be found in the backstabbing, logrolling, jackleg politician. Even the

most ignorant classes of America understood that politicians could not be trusted with expertise

because the)' remained untrained. Moreover, where the physician dedicated his life to the

principles of sanitar}' science for use against the ills of humanit)', the political leader acted as

benevolent or corrupt sachem for special interests. American physicians engaged in state

medicine agreed with the British physician Thomas Henr)' Huxley when he said that die efforts

of medical men could be easily destroyed, but rarely enhanced, by politics.'"

The worst insult for a practitioner of sanitar)' science was to be mistaken for a politician.

Propriety dictated that state medicine's activities in the public realm, which by definition included

all of them, avoid even the hint of political bias. Thus delegates to the Section on State Medicine

'' Henr)' P. Walcott, "Address in State Medicine," Transactions of the American Medical Association (May 26,1888): 639; Hunt, "Annual Address in State Medicine and Public Hygiene," 392, 394-8, 400-1; Pratt, "Address of the Chairman of the Section on State Medicine, etc.," 163,165; George Homan, "The Promise and Potency of Cleanliness," ]oiimal of the American Medical Association 5 (September 19,1885): 316; Carroll, "Address on State Medicine," 755. '"Deering ]. Roberts, "Address in State Medicine" ]oiinial of the American Medical Association 3 (July 5, 1884): 4; Gihon, "Address in State Medicine," 298, 308; "Progress of State Medicine," 313; Walcott, "Address in State Medicine," 637-9; Kedzie, "Minutes of the Section," 337-8; Hunt, "Minutes of the Section," 379; Reeve, "Minutes of the Section on State Medicine and Public Hygiene," 278-9; Schenck, "Address on State Medicine," 730-1. See also Tannenbaum, "Earnestness, Temperance, Industr)-," 251-83. 47 and members of the American Public Health Association proceeded cautiously in the pursuit of public health legislation, especially toward the goal of a sanitar)' bureau in the national government. Surgeon General John Shaw Billings, for example, although the chief architect of the National Board of Health, proved unwilling to submit his proposal to Congress for several years. "I do not think it is the province of physicians, as scientific men," he explained, "to urge the passage of a bill of this kind." He was later crushed when the National Board became likened in the press to a "politico-professional paradise" where physicians collected "fat salaries" and lived lives of "luxurious ease." He later apologized for ever suggesting the idea of a National

Board of Health.'"^

Politicians represented only one nonscientific threat. The forces of business could also damage the best laid plans of state medicine as die legislative machine. Mill owners constructed mill ponds that direatened the local health with noxious miasma. Managers of slaughter houses allowed all manner of offal to drain away down public streets. Resistance to the laws of health was "much more likely to come from the landlord than from the tenant; from the manufacturer than the artisan; from die employer than the laborer," noted Ezra Hunt. The extravagant claims for patent medicines, brazenly advertised by shameless hucksters stood as the verj' antithesis of enlightened principles of sanitar)' science.

The monopolists, in particular, seemed invulnerable to attack by sanitar)' experts. Yet even thev could be taken to the mat by science, for "science by her discoveries revolutionizing business frequendy breaks die back of monopolies, giving new courses to wealth." Capitalists, who seemed so friendly to those who cured the obviously sick, were instead construed as

"Kedzie, "Minutes of the Section," 329, 331; Hibbetd, "Address in Medical Jurisprudence, Psycholog)', Chemistr)-, State Medicine, and Public Hygiene," 430; Hibberd, "Minutes of the Section of State Medicine," 415; Billings, "State Medicine," 311. '''R.C. Kedzie, "Natural Purifiers," Transactions of the American Medical Association 27 (1876): 348-9; Granville P. Conn, "State Medicine vs. Journal of the American Medical Association 25 (November 10,1895): 863. 48 potential enemies to public health prevention. The ignorance of profit-driven businessmen blinded them even from that which appeared in their own best interest. Public health experts continually argued that "an ounce of prevention was worth a pound of cure," but found it difficult to convince business interests of the same.'^

It would be simplistic and misleading, however, to suggest that delegates to the Section on State Medicine or member of the APHA were constitutionally adverse to the making of money. They were not. The private clinic remained an essential part of the equation in healing the sick. Yet medicine, and state medicine in particular, was a profession founded on expertise.

It was more than a business; it was a calling, an avocation.^^'

The self-imposed disinterestedness toward pecuniar)' gain or fame did not preclude a basic economic motive behind state medicine. If the philosophy of state medicine could be summed up in a single sentence it was "health is wealth." This phrase was repeated often in defense of public health as economic securit}-. "If the individual is preser\'ed, a productive member of society- is added and remuneration rendered," explained A. N. Bell in his 1874 address to the Section on State Medicine entided "The Waste of Life." Establishing the authorit)' of the expert in state medicine, he wrote, allowed the nation to become much more efficient. Halting the spread of disease by calculated inti-epidit}' and eliminating foolish public panic saved untold millions of dollars.''

Capitalism encouraged class war. State medicine reduced the tensions between classes by leveling the playing field. Pubic health laws by their very nature protected the honest and

'"^Kedzie, "Natural Purifiers," 348-9; Billings, "State Medicinc," 311. '"^Hunt, "Annual Address in State Medicine and Public Hygiene," 386. "Schenck, "The Address on State Medicine," 733; Bell, "The Waste of Life," 366-8; John H. Rauch, "State Medicine: Some Practical Recommendations for the Exclusion and Prevention of Asiatic Cholera," journal of I be American Medical Association 3 (November 1884): 530; Pratt, "Address of the Chairman of the Section on State .Medicinc, etc.," 161-2; Staples, "Minutes of the Section on State Medicine and Public Hygiene," 2; Billings, "State Medicine," 311. 49 sensitive capitalist from the dishonest and careless, and protected the classes generally from the diseases of one another. Moreover, the demand for sanitar)- expertise by crafters of law prevented charlatans from rushing "incontinendy" to the legislature each time thej' needed protection for their own indusay. Physicians bore the dut}' to "direct public opinion on all matters of professional interest," wrote New Hampshire physician Granville P. Conn, "instead of hav[ing] it brought round in the grip of a commercial traveler." The public health practitioner should, in otlier words, rule over commerce rather dian be its subject.'"

The necessit)' of public participation in the institution of public health laws presented some interesting problems to delegates of the AMi\ Section on State Medicine. To what extent, they asked, should the citizenr}' understand the science of public health? Public health experts agreed that the lay public had already demonstrated that it could not remember much more than the rudiments of responsible hygiene. "The people are forgetful and neglectful," explained one

Section chairman, "and need to be constandy reminded of the sources of danger which threaten their health and lives." Yet full explication of the sanitar)' scientific principles guarding against such dangers remained the preser\'e of a "special class of men."''^

Success, most agreed, dictated some level of public understanding of the purposes, if not the principles, of state medicine. The public had to be informed of the canards of lawmakers and business people. The next generation of Americans must not see disease as the irrational and unstoppable visitation of divine punishment, but rather as the rational outcome of improper living and sanitary mismanagement. The new generation, in other words, needed a new public health. The public cared litde about "germ theories" and "vectors of infection," delegates

'^Staples, "Minutes of the Section on State Medicine and Public Hygiene," 359-60; Pratt, "Address of the Chairman of the Section on State Medicine, etc.," 164; Conn, "State Medicine vs. Fads," 864. ''E.M. Hunt, "Minutes of tlic Section," 335; J ohn Aver)-, "State and Local Boards of Healtli," Journal of the American Medical Association 6 Qanuan- 2,1886): 1, 4; Carroll, "Address on State Medicine," 756; Conn, "State Medicine vs. Fads," 864, 50 assumed, but only wanted to know what to do if diseases were "catching." The poor especially had a stake in public health as they represented the sole source of "capital" for the earning of wages.""

Even if the public at some point submitted perfectly to the expertise of state medicine, a gap always appeared between those who knew and those who did not. "The relation between the physician and public cannot be too closely connected," explained Albuquerque physician Charles

E. Winslow (not to be confused with C.-E. A. Winslow). "The masses look to the physicians as authorit)' on medical knowledge." Professional detachment required that the physician separate liis goals from those of the individual citizen. Each group, physicians and public, had aims and ambitions, but they were often not complementar)'. "We do not tr)' to make ever)- man his own health officer," remarked Pennsylvania physician Charles Mclntire. "1 think the health authorities in various cities submit themselves to much useless trouble to instruct with bullets

[bulletins] and cijrculars they send around.""'

As in the American Public Health Association, the miasmic or "filth" theor)' of disease dominated etiological thought in the Section on State Medicine. Delegates debated the relative merits involved in the proper sitiiig of buildings, improved ventilation systems, and poisonous chemical products of bacteria. Chemical theories also remained popular, and delegates to the

Section spoke openly about the production of a "vitiated atmosphere" created by the corrosive action of oxygen. Even alcoholism could be explained as the result of poor dwellings where the

"continual inhalation of impure and defective air is always followed by the accumulation of poisons, wliich in many ways unknown, cause reflex disturbances and reactions" that drove

^''Hunt, "Annual Address in State Medicine and Public Hygiene," 407; "Progress of State Medicinc," 314; Pratt, ".•\ddress of the Chairman of the Section on State Medicine, etc.," 163; Aver\', "State and Local Boards of Health," 1. Charles E. Winslow, "The Physician and the State," 296; James W. Cokenower, "Dut)' of the Physician to the 'P\\b]ic" joiinicil of the American Medica/ Association 27 (August 29,1896): 459-60; Charles Mclntire, "Health Boards as Disturbers of the Peace," Journal of li)e American Medical Association 27 (August 29,1896): 459. 51 people to drink. Cures for alcoholism, sleeplessness, hemorrhoids, nen-ous disorders, and insanit}- might be effected if only delegates worked toward the institution of a "societ)' for aerationists." Again, as in the APHA, least popular were Pasteur's living ferments and their poisonous chemical products,"^

Robert Koch is often invoked today by medical science as the investigator who subjected

Pasteur's ferments to the scrutiny of laboratorj' analysis and developed rational methods for locating the specific bacteria responsible for diseases. This method is summarized in Koch's postulates. A bacterium is regarded as the cause of infection if it can be isolated from the infected person, propagated in pure fonn on solid culture media, and produced disease when injected into an otherwise healthy subject. Antisepsis, likewise, is judged successful if the chemical agent breaks the cycle of bacterial reproduction in a sick individual or prevents an infectious organism from entering the body.

Bacteriolog)' did become an ever more important tool in the arsenal of those engaged in public health or state medicine. In 1899 the American Public Health Association established a special, permanent Laborator)' Section (the first of many special-interest sections) on Bacteriology and Chemistr)'. Thougli problems of control and character, standard nomenclature, and sources of disease were not immediately resolved by the invitation to a new constituency of bacteriologists into the APHA fold, the provision of a "center for the speciaEst where methods and results can be compared and discussed, so that tiie evolution of the best as the composition of forces at many hands may be attained" proved a fruitful way to puzzle out answers and erect standards under the unfolding umbrella of the germ theories."'

^"Hunt, "Annua! Address in State Medicine and Public H5'giene," 391, 395; Staples, "Minutes of the Section on State Medicine and Public Hygiene," 353-4, 358-9; T.D. Crothers, "A Study of the Effects of Poisoned Air, in the Causation of Inebriet^^" ]oitrnal of the American Medical Association 23 (August 25,1894): 291-3; Bell, "The Waste of Life," 362-4, 366-7; Kedzie, "Natural Purifiers," 343-5; E.M. Hunt, "Minutes of the Section on Public Hygiene," 317, 320-1; Cabell, "Address in State Medicine and Public Hygiene," 561. ®"\Villiam H. McBeath, "First Section; Laboratory," American Journal of Public Health 63 (August 1973); 667-8; 52

By 1897, Minnesota delegate to the AMA Section on State Medicine Franklin Staples, who sen'ed as first secretarj' of the Section in 1874, was prompted to remark that

the great discoveries and advances in bacteriology made in late years have laid a foundation for practical work in preventive medicine not before known. Laboratories are provided for by the State and municipal authorities, and expert bacteriologists and chemists are employed not only in the analysis of water and food products, but in furnisliing the means of diagnosis of disease, and, of late especially, in developing the various means for rendering the human body immune to the poison of infection."'*

APHA members and AMA delegates, however, came around to an appreciation of this new configuration of the laws of propagation of disease reluctantiy. Cleanliness remained the ubiquitous principle by which filth, dangerous chemicals, and germs were all eliminated. The new science of bacteriolog}' replaced an ambiguous aesthetic ideal open to individual interpretation in miasma (by nose, taste), and instead emulated the standardized laborator}' analysis of chemicals.

Unlike iniasma, which was literaUy sniffed out by an inspection of habitations and their associated systems for water supply and sewage disposal, germs were found under carefully controlled laboratory conditions. Here the differences between the new ideal of bacteriological causes and the older ideal of filth became most apparent. Under the artificially controlled conditions of laboratoiy practice, namre was not allo\Ved to indiscriminately intervene. Instead, inputs were carefully fed into the system, reducing the possibilit}' of erroneous conclusions. The concept of acclimation in disease production, for instance was no longer studied by collected

Kramer, "The Germ Theor}- and the Early Public Health Program in the United States," Bulletin of the His/or)' of Medicine (May-June 1948): 245-6; Charles Smart, "Proceedings of tlie Convcndon" Journal of Ihe American Public Health Association 20 (1895): 459-64; William Henrj- Welch, "Report of the ComrniXXtt" Journal of the American Public Health Association 23 (1897): 56-7; Charles Smart, et al., "Proceedures Recommended for the Study of Bacteria, with Especial Reference to Greater Uniformity in the Description and Differentiation of Species, Being the Report of a Committee of Bacteriologists to the Committee on the Pollution of Water Supplies of the American Public Health Association," sports and Papers of the American Public Health Association 23 (1897): 78, 89,100-1; Hibbert Winslow Hill, "Chairman's Address," American Journal of Public Health 32 (1908): 3. ^''Franklin Staples, "Concerning the Present Condition of State Medicine in the United States," Journal oj the American Medical Association 28 (April 28,1897): 686. 53 meteorological data in the field, but by subjecting test organisms to rigorous laboratory conditions where pressure, moisture, and temperature could be carefully controlled. As a final safeguard, proper conclusions demanded repetiuon in the laboratories of other experts."^

The senses were enhanced, then, not simply by the addition of a new theon' to the armament of sanitar)' science, but by a different way of experiencing the world, that is, by harnessing natural forces and subjecting ever)' experiment to laboratory verification. "To the exceptionally specialized scientific mind," noted one Section on State Medicine delegate, sanitar)' science was coterminous in definition "with the artificial cultures ... of the bacteriological laboratorv'." The laborator)' was a powerful complement to the weighing of information akeady a staple of scientific data collection and collation. It represented a powerful adjunct to objectivit)'."''

Finally, like the American Public Health Association the AMA Section on State Medicine dwelled on those classes responsible for what they showed to be a disproportionate share of disease. New immigrants displayed dismaying behaviors especially menacing to civic health.

Immigrants flocked to cities already crowded widi the dens of paupers, criminals, and the sick.

They also exhibited bizarre customs. Immigrants cooked strange and malnutritious foods, wore unusual and unhygienic clothing, and spoke strange languages inaccessible to health officers. A.

N. Bell lamented the large numbers of "troglodytes" living in dank New York basements

"poisoning the atmosphere around, and sucking the lifeblood of the people." The speed of the new steam-powered ocean liners and railroads allowed immigrants to move around quickly while presenting their habits. Most doubling, perhaps, immigrants refused to setde in America long

"Annual Address in State Medicine and Public Hygiene," 389; George H. Rohe, "Address in State Medicine: Recent Advances in Preventive Medicine," of the American Medical Association 9 Quly 2,1887); 7; John B. Hamilton, "Address of the Chairman of the Section on State Medicine," journal of the American Medical Association 14 (May 31,1890): 780. ®^Hunt, "Annual Address in State Medicine and Public Hygiene," 398-400; CarroU, "Address on State Medicine," 755; Henry D. Holton, "Address on State Medicine,"/owr/Wi^ the American Medical Association 24 Qune 1,1895): 824. 54 enough to become sufficiently Americanized, returning to tlieir homelands periodically. Efforts to reform immigrant life were frustrated by the new mobilit)' of America's foreign population."

Recurrent invasions of cholera and yellow fever from foreign ports into the nation also prompted particularly hostile feelings. Immigrants exliibited, in the minds of experts, profound insolence by arriving on American shores with disease. Such arrogant disregard for the laws of their proposed new homeland was considered tantamount to treason. Never mind that these new immigrants were not citizens; they accepted all the responsibilities, if none of the rights, of

American citizens die minute the)- entered steerage in European ports. Section delegates were smug when a "harsh" new Interstate Quarantine Act, the first in eight}- years, was passed to legalize immigrant health inspection in 1878.""

These emotions were not restricted solely to American public health experts. The

Medical Officer of Health for the cit)' of Glasgow, Scotiand, himself became convinced that if he could throw ever)' resident Irishman into tlie local prison the death rate might be cut in half In

America the Irishman would not become coequal with the native American in societ)', but proper training in matters of decent health might remake him into a good Irishman, less susceptible to disease and thus less of a threat to groups located higher up the social totem. The higher ranks of societ)-, in turn, had to be prevented from exploiting the urban and immigrant poor. Impure thoughts and imprudent actions were not the presence only of the underclasses. Extreme wealth and monopoly power could also unravel the social fabric and undermine national healdi."'^

"'Bell, "The Waste of Life," 363; Hamilton, "Address of the Chairman of the Section on State Medicinc," 782. The abilit)- to rapidly transport people across the oceans was a major factor behind the creation of the International Sanitar)- Conference in 1885. ®^Rauch, "Practical Recommendations for the Exclusion and Prevention of Asiatic Cholera," 524, 527; Cabell, ".•\ddress in State Medicine," 555. ^^Cabell, ".\ddress in State Medicine," 555; Rauch, "Practical Recommendations for the Exclusion and Prevention of .Asiatic Cholera," 524; Kedzie, "Natural Purifiers," 347; Hunt, "Annual Address in State Medicine and Public Hygiene," 407; Billings, ".-Address in State Medicine and Public Hi'giene," 279; Montgomer)-, "Chairman's Address," 348;JohnB. Hamilton, "On Health Departments of Large Cities and Tlieir OigAnizanon" Jomia/ of /he American Medical Associalioii 27 (August 29,1896): 460; Bell, "The Waste of Life," 370; idem, "Address in State Medicine and 55

So why did die American Public Healdi Associadon expand its membership so dramatically between the 1870s and 1910s while die AMA Section on State Medicine withered on the vine? The answer to this question is by no means simple, and has litde to do with what has been interpreted as medicine's increasing distaste for "socialized" health care. Rather, it had more to do with the shared Mxn of building a glowing pyramid of health—local, state, and national—an aim that made the Section on State Medicine increasingly irrelevant.'^"

Collaborative activit}' could remove dangerous individuals who by ignorance or dishonesty lived immorally. Individual liberty had to be circumscribed to protect the libert}- of the whole. That had been the foundation of "public" health since time immemorial. In the late nineteenth and early twentieth centuries experts assumed that only a surong federal system of authorit)' could protect societ}' from debilitated individuals. Voluntar)- associations, though useful, could not hope to provide the level of securit)' demanded by industrial civilization. Only an interlocking system of experts working in close proximit}' and at all levels of government could instill a "spirit of self-sacrifice and resu'aint" among the people.'^'

Proper administration of healtli demanded an unprecedented reorganization of health sen-ices away from isolated, autonomous units into a hierarchical, systematized whole. Such a whole was to be built from a liierarchy of health boards or departments. It anticipated Governor

Robert M. La Follette's progressive "Wisconsin Idea" of efficient government via a hierarchy of authorit)' and control by civil sentice experts, and the reorganization persevered intact into the age of communit}' health where it became modified again to meet die new needs. At the top stood the long-awaited and ill-fated National Board of Health. One rung down stood the state

Public Hygiene," 559; Hibberd, "Address in Medical Jurisprudence, Psychologj', Chemistr)-, State Medicine, and Public Hygiene," 427. '"Duffy, "The American Medical Profession and Public Health," 1-22, "Walcott, ".address in State Medicine," 645. 56 boards or departments of health, dominated wherever possible by state medical societies. On the bottom rung were municipal, town, and count)- health boards. Independent voluntar\' or auxilian' sanitar)' and healdi associations continued to exist, guarding the milk supply, roodng out tuberculosis cases and smallpox epidemics, or contributing to the hygiene of war, but ideally operated under the direction of health authoriues at each of the three main levels. These boards, at all levels, were to be populated with expert physicians directing the efforts of sanitar)- engineers, bacteriologists, and law enforcement officials.'^"

The hierarchical ideal, according to Foster Pratt, emerged almost witliout effort or foresight by "remarkable unanimit)'" and concordance among the various endties already at work in public health. A central office for health located in the District of Columbia would provide uniformit)' and standards for principles and pracdces. This office might derive its power from the commerce clause as plagues traveled from state to state irrespecdve of political boundaries.

State boards would be encouraged, if not compelled, by the national office to communicate with one another about their common problems. Standardized forms would be drawn up by the state boards to transmit the information to others, ^'ital statistics would be regularized, then regimented, providing a basis for comparison between state boards. Local boards would collect the information tabulated and dispersed at the state level above. In sum, a pyramid of health would solve all of the meddling problems of purpose, etiology, vocabularj-, methods, and standards of behavior described in detail in APHA and AMA correspondence and debate."

'"Gihon, ".-Kddress in State Mcdicine," 293. See also Roy Lubove, The Pro^ressim and the Stums: Tenement House Reform in Kew York Cit) . 1S90-1917 (Pittsburgh, Pa.: Universit)- of Pittsburgh Press, 1962); idem. The ProfessionalA/tmist: The Emer^ena of Soda! W'ork a Cawr (Cambridge, Mass.: Har\'ard University- Press, 1965); and Jean B. Quaiidt, Fran the SmaUTown to the Great Commnnity: The SodalThonght of Progressive Intellectuals (New Brunswick, N.J.: Rutgers Universit)' Press, 19~0). '^Pratt, ".Vddress of the Chairman of the Section on State Medicine, etc.," 166; Aver)-, "State and Local Boards of Health," 1; Schcnck, "Tlie Address on State Medicine," 732; Walcott, "Address in State Medicine," 639; Elisha Harris, "General Health Laws and Local Ordinances, Considered with Reference to State and Local Sanitar)- Organization," Reports and Papers of the American Public Health Association 1 (1873): 477; Charles P. Russel, "A Report on a Uniform System of Registration of Causes of Death Throughout the United States," Reports and Papers of the 57

Resolutions in favor of the establishment of a "National Sanitar}' Bureau" were passed in the chambers of both the American Public Health Association's Executive Board and the

American Medical Association's Section on State Medicine. "We must either lead on or follow," explained John Shaw BiUings of the Surgeon General's Office, and my impression is wc had better lead." There was great confusion about what other organization might step in to take over the national bureau idea if the APHA and AMA did not act. The Marine Hospital Ser\'ice and

Army Medical Sentice stood as two possible alternatives to a National Board of Health at the apex of the pyramid of health, but each seemed crowded with political appointees.'^''

American Public Health Association 1 (1873): 483. John Shaw Billings, "The National Board of Healih, and Narional Quarantine," Transactions of the American Medical Association 31 (1880): 435-55; Staples, "Minutes of the Section on State Medicine and Public Hygiene," 352; Hunt, "Minutes of the Section on Public Hygiene and State Medicine," 326-7, 332, 340. For more on the "National Sanitar)- Bureau" idea see William Har\'ey Allen, "Histor)' of the National Board of Health," Annals of the American Academy of Political and Social Science 15 (Januar)' 1900): 31-68; Frank Seaver Billings, "A National Board of Health," American 1 'eterinaiy Ret/iem 2 (1879): 465-79; John Shaw Billings, "The National Board of Health," Plumber and Sanitary Engineer?! (1879-1880): 47; idem, "National F-Iealth Legislation on Tm\," American Journal of Medical SciencelSi (1879): 478; Heniy Ingersoll Bowditch, "A National Board of Health," Boston Medical Surgical journal')^ (1878): 642; idem, "A National Board of Health," Boston Medical SurgicalJournal iOO (1879): 102-5; idem, "Report on the Proposition for a National Sanitan- Bureau, and the Organization and Practical Working of the Massachusetts State Board of Health," Transactions of the American Medical Association 25 (1874): 397-400; |ames Lawrence Cabell, The National Board of Health ant! the International Sanitary Conference of Washing/on (I'hiladelphia: Collins, 1881); idem, "A Review of the Operauons of the National Board of Health," Reports and Papers of the American PnbHc Health Association 8 (1882): 71-101; S.C. Cobb, "Work of the National Board of Health," Reports and Papers of the American Public Health Association 5 (1879): 234; Christopher C. Cox, "A Report Upon the Necessirj- for a National Sanitar)' Bureau," Reports and Papers of the American Public Health Association 1 (1873): 522-32; Charles F. Folsom, "The National Board of Health," Boston Medical C' SurgicalJournal (1879): 927; J.H. Gidner, et al., "National Government and the Public Health," North American Review 165 (December 1897): 733-52; "A Memorial Praying for the Establishment of a National Pubbc Health Board for the Purpose of Improving Public Hygiene," Boston Medical ZP" Surgical Journal 99 (1878): 609; H.R. Mills, "The Immigrant Inspection Service of the National Board of Health at Port Huron, Miclugan, and Its Bearing on the Public Health of the West and North-West," Reports and Papers of the American Public Health Association 8 (1882): 102-6; "The Nauonal Board of Health and Its Duties," Medical Surgical Reporter 4\ (1879): 169; "Nadonal Board o(Health" AmericaAledicalBi-lP'ee/sfy 10 (1879): 23; "A National Health Bureau," Medical Record (1879): 108, 253; "The National Health Bureau," A/fr/zVa/Rfforc/14 (1878): 375; "The National Health Bureau: An Editorial," Medical Record 14 (1878): 331; "National Legislation in Regard to Public Hygiene: An Editorial," Philadelphia Medical Times 9 (1879): 182; George Miller Sternberg, "National Health Bureau," North American Rsview 158 (May 1894): 529-33; Pinkney Tliompson, "Work of the National Board of Health," Reports and Papers of the American Public Health Association 5 (1879): 235; George Edwin Waring, Jr., "The National Board of HsM\" Atlantic Monthly' 4A (December 1879): 732-38; W.W. Willoughby, "National Department of HcAhh" AmiaJs of the American Academy of Political and Social Science 4 (September 1893): 292-7; U ,O.B. Wingate,. "National Public Health Legislation," North American Review 167 (November 1898): 527-33; Walter Wyman, "The Present Attitude of the National Government Toward Sanitar)' Science," Annual Report oj the New Jers^' Sanitaty Association 29 (1903): 1 -5; as well as secondar\' work by Peter W. Bruton, "The Narional Board of Health," (Ph.D. diss.. University' of Maryland, 1974); Walter M. Dickie, "Narional Department of Health Proposed in 1871 by Thomas M. Logan, M.D., of California," California & Western Medicine 52 (1940): 6-9; Wyndham D. Miles, "A History of the Narional Board of Health, 1879-1893," 2 vols. (Bethesda, Md.: Unpublished Manuscript of the Narional Liljrar)' of Medicine, 1970); 58

A few sanitaty experts thought that resolutions in favor of a national sanitar)' bureau were

premature given the present disorganization of state and local health boards. Others worried

that, unless approached prudendy, a nadonal health agency might become the tool of poliucians.

Resolutions for a national board, argued A. N. Bell, were "wholly wasted; or, possibly worse,

fraught with success encumbered by political conditions more calculated to hinder than the

promote sanitan' science.

Still, as indicated earlier in this chapter, a National Board of Health did emerge, instituted

by Congress in 1878. But the seeds of the National Board's desti'uction were sown before it even

began operating. Billings, one of the most active proponents of tlie National Board, sensed the

fragile position of the organization. "A hea^7 burden has been placed upon it, and, if it is to succeed, even partially, it must have your assistance and cooperation," he insisted. The confused

notions of a sanitar}' profession and sanitary expertise also exacted a toll on the National Board.

"Much of the unfriendly criticism of the National Board of Health has had its genesis in the idea

that prophylaxis was an exact science, and that perfect disinfection was at all times within the

reach of the diligent and well-informed," argued Indiana physician James F. Hibberd. "Of course

a superstructure erected on this feeble foundation soon falls a wreck about its occupants."'^^'

The National Board lasted only six years (1879-85). In part, the National Board's power

was diluted by the scope and diversit)' of the problems it was to supposed to handle: yellow fever

in Cuba, the utilit}' of various disinfectants, the adulterations of food and drugs, sewer

Wilson George SmiUie, "The National Board of Health, American Journal of Pub/kHea/lh 'ih (August 1943): 925-30; Manfred ]. Waserman, "The Quest for a National Health Department in the Progressive Era," Bulletin of the Histoiy of Medicine 49 (Fall 1975): 353-80; and the collection of primary- documents listed in Charles Zaid, Preliminary hwentoiy of the Records af the National Board of Health, Preliminarj' Inventories, no. 141 (Washington, D.C.: National Arcliives, 1962). '^BeU, "The Waste of Life," 366. ""See Ca\'ins, "The National Quarantine and Sanitarj' Conventions of 1857 to 1860," 404-26; Howard D. Kramer, "Agitation for Public Health Reforms in the Journal of the History of Medicine! (1948): 473-88; Ravenel, Half Century of Public Health; mdi Shr)'ock, "The Origins and Significance of the Public Health Movement in the United States," 645-65. 59 construction, the influence of soil tj-pes on public health, and the personal hygiene of the merchant marine. The task was admittedly enormous. But the National Board also suffered intense internal rivalries. These rivalries were stimulated by confusion about who really controlled and administered the National Board of Health itself. It devolved into just the sort of political problem objective sanitar\' scientists had tried to avoid.'^'

The National Board was technically an autonomous bureau of the Treasur)' Department.

In practice, though, board appointees subordinated its audiorit}' to sen^e tlie interests of their own constituencies. BiUbgs wanted the Department of the Army to direct die activities of die

National Board of Health. John M. Woodworth thought the National Board's program would be best guided by die Marine Hospital Sentice. In die end, "the presence upon the board, of representatives of the Army, Na\7, and Marine Hospital Ser\-ice, however conspicuous may have been the attainments of their respective representatives, was not advantageous," concluded

Henr}' P. Walcott in rettospect. "They represented interests which ordinarily are of far less consequence than those of New York, Chicago, New Orleans, or San Francisco." Each constituency, in other words, was essentially an inferior player in a king-of-the-hill t}'pe sttuggle against the National Board of Health. Each would rather have the organization fail than share what limited power they had. Illinois healdi officer John Rauch hoped that the board could be reorganized and rehabilitated before it became split asunder. He also wished that Congress would grant it greater power and larger sums of money so that it had a chance to inspire public and professional confidence.'"

""Billings, ".Xddress in State Medicine and Public Hygiene," 276-7; Hibberd, "Address in Medical Jurisprudence, Psycholog)-, Chemistiy, State Medicine, and Public Hygiene," 428-31; Gihon, "Address in State Medicine," 294-5; Walcott, "Address in State Medicine," 646-7; Rauch, "State Medicine: Some Practical Recommendations for the Exclusion and Prevention of Asiatic Cholera," 528. '^Hibberd, "Address in Medical Jurisprudence, Psychologj', Chemistr;^ State Medicine, and Public Hygiene," 428-31; Gihon, "Address in State Medicine," 294-5; Walcott, "Address in State Medicine," 646-7; Rauch, "State Medicine: Some Practical Recommendations for the Exclusion and Prevention of Asiatic Cholera," 528; Wood, "Minutes of the Section on State Medicme," 415; Roberts, "Address in State Medicine," 6; Franklin Staples, "State 60

But Rauch's desire was never met. Bills designed to enlarge the power and privileges of the National Board of Health were rejected on Capitol HiU. Priorities pulled the organization in a dozen different directions. Money was squandered in haphazardly planned, shoestring operadons across the countrj'. When the National Board finally mustered its combined enthusiasm and all of its resources behind one project for Southern quarantining activides, it was destroyed. The

National Board was for all purposes bankrupted in a cosdy yellow fever control operation launched in Pensacola, Florida, in 1882. In a speech before final revocadon of National Board of

Health funding, one congressman complained that a nadonal sanitary bureau was not established to become only a lowly "epidemic fund."'^'"'

The failure of the Nadonal Board of Health did not end efforts by either the APHA or the AMA to create a centralized public health agency at die national level. Many public health experts hoped for a reformed National Board established at a higher level, perhaps even elevating it to cabinet status. Dreams of the pyramid of health did not fade away. Worries that a chief of a nadonal department of healdi might become too much a political animal were regularly discounted.'""

In 1891, most leading physicians agreed diat any national department of health ought to include under its aegis the Marine Hospital Sen-ice, the Bureau of Education, the Bureau of

Animal Industrj', the Bureau of Vital Statistics, the Army Medical Sendee, the Na\'^-'s Museum of

Hygiene, the Geological Sun-ey, the Libraiy of the Surgeon General's Office, and the

Climatological and Signal Sen'ice. Illinois physician Liston Montgomery' favored a national

Medicine to the journal of the American Medical Association 2'i (October 12,1898); 788. ''Wood, "Minutes of the Section on State Medicine," 415; Roberts, "Address in State Medicine," 6; Staples, "State Medicine to the Present Time," 788. '""Roberts, "Address in State Medicine," 5-6; George Miller Sternberg, "Experiments Designed to Test the \'alue of Certain Gaseous and N'olatile Disinfectants," Bulletin of the National Board of Health 1 (1879-80): 219, 227, 287, 365. For the professional and private accomplishments of Sternberg see John M. Gibson, Soldier in White: The Life of General George Miller Sternherg(DMt\\am,i^.C.\ Duke Universit)'Press, 1958). 61 department complete with its own vaccine farm supplying material for smallpox immunizations and a national bacteriological laborator}'. But sanitar)' scientists did not get their wish. Nothing came of repeated resolutions submitted on behalf of proponents of state medicine by the APHA and AMA throughout the 1890s. The dream of a pyramid of health had to be deferred.""

But the pyramid of health idea inspired sanitar)' science in yet another profound way.

Sanitar)' science involved the determination, usually in the laborator)-, of the rules guiding health promotion and disease-fighting preventive progress among the many classes of people.

Successful state medicine, though, demanded that professionals adopt not only laboratory esthetics but appropriate levels of specialization. Without specialization, professionals and their students could not hope to acquii'e e.xpertise—vocabular}', methodology, techniques—sufficient advanced to meet the needs of changing human wants in all their varien- and complexit)-.'""

The pyramid also worked in reverse, guiding the articulation and differentiation of expertise. Sanitary and hygienic professionals divided themselves into a burgeoning number of specialties, some new and some old; bacteriology, child welfare, climatology, oral or mouth hygiene, municipal or sanitar)' engineering, epidemiolog}-, immunology, industrial hygiene, neurolog)', militan' hygiene, physiological chemistr)-, private dut)' or institutional or visiting or venereal disease or tuberculosis nursing, ophtlialmolog)', orthopedics, pathology, tropical medicine, and vital statistics. Students of these various specialties honed their expertise still further. One could become adept in the subspecialties of sewage farm management, interior lighting or heating or ventilation, mortuary practice, disinfection, garbage disposal, or physical

""Schenck, "Tlie Address on State Medicine," 733; Lindsley, "Address on State Medicine," 4-5; S.S. Herrick, "A Department of Health, Or a Bureau: W'hich?" joimial of the American Public Health Association 14 (May 31,1890): 464-5; Liston H. Montgomen-, "Arguments Favoring a Department of Public Health" Journal of the American Aleilica/ Association 14 (May 31,1890): 466-8; Staples, "Concerning the Present Condition of State Medicine in the United States," 686-7. '""Hibbert Winslow Hill, The New Public Health (New \'ork; Tlie Macmillan Company, 1916), 1-2; Lewellys F. Barker, "The Specialist and the General Practitioner in Relation to Team-Work in Medical Practice," journal of the American Medical Association!?! (March 18,1922); 773. 62 culture. Simultaneously, clinical medical science reduced itself into more and more parts, into specialties dedicated to obstetrics, pediatrics, psychiatr)-, neurolog)', ophthalmolog}-, otolog}-, orthopedics, urolog)', dentistn*, cardiology, hematolog}', rliinolog)^ and deriving tlieii' obser\'ations from more and more specialized instruments; spectroscopes, stomach tubes, cytoscopes, roentgen ray machines, bronchoscopes, string galvanometers, and respiration calorimeters.'"^

This specialization of the profession of health was essentially the mirror image twin of the professional drive for a national pyramid of health. Each problem facing the group—often defined by race or ethnic affiliation—and the individual within each group "must be met by specific measures, adapted to the eliminadon of the particular factor involved." Professionals urged each other to define and delineate the one particular path that guaranteed success against each particular malady, whether that malady be alcoholism, poor ventilation, or smallpox.

"Specific troubles must be met by specific measures directed specifically against the real specific cause of disease," explained Western Universit}' professor of public health Hibbert Winslow

HiU.'"^

Still, the process by which sanitan' scientists and practical hygienists crafted their professions seemed to inevitably produce remarkably similar, if not interchangeable, answers to questions posed and problems tackled. "The bacteriologist, the epidemiologist, and the vital statistician, sometimes working together, more often alone, in the dark and even at cross purposes," wrote Hill, "have nevertheless all reached the same point." Integration into a

The Neil' Public Health, 1 -2; Barker, "The Specialist and the General Practitioner in Relation to Team-Work in Medical Practice," 774. '""•Hill, The New Public Health, 2-3. 63 universal system was possible and achievable, yet that ver)' systematization could be guaranteed only through subdivision.""

And indeed, as noted before, an overwhelming share of the base assumptions derived by individual professionals fit neady into a set of common underlying assumptions guiding the sanitaiT and hygienic professions as a whole. Sanitar}' science separated itself from antebellum public health by t)'ing together common beliefs in a pardcular way. First, it was a science of health, that is, composed of experimentally verified and standardized facts. Growth of the science of health, noted Providence Superintendent of Health Charles V. Chapin, was after all

"merely truth systematized." Sanitar\' scientists brooked no patience with common sense or guesswork, and treasured instead the spirit of logic.""'

Objectivit)' led to quantification or measurement of natural phenomena in order to standardize and reduce them to scientific nat\.iral laws within the laboratory and without. "The progress of a science is largely dependent upon the extent to which quantitative methods are employed in research," explained Chapin in a 1909 address to the American Public Health

Association. Careful computation of thermal death points; counting and classification of bacteria; graphing of electrophoresis effects; weighing of biological and chemical samples; and biometrical analyses of anatomy and physiolog}' occurred inside the laboratory. Outside die laborator)' vital statistics schedules; appraisal forms; health score cards; sur\'-eys; birth, death, and marriage

certificates; life tables; morbidit)- and mortaUt)' reports; and population censuses provided a

steadv flow of information for analysis and synthesis.'"'

'"'l-Iill, The .\"w P/ih/ic Heallb, 8, 40. """Charles \'iilue Chapin, "Truth in Publicit)-," American journal of Public Health 5 (lune 1915): 493-502; idem, "Effective Lines of Health Work," Providence Medical Journal \1 0anuar\-1916): 12-22. '"'Charles \'alue Chapin, "The Need of Quantitative Methods in Epidemiological VX'ork," American Journal of Public Hygiene 20 (May 1910): 306-10. 64

Both the drive for national administration of public health and the speciahzation of the profession fatally wounded the AMA Section on State Medicine. Membership in the Section peaked at 39 in 1877, representing only four percent of total AMA membership. The ven- next year, though, the Section's chairman complained that a "great majoritii' of physicians and surgeons have taken very litde interest in public hygiene." In 1881, only three delegates attended the furst day of meetings. Apparently die weather had been bad, and so the chairman deferred papers to the next day. At the appointed hour only the transcriptionist and the chairman showed up. The section adjourned for the rest of the convention. AMA Secretary R.G. Jennings warned that unless next year's meeting was better attended, the Section on State Medicine would be discontinued and papers referred to the APHA. Fewer AMA members were attending national meetings of the APHA either, their interests increasingly specialized and thus with less common ground.'"'''

Some longtime state medicine supporters wanted to refocus the Scction in the face of dwindling attendance by concentrating, by specializing, on the aspcct of state medicine which seemed eminentiy "medical": disease control. State medicine was so wide a topic, admitted one delegate, that summarizing all of the new information in the Section each year was becoming

"k)nger than a Mongolian melodrama," a melodrama which nobody bothered to purchase tickets

to see. By 1900, membership stood at only ten. In 1901, the Section on State Medicine was

dissolved.'"'^

• • •

'""Hunt, "Minutes of tlie Section on Public Hygiene," 376; Kedzie, "Chairman's Report to the Section on State Medicine and Public Hygiene," 354; Billings, "Address in Stare Medicine and Public Hygiene," 277; R.G. Jennings, "Minutes of the Scction on State Medicine," Transadions of the American Medical Association 32 (1881): 293, 295. "''lennings, "Minutes of the Section on State Medicine," 293, 295; Gihon, "Address in State Medicine," 290-1, 292, 302, 306, 308; Billings, "State Medicine," 309-11; Carroll, "Address on State Medicine," 754; Walcott, "Address in State Medicine," 640-4. 65

Sanitar)' science and state medicine throughout the late nineteenth centur)' were considered quintessentially progressive. The more scienufic experiments performed and the more objective knowledge obtained, the greater die possibilit)- for true health advancement among Americans. True health advancement, however, usually meant "racial advancement."

Each race or ethnic group, it was understood, rode the rising tide of hygienic expectations in their own boat, and differential improvement was entirely possible. Further, by virtue of the differing hygienic starting points of each race, differential progress should continue but narrow over the course of time. As a matter of fact, die narrowing of positive h)'gienic potentials among the various races of Americans potentially created its own set of problems. Hygienic advance led to

"intermingling" of American races and ethnicities, creating new health problems for groups further along the path of hygienic perfection than others.""

Public health historian Elizabeth Fee is correct in her interpretation of progressive pubbc health as "defined in terms of its aims and goals—to reduce disease and maintain the health of the population—ratlier than by any specific body of knowledge," But it appears erroneous to see bacteriolog}' as the "ideological marker separating the 'old' public health, mainly the province of untrained amateurs, from the 'new' public health, which would belong to those trained in the techniques of science and laboratory research." The record is clear in this regard. "The creation of public health as a profession in the United States," notes Fee, was "part of a deliberate plan and su-ategy." But that plan and strategy revolved about the central questions of professional standards, defmitions, and mission, and die answers sanitary scientists, public health officials, and physicians. Thev found that the answers in this continuing struggle for professional identity had

' The New PMic Health, 116-7. 66 less to do with the ushering in of a bacteriological era but rather with the systematization and specialization of a liicrarchical whole in health.'"

That hierarchical whole disappeared in the new era of professional communit)' health emerging around 1915. It is immediately apparent in the work of William T. Sedgwick and C.-E.

A. Winslow, two public health experts described in the next chapter. Here, the tensions between specialized, departmentalized principles and practices and generalized principles and practices can be obser\'^ed in microcosm.

''' Elizabeth Fee, "Designing Schools of Public Health for the United States," in A Histoiy of Education in Pubiic Health: Health that Mocks the Doctors'Rji/es, eds. Elizabeth Fee and Roy M. Acheson (New York: Oxford University- Press, 1991), 158,161-2. 67

CHAPTER III. TWO VIGNETrES ON SANITARY SCIENCE AND COMMUNrn' HEALTH

The professional lives of William Thompson Sedgwick and Charies-Edwatd Amoty

Winslow, two of America's foremost hygienic experts, overlapped in significant ways. Both

Sedgwick and Winslow entered college in the expectation that they might become qualified physicians. Both abandoned this pursuit and became enamored with biological and bacteriological science. Sedgwick ser\'ed as Winslow's teacher at the Massachusetts Institute of

Technology, and together and separately they investigated epidemics, sewerage, and water supply.""

Still, Winslow's philosophy of hygiene in his student days at MIT came to differ substantially from the approach advocated by Sedgwick. Sedgwick understood hygiene in terms of "sanitaiT science," while Winslow offered something he called "the new public health."

Sanitan' science derived from specialization, special privilege, and objective laboratoiy practice.

The new public health, on the other hand, introduced qualitative social scientific objectives as the critical element. The structure of sanitaiy science was specialized and hierarchical. The new public health was generalized and associational. An examination of the massive corpora produced by these two luminaries in the historj' of American hygiene reveals the pronounced

"'A similar approach to understanding mid- versus late-nineteenth-centun' (progressive) health professional thought and activit}' througli individuals is taken by Regina Markeli Morantz in "Feminism, Professionalism, and Germs: The Thought of Mar)- Putnam Jacobi and Elizabeth Blackwell," American Oiiarterly 34 (Winter 1982): 459-78. Morantz describes Jacobi, who was professor of materia medica and attending physician in the New \'ork Infirmaiy for Women and Children, as having "not a trace of sentimentalit)' about her. . . . No one valued rational thinking more liighly; no one remained more frustrated with mushy generaUries that could not be grounded in empirical investigation and factual analysis, jacobi chose medicine out of a love for scientific rationalism." Blackwell, the founder of tlie institution Jacobi worked in, is described as "notliing if not sentimental. She entered medicine with a perfectionist concepdon of moralit)' and her own role in the moral universe" (p. 459-60). In the same vein, a comparison of progressive and modern therapeutics is found in Alan I Marcus, "From Ehrlich to Waksman: Chemotherapy and the Seamed Web of the Past," in Beyond Histoiy of Science: Essays in Honor of Robert E. Schojietd, ed. Elizabeth Garber (Bethlehem: Lehigh Universit)' Press, 1990): 266-83. 68 discondnuin- in the intellectual conceptualization of the profession between 1880-1915 and

1915-1940.

William Thompson Sedgwick began his academic career intending to study medicine.

He graduated from the Sheffield Scientific School in 1877 and entered Yale Medical School with this end in mind. Failing to complete his medical degree for unknown reasons, however,

Scdgwick then enroUed on fellowship at Johns Hopkins Universit)' in 1879. Here he studied biolog)' under Henry Newell Martin, a disciple of the evolutionist Thomas Henr)' Huxley. For

Martin and Huxley the theory of organic evolution, the most important aspect of biological science, involved the progressive and cyclical transformation of lifeless matter into a living physical mechanism, a state soon enough decaying back into Ufelessness by microbial action."'^

The structure and general plan o£A// hitrodnction to General Bioh^' (1886) published by Sedgwick and Columbia zoologist Edmund Wilson is attributed to Martin's guidance. The university granted Sedgwick his Ph.D. in 1881.""'

Almost immediately MIT president Francis A. Walker, staff officer and political economist with the Army of the Potomac in the Civil War and former superintendent of the ninth U.S. Census, secured Sedgwick a position as assistant professor of biology. He spent the rest of liis life in the MIT Department of Biology and Public Health. Sedgwick conducted scientific investigations in bacteriology, sanitaiy science and engineering, general biology, and the histoiT of science, publishing several textbooks and over one hundred publications on these

' '^Indeed, Sedgwick believed that the process of decay began almost immediately after the creation of life out of inert material. "It is a significant fact that the quanritj- of lifeless matter in the organism tends to increase with age," remarked Sedgwick. "Tlie ven- young plant or animal probably possesses a maximum proportion of protoplasm, and as life progresses lifeless matter gradually accumulates witliin it or about if—sometimes for support, as in tree-trunks and bony skeletons; sometimes for protection as in oyster and snail shells; sometimes apparently from sheer inability- on the part of the protoplasm to get rid of it," See William Thompson Scdgwick and Edmund B. Wilson, An Inlroduction to General Bioh^' (New York: Henn- Holt and Company, 1895), 18-9. ' '"'james Alner Tobey, "William Tliompson Sedgwick," Dklioiiaiy of American Kiograpliy, vol. 16 (New York: Charles Scribner's Sons, 1935), 552-3; Sedgwick and Wilson, An Introduction to GeneralBiohg)', 2-5. 69 subjects. His researches were assisted by the establishment of the Lawrence Experiment Station in 1886, a state (and soon federal) institution dedicated to cultivating agricultural and engineering expertise. Sedgwick also helped found the Societ)' of American Bacteriologists (1900) and

Han'ard School of Public Health (1913) while at MIT. Before his death, Sedgwick became recognized within the highest echelon of his profession, alongside such luminaries as medical professor William Henry Welch of Johns Hopkins and Hermann Biggs of New York Cit)''s

Department of Health."^

Sedgwick inaugurated a new approach to teaching professional sanitar)' science in his early years at MIT. Most early professors of sanitar)' science, which involved special-purpose and expert cit)' inspection, laboratory analysis, and removal of nuisances (including, sometimes, disease-ridden segments of the population), derived their authorit)' chiefly from biolog)- and chemistn'. Sedg\vick added civil engineering to the list of subjects from which he derived his

"proper working theon-" of sanitar\' science, by which he meant the developmental natural laws derived from obser\-ation of nature. A young George C. Whipple, later a statistician and sanitary engineer at MIT, was attracted to sanitan' science specifically because of Sedgwick's popular lectures for civil engineers. Sedgwick apparendy could rivet an audience simply by describing the number and t)'pes of dangerous bacteria living in a glass of drinking water. Still, "the combination of chemistr}' and biology with engineering," Whipple later remarked, and not

' '^Tobey, "William Thompson Sedgwick," 552-3; George Chandler Wliipple, "The PubUc Health Work of Professor Sedgwick," Science 53 (February- 25,1921); 173-7. A careful analysis of experiment stations is presented in -Man I Marcus, Agriciilltiral Science and the Quest for Legilimaiy: Farmers, Agriciil/nral Colleges, and Experimen! Stations, 1870-1890 (.-Vmes: Iowa State University Press, 1985). See also Francis Amasa Walker, Political Economy (New York: Henr\' Holt and Company, 1883); idem, Discussions in Economics and Statistics (New York: Henn' Holt and Company, 1899); E.O. [ordan, et al., A Pioneer of Pidilic Health: William Thompson Sedgwick (New Haven, Conn.: Yale University- Press, 1924)'. 70

Sedgwick's somewhat disorganized lectures, "made the profession of sanitar)- engineering what it is.""^'

Sanitary sciencc for Sedgwick was much more than simply the sum of its subjects, however, because it involved an entirely new theor)' and methodology; bacteriology.

Bacteriology for Sedgwick represented the natural synthesis of biology, chemistr}-, engineering, and the achromatic lens. The "microscopical renaissance" revealed to the sanitarian a new world, a world teeming with microbial life. The complexit)' of this world, Sedgwick claimed, required germ theor)', laboraton' techniques, equipment, and sterile media. More particularly,

Sedgwick likened bacteriology to beekeeping, both subjects where the study of the individual became supplanted by the study of colonies, groups linked hierarchically to a superior form (the queen) or ancestral forms (undifferentiated, common types of primordial bacteria)."^

Sanitar)' science generaUy, according to Sedgwick, involved the consen*ation and

extension of life. He arranged sanitar)' science into three main divisions. The health of the

individual he called "personal hygiene." Family health he termed "domestic hygiene and

sanitation." The health of the aggregate population Sedgwick called "public hygiene and

sanitadon." The pun'iew of professional sanitary science extended only into this last division of

1hygiene. • lis

SanitaiT science in other words represented in essence the science of aggregate longevit)',

encapsulating the scientific knowledge base developed to consen'e and extend healthy living.

"^George Rosen, Histor)' of Public Hcahh (New York: MD Publications, Inc., 1958), 211-26; Whipple, "The Public Health Work of Professor Sedgwick," 172. ' '^William Thompson Sedgwick, "The Origin, Scope, and Significance of Bacteriolog)," Science 13 (Januan' 25, 1901): 121-2,126-7; William Thompson Sedgwick, Principles ofSaiiilaiy Science and ll)e Public Health (New York: The Macmillan Company, 1902), \'ii; Sedgwick and Wilson, ^4// Introduction to General Biolo^', 19. '' ^Sedgwick, Principles of Sanitaiy Science and the Public Health, 17-20; Tlieodore Hough and William Thompson Sedgwick, Elements of Hjgiene and Sanitation (Boston: Ginn & Company, 1907), 301-3. 71

Scdgwick stated that the traditional subjects of hygiene—climatology, clothing, ventilation, and

nuuition—should be reduced to "simple scientific terms," that is, scientific principles grounded in natural laws. Once hygiene had become fuUy scientific, whole chunks of it could be replaced

by the science of sanitation. Perfect health was perhaps impossible, but science could assist individuals and groups to improve tlieir absolute degree of health."'^

Disease in particular involved "misbehavior" or "disturbance" in the physiological

operation of the human body. Predisposition to disease led inevitably—though perhaps only in

the long-run—to deterioration of ideal functioning. Sedgwick identified four ways the body

becomes predisposed to disease. First, the body might suffer from a poor internal constitution.

These he called "intrinsic defects." Second, the parts of the body might be poorly joined into a whole. Sedgwick called these "structural defects." Third, the body might be abused in some way. These abuses he termed "extrinsic interferences." Finally, "unfavorable environmental

conditions," what Sedgwick called "extrinsic diseases"—t\'phoid, diphtheria, smallpox, tetanus,

et al.—might contribute to a predisposition favorable to disease.'""

Sanitaiy science, though, dealt only with the last categoiy of predispositions. Sedgwick

sometimes called this category of external envii-onmental predisposing forccs the "diseases of

defective civilization," because ignorance and neglect gave them the freedom to terrorize the

populace. Extrinsic diseases were of two t)'pes: physical or mechanical obstruction by microbes

of the body's circulator)' or vascular systems, and chemical interference in the form of toxic

substances produced by microbial fermentation.'"'

' '^Sedgwick, Principles ofSanilaty Science and the Public Heahh, 19; Hough and Sedgwick, Elements of Hygiene and Sanitation, 293-4. ' ^''Sedgwick, Principles of Sanitaiy Science and the Public Health, vii-ix, 10-13; Hough and Sedgwick, Elements of Hygiene and Sanitation, 296-300. '"'william Thompson Sedgwick, "Introductor)- Essay," in Typhoid Fever. Its Causation, Transmission, and Prevention, by George C. Wliipple (New ^'ork: John Wiley & Sons, 1908), xxiv; Sedgwick, Principles of Sanitary Science and the Public 72

Applied sanitar)' science meant removing the "breeding-places" for germs according to scientific principles derived from laboratory experience. These principles were developed by

Sedgwick in his MIT laboratory and at the Lawrence Experiment Station. Sanitary science as applied to the problem of sewerage, for example, could be reduced to the fundamental principle of purification. Purification of sewage could be effected by dilution in a clean body or stream of water, by introducing sewage to an "unfavorable envir'onment" that disinfects or digests waste, or disposes of infectious solids by filtration and irrigation on land.

Once the principles of sanitar)- science had been established, a "sanitary index" might be created to accurately measure the absolute purit)' of any extrinsic environment, that is to assess the "degrees of disease," and record the progress of scicntific efforts to remedy deficiencies.

Experts in state and municipal boards of health—and Sedgwick sei-\^ed a longtime advisor to the

Massachusetts Board of Health—were granted special privilege to regulate and improve the sanitar\- environment. Here, Sedgwick related, these experts frequently exercised the "duty- of subordinating personal liberty' to the public good."'"

Sedgwick spent an appreciable amount of his time refuting the "vagaries of sanitar)'

pseudo-science," especially inid-nineteenth-centur)' pythogenic public health. Pythogenic public

health found the source of disease in miasma; the noxious smells emanating from rotting

vegetation, stagnant bodies of water, garbage, and sewage. Sedgwick recognized that these

threats were often the foci of unsanitary environments, but rejected the notion that diseases

sprung directly from them. Rather, he recommended, they were vehicles for harmful bacteria.

Dirt in and of itself was no menace to public hygiene. Rather, a special t)'pe of dirt that he called

"drit" was a menace since it was by definition infected with excrementan- bacilli. Puuefactions,

HEAHB, 13-15. '^^Sedgwnck, "Introducton- Essay," in Typhoid Fever, xxviii; Hough and Sedgwick, Ekmenls of Hygiene am! Sanitation, iii, 293. 73 sewer gas, and other bad smeUs posed negligible risk to health inasmuch as they did not necessarily contain harmful bacteria. The miasma-laden air supposedly formed in must}' cellars, in fact, when subjected to sanitar\- science revealed a "pracdcally germ free" atmosphere.'"^

Sedgwick was gifted with the abilit)- to popularize sanitary science dirough public lectures, but became increasingly irritated by other popularizers of the field without established scientific expertise. "Ever)' Tom, Dick, and Harr)' is now talking about it," he related shortly before his death in 1921, "and most of what they say is so exaggerated that it casts discredit on all of us who are d.ying to speak within the bounds of sanitaiy science." Further, Sedgwick argued that sanitarj' science had not developed sufficiendy to allow for global application of the results of the laboratoiy since "valuable though they arc, [they] must wait until their relations to even'day life become clearer."'""*

Sedgwick trained many future leaders in sanitar)' science including among them Edwin

O. Jordan (Univ. of Chicago), George C. Whipple (MIT), Charles Edward-Amoiy Winslow

(V'ale Univ.), and Samuel C. Prescott (MIT). Sedgwick encouraged his students to seek out bacteria in aD sorts of places using his own standard scientific methodology and a plethora of scientific instruments, some of which, like the "aerobioscope" and "Sedgwick Rafter," were developed at the Lawrence Experiment Station. Sedgwick's students sought out bacteria in milk, food, ice, sewage, and soil. Students who passed through Sedgwick's laboratory' became bacteriologists, health officers, laborator}' assistants, manufacturers, nurses. Red Cross workers, and sanitaiy engineers.'"'

' ^^Sedgwick, Principles of Sanitaiy Science and the Public Health, 114-7, 347-62. '^''whipple, "The Public Health Work of Professor Sedgwick," 176. '^^See Biological S Indies by the Pupils of William Thompson Sedgwick (Cliicago: Universit)' of Cliicago Press, 1906); VCliipplc, "The Public Health Work of Professor Sedgwick," 172-3. 74

Arguably the greatest of Sedgwick's students was C.-E. A. Winslow. Winslow matriculated as an undergraduate at MIT, also intending to secure a life in medicine. He ended

up, however, majoring in biolog)- with a specialization in bacteriology under Sedgwick's guidance. Winslow earned his B.S. in 1898, and his M.S. in 1899. Most of Sedgwick's other undergraduate and graduate advisees were inclined to pursue medicine or engineering degrees,

but Winslow continued to follow liis mentor's sanitarj' bent. Between 1900 and 1910, Winslow assisted Sedgwick in the Department of Biolog)' and Public Health and super\nsed the daily operations of the MIT sewage treatment farm at the Lawrence Experiment Station. For the next

five years Winslow worked as an assistant professor of biolog}- at Cit}- College of New York. He wrote over fift)' articles during this brief period at CCNY, and over five hundred thereafter.

Winslow for the remainder of his Ufe ser\^cd as chair of the newly endowed Department of

Public Health in the Yale Universit}' Medical School.'"'^'

At MIT and CCNY Winslow cleaved closely to the work of his mentor. Much of his

research and writing followed in the footsteps of Sedgwick and his "proper working theor)-" for

sanitar)' science. He investigated the source of a t)'phoid fever epidemic in Newport, Rhode

Island, tracing it back to a public well. He located the focus of an outbreak of acute tonsillitis in

the town of Boston and its environs to one particular count)- in east-central Massachusetts. He

determined the presence or absencc of bacteria in common ice. Winslow also studied the course

and effects of the devastating influenza outbreak of 1918-19. It has been noted, however, that

in epidemiolog)' he "developed no new techniques; nor did he cut fresh paths through the

jungles of the unknown though he sometimes cleared its fringes" during this period.'"^

'^^See Arthur Jack ^'iseltear, "Charles-Edward Amorj- Winslow," in Dic/ionaij' of American Bio^raply, supplement 6 (New York: Charles Scribner's Sons, 1980), 701-3; idem, "C.-E.A. Winslow and the Early Years of Public Health at Yale, 1915-1925," Yak Journal of Biolo^' and Medicine 55 (1982): 137-51; and idem, "C.-E.A. Winslow and the Later Years of Public Health at Yale," Yak journal of Bioh^' and Medicine (iQ (1987): 447-70. 127 Charles Edward-.^mor}- Winslow, "Typhoid Fever at Newport, Rliode Island, in 1900 and Its Relation to 75

Winslow's investigations of bacteria-contaminated sewage and public water supplies at the MIT sewage treatment farm were also unremarkable in the sense that they only exemplified

Sedgwick's established sanitarj' science principles. With other Sedgwick students, his wife-to-be

Anne F. Rogers and Samuel Gate Prescott, Winslow built upon and more fully articulated the existing framework of sanitary' science. He spent considerable energies upon the classification of

"natural t^'^pes" of Coccaceae bacteria, found in great number in sewage, in his fii'st book on The

Sj'S/ema/Jc Relationships of the Coccaceae (1908). Winslow used eleven quantitative laborator)- rests—morphological dimensions of individuals and groups (colonies) as determined under the microscope, Gram staining, cultural or habitat characteristics, biochemical reactions, thermal death points, etc.—to systematically determine the ancestral bacterial tj'pes out of which the various species and varieties had evolved by impressed, environmental,'"^ or racial variations.

The sexamodal distribution of the now infinitely varied coccaceae under the biometric cur\'c revealed sLx natural groups—or genera using the Linnaean nomenclature Winslow favored—comprising together the Coccaceae family.'''''

Dcfectivc Sanitation," Tedmoto^'Quarterly 14 (1901): 110-23; Charles Edward-Amoi-)- Winslow, "An Outbreak of Tonsilitis or Septic Sore Throat in Eastern Massachusetts and Its Relation to an Infected Milk Supply," /oz/rWo/' Infectious Diseases 10 (1912): 73-112; Charles Edward-Amon- Winslow and William Thompson Sedgwick, "I. Experiments on the Effect of Freezing and Other Low Temperatures upon the \'iabilit)' of the Bacillus of Typhoid r'ever, with Considerations Regarding Ice as a \'ehicle of Infectious Disease. II. Statistical Studies on the Seasonal Prevalence of Typhoid Fever in \'arioiis Countries, and its Relation to Seasonal Temperature," Memoirs oj the American Acade>»y of Arts & Sciences 12 (1902); 469-577; Charles Edwatd-Amor)' Winslow and Ann F. Rogers, "Statistics of the 1918 Epidemic of Influenza in Connecticut with a Consideration of the Factors which Influenced the Prevalence of tliis Disease in Various Comtnunincs," Journal of Infections Diseases 26 (1920): 185-216. See Roy M. Acheson, "Tlie Epidemiology of Charles-Edward Amor}- Winslow," American Journal of Epidcmiolo^' 91 Qanuan' 1970): 1-18. P8 " By "impressed" Winslow meant those characteristics assumed from historicistic evolutionary' pressures. "Environmental" evolution referred to immediate changes in the organism determined by observable variations in temperature, moisture, pressure, etc. 129Charles Edward-Amor)' Winslow and Ann F. Rogers, "A Statistical Study of Generic Characters in the Coccaceae," in Biological Studies, 146-207; Charles Edward-Amorj- Winslow and Ann F. Winslow, Systematic Relationships of the Coccaceae (New York: John Wiley & Sons, 1908), v-\i, 1-30. See also Samuel Cate Prescott and Charles-Edward Amory Winslow, Elements of Water Bacteriology (New York: John Wiley & Sons, 1904). 76

Winslow also studied the purification of sewage at MIT, a favorite subject of Sedgwick, and demonstrated its scientific application in New Haven, Connecticut. He and his assistants took over 2,000 samples from the cit}''s five main sewer districts and harbor waters and submitted them to a large number of different laboratory' tests to determine constituent bacteria and industrial chemical effluvia. Winslow considered several solutions to the bacterial and chemical pollution of the bay, the beaches, and the valuable oyster crop. Untreated sewage he concluded, as a stopgap, might be dumped into the main channel via a submerged pipe extending far out into the harbor and into which die five current shoreline ouricts might profitably be directed. Still, strong tides could churn up the sludge and even deposit it seven miles up the banks of Quinnipiac River. Fine screening of solids, activated sludge aeration and settling tanks, and chlorinating, were all tried and set aside for economic or bactericidal insufficiency. The most efficient and cost-effective treatment system for New Haven's waste,

Winslow discovered, was the Miles Acid Treatment, developed by George VV. Miles and R.S.

Weston at MIT. The Miles Acid Treatment involved adding sulfuric or sulfurous acid to the sewage which precipitated solids, disinfected liquids, and helped recover valuable grease and nitrogen-rich substanccs.''^"

Winslow also extended Sedgwick's use of the achromatic microscope in laboratory analysis. Sedgwick's principles of good microscopy were tacked on as a short appendix to his hitmdiniio)! to General Bio/og)i. Winslow explored the subject in greater detail, intending his volume on Ehmeuls of Applied Microscopj (1905) to sen-e as a introductory,' textbook for second-year students of chemistry' and biology at MIT. As such, Winslow organized the volume into three

'^"charles Edward-Amon* Winslow, et al., Report OH the Sewage Disposal Problem of New Haven (New Haven: Field Press, 1918); Charles Edwatd-Amorj- Winslow and F.W. Mohlman, "Four Methods of Sewage Treatment Studied at New Haven Testing Station," Engineering Nem Record 82 (1919): 32-6; Charles Edward-.\mor\' Winslow and F.W. Mohlman, "Miles Acid Treatment of Sewage," Municipal]oiintal AS (1918): 280-2, 297-9, 321-2. 77 parts. Students began by learning the parts of the microscope, focusing, and preparing the objective. In the second part, students used their microscopes to describe common starches, adulterants in coffee and spices, and textile fibers. This practice proved useful, for tliese objectives bore relations in parts and size to cells from various parts of the body, microbes, and chemical crystals discussed and illustrated by Winslow in the final chapters of the book.''^'

The great bulk of Winslow's academic life,' ^" however, was spent at Yale Universit)' in the Department of Public Health, and it was here he constructed a "new public health" that came to differ substantially from the professional sanitar)' science of Sedgwick. From the beginning, Winslow viewed the Department of Public Health as an integral part of the whole medical school, rather than as a specialized subject. Winslow, with this in mind, constructed a combined graduate degree program by which medical students and public health students could receive a joint M.D.-D.P.H. degree. Medical students were encouraged in this manner to appreciate prevention, and public health students became inculcated in the art and science of medicine. Not one medical student enrolled for the joint degree, but abiiost all of the public health students broadened their programs by studying in one, and usually more, specific areas • including bacteriology, epidemiology, engineering, statistics, clinical medicine, nursing, pediatrics, social work, industrial hygiene, housing, nuuition, education, economics, law, and administration. Indeed, many of the undergraduates enrolled in the graduate program were deUberatelv recruited out of diverse fields such as these.

'^'Sedgwick and Wilson,hilrodiiclion to GeneralBioh^', 205-25; Charles Edward-Amor)- Winslow, Elements of Applied Microscopy (New \'ork; John Wiley & Sons, 1905). '^"Winslow retired in 1945. '^^N'iseltear, "C.-E.A. Winslow and the Early Years of Public Health at Yale, 1915-1925," 137,143-44,146; idem, "Charles-Edward Amon- Winslow," in Dictionaiy of American Biography, 702; Ira Hiscock, "Public Health at Yale," Yak journal of Biolo^' and Medicine 19 (March 1947): 394-6. 78

Lack of interest on the part of medical students under Winslow's program might be explained in part by his downplaying of the ultimate importance of the physician within his vision of a coordinated, cooperative, communit)--based public health movement. Physicians as individuals could not by nature possess all of the skills or perspectives necessan' for the proper functioning of the whole public health apparatus. The new public health demanded well-rounded physicians and public health experts, but for Winslow also required the assistance of other experts in other fields and lay communitj' involvement. Professionals and laypeople, in

Winslow's conception of communit)- health, were ultimately responsible for the health of all b)' contributing their own particular skills, abilities, and personalities. Sedgwick's Y-plan, by contrast, grouped students of sanitation and medicine together in the first year of the program, as they took the required basic science and laboratory courses together, then split them up in subsequent years for more intensive specialized work in their respective professions. The Y-plan was far more popular among those studying medical science.""*

The new public health, though reminiscent of Sedgwick's closely circumscribed profession, incorporated much that his mentor excluded. Winslow defined public health as

the science and the art of preventing disease, prolonging life and promoting physical and mental health and efficiency through organized communit}' efforts for the sanitation of the environment, the control of communit)' infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing sen-ice for the early diagnosis and preventive treatment of disease, and the development of the social macbinety which will ensure to eveiy individual in the communit)' a standard of living adequate for the maintenance of health; organizing these benefits in such fashion as to enable ever)' citizen to reaEze liis birthright of health and longevit)'.'"^^

The science of longevit)- had been transformed. Winslow's program, unlike Sedgwick's, sttessed the need to understand the science of all aspects of hygiene, personal as well as communit)',

'^^Whipple, "Tlie Public Health Work of Professor Sedgwick," 177. '^^Charles Edward-Amorj' Winslow, "Tlie Untilled Fields of Public Health," Science 51 (1920): 23-33. 79 mental as well as physiological. More than this, Winslow's vision stressed the importance of the social sciences in effecting positive hygienic change. Finally, the role and authorit}- of the communit}' health organization as a whole superseded the role of any one of its (nevertlieless important) constituent experts.

Winslow further differentiated himself from the specialized sanitan' scientific model following his ser\ace as chaii' of the Committee on the Costs of Medical Care between 1926 and

1932. The fmal report of the Committee, to which Winslow contributed substantially, internalized the spirit of liis cooperative, communit)'-based public health. The five main recommendations proposed in the majorit}' report were organized group practice, public and private health ser\'ice, public and private group payment insurance, coordinated medical ser\'ice, and a broader educational experience in professional training schools. Sedgwick's older understanding of applied sanitar)' science, on the other hand, could brook no relationship between public and private efforts to improve public health, and encouraged specialization, not broadening of responsibilit}' by generalization.'"

Winslow envisioned, by applying the principles of this reconfigured profession, what he called a "coordinated, completely interlocking, dovetailing health program." The time was ripe for die application of sciendfic principles to the health of the people. The new public health required social activit)', not simply the intellectual brooding of disciples of the laboratoiy.

Laypersons and popular language were crucial to this movement for without them the expert could, Winslow claimed, not succeed. Mass distribution of leaflets, posters, popular handbooks,

' ^^See also Charles Edward-Amon' Winslow, The Evolution and Significance of the Modern Public Health Campaign: An Address Delivered Under the Auspices of the Gamma Alpha Fraternity of Yale University (New Haven, Conn.: Yale Universiu- Press, 1923), esp. pages 49-65. ' ^'committee on the Costs of Medical Care, Medical Care for the American People: The Y-'inal Report of the Committee on the Costs of Medical Care (Chicago: Universitj- of Chicago Press, 1932), 103-44; Wliipple, "The Public Health Work of Professor Sedgwick," 176. 80

children's skits,and radio programs became, for Winslow, the best way to educate the public and bviild a comprehensive communit)' health program.

Moreover, the new public health demanded "health promotion" toward a healthy and enriched life, and not merely successful attempts to stay the grave with sciencc. The new public health, Winslow argued, must overcome the avalanche of scientific facts and laboratory techniques and contribute something useful to a new philosophy of life. Sanitar\' science was deficient, he claimed, becausc its unbiased, amoral, cynical, and professional detachment cast society adrift on a directionless vacuum.'""' "We have had no time to coordinate, to interpret,"

Winslow remarked, that is, to apply the scientific resources already gathered to a beneficial end.'^'

Yale's School of Nursing was founded in 1920 along these veiy lines by Milton

Winternitz, Winslow's longtime friend and colleague who agreed that medical specialization often obscured the complexit)' of disease and all aspects of its prevention and ueatment.

Winslow, himself active in matters concerning the organization of bedside nursing, clinical nursing, and public health nursing, contributed no less than thirt)'-five articles on these subjects over the coursc of his career.'""

138One such skit entitled "Queen of the Milk Fairies" written by Marion Phalam of tiie USD.\ may be found in Winslow's The Laws of Health and How to Teach Them (New York: Charles E. Merrill Compan\', 1925), 296-304. 139Charles Edward-Amon' Winslow, "Preventive Medicine in a Cooperative Health Program," Cooperative Health 1 (1938): 5-6, 14-15; Charles Edward-Amon' Winslow, "The Public Health Aspects of Medical Care from the Standpoint of Public Health," American Journal of Public Health 29 (1939): 16-22; Charles Edward-Amor)' Winslow, "Medical Care for the Nation," Yak Review 28 (1939): 501 -20; Charles Edward-Amor)- Winslow, Man and the Microbe: I'loii' Commiiiiicuble Diseases are Controlled (New York: Funk & Wagnalls Company, 1924), i. vacuum, incidentally, that the totalitarian nations and religious mystics were exploiting to gain the favor of disillusioned American youth. '''' Charles Edward-Amon- Winslow, "The Future: Problems and Trends," in The University and Public Health Statesmanship (Philadelpliia: Universit)' of Pennsylvania Press, 21-33. '"'"Milton C. Winternitz, "Medical Education at Yale Universit)" A Summar}' of Its Progress in Recent Years," Yale Ahtmni Weekly 0anuan- 28,1932): 345-7. 81

The combination of coordinating, cooperating functions and dedication to science gave

great apparent authoritj' to the public health nurse in particular. Generalized service, in which

specialized nursing ser\'ices are combined under one roof, offered communities a social and

scientific network otherwise unavailable. Winslow saw these nurses as the chief translators of

scicndfic public health principles for patients, school officials, health scrvicc workers, and even

physicians. Public health nurses on the front lines transmuted the "findings of the laborator)'

and desk into the language of the man in the street." Supervising public health nurses in

community health boards linked "public health science on the one hand—with the laws of

physiology and the laws of sanitation and the laws of society—and with the individual family on

the other." Winslow demonstrated the place of the coordinating, cooperating, pubUc health

nursing association within community health organization graphically [see Figure l].'"*'^

Com

Pqfi'ent' Pyblitf Health Nurse. Science. ~

OCnOOJ

ramil HeaMh

Figure 1. Winslow's tracing

143Charles Edward-.Amon' Winslow, "Tlie People You Nurse," Ya/eyi/imnae Ma^a;y/ie iS ()uly 1936); 91-9; idem, "Some Implications of Public Health Nursing," HospitalSoaa!Servke 22 (1930): 147-59; idem, "Public Health Nursing: An Old Name for a New Profession," The Forum 78 (1927): 726-32; idem, "Tlie Public Health Nursing Supervisor: Her Functions and Ideals," Public Health Nursing 24 (1932): 551-6. 82

Winslow also took great interest in the public health demonstrations sponsored in the

1920s by the Milbank Memorial Fund, started as a philanthropic gift from the wealthy widow

Elizabeth MObank Anderson, in rural Cattaraugus Count)% N.Y.; urban Syracuse, N.Y.; and die metropolitan Bellevue-YorkviUe district of New York Cit)'. Demonsttations in a variet)- of t}-pical communities were "somediing between research and education," he explained. "It takes a concept which has already been developed to the point of tentadve acceptance in general outline and tries it out in the social mpis mk,—to test b\' actual experience its general ^'alidit)-."

The fruits of these demonstrations, so far as Winslow was concerned, were many. The Milbank demonstrations proved the utility of aU sorts of communit)- concepts to improve health: model bakeries and laundries, and even model school ventilation plants.'"''*

The demonstrations were also in accord with Winslow's new public health. He compared the demonstrations to the Greek conception of the cir\'-state as an "organic unit in which diverse individuals and diverse talents play their part for the good of the common whole."

Leaders in these communities represented the motives of the citizens as a whole, Winslow argued, since leadership involved a "mutually educative process, from which the citizen acquired

and realized the desire for new satisfaction which he would never ha\'e ever dreamed of as an

isolated individual."'"*'^

In Syracuse, for example, the Milbank demonstration's Technical Board and Advisory

Council blended and fused fifty-six public and private agencies into "one intricate and complex

'''''charles Edward-Amon* Winslow, "The Living Hand: Elizabeth Milbank Anderson," in Milbank MemorialI'umt: A Meeting Commemorating the Twenty-Fifth AnniversaQ' (New York: Milbank Fund, 1930), 11-62; idem. Health on the harm and in the I 'illage: A ^fieu> and Evaluation of the Cattarangns County Health Demonstration with Special Reference to Its Lessons for Other Rjiral Areas (New York: Tlie Mactnillan Company, 1931); idem,^ City Set on a Hill: The Significance of the Health Demonstration at Syracuse, New York (Garden City, N.Y.: Doubleday, Doran, & Company, 1934). Tlie Commonwealdi Fund also sponsored demonstrations in Fargo, North Dakota; Clarke County, Georgia; Rutherford County, Tennessee; and Marion County, Oregon, in the 1920s. '"'^Winslow, A City Set on a Hill. 3-11. 83 pattern for the benefit of the district as a whole." Winslow described Syracuse under demonstration as an ideal beacon for public healdi pracdce, a veritable "Cit}" Set on a Hill," the only American cit}' to generate a perfect score on die American Public Health Associadon's

Appraisal Form. Cooperation between private benefactors and government programs was also a goal in the Bellevue-Yorkville district. Milbank officials and local citizens sought to blur the

Enes between prevention and cure by engaging all sorts of experts and laypersons in the interest of public health. The Milbank Fund encouraged coordination between a plethora of official and voluntas' agencies at the local, count)', and state levels. Groups as diverse as the State

Department of Health, mental clinics, crippled children's committee, count)' tuberculosis service, plumbing inspectors, and township Red Cross volunteers were all enjoined by Milbank's

"guardians of the commonweal"''"^' to cooperate with one another for the common good.'"*^

Even Winslow's efforts to improve "healthful housing" by ventilation, temperature control, and relative huinidit)' demonstrated faithfulness to the new public health. Winslow received funds and facilities to study these components of healthy living from New Haven's

John B. Pierce Laboratorv of Hygiene established and supported by the American Societ)' of

Heating and Ventilating Engineers in 1933. Winslow understood housing as an environment promoting the psychological and physical equanimit}' of the individual. Good housing contributed to normal private and public family life. Winslow thus envisioned family rooms as gathering places suitable for family members and club rooms, common rooms, or living rooms as necessar}' for entertaining guests. Residential communities themselves, moreover, ought to offer side-by-side accommodations for large and small families, and for people of all stations in

phrase cribbed from Plato's Kepublk. '"'^Winslow, A City Set on a Hill, 3, 50-80; idem, Health on the Farm and in the Village, 79-95. 84 life. These balanced communities, in turn, ought also have immediateh" available a wide range of ser\'iccs; schools, churches, libraries, hospitals, parks, theater houses, and shopping.

Winslow may have been encouraged and emboldened to reconfigure Sedgwick's sanitary science by reinterpreting statements attributed to Sedgwick himself. Sedgwick in his writings sometimes seemed to recognize the essential correlation and cooperation of parts in the whole by comparing the living machine to the workings of a timepiece;

For precisely as the experienced watchmaker carries in his mind's eye and can at any moment summon up a mental image of intricate, correlated and interdependent parts—springs, wheels, bearings—lying concealed within, but which, taken together and in a certain definite and orderly relation one to another, make up the works of a delicately adjusted chronometer in actual operation, and constitute a valuable time-keeper; so the physiologist, familiar with bones, muscles and ner\'es, with good red blood and beating heart, all cooperating to a common end—the healthy, normal Ufe of the organism—can summon up at will the picturc of normal, vigorous, almost superfluous vitalit)' in some vascular life-keeper.'"'''

In another place Sedgwick noted of the body's constituents that

these parts are mutually interdependent, and that the organism as a whole is greater than any of its parts. Precisely as a chronometer is superior to an aggregate of wheels and springs, so a living organism is superior in the solidarity' of its parts to a mere aggregate of organs, tissues, and cells.

Another of Sedgwick's students, George Whipple, also remarked on the necessary correlation of parts in his early work, noting that "the human body is more than a machine; it is an organism of living cells, each a living entit)', and each working for the good of all."'^'

148 Charles Ed\vard-.-\mor\' Vi'inslow and L.P. Herrington, Tmperatnre aiul hliiman Life (Princeton, N.J.: Princeton L'niversin- Press, 1949), vii; Committee on the Hygiene of Housing, "Basic Principles of Healthful Housing," American joiinml of Public Hea/tb 28 (March 193S): 360-3, and modestly revised for publication separately in 1939. See also the massive I 'eiililatioii: Keporl of the New York Stale Commission on I 'entHalion (New York: E.P. Dutton & Company, 1923), the fruits of a commission chaired by Winslow. See also Gail COO^QX, Air-Conditioning America: Engineers and the Controlled Environment, 1900-1960 (Baltimore: Johns Hopkins Universit)' Press, 1998). ''"Sedgiwick, Principles ofSanitatj Science and the Public Health, 4. '^'^Sedgwick and Wilson, An Introduction to GeneralBiolog)', 19. ' ^' George C. Wliipple, Typhoid Fever. Its Causation, Transmission, and Prevention (N ew 'i'ork: ) ohn Wile}' & Sons, 1908),

X. 85

Ultimately, however, Winslow's new public health differed substandally from the sanitary science practiced by his mentor and students, including himself, at MIT. Sedgwick grounded sanitary science in experimental laborator)- discipline and quantitative, mechanistic theon* formation. He sttessed the importance of professionalized sanitation as the exclusive presen-e of scientific e.xperts. Expertise, moreover, could be segregated by sttucture and function.

Sedgwick imbibed heavily in his age's scientific progressivism in a drive to specialization and hierarchical arrangement of parts.

Winslow, bv conti-ast, grounded his new public health in the methodological fruits of quantitative natural science coupled with advances in qualitative social science. He sttessed the defmed (though different) roles of the layperson and the expert in successful private and public communit)' health initiatives. The profession and its expertise could not be separated from the good of the whole, and a generalized, cooperative, coordinated model was favored over the inefficiencies and estrangements inculcated by a neuttal science. In sum, Sedgwick's sanitary- science and Winslow's new public health bore only one great similarit)-, albeit an important one: a commitment to progress in the sphere of human health. 86

CHAPTER IV: PUBLIC HEALTH NURSING

An elderly cripplc was the ideal candidate for the sort of help that Doroth)' Carter coukl provide. Mrs. Lewis was nearly blind and subsisted on a diet bordering on star\''ation. The rotten condition of her teeth meant that the widow could barely consume her meager portion of food.

Carter, a public health nurse, swung into action, securing and coordinating the efforts of various local health agencies on Mrs. Lewis' behalf. Witliin a month a remarkable transformation had taken place. New prescription glasses arrived. A trip to the dentist netted a new set of teeth.

Mrs. Lewis soon began receiving a regular allowance of food and money from the local communit)' chest. Carter also called a nutridonist to help Mrs. Lewis establish restoradve meals.'"

Impro\'^ing the health situations of individuals like Mrs. Lewis during the roaring Twenties and sagging Tliirties demanded cooperadon between a large number of constituencies. These constituencies conccived of public health as a complex, interconnected whole. Morbidit}' and mortaUt)' depended on the efforts of physicians, but included a variet)' of other factors like the presence of hospitals, funding from public and private social welfare institutions, family and ethnic customs, wealth, and even climate. No one factor was more important than any other, and an imbalance in any one factor could damage the effectiveness of all public health initiatives.'^-^

The key player, if one existed in an era of such close cooperation, was the communit)' public health nurse who, as an educator, home visitor, and social worker investigated homes for

'^"Dorothy j. Carter, "Tlie Public Health Nurse and Orthopedic Nursing Care," American Jotirnal of Public Health 28 (1938): 458-63. '^^"Infant Mortalitj- in Our Cities" American Journal of Public Health 19 (1929): 1352. 87 disease and vice. The community health nurse bridged the gap between home and clinic in a way that no other health operative could hope to accomplish. The preeminent middleperson, the community health nurse believed that she could coordinate the entire supply and demand for health. Her especial sensitivides to the needs of the family, the ultimate group, clinched her place as a perfect adjunct to all health work. As such, nurses were widely employed in locally-sponsored community health centers and by city and state departments of health where

they worked in close alliance with physicians, health officers, and laypeople.

Community health nurses, seeing themselves as the essential lubricant in the integrated health care machine, struggled throughout the interwar period to achieve greater cooperation between health agents and agencies. Yet, by and large, community health nurses failed to advance as a truly independent profession, or accomplish their goal of merging the public health department and the private clinic. Rapid improvement in communicable disease rates, increasing

acceptance of hospitalizadon by the middle class, and declining numbers of immigrants needing

Americanizing have all been offered as reasons for community health nursing's demise."''

Another impression, however, emerges from an examination of the worries and laments

of leading community health nurses themselves. First, nurses conceived of themselves as adjunct

to all other professional groups. Community- health nurses denied their own independent idendty

especially in carrying out the physician's directives. Second, the centrality of the family unit in the

health planning of the communit\' health nurse marked her as less a scicntific agent for efficiency

and more an efficient social scientist or even amateur psychotherapist. Educational prerogatives

sliifted away from the development of scientific nursing knowledge, which they saw as already

"''See Karen Buhler-Wilkerson, "False Dawn: Tlie Rise and Decline of Public Health Nursing in America, 1900-1930," in Niirsi/ig Histoty: J\W Perspedives, New Possihililies, ed. Ellen Condliffe Lagemann (New York: Teachers' College Press, 1983), 89-106; and Jane Pacht Brickman, "Public Health, Midwives, and Nurses, 1880-1930," in Xursiii^ His/or)-: Perspectives, New Possihililies, ed, Ellen Condliffe Lagemann (New \'ork: Teachers' College Press, 1983), 65-88.' 88 well established by 1920, and toward the development of an appropriate nursing personalit}'.

Communit}- health nurses argued that they were collectively empowering themselves in the process, but instead they cast off the mande of pure science wliich had made them most authentic.

Third, the coordinating and cooperating role assumed by communit)' health nursing made dieir efforts less visible than earlier specialized acdvides. Community' health nurses expended less effort organizing immunization drives and giving lessons in hygiene door to door, and more time

"selling" more intangible bureaucratic sen'ices. Communit)- health nurses sttessed theii- nadve abilit}- to coordinate disparate public health functions into an organized whole. They reconfigured themselves as comprehensive care providers rather than as specialized caregivers, something they considered an ouunoded function fu-st assigned to them in the late nineteenth centuiy. The coordinating position, when administered appropriately, however, moderated necessary commercialization in modern times. Cummunit)- health nurses appeared to achieve this state of invisibility' with great rapidit)-, a sure mark of the efficiency with which they pursued this aim. It was this positioning of the profession as coordinators and cooperators that hurt it most, for it left communit)- healdi nursing with no specific, promotable talent. Community healtii nurses could not diagnose or treat more than superficial wounds; they were not this kind of specialist. They represented instead the eyes, ears, and social conscience of the physician, but never the hands.

Communit)' health nurses usually traced their roots to Lillian Wald's labors at the Henry

Street Setdement House in New York Cit)-. Here among some of most treacherous blocks of

Lower East Side of Manhattan, social evils supposedly got their start, leaching outwards in concentric circles from immigrant slums to more and more prosperous neighborhoods. Wald 89 organized this "Nurses' Settlement," as it was first called, in 1893. Hcnn- Street setdement workers sti'essed science-bound public health inidadves like cleanliness, bacteriological examinadons for communicable diseases, and immunizadon drives to improve what they perceived to be die sorrj' state of American immigrant life. Workers also sought to curb immigrant passions, thereby making them splendid e.xamples of their own races.

The Henr}- Street model for nursing care was widely copied, and by 1900 had spread well beyond purely immigrant communities. Public health nursing ser\-ices, known at the dme as

"district" or "visiting" nursing, were inaugurated in Chicago in 1890, Buffalo in 1891, Kansas

Cit)- in 1892, Detroit in 1894, Baltimore in 1896, and New York Cit)- in 1898. In 1895, owners of

\'ermont's Proctor Marble Company inaugurated nursing visitadon to help "conser\^e the health" of their employees, john Wanamaker, Philadelphia's largest retailer, enlisted the sendees of visidng nurses two years later. By 1909, heeding advice of Lillian Wald, the Metropolitan Life

Insurance Company installed visidng nursing alongside its other famous sendees to industrial policyholders.'^^'

Visidng nurses began aspiring to membership in nadonal professional organizadons soon thereafter. In 1912, nursing leaders established a National Organization for Public Health

'^^The roots of public health nursing are sometimes extended to inchide the efforts of Florence Nightingale in the Crimean War. Karen Buhler-Wilkcrson, "Lillian Wald: Public Health Pioneer," Research 40 (September-October 1991): 316-7; Lavinia L. Dock, "The Histor}- ofPublic Health Nursing," in^l Ha/j'Cei!liiQ> of Public Heal/h: Jtibi/ee Historical I 'ohime of the American Public Health Association, ed. Mazyck Porcher RavcncI (New \'ork: .•\mcrican Public Health Association, 1921), 439-41. A veritable bonanza of scholarly research has been done in the area of immigrant healtli. Starr with Beth Brodie, "'Fir to be an American': Health and Social Requirements for Immigrants, 1896-1914," Kursingconnections A (Fall 1991); 32-7; .-Man M. l

Nursing (NOPHN) under the auspices of the American Nurses' Association, and began publishing a monthly magazine. The purpose of this organization, matching the cooperating and coordinating aims of other professions in modern America, read as follows:

To stimulate responsibilit}' for the heahb of the commiinily by the establishment and extension of public health nursing; to facUitatc efficient coopemtion between nurses, physicians, boards of trustees, and other persons interested in public health measures; to develop standards and technique in public health nursing ser\acc; to establish a centra! bureau for information, reference, and assistance in matters pertaining to such ser\'ice; and to publish periodicals or issue bulletins from time to time in the accomplishment of the general purpose of tlie organization, (emphases added]'"

Lillian Wald, who served as first president of this new organization, defined the purposes of the visiting nurse further, stressing the need for ser\tice to the entire population, not just the immigrant poor. She and other leaders of the new organization conceived professional "public health nursing" as comprehensive, but organized into certain specialized departments that nurses mastered individually. These departments included maternal health, infant and preschool health, school health, industrial nursing, adult health, communicable disease control, clinical care, orthopedic ser\tice, vital statistics, sanitation, mental hygiene, nutrition, and visiting nursing.'^"

That same year, the American Red Cross organized its own visiting nursing semce, first called the "Red Cross Rural Nursing Ser\''ice," then renamed the "Red Cross Town and Countr)'

Nursing Service," and finally in 1920 the "Bureau of Public Health Nursing." In 1923, a third visiting nursing organization joined the ranks in the form of a permanent section of the American

Public Health Association. Membership, particularly among the leaders, overlapped in all three of these nursing organizations.'^'^

'''Dock, "Historj' of Public Health Nursing," 442-4, 446-7. ''^McNeil, His/or)' of the Public Heahh Nursing Section, 1 -5; Farnham, Pioneering in Public Health Nursing Education, 27-47, "'Dorothy Deming, "Milestones of the Past Fifteen Years in Public Health Nursing," American Journal of Public Health 29 (1939): 128-34. 91

Schools for u-aining and specializing public health nurses accompanied tliis drive for professional organization. M. Adelaide Nutting established the first course in visiting nursing at

Teachers' College, Columbia Universit)', in 1910. Other universit)' and college programs followed in quick succession at the Universit)' of Pennsylvania, the private women's institution of

Simmons College in Boston, the Universit}' of Minnesota, Universit)' of California, Western

Reser\'e Universit)', Universit)' of Iowa, Universit)' of Oregon, St. Louis School of Social

Economy, Richmond School of Social Work and Public Health Nursing, Universit)' of Michigan,

Yale Universit}', and Washington Universit)'. These nursing programs, though quite diverse, were united in their desire to substitute "scientific matter and manner" akin to sanitar}' science for the

"trial and error method of its infancy.""^^"

The role or place of visiung nursing changed dramaucally in the late 1910s and 1920s.

Visiting nursing leaders rejected their ti'aditional posiuon as a specialt)' under nursing, and the}' now asserted that all nurses were potentially communit)' health nurses. They argued that visiting nurses, as well as the other two recognized nursing specialties—private dut}' and institutional nurses—could easily become communit)- health nurses with brief field experiences and a postgraduate course or two. Many private dut)' and institutional nurses agreed, and distinctions between the three major branches of nursing became ever more indistinguishable."^''

Public health nurses for almost twent)' years before 1920 had limited themselves to what later bccame known as "specialized service." Specialized sendee meant grounding one's expertise in the scientific principles of one particular subdiscipHne. This "compulsion to specialization" represented the driving engine of medical science in the late nineteenth century, but at a cost in

"'"Elizabeth Fox, "Advances in Public Health Nursing," jouma/ of Public Health 27 (1937); 1227-31; Farnham, Pioneering in Public Health Nursing Education, 2-7. Annie Maria Brainard, Organisation of Public Health Nursing (New York: The Macmillan Company, 1919), 4-5,11; Mar)' Beard, The Nurse in Public Health (New York: Harper & Brothers Publishers, 1929), 208-9; Mar}' Sewall Gardner, Public Health Nursing, 2nd ed. (New Y'ork: The Macmillan Company, 1927), x. 92 seeing the whole picture. That, at least, was the claim of later generalized servants. Visidng nurses took classes, beyond standard training or experience in nursing, almost exclusively in the science of bedside nursing. Communicable disease nurses speciaHzed in bacteriological science.

Tuberculosis control, diphtheria control, public school health, child welfare, infant welfare, prenatal nursing, maternal nursing, venereal disease control, dental clinic work, and mental hygiene were other possible paths for specializing public health nurses to foUow. None of these specialists—theoreticaUy at least—could share in the expertise of any other.

The manifold responsibilities and dynamic coordinating and cooperating role of the public health nurse in modern America demanded something more. This something bccamc referred to as "generalized seiTice." Nursing leaders began advancing arguments in favor of generalized service in the late 1910s, but did not overwhehn those enamored by specialization until the mid-1920s. Mar\- Gardner, perhaps the great statesperson in modern communit\- health nursing, advocated generalized nursing in the fu'st edition of her textbook Public Hecillh Nursing, but only halfheartedly. She repeated the contention of others that generalized sen'ice had certain advantages;

(1) duplication of overhead expenses induces a temptation to economy of supcn'ision, (2) the entrance of several different nurses into a household tends to weaken die influence of each, (3) the constant presence in the small district of one nurse so familiarizes her to the people that they learn to call upon her readily for advice in health as well as sickness, (4) the average nurse variet)' of work acts as a helpful stimulant, (5) specialization delays or prevents recognition of the whole public health problem behind each individual phase of disease, and (6) proof of success by individual nurses to handle all aspects of public health nursing work in rural areas and small towns.

Yet Gardner accepted that specialized service worked better than generalized sen-icc in the largest cities. Specialized ser\'ice was preferable in small towns and rural areas too, but was

""•Rue, Public Health Knrse in the Commiiiiilj. 26, 34; Dock, "Histor)' of Public Health Nursing," 451-2. '^'Gardner, Public Heahh Nursing, 67-73. 93 practically impossible to support fmanciaOy. Generalized sen'ice fit the t}-pical, or mid-sized cit}' best, as it was practical for one nurse to know and supen-ise all the families of the community' personally. Specialized nurses in the work encountered only a small fraction of the population.'^"*

Generalized ser\ace did not become the central organizing principle of community' health nursing, or all of public health for diat matter, widiout a fight. Cridcs charged that generalized ser\dce gave too much responsibilit)' to individual communit)' health nurses who might or might not have encountered specific situations and emergencies before. Generalized nurses in rural areas, some thought, became loose cannons without close supenasion. Gardner respected diis contrar}' opinion, nodng as she did diat "serious objections to specialization are not insuperable.'"^'^

Generalized ser\'ice, which ultimately triumphed over its detractors, meant that nurses had to be multipurpose and multitasking personnel. Generalized communit)' health nurses worked even^vhere, from the lonely deserts to the crowded metropolises, and did just about ever}*tliing. They acted as "probation officer, tenement house and sanitary inspector, count)' bailiff, domestic educator, and hospital social sentice worker" all rolled up into one neat package.

They were to be acquainted even with the "work of the dog and rat catcher, for if a child is bitten bv a dog, it is the nurse who follows up the case." They treated adults and children, worked in the cornfield and the factory, and gathered information on ever)'thing from mental defects to tuberculous infants.

Bv 1930, the trend had resolved itself into virtual unanimit)'. Generalized sen-ice reigned supreme among the elite. Public health demonstration projects, very visible displays of

'^""Gardner, Public Hea/lh Nursing, 67-73; Brainard, Organi^tion ofPiiblk Health Nursing, 25. '^'Gardner, Public Heal/h Niirsiiig, 67-73. "'''Gardner, Public Health Nursing, 29; Waterman, Nursing/or Community Health, vii; Man' G. Taylor, "A Generalized Cit\- Health Sen'ice," Public Health Nursing 23 (1931): 428-31; Ross, "Another \'ote for Generalized Nursing," 584-7. 94 communit}' health expertise tlirough the mass cultivation of health habits in so-called "narural" or

"average" communities, added to a growing corpus of evidence for general-purpose nursing strategies. The East Harlem Nursing and Health Demonstration, in particular, was often cited as conclusive proof of the efficacy and superiorit)' of generalized ser\nce. Generalized ser\'ice did not eliminate the need for specialists, but those specialists became less important in the day-to-dav activities of community' health nursing. Specialized nurses continued to exist, but increasingly became charges of generalized nurse administrators. Specialized nurses just did not appear as closely correlated to the main movement of communit}- health nursing.'^"

Communit)' health nurses by the 1930s uniformly argued that generalized ttaining might make their efforts more efficient and more useful to dieir padents and families. Generalized nursing connoted less inti-usion into family life. Not only were the families of padents disrupted less often by visits, but they dealt with a single nurse to whom they could more easily entrust delicate information. Dealing witli one nurse also created less confusion in the patient's iTiind.

Single visit sen'ice encouraged patient independence. And, die multipurpose nurse, looking at the family situation as a whole, recognized problems that specialized nurses would undoubtedly miss.'''"

The greater varietj' of work stimulated and satisfied generalized communit)' health nurses.

They no longer had to undo or countermand the instructions of another nurse, nor did they need to worn' that some aspect of the work at hand might become neglected. Multipurpose nursing avoided the "contradiction of teaching in the home which weakens the influence of each teacher" under specialized routine, commended one community' health nursing panel. Finally, generalized

'^^Rue, Public Health Nursing in the Community, iii, 26, 34. '^^"Generalized Versus Specialized Nursing," 561-3. 95 community health nurses usually ended up with a smaller territory- to cover each day, a great relief

to those who wished to know the communit)- better.'^''

Multipurpose efforts in communit)- health nursing solidified further in the face of the

1930s bleak economic picture. Generalized sen-ice obviated the necessity for muldple trips to

the same home for different purposes. A single general-purpose nurse could provide all the

necessar)- functions with just one stop. Generalized ser\-ice thus saved on wages, overhead, and

precious gasoline. Generalized nurses also need to maintain only one set of records, whereas

specialized nursing demanded scores of carefully transcribed and copied records. Specialized

public health nursing in a time of depression seemed especially "wasteful and ineffective.'"'"

Health officers and physicians also favored a broader approach to nursing during the

Depression. "Generalized nursing," noted one city' health commissioner, "is now recognized as a

more effective and efficient form of sendee." Other professionals argued that the community

health nurse's mind ought to remain uncluttered by trivialities, instead populated by useful

knowledge. Nurses, they argued, should know the essential aims of public health, how to collect

and use vital statistics, and regulate milk distribution in schools. xVmalgamated sendees also

reduced the number of individual visits between physicians, health officers, and nurses, speeding

caregiving and saving money.'''

The more varied role ascribed to the community health nurse after 1920 encouraged her

to understand community organization and select initiatives in terms of e.xamining and

interpreting that which seemed "t}'pical" or "normal." Typical or normal communities were

""'Haupt, "How Can Public Healtli Nursing Ser\'ices Be Combined?" 349-53; "Generalized N'ersus Specialized Nursing," 561-3. """Generalized \'ersus Specialized Nursing," Pnh/k Heahh Nursing 24 (1932): 561-3; Winslow, "The Public Health Nurse Super\'isor," 551-6. "'Naomi Duetsch, "Generalized Public Health Nursing Service in Cities," Americcm jotinial of Public Heahh 25 (1935): 475-9; Gracc Ross, "Is the Health Officer Fulfilling His Responsibilirj- in Relation to the Nursing Program?" American journal of Public Health 29 (1939): 305-10. 96 eminently healthy communities. Abnormal and at]i'pical cities were not. This, of coursc, made the largest cides and most unpopulated rural districts among the most at)'pical and hence unhealthy. Although the nurse ideally did not overlook the small or the large, she usually focuscd her attention and gained inspiration for her work upon that which bulged in the middle.' "

On a day to day basis, community- health nursing's most important coordinating activity- remained home visiting. Neither the superiorit)' of objective science nor simple force was enough to coerce laypeople into joining professionals in the interest of health. Rather, the nurse used her more intangible assets like sincerit}-, intelligent tolerance, and sometunes cajoling, to marr}' the two groups. Nursing leaders encouraged publicit}' work through newspaper editorials and radio inten'iews. Nurses acting as "galvanizing agent[s]" adapted their programs to the needs and histon' of the family and adapted the family to the needs of the communit}'."'

The en\-ironment of the public health nurse was not only a communit)', but a communit)' of communities. Nurses knew those communities of communities as "families." Noted one nursing leader, "The family is the center of interest to a public health nurse, and family health is the end she hopes to attain." Speciahzed sen'ice had not, in their minds, met the needs of families because it did not focus on the family, but only upon its constituent parts: individuals.

The maladjusted individual spread disease and disorder to other members of the family.

Assisting the individual, then, did not guarantee that a public health problem had been eliminated.''"'

Generalized ser\'ice, however, seemed tailor-made for familial public health care.

Reaching out to patients or individuals at risk depended on cultivadng rapport between the family

"Gardner, Public Health Nursing, iv-v, 67-8. "^Grant, Nursing: yl Commtinily Health Service. 46-9; Wales, Public Health Nurse in the Community, 424. """Rue, Public Health Nursing in the Community, 78; Beard, Nurse in Public Health, 2-3,11-2; National Organization for Public Health Nursing, Principles and Practices in Public Health Nursing, 75-7. 97

and nurse. Counseling and educating the individual inevitably failed without the approval of thcii- faiToilies. Concentration on the family as the most fundamental unit of community' health nursing pracuce had several benefits beyond securing family members as agents of patient sur\''cillance.

Nurses found it difficult, if not impossible, to ignore the wider family problems contribudng to sickness or the potential for sickness in the frrst place.

Nurses did not separate families from their immediate environments either. Families were members of the communit)', and that communit)- could harm healthy families or be harmed by unhealthy ones. The tnission of the communit}- health nurse was to "bring about harmony between the family and its physical, social, and emodonal environment by adjusting the family to that environment or by modifying the environment itself" Producing healthy families required great choreographic skill on the part of the nurse correlating the needs of the communit}' with those of all families.''''

The home was an ideal place to glean pertinent health information. Home visits allowed communit}- health nurses to sample real situations and use theu" abilities to "think and feel with

the family." Taking family liistories rather than indiindual health histories revealed a more

comprehensive health picture, directing the efforts of the communit}- health nurse more surely.

Communit}' health nurses recorded their obser\'ations in "family folders." These folders, made

of tough manila, contained all the necessan' forms for tracking the health and social progress of a

single familv. Family folders assembled by communit}' health nurses often contained intimate

details of family life because, as several authors put it, interrogations in the home loosened the

tongues of othei-wise reser\'^ed individuals. But this was exacdy the point. The public health of

"^N'iolet H. Hodgson, "Wliom Do We Sen^e and How?" Pub/ic Health Nursing 25 {1933): 299-301; Gracc Ross, "Another \'ote for Generalized Nursing," Public Health Nursing 27 (1935); 584-7; "Record Forms for Public Health Nursing," journal of Public Health li (1933); 473-5. '""Katherine Fa\'ille, "Responsibilit)' of the Public Health Nurse for Social Phases of Her Work," American journal of Public Health 20 (1930): 165-70; Winslow, "National Health Challenges," 120-4. 98 the individual was completely tied together with the thoughts, feelings, racial or ethnic customs, and emotional context of the family in Mo. Nurses, having collected all the perdnent information about households, then turned over particular tasks to particular groups in the communit)' best attuned to carr}' out her wishes or, in the case of other health professionals, engineer soludons.' '

The coordination-cooperadon model followed by communit}' health nurses when dealing with families is exemplified in efforts to control venereal diseases and mental illness. Significant ly, nurses reconfigured venereal diseases as "family diseases," not a disease of any one particular individual. Syphilis, for instance, became "familial syphilis" and communit}' health nurses spoke about whole "svphilidc families." Nurses saw venereal diseases as fanulial in two important respects. First, syphilis and other "social diseases" tended to strike adult males, the breadwinners of families. This tendency generated all sorts of unpleasant effects upon the family, including

povert}' and social sdgma. "Sypliilis in the family causes more unhappiness than any other single disease," announced one communit}' health nurse. Second, syphilis spread easily from husband

to wife, wife to husband, even mother to child in ukro. Clearl}', \'enereal diseases ti'aumadzed the whole famUy.''"

Communit}' health nurses, then, su-essed the totalit}- of venereal disease control over the

identification of smcken individuals. These diseases moved in fainilies and could not be

controlled by simply treating infections as they became known. "Resort to medical control alone

is like bailing out the kitchen when the water pipe has burst," exclaimed one nurse, "instead of

shutting off the water and fixing the pipe." Besides, infected individuals often deliberately eluded

'^^"Record Forms for Public Health Nursing," American Journal of Public Health 23 (1933): 473-5; Wales, Public Health Siirse in Action. 423; Waterman, Nursing for Community Health. 49; Grant, Nursing: A Communily Health .Service, 47-8. '^^Gladys L. Grain, "Familial Sypliilis," Public Health Nursing 25 (1933): 103-6; idem, "Public Health Mursing and the Medical Aspects of Social Hygiene," Public Health Nuning 24 (1932); 377-80; Dcutsch, "Generalized Public Health Nursing Ser\'ice," 475-8. 99 discover}'. Prevention depended upon educating the whole family, treating the whole family, and eliminating the immoral influences that encouraged disease.'

Comprehending and reducing mental health problems also became a family affair.

Emotional disturbances like fear, worrj', irritabilit)', jealousy, suspiciousness, depression, excitabilit)', and aggressiveness gripping one member of die family invariably affected all the others. Anxiet}' in one member might transfer direcdy into sons, daughters, siblings, and other fainil}- members, or it might create different yet related symptoms like over-zealousness, o\-cr-conscientiousness, and h)'peracdvir3'. Mental problems in one patient could even provoke physical ailments in other family members.'""

Nurses approached the patient as they did their families. Flesh, mind, and spirit became indistinguishable parts of the whole fabric of the individual. Mental stresses, for instance, could ener\'ate physical distresses through "conversion." Explained the famous physician and mental hygienist Karl Menninger in a 1939 essay for the journal Public Health Nursing, "Gastric distress, biliousness, and heartburn may frequently have a symbolic significance [in] insecurit}', or a threatened loss of love, of which the individual is entirely unaware.'""'

In complex modern societ)', nearly ever}- family stood in need of communit}' health nursing assistance. "If some engineer with a flair for social work could devise a coefficient that would express in numerical terms the complexit)' of 1937 societ)' in terms of the year 1900 as a base, and if 1900 represented by tlie index number 100,1 have a suspicion that the year in which we live might be rated at 1000 or 2000 or perhaps 5000," argued a lay commentator in the pages of Public Health N//rsi>ig. Few individuals lived up to their u-aditional roles in this rapidly changing

"'Deutsch, "Generalized Public Health Nursing Ser\'ice," 475-8; N.A. Nelson, "The Nurse in Control of Gonorrhea and Syphilis," Public Heatt!) Nursing 25 (1933); 199-204. ' ^"Menninger, "Mental Health of the Family," Public Health Nursing 31 (1939): 375-82. '^'ibid. 100 world with a socict)' turned upside down. The "father" often failed as sole breadwinner, the

"mother" failed as homemaker, and the "children" failed as providers for their elderly parents,

Communit)' health nurses bolstered the family by providing continuity at times when family roles and relationships disintegrated. Protecting the family had the prophylactic cffect of protecting the community. "Through the improvement of living conditions of this small unit," noted one nurse, "society as a whole is benefited."'""

Community' health nurses, following principles of "Christian charit)'" developed in the distant past, advocated no particular religious affiliation or political party. Her "ministry" instead, devolved solely to instilling the principles and practices of good living. Jews, Protestants, and

Catholics often cohabited in the same communities in America, and nursing leaders felt that none of these groups ought to feel so uncomfortable by the demeanor or opinion of the community- health nurse that they might refuse aid. Community health nurses could, however, cncourage a family's preexisting religious or political beliefs. Religious and political participation was not an evU to be avoided, but instead instilled positive feelings toward civic life. Church attendance and voting were, moreover, good ways to link up members of the community."*^

Given her role as essential coordinator and cooperator in the communit}' health movement, the nurse's avowed professional apathy toward politics smacks of hypocrisy. It might easily be argued that communit)' health nurses were the most political members among all the health professions of her day. Nurses did not have to repudiate particular religious or political views, only examine their own motivations and mask them from the outside world. The)' asked

'^'National Organization for Public Health Nursing, Principles anil Practices in Public Heahh Nnrsing, 91-2; Grant, Nursing: A Community Health Service, "4; Griswold, "What Can the Layman Do?" 89-95; Fox, "Advances in Public Health Nursing," 1227-31; Buell, "Social Planning for Family Health," 405-11; Winslow, "The Public Health Nursing Supeivisor," 551-6. '^•^Brainard, Evolution of Public Health Nursing, 420; Brainard, Organi:;ytio/i of Public Health Nursing, 1, 27; Gardner, Public Health Nursing, 41; National Organization for Public Health Nursing, Principles and Practices in Public Health Nursing, 14-5. 101 each other only that they submerge personal feelings in favor of cultivating the feelings of the entire cormnunit)'. Nurses calibrated themselves not to create factions, but to many those

factions into a whole."*''

Communit)' health nurses, chamcleons of sorts in the interwar decades, created roles for

themselves that varied widely. They could be rural district nurses, school nurses, communicable disease nurses, child health workers, factory nurses, mental hygienists, or any type of social ser\'-icc nurse. As malleable professionals, cotnmunit)' healdi nurses conscientiously shaped their

work to fit the needs of individual communides. Still, the central goal of professional community

health nursing was to create and coordinate a comprehensive, integrated health organizadon by voluntar)' cooperation between all public and private groups in the community.'"^

Modern public health nurses, as they saw it, oriented their ser\-ices with the best interests

of the whole communit)' in mind. Nurses abhorred the thought of radically different sendees

geared exclusively to the needs of particular classes, races, or creeds. They challenged themselves

and other health professionals not to be islands. C.-E. A. Winslow noted that the nurse who

acted alone lacked guidance, and soon "fails to realize the fact that she is a public health nurse at

all.'"""

Public health nurses, in sum, were active participants in communit)' planning and

decisionmaking in modern America. The}' fancied theii' profession as the critical mediator

between participants in the smooth functioning and enforcement of communit}' health standards.

Nurses created for themselves a role as ultimate coordinators and cooperators for the greater

"•'Wales, Pub/ic Health Nurse in Aclion, xvi. "^'Mational Organization for Public Health Nursing, Suney of Pubik Health Nursing: Adrnimstration am! Practice (New •^'ork: The Commonwealth Fund, 1934), 11; idem. Manual of Public Health Nursing (New York; The Macmillan Company, 1939), xi; Brainard, Organisation of Public Health Nursing, xi. '®®Mar)' Sewall Gardner, Public Health Nursing (New York: Macmillan Company, 1917), iii-iv, 52; Annie Maria Brainard, The Evolution of Public Health Nursing (Philadelphia: W.B. Saunders Company, 1922), 393; Violet H. Hodgson, Public Health Nursing in Industry (New York: The Macmillan Company, 1933), v, 3; Amelia Howe Grant, Nursing: A Commum/j Health Service (Philadelpliia: W.B. Saunders Company, 1942), iii-iv, 20. 102 good in public health, a role which ensured that the relative importance of their work might be sustained and passed on intact to future generations.'"'

Communit)- health nurses accepted the truism that "life surges warm and chaotic" around them. They regulated the flow among the professions of health. Communit)- health nursing's responsibilities for interpreting and educating linked it direcdy to other professions and to the public. Communit)' health nurses ti'ansmitted information and transferred effort throughout the community, interpreting the orders of physicians to social workers, the desires of teachers to mothers, and the worries of children to adults.'""

Their gusto for cooperative sen'ice cannot be separated from wider cultural enthusiasm for "group tliinking." While some health care professionals worried about the dangers of an extreme beehive mentalit)', most regarded harmonious, universal action as more effective. "Just as there is no part of the human body that is safe when infection exists in another part," noted one nurse, "there is no part of the human body that is safe when infection exists in another part; there is no part of the social body that can remain unconcerned if disease, immoralit)', delinquency, and crime are allowed to develop at some point." The conceptualization of societ)' as a network where the whole was greater than the sum of its parts also eliminated the demeaning power struggle naturally accompanying majorit)- decisionmaking. Instead, all players became equal partners, united bv common problems and common enemies. The ver)- spirit of democracy depended, in effect, upon voluntar)' cooperative effort for the common good. Little

'^^Gardner, Ptiblii: Heahb Kurs'mg, iv-v, 29; National Organization for Public Health K\xtsmg,MaimeilofPMicHeallb Nursing, xiv. '^^Nationai Organization for Public Health Nursing, Mmma!oj Public Health Nz/rsi/ig, 105; Rue, Public hleahb Nurse in tbe Comtntmity, 53, 57; Tlieda L. Waterman, Nursing for Community Health (Philadelpliia: F.A. Davis Company, 1944), 85; Grant, Nursing: A Community Health Service, 68. 103 wonder, then, that the new definition of public health nursing encompassed the individual as part of the family and the family as part of the communit\'.'"'^

\'iolet Hodgson, Assistant Director of the National Organization for Public Health

Nursing in the 1930s, likened the American societ}' wliich her profession regulated to a "complex machine" which "is only as perfect as the sum total of perfection of its individual parts." Public health nurses saw themselves as an essential and inseparable part of that communit)' machiner)-.

They were ghosts in the machine, augmenting and shaping its activit}-- but not supeivening or subordinating it. Most augured that their profession stood foremost as a buttress against chaos and disorder in consen'^ing the nation's health.''"'

Nurses, leaders asserted, bore responsibilit)' for policing and enforcing the collective will of the people in matters of public health. As such, they countenanced no group that exhibited contrar}- will or intolerance to community decisions. Leaders stricdy warned communit)' health nurses against incubating excessive "agency consciousness" or associating with organizadons fostering any hint of exclusivit)'. Instead, they were to reach out and join the hands of professionals and laypeople, private and public sponsors, making public health one large social-medical complex. As one director of nursing ser\dccs in Milwaukee put it, "No group is all important and no individual or group is too small or insignificant to be ignored in the effort to pool resources for the greatest common good."''^'

Communit}- health nurses argued that a valuable ser\'ice had been rendered even when their first attempts to sponsor teamwork met apathy. Their one-sided efforts often brought

H. Griswold, "W'Tiat Can the Layman Do?" Public Heahb Nursing 30 (1938): 89-95; Cliarlcs-Edward Amon- Winslow, "The New Leadership," Public Heahh Nursing 23 (1931); 108-13; idem, "National Health Challenges: E-low the Public Health Nurse is Meeting Tliem," Public Healtl) Nmingll (1935): 120-4; Naomi Dcutsch, "Generalized Public Health Nursing Service in Cities," American Journal oj Public Heahh 25 (1935): 475-8. '^"Hodgson, Public Heahh Nursing in Industij, vii-%'iii; Ruth Gilbert, Tije Public Heahh Nurse and Her PalienI (New York: The Commonwealth Fund, 1940), vii; Brainard, Evolution of Public Heahb Nursing, 419. "'Grant, Nursing: A Community Heahh Service, 70-1, 74-6; Clara B. Rue, The Public Heahh Nurse in the Community (Philadelphia: W.B. Saunders Company, 1944), 63, 68. 104 rewards in the long run. Nurses' overtures built up an unconscious awareness of dereliction of dut}-, of embedded communit)' expectations, among the seemingly bored and uninterested. Some members of the communit)', they reasoned, did not realize their responsibilities until they became readily aware of them. The more discouraged the potential worker, the more encouraging the calculated response.''^"

Coordinating the experts and the masses involved pooling all community' resources and negotiating mutually beneficial compromises. "To reach her goal she must be willing to use all the forces of her city," wrote Marj- Gardner in one of the earliest public health nursing textbooks,

"from the timid litde volunteer with her inexperience to the worn veteran with his somewhat immobile mental attitude." The windfall of economy and enhanced dynamism wrenched from cooperative efforts proved the nurses' place more surely than decreases of mortalit)' revealed in statistical tables.''''^

No one individual or individual group controlled public health, not even communit)' health nurses. "Alone, the nurse is powerless to change conditions for her patients," admitted one nurse. "To attain her best usefulness she must know every source to tap for health in meeting the conditions caused by the complexit}' of modern life." Nurses assisted communit)' health by organizing local health councils, or better yet, more inclusive community associations.''^"^

Nurses ideally were also supposed to cooperate with each other. The nursing super\'isor acted as coordinator of the coordinators. The supei-visor, wrote C.-E. A. Winslow, acted as "the channel tlirough which scientific knowledge comes to the staff nurse,. . . developing each individual's potential contribution and fusing it into a whole which is greater than the sum of its

'"'•Rue, Public \-\ealih Nurse in the Community, 76. ''^'Bethel ]. McGtath, Nursing in Commerce and Industiy (New York: The Commonweahh Fund, 1946), 307; National Organization for Public Health Nursing, Manual of Public Health Nursing, 6,15; Gardner, Public Health Nursing, 46-9. ''^''"Public Health Nursing," ^American journal of Public Health 23 (1933): 168-71, 281-4, 379-81, 519-22, 637-8, 747-50, 873-4, 1000-1,1202-4, 1326-8; Brainard, OrgaHis^ation of Public Health Nursing/ 40-1. 105 parts." He also encouraged supen'isors to act with "centrifugal" leadership, and not "centripetal" leadership. Super\4sion did not (again, ideally) disenfranchise staff nurses. Far from it. The individual nurse remained ultimately responsible for her own self-interpretadon, coordinadng her own diverse and sometimes contrar)- ideas to the wider profession. Any "program is not really successful unless the person engaged in it believes it is important to the sum total of activities desirable for human progress," noted one nursing leader.''^"

At the local level, nurses organized themselves into public health nursing bureaus in count)' and state departments of health where diey exchanged information, distributed nursing ser\"ices, and developed compadble community' health projects. At the national level, public health nursing organizations joined together with the three national nursing organizations in a

Joint Committee on Communit)' Nursing Sen'ice so that a more "fully coordinated and ti-uly effective" health program might be developed.

"Collective morale" enhanced "individual effectiveness" in all aspects of public health professionalism in the eyes of the communitA' health nurse. The nurse engaged in morale-buUding activities in part by sponsoring convivial meetings bringing together all professionals, especially those she dealt with most often: the physician and the health officer

(almost always a physician liimself). During conferences, public healdi nurses encouraged the incubation of conimunit)^-wide health policies. The articulation agreements emerging from these

meetings with the help of the nurse-intermedian- nurtured all the professions of public health.

The sheer numbers of communit)- health nufses and their ubiquitous presence in all

communit)- healdi agencies assisted their organizing efforts. The large numbers of full-time

"'Beard, AV/nc in P/iblic Health, 206; \'iolet H. Hodgson, Supervision in Public Health Kmsing (New York: The Commonwealth Fund, 1939), 2; Rue, Public Health Nurse in the Community. 239. "''X'irginia Howlett, "Tlie \'olunteer Looks at tiie Professional," Public Health Nursing'h\ (1939); 10-5; Charles-Edward Amory Winslow, "Nursing and the Communit)-," Public Health Nursing 30 (1938); 230-7. 106 nurses working in health and health-related organizations also gave the profession significant leverage. Fully half of all health workers in the United States by the 1930s were nurses. These nurses were employed in over 1,800 health agencies nationwide. Communit}- health nurses found employment in many places in the community', more places than any other t)'pe of health professional. Nurses worked for physicians and health officers, but also in insurance companies, tuberculosis associations, industr)', and a vast array of welfare organizations.''"

The organization of cirj- semces in Cleveland demonstrates the great diversit)- of communit)- health nursing work, and the large number of disparate public health units that could be brought together. Communit}' health nurses worked in the dispensaries of Maternit}' Hospital, the Babies' and Children's Hospital, the Health Division of the Board of Education, the Visiting

Nurse Association, the Universit)' Public Health Nursing Station, and the Red Cross Teaching

Center. Nurses choreographed these agencies into a Central Committee of Cleveland.''^"

Emergencies, whether epidemic, economic shock, or social dislocation, highlighted the utilit}' of close-knit organizations. Communit}' health nurses were keenly aware of the linkages between people that promoted health in good times and illness in less fortunate times. The maladjustment of even one family, though, had consequences that reverberated throughout the network of health. Correction of individual defects by prevention or cure generated positive effects: chain reactions of public health promotion among individuals in the communit}'. The

job of communit)' health nurses often involved following a "train of symptoms" back to the source and then eliininating the problems locatcd at that source.

"^Anthony ]. Borowski, "Positions and Rates of Pay in Public Healtli Agencies," American journal of Public Health 28 (1938): 1197-1202; Mrs. .-Vrch Trawick, "The Use of Laymen in Official Public Health Nursing Programs: State," American journal of Public Heahh 24 (1934); 722-6. Josephine Smith, "Coordination of Nursing Resources in a Community," Public Health Nursing 22 (1930): 369-71. "'Brainard, Evolution of Public Health Nursing, '59'i; Grant, Nursing: A Community Health Service, 74-6; Hodgson, Public Health Nursing in Industry, 163-4. 107

Mastering a role as quintessential coordinator and cooperator had some well-known drawbacks. "At times she seems caught in a hampering entanglement of red tape," complained one mental healdi nurse. Too, health administrators were notoriously stultifying at times.

Negotiating a solution sometimes meant bending another's will more than their own: "A tactful nurse will not, of course, appear to be directing her directors, although in realit)' that is exactiy what she must often be prepared to do." And, the community- health nurse could be forced into a compromising position by personal or professional skirmishes."""

I'he public liealth nursing's best work in coordinating the efforts of the entire communit)' came when it disappeared into the woodwork. Their role on the stage of public healtii, nurses thought, should not be a dramatic one. A harmoniously functioning communit)' health agenda left no room for praise for the efforts of the public health nurse, nor praise for any particular

profession. Functions assumed by the public healtli nurse in the wider communit)' also made the

problems of authorit)' and subsen'ience irrelevant. "The partner that raises the question of

power has obviously missed the essential significance of a working partnership," noted one

obser\'er.""'

True communit)' organization meant reconciling two heretofore irreconcilable

benefactors of public health nursing: private institutions and government agencies. Coordinating

the activities of these two groups was not easy, but frictionless relations gave the nurse some

assurance of permanency and elasticit)' in her work. One of the best ways to accomplish

cohesion was to encourage "nurse exchanges" between private and public organizations."""

"''"Gilbert, Public Health Nurse and Her Patient, 353; Btainard, Emiiition of Public Health Nursing, 51. ""'Anderson, "Role of the Public Health Nurse," 66-75; Felk J. Underwood, "A Critical View of Nurses and Nursing Programs," Journal of Public Health 29 (1939): 318-20; Hart\' M. Carey, "Communit)' Partners," Public Health Nursing 29 (1937): 560-6." """Brainard, Organit^lioH of Public Health Nursing, 10; Gardner, PtMc Health Nursing, 63-5. 108

Physicians controlled expertise within private institutions, and physicians acting as health officers doininated public organizations. "Public health nursing has had in the mcdical profession its greatest friend, wrote nursing leader Mary Gardner in 1917, "and not infrequently its greatest stumbling block." Nurses actively sought to cooperate with physicians, their closest medical allies, for the great good of the communit}'. The prevailing local medical opinion of their work, in particular, determined their success in the local communit)-.-"^

Nurses deliberately consuucted their profession as one largely dependent on the skill of physicians. Physicians, more than any other assisting group, encouraged a level of communit)' health nursing quality- "impossible alone." Nurses depended on physicians for their "standing orders," without which nurses would be reduced to impoverished duties unworthy of calling professional. Thus, it was commonly assumed that all communit}- healtli nursing organizations sought to appoint physicians from the local medical societ}' to advisor)' positions in nursing councils.-"''

Communit)' health nurses interpreted the will of the doctor to the patient, but did not prescribe or treat serious illness or injur)' without the physician's approval. They did not diagnose, prescribe medications, tteat more than minor wounds, or even recommend specific doctors. Nurses only obsen^ed conditions, susceptibilities, and deviations from normal states, and reported tliese findings back to tlie physician for interpretation. "The physician should expect the nurse to supply pertinent information in concise and usable form," wrote a lecturer in

Teachers' College, Columbia Universit)'. "Exchange of information is mutually helpful, but should be accomplished with the least possible use of time."-"^

-"•^Gardner, Public Heahh Nursing, 43-4; Beard, Nurss in Public Health, 11-2; National Organization for Public Health Nursing, Manual of Public Health Nursing, v. ""''Gardner, Public Health Nursing, 43-4; Rue, Public Heahh Nurse in the Communit;), 55-6; National Organization for Public Health Manual of Public Heahh Nursing. 8-9. •"^Gardner, Public Heahh Nursing, 43-4; Hodgson, Public Heahh Nursing in lndiislr^\ 32; Grant, Nursing: A Community 109

Yet the nurse conceived her position as neither above nor below that of other medical or public health authorities. Nurses dealt "with the professional staff as partners," noted one nurse.

The relationship between the health officer and the community' health nurse was ideally equally congenial. One nursing director described the reladonship as similar to that "between an administrator and an executive." The healdi officer as administrator deterinined policy and controlled "the progress of the enterprise in its fight for existence and advancement." He kept public health initiatives in "proper balance" by coordinating the various "paths of action." The community health nurse as executive, in turn, bore responsibility for executing and supentising the work assigned by the health officer."'"^'

Nurses worked hard to overcome an unequal balance in their relationship with physicians, l^hey supplied information quickly to harried physicians and gathered evidence in the home a physician might never uncover in the doctor's office. They referred business by supplying patients with lists of approved local physicians. Each nurse was "handmaiden to the doctor, and soother of fevered brows."""

The communit)' health nurse counted herself perfecdy coupled with the health officer and engaged in the same heady enterprise. They held each other, again ideally, in high esteem and refrained from stepping on the other's toes. "With the fellowship and understanding of a

health officer who invites friendship and cooperation," explained one American Public Health

Association section member, "a nurse should grow into ever broader ideas of ser\tice and ever increasing value to the community'." Communit}- health nursing leaders were adamant that

physicians never be criticized in public or private. "Professional etiquette," though, was a

Heahh Service, 84-5. Agnes J. Martin, "W'hat a Public Health Nurse Expects of Her Chief, the Health Officer," American Journal oj Public Health 2\ (1931): 1236-42. •"^Granr, Nursing A Community Health Service. 84-5; Ruth B. Freeman, Techniques of Supervision in Public Health Nursing (Philadelpliia: \\".B. Saunders, 1945), 3. 110

r\vo-vvav street. Nurses demanded respect from physicians as surely as they gave it. The)- expected superior scientific knowledge, procedural guidance, and trusrworthy decisionmaking from the health officer. The cotnmunit)- health officer, in turn, appealed to the communit)' healdi nurse to popularize sendee and represent the interests of tlie family. Nurses also provided a valuable "connecting link and buffer" between the health officer and clinic doctor. Most intriguingly, community health nursing leaders assumed that health officers held slight advantage in terms of power even though they usually super\'ised the hiring of new staff nurses."""

Becoming a coequal partner with die general pracdtioner proved more difficult. The nurse had a double responsibilit)' to put herself in the shoes of the patient and the doctor.

Undeniably, however, the audiorit}' of the patient paled in comparison to that of the medical man. "Virtually everything that you say, eveiytliing that you do, even'thing that you attempt," explained one National Organization for Public Health Nursing officer, "is subject to the veto of the family physician." Nurses did not argue that they possessed equivalent sldll in the healing arts, merely that their skiU bore no relation at all. They could not be compared on the same scale.

The nurse's skill in debreeding of wounds and monitoring of bed sores could not rival a physician's sldll in surgeiy, but because each skiU was indispensable they therefore were equally important. Communit)' health nurses dispensed valuable sendees too routine, too irregular, or too labor-intensive for physicians to copy. Nurses ordered biological supplies and directed immunization clinics. Thej' took throat cultures and temperatures, listened to heart and lung sounds, charted bowel movement irregularities, and looked for predisposing causes in the home.

Community health nurses also deflected a large, impoverished population with no potential for

"'"'jacolj C. Geiger, "Relationship Between Health Officer and Nurse; Points of \'ic\v of a Health Officer," American Journal of Public Heahh 23 (1933): 697-9; Henrj- F. \'aughan, "How the Nurse Can Help the Health Officer to Gel His Message Across," American Journal oJ'PubHc Health 20 (1930): 930-4; Rachel K. Miller, "VCTiat the Nurse Expects of the Health Officer," Public Health Nursing 26 (1934): 16-9; Martin, "Wliat a Public Health Nurse Expects," 1236-42; Gardner, Public Health Nursing, 43-4; Grant, Nursing: A Community Health Service, 84-5. Ill fee-paying away from the doctor's office. But they also supplemented the income of physicians by encouraging patients with abilit)' to pay to seek a physician's care. "Seldom does a mother delay calling the doctor after the nurse points out the importance of doing so," noted one nurse.-''(I'J

No other health agenc)' proved more difficult to integrate into communit)' ser\ace than the private clinic. The communit)' health nurse thought that physicians felt intimidated by the scope and power of her collective resources, and that they worried incessantly about being replaced. Nurses also assumed that physicians stood as ti-aditional bastions of individualized health care. Physicians appeared indifferent or unwilling to change for the better by adopting a generalized communit)' health model. "She is a member of a group; he is on his own," remarked one nurse. "He fears her because she appears less as an individual than a group member. If he could only know her as an individual his apprehension about her activities would probably fade away." Communit}' health nurses accepted partial responsibilit)' for ongoing disarray in the nurse-physician relationsliip. Nurses occasionally overstepped their bounds, misunderstood orders, or evinced "lapses in professional ethics." They also aggravated physicians by inaugurating free clinics without consulting the local clinics, or by requesting free setvice for patients more often than warranted."'"

The communit)' health nurse ultimately, and unintentionally, constructed a place for herself that dramatically circumscribed her own powers. Acting as warden of professional health communication put her in an awk\vard posidon. Nurses took it as their responsibilit)' to break down boundaries between the professions of health, even as they sought to police those same

""'a.D. Lazenbv, "The Place of the Nurse in IndustnV Pubik Health Nursing 28 (1936); 713-8; Marguerite A. Wales, "W'liv Not Save Hospital Beds}" Ameriiaii Journal of Public Health 24 (1934): 379-84. "'"Charles-Edward Amor}' Winslow, "The Challenge of Today," Public Health Nursing 26 (1934): 283-91; "Public Health Nursing," 168-71, 281-4, 379-81, 519-22, 637-8, 747-50, 873-4,1000-1,1202-4,1326-8; Helen LaMalle, "Successful Teamwork," Public Health Nursing 28 (1936): 611-6. 112 boundaries. Cooperation without duplication creatcd for communit\- health nurses, in the words of one medical social worker, "a maze of apparendy conflicting responsibilities and relationships."""

The unenlightened in the medical communit)' hampered greater consanguinit)' between the professions. Physicians, especially in small towns, tolerated each other well. In larger communities, however, they exhibited (in the nurses' eyes) narrow individualistic attitudes and disdain for public health nursing work. "Unless she takes the initiative in formulating a plan for cooperative work with the private physician," wrote one nursing leader, "the correlation of medical practice and nursing is Likely to remain an unsolved problem."''"

As communir\' health nurses assumed more responsibilit}' for coordinating public health efforts, they increasingly refused to act as "fu'st lieutenants" to health officers and private physicians. The possibilit)' of conflicting physician opinion or orders predisposed nurses to assume a deferential attitude in the presence of other health professionals. One nursing leader cautioned her colleagues to "deal with physicians on the assumption that the highest ideals of the profession dominate its even' member" even while conceding that doctors as humans made grievous mistakes."'^

Relationships with laypeople proved easier. Communit}' health nurses situated volunteers as intermediaries between themselves and the unorganized public. Recruiting them for public health work involved reducing health principles and practices to "language as simple as that of the radio," recommended one authorit}'. They worked hard not to belittle their audience and

"'' Huntington Williams, "The Health Department Nurse and Private Medical Practice," Public Health Nursing 27 (1935): 303-6; Bradley Buell, "Social Planning for Family Healdi," Public Health Nursing 30 (1938): 405-11. "'"National Organization for Public Health Nursing, Manual of Public Health Nursiji^, 24-5; Rue, Public Health Nurse in the Community, 54. "'"^Mathilde S. Kuhlman, "Public Health Nursing Legislation: W'liat It Should Include," American Journal of Public Health 20 (1930): 408-11. 113 some nursing leaders suggested diat the profession tn' to interpret complex direcdves to laypeople in words of no more than two syllables. Others advised that the attention of the public could be gained by using "lay language and lay thinking" to tell human-interest stories, that is, by being as "untechnical, as dramatic, and as brief as possible." Volunteers selected from the masses tended to share characteristics like pliabilit)' and erudition. The best volunteers spoke tlie language and experienced the emotions of the common man and easily acquii-ed loft)' ideals instilled by experts. Volunteers ideally had no special interests or preconceptions."'''

Lavpeoplc enlisted for public health work complemented communin- health nurses in sc^•eral wa)-s. Voluntarism alone contributed direcd)' to producing communit)' unit)'. Volunteers motivated apathetic laypeople to action. They added to causes "zeal and spirit" as "potent as that of the early pioneer." They organized citizen's groups to raise money or manpower, and engaged preexisting communit^' organizations like the American Legion, PTA, Junior League, Federated

Women's Club, labor unions, church denominations, and sen'icc clubs like the Rotary, Iviwanis,

Civitan, and Lions to do die same. These organizations formed a "blood brotherhood" to communit\' health nursing. Interestingly, communit)' health nurses saw lay leaders as the)- saw themselves, as anonymous coordinators of effort. The remarks of one nurse is instructive: "The key man is not always the chairman or president of the group. He may be the person who shuns the limelight but who will always be found as a powerful influence behind the scenes."

Collectivit\' in lay participation focused the disorderly if well-meaning work of individual

"'''Grant, Nursing: A Community Health Service, 39-40; Man- Sewall Gardner, Public Health Nursing, 3rd cd., revised (New York: The Macmillan Company, 1937), 440; Martin, "Wliat a Public Health Nurse Expects," 1236-42; Marion G. Howell, "Preparing the Nurse to Meet Communit)- Needs in Public Health," yAmerican journal of Public Health 28 (1938): 566-''0; Anderson, "Role of the Public Health Nurse," 66-75; Winslow, "National Health Challenges," 120-4; Kuhlman, "Public Health Nursing Legislation," 408-11; Griswold, "What Can the Layman Do?" 89-95; Hewlett, "Volunteer Looks at the Professional," 10-5. 114 laypeople. Nurses, often faced with inadequate funding and pinched priorities, saw a vast reser\'oii- of public energy being squandered on haphazard, uncoordinated relief efforts."' ''

Laypeople carricd out tasks that professional communit)' health nurses considered drudgciT. They sought out patients who missed appointments and drove them to the proper clinics. They restockcd supply closets and the nurse's bag, tj'ped up reports, made bandages, and weighed babies. Volunteers with special skills mimeographed statistical reports and fliers, took dictation, and copied and filed nurses' field notes. Some checked on the progress of shut-ins and contributed slogans for publicit)' campaigns. To guarantee their continued support, nurses demonstrated to laypeople the "the relationship between such duties and the work of the organization as a whole."""'

Public organizations gradually came to dominate community health nursing activit)-. In absolute terms, publicly-employed nurses oumumbered privately-sponsored workers by a substantial margin. Tax-supported community- health nursing departments by and large conti'olJed the purse strings, spending the bulk of total available fund for projects. "No longer can die public health nurse be called the 'Ser\rant of the Poor,'" remarked one leader. Instead,

"she has become a 'public ser\''ant.'"-'^

Government nursing agencies at the local, state, and national level stressed the importance of efficiency in their operations, favoring tried and true solutions to organizational

•''National Organization for Public Health Nursing, Manualoj Public Health Nursing, 32; Rue, Public l-leahb Nurse in the Commmily, 94; Ada Greenfield McRae, "Lay Participation," Public Heahh Nursing 26 (1934); 662; \'aughan, "How the Nurse Can Help the Health Officer," 930-4; Olivia Peterson, "The Use of Lay Boards by Official Health Agencies," American Journal of Public Health 27 (1937): 499-504; Charles-Edward Amon' Winslow, "Tlie Public Health Nursing Supervisor," Pub/ic Health Nursing 24 (1932); 551-6; Jose Bosley, "Selling Ser\'ice," Public Health Nursing 24 (1932): 449-51; Evelyn K. Davis, "The Volunteer; Asset or Liability'?" Public Health Nursing 26 (1934): 598-603; J .D. Dowling, "Tlie Use of La}TOen in Official Public Health Nursing Programs; City," Amrican Journal of Public Health 24 (1934): 880-6; Agiies Nicholson Stokes, "Tlie Biennial Convention: Through the Eyes of a Layman," Public Health N/trsing 26 (1934): 276-7; ".-Vdjustments in Public Health Nursing," Public Health Nursing 24 (1932): 663-6. "'^Gardner, Pul)lic Health Nursing, 3rd ed., 440; Rue, Public Health Nursing in the Community, 86. ""Brainard, Evolution of Public Health Nursing, 393. 115 and distributive public health problems. Nurses had to take care not to step heavily on the imaginations of private organizers who had, after all, inaugurated most of what communit)' health nursing had become. They did not expect private efforts to disappear, despite the growing margin between public and private in both employment and funding. Rather, communit)' health nurses anticipated an outpouring of new perspectives and new strategies from these dedicated private helpmates. Public funding lent private workers freedom and a strategic place in the commumt)-.-'IK

Those nurses working in the private sphere were thought of as experimentalists. Private parties cared less about efficiency—though always a consideration—and more about demonstrating new and progressive preventive techniques. Mistakes, then, could be ironed out

before a particular program was taken up b)' public agencies. More and more, field work in

remote countries imbued with so-called alien "local color" replaced the cold artificiality' of the

scientists' laboratory. Indeed, the private demonstration project bccame the new "laborator)'

where new pieces of work are tried and tested," and where waste could be whittled away."''^

More importandy, private organizations safeguarded public health's soul. Privately

initiated community' health nursing efforts brought to the profession a "spirit of devotion and

self-sacrifice" of incalculable value. Reducing or channeling these projects into a narrower

specti'um of activity' only retarded initiative in public health as a whole.^"

Public health nurses brought private and public interests together into community health

boards. All public health problems could be equilibrated in these boards. The nurse provided

the crucial link between each member, and between the board and the public at large. The nurse

was responsible, particularly as the health boards got larger, for providing an "intimate

""Srainard, Evolution of Public Health Nursing. 393; Grant, Nursing: A Commimity Health Service, 39. •"Gardner, PUIJIU- Health Nursing, 63-5; Brainard, Evolution of Public Health Nursing, 402. ••"Gardner, Public Health Nursing, 63-5. 116 anonymous picture" of the health needs of the community' since no one board member could possibi)' visit all homes."'

Communit)' healtli nurses did not seem particularly alarmed about merging their own identit)' with other professionals on health boards. "In the past, public health nursing was frequendy developed as a separate enuf}'," noted one nurse. "Nursing leaders now recognize that it should be developed as an integral part of the entire community' public health program."

Community' health nurses consciously sought to make their aims and abilities indistinguishable from those of the health professions generallr. Though "more and more manifold dudes are being assigned to the nurse, greater responsibilities are being placed on her shoulders, and a keener initiative is being demanded of her," explained another nurse. "Her ver\- designation as

'nurse' is becoming a misnomer."""

Community' health nurses also brought the powers of coordination and cooperation to lay councils. Councils brought together the medical and health professions, businesses, churches, fraternal orders, and women's and men's clubs together in sen^ice to the communit}-. Such councils or associations seemed in part "self-evident," but there were tangible fruits too. Sharing ideas in common councils promoted better understanding of the plans, purposes, and needs of community- members. Acting in unison produced a synergistic effect as each player sought to fortifv' the activities of the others, producing ser\"ices of uniformly high quality. "These workers arc, indeed, like the fingers of one hand," explained Lillian Wald. "They cannot grasp any measure or untangle anv knot unless they work with a feeling of sympathy and mutualit)' and a

full realization of the contribution made by each of them.""'

""'Hodgson, "Have '^'ou 'Sold' Your Board?" Pub/ic Health Nursing 24 (1932): 611-5. """Marian G. Randall, "The Public Health Nurse in a Rural Health Department," American journal of Pnblic Health 21 (1931); 737-50. ""^Brainard, Organit^ation ofPMic Health Nursing, 1; National Organization of Public Health Nursing, Principles am! Practices in Public Health Nursing Including CostAnajysis (New York: Tlie Macmillan Company, 1932), 14-5, 75-7; 117

Combining professional and lay public health scn*ices into united organizations generated great efficiency. Cost savings came by eliminating overlapping and duplication of effort

produced by multiple agencies. "It is not difficult to demonstrate that time and money arc saved if one central agency is doing a piece of the work," commented one member of Cleveland's

Central Committee, "instead of a number of isolated agencies." Community health nurses eliminated duplicated ser\dces and reduced the number of intrusions into a patient's life by

establishing multiple functions for each health worker. "We have thinned our ser\dces by dividing them up into too many parts and too many agcncies," remarked one nurse. "In some

communities . . . one generalized ser\'ice is sufficient." The communit)' health nurse herself

became a multipurpose figure in the process.""*

Community' health nurses only became alarmed when tlicir functions became wholly

coterminous with those of la)- organizations. They fretted, for example, when theii* activities

became interchangeable with such relief efforts as the coordinated fundraising activities of local

communit\' chests. Nurses themselves bore some of the blame for this difficult)'. Differentiating

themselves became difficult after so much of their effort had gone into homogenizing public

health motives. Nurses could not separate themselves from the public without refusing to assist

in certain parts of the whole of public health, which they refused on principle, or by raising the

bar for membership in the profession through educational qualifications and credentials."^

Communit)' healtii nurses pursued this second option vigorously. Concerned about

distinguishing themselves from the masses and refreshed by the broader generalized conception

Marguerite .A. Wales, T/.n' Piihlic hleahh Knrse in Aclion (New \'ork: The Macmillan Company, 1941), xiii; Hodgson, Public hleahh Nursing in hidusliy, 163-4; National Organization for Public Health N ursing, Sumy of Public Heahh Nursing 12. ""''National Organization for Public Health Nursing, Surv^' of Public Heallh Nursing, 12; Smith, "Coordination of Nursing Resources," 369-71; "Adjustments in Public Health Nursing," 663-6; Alma C. Haupt, "How Can Public Health Nursing Ser\'ices be Combined?" Public Health Nursing 26 (1934): 349-53; Stokes, "The Biennial Convention," 276-7. ""^Carev, "Community' Partners," 560-6. 118 of their profession, a large number of nurses returned to the classroom or sought out different field experiences to differentiate and round out their expertise. Holism, the organization of parts into a whole greater than the sum of tliose parts, uiumphed in the classroom as it had on the

"front lines." Modern communit)' health nursing education represented no "mere hodge podge of unrelated though interesting information," but rather "closely related aspects of one vast subject." Nursing classes ideally netted an "awakened spirit" among students while alerung them to the widening horizons of their work."'^'

Paradoxically, perhaps, generalized practice simultaneously eroded the value placed on the nurse well-versed in the basic sciences. xVdmittedly, science remained a crucial component of communit}' health nursing in modern America. Since the 1870s, public health nursing derived significant authorit}- from guiding scientific principles. Nurses were expected to know some chemistry, some medical terminology, antiseptic wound dressing, something about immune sera, and quite a lot about anatomy and physiolog)'. Nurses sought to keep abreast of new scientific advances by attending local, state, and national conferences and by reading relevant periodicals."'

The combination of coordinating, cooperating functions and dedication to science gave great apparent autliorit)' to the communit)^ health nurse. The nurse described herself as the chief translator of scientific public health principles for patients, school officials, and lay health semce workers. She transmuted the "findings of the laboratory' and desk into the language of the man in the street." Super\'^ising public health nurses in community' health boards thus linked "public health science on the one hand—^with the laws of physiology and the laws of sanitation and the laws of societ)'—and with the individual family on the other.""*'

""''Gardner, Public Heahb Nursing, 56-7, 62; Waterman, Nursin^Jhr Community Health, vii. "•^Philip Stephens, "Tlie Industrial Nurse," Public Health Nursing 28 (1936): 608-10; Leah M. Blaisdell, "Preparation of tlie Nurse of the Future," Public Health Nursing 29 (1937): 467-72; MeKin N. Newquist, "Industrial Nursing: Past, Present, and Future," Public Health Nursing 31 (1939): 162-6. ""''"Tlie Function of the Public Health Nurse," Public Health Nursing29 (1937): 246-7. 119

Yet as public health nurses assumed more responsibilit}' for coordinating the health of the community-, they found themselves assuming a bewildering array of skills for which they had never been trained. Nurses had to know sometliing of social relationships between family members, the effects of income, and better ways to educate illiterate and recalcitrant patients.

Remaldng the public health problem as irremediably interconnected with social and economic matters bolstered the community- health nurses' choreograpliic function. Nurses had always attempted some aspects of social work, but these functions expanded gready in the 1920s and

1930s.--'

Moreover, experts generally agreed that the science of public health nursing by the late

1920s represented an adequately tilled field. The great discoveries had already been made; now was die time for application. Much remained unknown about human interactions and

transactions, creating a public health nursing profession "out of step" with socief\'. Public health

nurses turned to the social sciences for direction in applying their scientific principles. Universit)'

public healdi nursing curricula adopted new subjects derived from the sciences of societ)' like

psychology, sociology, economics, health promotion, and family case work. "Psychologic

science" in particular helped nurses understand the underlying emotional and intellectual

components of sickness and health. Public health departments clamored for graduates of these

programs, and looked especiaUv to hire combination "nurse-social workers," considered ideally

attuned to family and communit)- scnace.*'"

The meager stable of potential public health nursing students available during the

interwar period meant that many nursing schools accepted marginal applicants. The average

••''.Vgiics ). Martin, "The Biennial Convention: Through the Eyes of a Nurse," Public Heahh Ntirs/iig 26 (1934); 278-9; Donna Pearce, "Coordination of Health and Social Ser\'ice," Public Heahh Nursing 24 (1932): 371-6. -^"Howard W. Haggard, "Wlio Owns Health?" Public Health Nursing 28 (1936): 214-21; Faville, "Responsibilit)' of the Public Health Nvirse," \65-70;3eiitd. Nurse in Public Heal/lj, 165-6; Hodgson, Public Health Nursing in Indust^', 226; Grant, Nursing: A Community Health Service, 104-5; Gardner, Public Health Nursing, 3rd ed., 113-4. 120 applicant for a position had three years experience as an undergraduate hospital nurse and no experience in a public health agency or private clinic. The average applicant, admitted one nursing leader, was "not a ven" intelligent . . . woman." Graduate programs suained to improve the skills of student nurses with low intelligence and poor work habits. Most public health nursing programs sought to improve the pool of applicants by encouraging high school students to set a goal to become a professional community' health nurse before they began theii' undergraduate training."^'

In the 1920s debate turned to selecting and inculcating appropriate nursing personalities.

The cooperating, coordinating, communitA'-oriented role of the public health nurse highlighted the importance of personality in getting her message across. "Knowledge alone is not sufficient," explained one nursing educator. "The way it is used is of parallel significance." Public health nursing educators began selecting students on the basis of their personalities and common- sensical knowledge of human behavior. Educators by no means abandoned the promise of scientific management of the patient, but increasingly saw scientific expertise as a secondary qualification. Indeed, dramatic proof of this came in a sun^ey conducted by the Public Health

Nursing Section of the American Public Health Association which found that members preferred nursing recruits "with insufficient public health nursing training or experience, but with excellent personalit)' and good general background" over those "with good public health training or experience, but lacking in personality.""'"

A good communit)- health nurse understood human and family nature by sharpening her native abilities of intuition. In this way nurses put on appropriate masks and adopted appropriate

"^'RUC, Public Health Nurse in the Community, 89. •'"Hodgson, "Whom Do We Ser\'e and How?" Public Health Nursing 25 (1933): 299-301; I. Malinde Havey, "Wliat Preparation Sliould tlic Public Health Nurse Have for Rural Work?" American Journal oj Public Health 20 (1930): 734-40; Gardner, Public Health Nursing. 41; Rue, Public Health Nurse in the Community, 238-9; Hodgson, Public Health Nursing in Industiy, 65. 121 strategics to achieve desired ends. That is, they defined pcrsonalit)- as plasticity. Communit)' health nurses held court in a businesslike way when it seemed expedient, and engaged families in more entertaining, even playful ways when that seemed a better approach. They also became emotional or expressionless when nccessit)' dictated.'^^ Overall, a pleasant disposition went a long wa)' toward ad\'ancing the communit)''s health:

The acquisition of a smile can be cultivated like a personalit)'. If you diink smiling is a common practice, notice people on a bus or streetcar, or pedestrians whom you pass on the street. How many of them actually look happy? [The nurse] should not only radiate happiness through her smile but through leaving a cheerful word. A mere "Good morning," for example, wiU often change the day for an individual. He will look around and see that it was really a good morning. He will absorb part of her radiation of happiness and cany it to his associates."^'*

Communit}^ health nurses debated the constituent parts of public healdi nursing personalit}' extensively. One nursing director maintained that the ideal communit)' health nurse

had a "New England sense of obligation" and an "Irish sense of humor." A health

commissioner described the successful communit)' health nurse as tactful, discriminating,

expressive, and (finall)') adequately ttained. One nurse described the ideal candidate as a "helpful

psychotherapist . . . and ambassador of good wiU." Other adjectives used to describe the

appropriate community' health nursing personalit)' included poise, friendliness, kindliness, loyalt)',

honest\-, gendeness, sympathy, dependabilit}', courtesy, sincerit)-, tactfulness, diplomacy,

industriousness, coolness, and cheerfulness—all die qualities of a saint and a Saint Bernard."^'

•^'Rue, PrtW/'f Health Nurse in the Commmily, 77-8, 238-9; Gardner, Public Hcahh Nursing iv; Grant, Nursing: A Community Health Service, 54. ""'Llovd Sherrill, "Getting Along With People," Public Health Nursing 30 (1938): 385-9. "'•^N aughan, "How the Nurse Can Help the Health Officer, 930-4; Kulilman, "Public Health Nursing Legislation," 408-11; Newquist, "Industrial Nursing," 162-6. The search for the ideal nursing personalit)- is strikingly similar to the "s\-stcmatic living" movement encouraged by Henn- Ford's Sociological Department. This department, in addition to conducting time-and-motion studies of the worker on the job, invaded and reformed the home and conducted personality' tests. Examiners looked to match certain mental qualities with particular rj-pes of work, determining whether individuals were fit properly to jobs on the factor)- floor, in auto showrooms, or as personnel counselors and foremen. See Stephen Meyer, The Five Dollar Dc^>: Labor, Management, and Social Control in the Ford Motor Company. 1908-1921 (Albany: State Universit)- of New York Press, 1981). 122

Most commentators agreed that, whatever her particular personalit}' strengths, communit)' health nurses ought to demonstrate unobtrusiveness above all else. Nurses with good personalities did not drive patients away with threats or cocrcion, denigrate the illiterate, or underestimate the citizen's common sense. They ideally listened to complaints from patients and their families, professed allegiance to the patient and the patient's physician, and responded honestly

Despite the importance of personalit}' in the communit)' health nursing programs of

American educational institutions, nurses were emphatic in asserting that they were not psychologists or social workers. Nurses discerned and analyzed the social components of public health problems; psychologists and social workers analyzed the health components of social problems. The difference in the eyes of community' health nursing leaders was enormous.

Health problems were the preser\'e of communit)' health nurses, not social scientists, no matter how wedded they became to social science ideas concerning the mental and social disturbances of the family."^'

A large percentage of newly minted generalized communit)- health nurses failed to live up to the standards demanded in the real world. One pedagogical tool, the "case conference," sought partially to fill the gap between the skills and personalities of these new graduates and the demands of health departments and clinics. Case conferences emphasized "group thinking" to solve die real health problems of anonymous families in the local communit)-. Nurses

constructed solutions to problems with the help of other professionals and the health library

rather than individually."'"

•^''Elizabeth I. Adamson, "Function of tlie Public Health Nurse," PublicHeallb Nursing 26 (1934): 542-6; La\'ona Babb, "Industn-'s Challenge to the American Joitrnal ojPublic Heallb2S) (1939): 1025-8. "^'Crant, I\iirsing: A Community Health Service, 81. "•^^Wales, Public Health Nurse in Action, 421. 123

The instrumental source for continued growth and funding for communit\' health nursing in modern America came about through passage of the federal Sheppard-Towner Act in 1921.

Sheppard-Towner, also known as the Matcrnit}' and Infancy Act, provided support to state programs for cliild health centers and prenatal care. By 1927, all but three states had inaugurated matching fund programs under the requirements of the act. Communit)' health nurses tended to dominate the activities of these centers, dispensing information to expectant mothers and e.xamining newborns. Rural distiicts and small towns especially made marked progress in establishing health centers under Sheppard-Towner."^''

Sheppard-Towner funds, apparent unit\- of purpose in communit}' health nursing, and a rosy economic picture helped create what seemed a golden age for the profession in the 1920s.

Representatives of the Children's Bureau in the Department of Labor who administered funds provided under Sheppard-Towner, claimed great success in their efforts. The bureau staff maintained it had nearly halved the infant death rate for gastrointestinal diseases and significandy lowered those for respirator)' disease in onlv six ye^ii's. The National Health Congress, organized to unif\' the disparate public health agencies working in the countr)', welcomed community' health nurses with outstretched arms. Outstanding individual figures in public health like Charles V.

Chapin and WiUiam H. Welch singled communit}--oriented public health nurses out for special appreciation in national addresses."""'

"''j. Stanlcv Lemons in his avticlc "The Sheppard-Towner Act; Progressivism in the \920s" Joiir/talof Ammwi History 55 (March 1969); 776-86, labeled it the "first venture of the federal government into social sccurit}- legislation." Blanche M. Haines, "Effect of Antepartum Care of the Mother," American Journal of Public Health 20 (1930): 273-4; McN eil. History of the Public Health Niirsin^ Section, 2-3; Richard Arthur Bolt, "Wliat the Sheppard-Towner Act Has Accomplished," Nation's Health 7 (December 1926): 833; Frances Sage Bradley, "The Sheppard-Towner Bill as It is Worked Out by .\rkansas Women," Medical Woman's journal29 (.-\ugust 1922): 196-7. "•'''Ga^ lord W. .Vnderson, "The Role of the Public Health Nursin in Communicable Disease Control," Public Health Nursing 26 (1934): 66-75; George C. Ruhland, "Public Health Nursing Program of the Fumre," American Jotmial of Public Health 29 (1939): 1015-8; Deming, "Milestones of the Past Fifteen Years," 128-34. 124

The health centers crcated under Sheppard-Towner proved too effective, it seems in retrospect, because intense lobbying by American Medical Association in 1927 convinced

Congress that maternal and child health ser\'ices were too important and too lucradvc to leave in the hands of communit^' health nurses. They were, moreover, interfering with the more inclusive famil)' pracuce clinics maintained by physicians. The program lost all funding just as the

Depression began. Repeal of the act hurt health centers, particularly at the local level, gready.

Communit)- health nurses closed centers in several states, particularly in the South and West.

Communit)- health nurses were, then, already \'ulncrable to unemployment and underemployment when die economy collapsed in 1929. Loss of Sheppard-Towner funds and general economic malaise represented two main threads undermining what even ANIA members conceded were important efforts to transform public health nursing educadon and practice from specialized to generalized, from knowledge-based to personaliti|--enhanced.

Communit}' health nurses speculated gready on the public health effects of drought and econoiTiic privation, yet theii- conclusions did not immediately match realities. PrognosUcadons hv nurses were decidedly negadve, and they endorsed the pessimisdc posidons of other health officials. Mental health was sure to worsen, they reasoned, as were nutriuonal problems, epidemic diseases, and care for the elderly. Children, the special preser\'e of the nurse, were pardcularlv susceptible to poor health during economic disasters, they claimed, and stood to suffer from stunted growth and reduced stamina.'""

Interestingly, however, the rise in mortalit}' predicted by health officials failed to materialize until the late 1930s. Communicable disease rates, save those for the relatively "new" disease of polio, continued dieir liistorical decline. Food shortages seemingly improved the

"'"Alma C. Haupt, "Some New Emphases in Public Health Nursing," JournalojPublic hiealth 25 (1935): 1346-52; Hortense Hilbert, "Nursing Ser\'ices for Mothers and Children as Part of a Balanced Public Health Nursing Program," American journal of Public Health 27 (1937): 875-9. nutxition of some children spoiled witli sweets by their parents. Maternal underemployment left women available for regular breast feeding which favored the development of infant immune systems. The lack of immediate trouble on the health front, beyond a long-standing deplorable

national maternal and infant mortalit)' rate, bred public apathy. "An outstanding problem in

public health publicity' and interpretadon just now," exclaimed one anonymous commentator,

"seems to be to get the public opinion back of reasonably high standards of public health work in

face of generally low death rates which seem to make retrenchment much more safe than it realty is."-^-

Low mortalit)' figures did not relieve many in the public health professions who saw chaotic epidemics around the next corner. Members of the public health nursing communit)- warned that this luU could not continue. They blustered about warning signs cropping up around

the counuy. The drought on the high plains brought about an early har\'est of tj'phoid and

pellagra. Drought compromised the milk supply in many areas as bovine udders shriveled from

want of water and grass. The number of children identified as seriously malnourished doubled in

1929 alone. Tvphoid fever sickness in Missouri rose over one hundred percent that same year.""'^

Communit\' health nurses also faced the prospect of dwindling dollars to service a

population they saw as increasingly at risk. Public and private health agencies learned to stretch

each dollar as far as possible. The sen'ices of communit)' health nurses quickly became diluted

over larger geographical areas as each nurse sought to maximize her efficiency. Soon, howe\-er, it

became ob^'ious that some functions of the communit)' health nurse would have to be sacrificed

"''"Mazyck Porcher Ravenel, "Drought and Health," American journal of Public Health 21 (1931): 1198-1202; "Public Health Nursing," Journal of Public Health 23 (1933); 168-71, 281-4, 379-81, 519-22, 637-8, 747-50, 873-4, 1000-1,1202-4,1326-8. Moses, "Drought and Health: Discussion," American journal of Public Health 21 (1931): 1216; Lewis S. Finch, "Sewage Disposal Difficulties Due to Drought," American journal of Public Health 21 (1931): 1219-21; D. Dickens, "Health in Relation to Prosperit\' in the Sowth," journal of Home Economics 30 (|une 1938): 370-5; "Effect of tiic Depression Upon Healtli," Moiilhlj Labor Reriew iS Qanuar)- 1934): 82-7; W. Wallace Weaver, "Modern ^'outh: Retrospect and Prospect," Annals of the American Academy of Political and Social Science 194 (September 1937): 2-3. 126 in order to avoid jeopardizing the entire enterprise. Communit)' health nurses shed those functions that the public found unable or unwilling to afford, those that demanded great expense in terms of training, and those that did not fit into the "total communit}' picture" formed b)- other health care providers, pardcularly private physicians who were hard pressed to collect fees."''"'

The economic pressures of the Depression reinforced preexisting conceptions of coinmunit)' health nursing as cooperative and communit}'-oriented. Nurses accepted above all that public health was no individualistic matter, and that the communir)' health nurse performed intricate teamwork eliciting the em7 of physicians and laypeople. The community health nurse strove for team play, not just with other nurses, but with the wider professional and social communiues. Nurses understood that success in raising the health consciousness of one body strengthened all bodies. Most importandy, they decried "cold and heardess ostracism" and an absent spirit of "sympathedc help" that accompanied health work in previous decades."""

CommunitN" healdi nurses posiuoned themselves carefully to meet the public health needs of the Twenties and the Great Depression. Uniformly, the community' health nursing profession argued that it had succeeded in meeting the needs of the time. Indeed, one nurse proudly noted that communitv-oriented public health nursing was "the only professional group that did not have to revise our program to fit the New Deal.""'"^'

When viewed widi late-twentieth-century eyes, it appears that emphasis on personalit)' and generalized sen'ice cheapened the profession and left nursing with a sizable credibility' gap.

Relativeh' speaking, other professions of health emphasized specialization and basic science as

""'"'Alma C. Haupt, "How Can Public Health Nursing Fir into a Budget?" Aniericmi Jonrna/ofPiihtkHea/lh 24 (1934): 17-21. "''^VC'.W. Bauer, "How the Official Health Organization Can Aid tlie Nurse in Industn'," Public Heailb Nursing, 22 (1930): 382-4; Anderson, "Role of the Public Health Nurse," 66-75. "'"'Martin, "Tlie Biennial Convention," 278-9. 127 defining characterisdcs of professional character to a greater extent than did nurses. By not stressing her sciendfic qualificadons and the applicadon of those qualifications to specific problems in the form of carefully culdvatcd abilides, the communit)' health nurse found herself markedng less concrete skills of cooperadon, coordinadon, and personalit)'. The redefinidon of public health nursing pracdce as general-purpose and personalit}--driven left the nurse in the long run with no specific, tangible skill which she could call her own, or that could be reduced to numerical amounts on medical bills or health department reports. As community' health nurse

Rachel K. Miller explained it,

The profession of public health nursing is unique among the professions in that it never functions independendy of that other great profession, the mcdical profession. The public health nurse does not originate knowledge—the scientist does that and the nurse accepts it for public dissemination only when the medical profession accepts it. She does not determine what the health needs of a communit)' may be; the statistician does that, and she looks to the medical profession to interpret the facts for her; she does not recommend what u-eatment an individual should rcccivc, she refers to the individual physician for that; she does not inaugurate policies and programs of public health nursing, she looks to the constituted health authorities for that.""*'

Finally, the requirement that nurses sen-e many masters, a key component of her cooperating and coordinating responsibilities, often had the opposite effect. Community health

nurses, with their hands in every pot, sometimes seemed like inefficient duplicators themselves.

Physicians increasingly resented nurses who trespassed their professional boundaries using

generalized seiTice as an excuse, and cozying up too close to private and public agencies. The

communit)- health nurse's easy movement from agency to agency and family to fainily produced

die vilest insult physicians could throw at them: diat they represented "excessive

individualism."-''"

•'"Miller, "Wliat the Nurse Expects of the Health Officer," 16-9. Rosslyn Earp, "The Supervising Nurse," American journal of Public Health 27 (1937); 817-8. 128

Stdll, community health nursing leaders and educators in modern America impressed what order thev could out of chaos. They used theii' skills as coopcrators and coordinators in generalized ser\-ice to generate creative, coherent programs out of a cacophony of public health needs, desires, and demands. Nurses enlisted even'body to work on theii' behalf, including professionals, private endowments and organizauons, and laypeople. Nursing stiessed the family as the locus for flexible activism and the importance of the nursing personality in interpreting her work. Ideally, with effort and experience, professional community health nurses tried to

"become that superior being; 'all things to all people.'""'*'^

•""Waterman, Nursin^ for Community Hea/lh, 64. 129

CHAPTER V. CHILD HYGIENE

The federal government of the United States undertook unprecedented action to improve child health between 1921 and 1929. Funds for child health programs allocated under the Sheppard-Towner Act of 1921 created new clinics in small towns and rural districts, extended communit)' health nursing, and encouraged specialization in pediatric medicine. The infant mortality rate tumbled downward at a three percent annual rate. Health experts promoted

American infant and child mortalit}' out of the lowest ranks where it languished with nations like

Eg)'pt and India. By 1929, when the act was repealed, American child health compared favorably against that found in European nations."'"

The effects of the Sheppard-Towner Act have been scrutinized elsewhere. The histor)' of child health between the repeal of Sheppard-Towner and the restoration of this work under

the Social Securit)' Administration in 1937, however, has not been carefully examined. During

these years, private agencies and local governments stepped into the gap, cooperating to provide some health ser\aces to children. Promoting child health became an especially important goal of

the American Public Health Association (APHA) during this period of social and economic insecurit\'. The work of the Child Hygiene Section of the APHA stands as an exemplar of the

kinds of cliild healtli activity pursued in the 1920s and 1930s. The Child Hygiene Section had

few financial resources at its disposal. Instead, the Section published recommendations and

^^'^Richard Arthur Bolt, "T)ie Infant Before, During, and After Birth," Americaii journal of Public Health 21 (1931): 843-50; Mattliias Nicoll, "Maternitj' as a Public Health Problem," American Journal of Public Health 19 (1929): 961-8; Blanche M. Haines, "Effect of Antepartum Care of the Mother," American journal of Public Health 20 (1930); 273-6; "Child Hvgiene: The United States' Children's hmnan" American Journal of Public Health 23 (1933): 166-8. On Sheppard-Towner see J. Stanley Lemons, "The Sheppard-Towner Act: Progressivism in the 1920$" Journal of American History 55 (^vlatch 1969): 776-86; and Molly Ladd-Taylor, "'Grannies' and "Spinsters': Midwife Education Under the Sheppard-Towner Act," Journal of Social History 22 (Winter 1988): 255-75. 130 guidelines for physicians, nurses, public health officers, and other professionals to foUow and adapt to their communities. Section members focused their attention on the "normal child," an entit)- that grew from fetus to schoolboy or girl by demonstrating greater mental and physical complexit)', passing regular developmental benchmarks, and displaying dynamic, well-adjusted responses to the external envii'onmcnt.""^'

The Child Hygiene Section did not dwell upon particular therapeutics; vaccines, feeding techniques, eye drop regimens, or proper diaper disposal. Rather, the Section sought to coordinate all the various communit\' agencies with a potential stake in child health. Though these agencies included the American Child Health Association (ACHA), the United States

Cliildren's Bureau, and United States Public Health Sen'ice at the national level, the Cliild

Hygiene Section directed most of its energies towards reforming health organizations at the regional level or lower. Health workers were encouraged to work together with laypcople in their communities, molding uniform, balanced children. Tracking and directing every aspect of the health of the "whole child"—that is, the child before and at birth, in infancy, as preschooler, and at school—produced "superior children," children that grew at a regularized rate and with normalized behaviors."'" Members of the Child Hygiene Section, noting the great complexit}' in normahzed child development, became the chicf choreographers of cMd health in the Great

Depression.

The economic pressures of the Depression reinforced and clarified a preexisting model of cooperative, communit}'-oriented child health organization. Akeady by 1920, a patchwork of

lohn Zahorskv and Elizabeth Noyt'S, The Iiifciiil ami Child in Hcahb and Disease 2nd ed. (St. Loiiis: Tlic C.\'. Mosby Companv, 1939), 21-39; Elizabeth B. Hurlock, Modem Ways wilh Babies: Physical am! Mental Development (I'liiladelphia: J.B. Lippincott Company, 1937), 1-11. "^"1. Newton Kugelmass, Growing Superior Children 3rd ed. (New York: D. Appleton-Ccntury Company, 1937), 533-5. See also Christina Hardyment, Dream Babies: Child Care from Locke to Spock (London: Jonathan Cape Ltd, 1983), csp. pp. 159-220; and Hamilton Cravens, Before Head Start: The Iowa Station and America's Children (Chapel Hill; Tlie University of North Carolina Press, 1993). 131 private and public organizations at tlie local, state, and national level worked to improve child health. These organizations reflected a new desire to apply modern science towards alleviadng the sufferings of the smallest Americans. Public health professionals "foUowcd up the feeders of the river of human miser)'" and located die wellspring of poor health in the social and envii'onmental conditions of children. Moreover, these organizaUons began in the 1920s to change their goal from "child saving," where lowering infant mortalit)' by controlling communicable diseases was tlie primar)' goal, towards "total cliild welfare," where the physical, social, and mental health and development of children in all age groups was at issue."''^

Child health professionals themselves could not really be disdnguished from one another. They recognized in practice that prenatal, maternal, infant, preschool, and school health were separable, and that each authorit)' must select a specific part of child development upon which to concentrate. However, these lines or boundaries of experdse were ultimately illusoiT since all e.xperts contributed an indispensable service towards the total health of cliildren. In other words, each authorit)' concentrated upon a parucular span in child development, but all authorities were accepted as contributors to the whole child. "The field of education, of industn'; the field of child welfare, of health; the problem of dependency, delinquency, and crime," wrote one public health nurse, "and now we realize that our various fields are but small lots, separated from each other only by imaginary lines, in one great general field where wc must do joint batde for our common cause; consen'adon of our greatest national asset, our men, women, and children.""^''

^^^[ames H.S. Bossard, "Editorial Foreward; Child Welfare," 0/ the American Academy of Political and Social Science 98 (November 1921): vi-vii; Edward Alsworth Ross, Latter Day Saints and Sinners (New York: B.W. Heubsch, 1910): 46; Henr)* W. Thurston, Proceedings of the National Conference of Social Work 45rii Annual Meeting (1918): 48-9. ^^''losephine Roche, "Economic Health and Public Health Objectives," American Journal of Public Health 25 (1935): 1181-5. 132

Child health experts approached their task in a rigorously scientific manner, framing their research questions around specific problems endangering normal, balanced development.

Much knowledge had been acquired within the public health and medical communities by the

1920s, knowledge that the various organizations interested in child health found useful when generalized and applied in specific situations. Most direct causes of infant mortalit\', for instance, were known: congenital defects, prematurit}', syphilis, cyanosis, diarrhea, dysenten', pneumonia and bronchitis, tuberculosis, whooping cough, measles, influenza, scarlet fever, and diphtheria. Indirect causes were also suspected in abundance: racial stamina, manners and customs, population homogeneit)', stabilit)' of residence, prevailing winds, relative humidit)\ milk and water supply, public and priv^ate sanitadon, housing conditions, and unemployment of parents, torr instance."'55

However, cliild health experts generally agreed that the interconnected problems of public health demanded the formulation of a science more inclusive than that developed in the laboratory. The social scicnces could help link direct causes of poor child health with their indirect causes. Child health workers began incorporating methods gleaned from classes in psvcholog}', sociology, economics, mental hygiene, and family case work. Public health departments clamored for graduates trained in the social sciences and child health scicnce as these combination workers were considered better attuned to family and communit)- scmce.

Renewed interest in teaching pedagogj' was also evident."^'^'

Child health professionals also began recognizing the important role of laypeople in their social engineering efforts. Laypeople, "Mrs. Eveiybody and Mr. Ordinary," were as important a

^^^|ulia C. Lathrop, "Standards of Child Welfare," Annals of the American Academj of Political am! Sodal Science 98 (November 1921): 7-8; Richard Arthur Bolt, "Fundamental Factors in Infant Mortalit)'," Annals of the American Academy of Political and Social Science')% (November 1921): 11,14. "^^Waltcr H. Brown, "Communit}' Health Program as it Applies to the Child from Six Years to .•\dolcscence," American jannial of Pnb/ic Health 2\ (1931): 857-61. 133 factor in promoting the health of children as medical science or social sciencc professionals.

Physicians, nurses, and child social workers worked more effecdvely when the community- as a whole supported them. "Certainly progress at present made in the field of maternal and infant hygiene in the cities would not have taken place had the sole responsibilit}' been assumed by the professional workers," claimed one public health worker. Professionals were even enjoined to refrain from using the personal pronoun "I" in their speeches, but should rather use the more inclusive "we" in the best interests of community,'. Mothers and fathers were critical p]a}'ers in the drama of child health. Ultimatelv, they were the inviolable guardians of cliild health, and trained cliild health workers who did not understand this guardianship were, as one field director put it, "doomed in large measure to failure.

The L'SPHS, Children's Bureau, APHA, and ACHA in the 1920s manipulated the many direct and indirect factors conuibuting to public health to influence the health of children. This proved no small task. Sur\'eys of the twent)' million elementar}' school children in 1920 revealed intolerable levels of ill-health in children. One quarter of all children had defective eyesight, hearing, or tonsils and up to sevent^'-five percent had teeth so rotten they had difficult)' eadng.

Ten to r^vent^•-fivc percent of aU elemcntaiy school children suffered from malnutridon. Home visits by cliild health workers revealed stunning povert\% ncglect, improper guardianship, immoralit\', and cruelty towards dependents. Funds were often difficult to come by, even in this period of relative prosperir\-. The public generally supported the work of child health workers, but rarely contributed their own muscle without prodding."^*^

"""'^Jane F. Culbcri, "The \'isif:u.\gTQ9.ch.cu" Annals of/he Amerti-m! Aiademj of Po/itkat am! Social Sdeiin''i)% (November 1921): 83; Elma Rood, "Participation of Lay People in the Promotion of a Rural Child Health Program," American loiiriial of Public Heahh 22 (1932): 1027; J.H.M. Knox, "Reduction of Maternal and Infant Mortalit}- in Rural .-Xrcas," American Journal of Public Health 25 (1935): 68-75. ^^^Harriet L. Leete, "Positive Health for American Cliildren," Annals of the American Academy of Political and Social Science 98 (November 1921); 27, 32-3. 134

One insu'umental source for funding, prioritizing, and coordinating child health efforts came under the Sheppard-Towner Act of 1921. Sheppard-Towner provided matching funds to state programs for cliild health centers and prenatal care. By 1927, all but three states had inaugurated matching funds programs under die requirements of the act. Public health nurses tended to dominate the activities of these centers, dispensing information to expectant mothers and exainining newborns. Rural districts and small towns especiall)' made marked progress in establishing health centers during the period."^''

Sheppard-Towner funds and a rosy economic picture helped cooperating authorities and laypersons reduce many exacerbating child health problems in the 1920s. Representatives of the

Children's Bureau of the Department of Labor, who administered the funds provided under

Sheppard-Towner, claimed great success. The Children's Bureau inaugurated breast feeding campaigns, set educational requirements for pediatricians and specialists, and set minimum goals for child health in its publication. Standards of Prenatal Carer''''

New York Cit\' utilized the windfall of revenues to expand the scope of the Maternit\-

Center Association, originally organized as a small locally-funded demonstration project in 1918.

In 1920 the Matcrnir\' Center Association served only a small fraction of the population of the cir\'. Sheppard-Towner dollars, claimed one authorit)', helped "organize a local effort to control the unnecessar)^ maternal and infant tragedies" by shaping "a sound public opinion which would demand correction of the existing evils." The Association offered free clinics to women, home

"^^Haines, "Effect of Antepartum Care of the Mother," 273-4; McNeil, A hlistoQ' oj the Public Health hiirsiii^ Section, 2-3. ^^'^Gaylord W. Anderson, "The Role of the Public Health Nurse m Communicable Disease Control," Public Health Nimiit^26 (1934): 66-75; George C. Ruhland, "Public Health Nursing Program of the Putuie," Amrica/i Joi/riialof Public Health 2') (1939): 1015-8. 135 visits by nurses, instxuction during pregnancy, postpartum physicals, and periodic infant health assessment throughout the 1920s."^''

The Minneapolis Infant Welfare Societ)-, fu'st organized in 1910 and reorganized in 1922, offered many of the same ser\dces with the new infusion of federal money. Well baby clinics were launched throughout the cit}^ and immunizations against smallpox and diphtheria were

furnished free of charge. So popular was the program, recounted one clinic worker, that local

private practitioners protested for lack of work. Soon, parents earning over SI 30 per year

became ineligible recipients of aid. Tliis conflict of interest between free clinic providers and

private practitioners in Minneapolis mirrored those emerging at the same time in other cities."^'"

Improving and maintaining the public health and cliild health in the 1930s—as in the

1920s—was perceived as a complex, interconnected phenomenon, demanding cooperation

among a large number of constituencies. Infant mortalit)- represented only one factor among

many contributing to child health. Editors of the Amencan Journal of Public Health argued that the

economy was only one among many reasons for the poor state of child health. The number of

hospitals and children's homes in a communit)', family and ethnic customs, and wealth also

affected child health. No one factor was more important than any other, and an imbalance in

any one factor could damage the effectiveness of all child health initiatives."'^'^

The importance of communit)' balance in the protection of child health cannot be

overstated. The nurseries of New York Cit)^ hospitals, for instance, suffered excessive

"^'l.ouis Israel Dublin, "Tlie Problem of Miircrnin" Sun'ey nnd Forecast," American Joiintalof Pitlilic Health 29 (1939): 1205-14; Bolt, "The Infant Before, During, and After Birth," 843-50. Huenekens, "The Well Babv Clinic at the Office of the Family Physician and Pediatrician," American jonrna!of Public Health 20 (1930): 747-50; Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 260-1; Bolt, "The Infant Before, During, and After Birth," 884. ^^^"Infant Mortality' in Our Cities," American Journal of Public Health 19 (1929): 1352; L.M. Graves, "Housing Problem in a Southern Citv: With Special Reference to Its Influence on Residual Typhoid Fever and on Infant Mortality," Journal of Public Health 25 (1935): 21-30. 136 mortalities due to the outbreak of an unspecified disease in the summer of 1934. Sevcnt)'-rwo children exhibited signs of the malady, and thirt)'-t\vo died. An event such as this was

unremarkable in its dme. However, a descripdon of the causcs and effects demonstrates the interconnectedness seen by cliild health authorities;

Although infants born to mothers of the poorer classes of the cit\' have been attacked most heavily, yet babies of the better classes arc also affected, depending upon the operating interrelauonships of the ward and private maternit)' sen'ices of the various individual hospitals."^'"*

Negro child health, liistoricaUy notorious in this countr)', was also perceived as a

communit\'-oriented problem. The death rate for black infants was double that for whites in the

1920s. The Negro death rate surpassed 200 per thousand live births in some places. New York

Cit)''s black infant mortalit)' rate in 1920 was 164 per thousand and the white infant mortality-

rate 82 per thousand. Some of this disproporuonate mortalit)' exhibited in black youths was

deemed hereditar)' in the 1920s and 1930s, but a preponderate share of it was blamed on

isolauon of Negroes into "communides of their own." Hence, the "worth while racial

potentialities of Negro infants born and reared in the rural southern environment arc not

sufficicndv well developed at chronological maturity to make them either a local community-

asset or prepare them for respectable social adjustment elsewhere." Blacks, some child health

workers claimed, were not fully habituated within American culture, costing them jobs,

education, and health. Further, they were becoming resen'oirs of ill-health and disease.

Segregation of blacks from other segments of the population could not help but breed

neglect and, as USPHS Office of International Health Relations Surgeon Hildrus Poindexter"^'^'

^^''Samuel Ftant and Harold Abramson, "Epidemic Diarrhea of the New-Bom" Amema/i Journal of Public Heahb 28 (1938): 36-43. ""^^Eugcne 1-Cinckle ]ones, "Problems of the Colored Child," Annuls of the American Academy of Political and Social Science 98 (November 1921); 142,144-5; Hildrus A. Poindexter, "Handicaps in the Normal Growth and Development of Rural Negro Children," American journal of Public Heahh 28 (1938): 1048-52. "''''An African American, Poindexter was later director of the USPHS Mission to Liberia, which sought to control 137

argued, blacks bore much responsibilit}' for poor child heakh by seeking out neighborhoods where diey could not be accosted by well-meaning and benevolent police officers, public

sen-ants, and health workers. Hence, "the histon' of the social evO in Chicago," explained the

author of the 1921 Chicago ^'ice Commission report, "is intimately connectcd with the colored

population. Invariably die largest vice districts have been created in or near setdements of

colored people." The deliberate isolation of blacks into exclusive communities, it was thought,

prevented them from enjo)'ing the fruits of the wider whiter communit)- as a whole.

The rural-urban dichotomy of American life also demanded reconceptualization in the

complexified, communit)'-oriented 1920s and 1930s. The particular problems of rural child

health were of great interest to public health officials ever^'where because the hospitalization of

expectant mothers brought in from the countryside skewed the mortalit}' rates of urban

hospitals. These pregnant women overburdened the facilities and generated unanticipated cost

overruns, and included primarily the most difficult cases, that is, those that could not be dealt

with successfully by rural physicians."'^''*

Maternal and infant mortalitN* rates in urban hospitals, then, were higher than they might

otherwise have been. Flight of mothers carr}dng difficult pregnancies to the cities also lowered

the mortality- rate in rural areas. "Conditions in the rural field of child health point toward a

cooperati\'e program as the only one that can really reach every child," argued one public health

nurse. The solution, ultimately, was the creation of a new geographical space for child health

diseases and establish a sanitaiy regimen tiicre. ^^^Jones, "Problems of the Colored Cliild," 142,144-5; Poindexter, "Handicaps in the Normal Growth and Development of Rural Negro Children," 1048-52. Dorothy G. Wiehl, "The Correction of Infant Mortalit}' Rates for Residence," American journal of Public Heahh 19 (1929): 49^6. 138 activit)-—the district—including within its bounds a designated share of rural and urbanized populations, oftentimes irrespective of preexisting political boundaries."'^''^

Moreover, only a variety of public health workers could alleviate the problems of child health. Child health demanded technical expertise in many areas, but the best child health workers were generalists. "Leaders in child hygiene must have adequate ttaining in both pediatrics and public health administration with its related subjects of vital statistics and sanitan- engineering," noted one Boston pediatrician. "They are not expected to be technical experts in pediatrics, bacteriolog}', statistics, tuberculosis, or other specialties." Demonstrable expertise in several areas removed work from those "intrusted [sic] too often, . . . lay persons whose only qualificadons were based upon interest in and sympathy for children.""^"

The key expert, as in communit)- health as a whole, was the public health nurse who investigated children's homes for disease and vice. Public health nurses struggled throughout the Depression to achieve greater cooperation between health agents and agencies. Funds for child health education were extremely limited throughout the 1930s. State boards of health and their child health divisions lived "hand to mouth" or not at all. Diphtheria and t)'phoid control programs were curtailed or halted all across the countn* as an economizing measure. It was difficult to encourage nurses and physicians to take up child health because there was so litde money in it. This was, of course, true of public health generally. "Present conditions as to compensation and securit}- of tenure are too unsatisfactory to attract the best class of young men

269Henn- BL\by Hemenwaj', "Tabulation of Maternal Deaths, and of Causes of Stillbirths and Deaths of Very Young Infants," Journa/ of Public Health 19 (1929): 1337-8; Rood, "Participation of Lay People," 1027. 270 John .-K. Ferrell, "Training in Administrative Procedures of Personnel for Child Health Work," American journal of Public Health 22 (1932): 706-8; Richard M. Smith, "Postgraduate Study in Cliild Hygiene in the United States and Canada," journal of Public Health H (1932): 719. 139 and women to public health work," decried one adininisttator. "Moreover, many of those now engaged in this work are not ver\' promising persons."*^'

Opportunities for improving the pool of child health workers were limited. Universit}- programs in child health were usuall)' restricted to courses in clinical pediatrics. Only a few schools treated child health in more than a cursor)' fashion in their training of doctors, nurses, and sanitarians. Johns Hopkins used a mishmash of activities to impress the importance of child health. Classroom education was confmed to one elective course meeting twice each week for a semester. Most training occurred in the field by obsemng the operation of milk stations, open air schools, schools for tiie blind and other handicaps, and cliildhood tuberculosis sanitoria."'"

Harvard devoted more time to classroom instruction in three elective cliild health and welfare classes, coupling these activities to a semester's work in the field obser\ting an assortment of prenatal clinics, postnatal clinics, child welfare clinics, school health programs, and institutions for the feebleminded. Yale's School of Bacteriology, Pathology, and Public Health had a single course dedicated to child health, though the Graduate School of Education occasionally used its "Psycho-Clinic" to study child development and health. The Universit\' of

Iowa conducted summer courses in child welfare, focusing upon principles of nutrition, child psychology, physical growth, and genetics. The Universit)' of Minnesota had an Institute of

Child Welfare providing a master's or doctorate to students, dwelling upon child training

"^'m. losephine Smith, "Coordination of Nursing Resources in a CommunitT,-," Piiblk Health Nursing 22 (1930); 369-71; "Adjustments in Public Health Nursing," Public Health Nursing 24 (1932): 663-6; Haupt, "How Can Public Health Nursing Ser\'ices be Combined?" 349-53; Charles F. Wilinsk}', "The Communit)- Health Program as it Applies to the Cluld of From One to SL\ Years," American Journal of Public Health 21 (1931): 851; Ferrell, "Training in Administrative Procedures," 707; "The Depression and Public Health," American Journal oj Public Health 22 (1932): 395. See also Karen Buhler-Wilkerson, "False Dawn: The Rise and Decline of Public Health Nursing in America, 1900-1930," in Xiirsin^ History: New Perspectives, New Possibilities, ed. Ellen Condliffe Lagemann (New York: Teachers' College Press, 1983), 89-106; and Jane Pacht Brickman, "Public Health, Midwives, and Nurses, 1880-1930," idem, 65-88. 272Smith, "Postgraduate Study in Child Hygiene in the United States and Canada," 715-8. 140 regimens, physical development, parental education, and mental assessment. Child health was only a small annex to the Institute."^"'

More common were the experiences of the Massachusetts Institute of Technology and

Boston Universit)'. MIT argued that no specific training was necessary' in cliild health; the general health education classes of the Department of Biolog)- and Public Health were thought sufficient to render whatever experience necessary. No field work in child health was offered either, even though practical experience was advised. Boston University' restricted itself to providing health instruction in those areas useful to future teachers: first aid, school lunch nutrition, mental hygiene, and athletics."^"*

Despite the best of intentions, cliild health work was thought to be exceedingly inefficient and divisive at the outset of the Depression. "The borders of the field are continually impinging on the rights and prerogatives, real and fancied, of other official and nonofficial agencies," noted one state health commissioner at the 1929 Washington Conference of State and

Provincial Health Authorities of North America. "The [mortaht)'] figures . . . are most disheartening, and a reproach to public health adminisuration and its frequendy vaunted claims of rapid progress in the acliievement of defmite results." The patchwork of organizations supporting child health began looking like an ineffective crazy-quilt, rather than the tightly organized, interlocking, holistic enterprise it was supposed to be."^'

The Child Hygiene Section was organized during the 1927 meeting of the APHA

foOowing a floor debate over the presentation of a paper by Lee K. Frankel, second vice-president of the Metropolitan Life Insurance Company, entided "The Present Status of

^^^Nicoll, "Maternin' as a Public Health Problem," 961. 141

Maternal and Infant Hygiene in the United States." The expiration of Sheppard-Towner added an aspect of urgency to the proceedings. The Cliild Hygiene Section may not have had the money to soh'^e the public health problems of children during die depression years, but it became a clearinghouse of information on the subject from 1929 to 1937 and beyond. The

Section encouraged studies of all sorts, and sought to ameliorate the deleterious effects of the

Depression on America's children. The Section also reported on child health initiatives in

Europe, Canada, and South America. It encouraged studies in child nutrition, school health, prenatal and maternal care, rural and urban health, parental and professional healdi education, mental health, child labor, and sponsored Child Health Day programs ever)' May Day."^^'

In 1935, the t\venr}'-sLx year old American Child Health Association was absorbed by the

Child Hygiene Section of the American Public Health Association. All copyrights held by the

ACHA were uransferred over to the APHA the next year, including the popular magazine Mother and Child, and tiie more staid, professional organ, the Child Hecihh Biillclin. The American Child

Health Association had formerly focused primarily on weighing and measuring children and making scientific recommendations for progressive, non-normed, development. Revenues sccured from dues paid by members of die merged group increased briefly, but deficit spending for programming quickly absorbed the new windfall."^^

The chairman and most prominent member of the Child Health Section in die 1930s was Richard A. Bolt. Bolt during the 1920s was chairman of the American Child Hygiene

Association and director of tlie Cleveland Child Health Association, an organization intensely interested and active in communit)'-oriented child health. Bolt helped solidify the general

"'^Lec Kaufer Frankel, "The Present Staais of Maternal and Infant Hygiene in the United States," American jonrna/of Public Health 17 (1927): 1209; Julius Le\T, "Maternal and Infant Mortalit)'," American Jnumal of Public Heahh 19 (1929): 228. ^77"-rhe American Cliild Health .\ssoQ\Mon" American Journal of Public Health 25 (1935): 1142-3; Louis Israel Dublin, "Health of the People in a Year of Depression," American journal of Public Heahh 22 (1932): 1123-35. 142 program of health during the Depression, oudining on several occasions and in many places how modern scientific methods might be commingled with social science experience in forming a single cliild health team composed of physicians, educators, welfare agents, and lay volunteers.

Mustering together the communit}' resources appropriate to child health was difficult, he admitted, but was the only guarantee that the health of the total child could be secured. Bolt himself identified no less than nine constituencies that contributed to and had a stake in the good health of children: (1) physicians and dentists, (2) local health centers, (3) public and visiting nurses, (4) local health departments and theii* bureaus of child hygiene, (5) nurseries and kindergartens, (6) guidance clinics, (7) PTA organizations, (8) municipal playground authorities, and (9) parent educators."^**

Bolt encouraged Section members to define heath in homcostatic terms, as a "delicate balance which the individual maintains between a number of conflicting forces, some of which reside in the child himself, . . . others from his immediate environment." He wrote that no children were so well adjusted that unanticipated forces could not upset their "health equilibrium." He agreed with other experts that the necessary scientific knowledge for cltild health akeady e.xisted, and that it only required more extensive application. Preser\ting the balance of child health became the central goal for all Section members under Bolt's tutelage."'^

Seven planks formed Bolt's holistic child health platform. The first was extension of systematic health examinations of children. All health workers were to examine children separately and within their age group. Second, all children should be guaranteed access to

vaccines, but administration of these vaccines depended upon the cooperation of the parents.

270 Richnrd Arthur Bolt, Reduction ojhAaternalMortality in Cleveland (Chicago; American Medical Association, 1939), 1-18; idem, "Child Hygiene," American Journal of Public Health 21 (1931); 1164. ^'^Richard Arthur Bolt, "Cliild Health Today," American Journal of Public Health 22 (1932): 1005-8. 143

Promotion of good nutrition and prevention of malnutrition formed a third goal. Fourth,

Section members advised prompt treatment of rheumatic fevers diat caused heart disease and abnormalities in children. The fifth point was directed at good "mouth hygiene," by which was

meant care of the jaws and teeth. The sixth plank was school safet)' programs to prevent

unnecessar}' injuries. Last, the members advocated intensive clinic-based mental hygiene

projects to improve tlie psychological and physical health of cliildren."'"'

Bolt, however, left the countr)' just as the Child Hygiene Section was finding its

Depression-fighting bearings. The APHA had awarded Bolt the Oberlaender Trust Award to

"carr)' on a detailed study of maternal and child welfare conditions in Germany and Austria," and build a new friendship between Americans and the German-speaking nations of Europe.

His absence proved critical, hamstringing the progress of cliild health in the United States as a

result.-"'

Bolt expanded the mandate of the Oberlaender Trust to include visits to child health

institutions in England, Francc, Russia, and Belgium. He grew particularly enamored of child

health progress in Fascist Italy and Nazi Germany. Point XXI of the Nazi Code, he explained,

guaranteed that "the state must see to raising the standards of health of the nation by protecting

mothers and infants, prohibiting child labor, increasing bodily efficiency by obligator)'

gymnastics and sports laid down by law, and by extensive support of clubs engaged in bodily

development of the young." Bolt considered the Hider Youth with its regimentation, active

sports program, and fresh air, a model for child health programs in the United States. Iniually,

Bolt was not alone among American health authorities in his praise for state-controlled

cliild-rearing, and especially Germany's "communit)' units of cooperative health work."

'^'^Richard Artliur Bolt, "Cliild Hygiene," 1163-4. 281"Dr ggjj Receives Oberlaender Award," American journal of Public Health 23 (1933): 253. 144

American child health workers admired Hider's "each for all and all for each" pledge, and the careful balance maintained between consensus-building health coordinadon at the national level and flexible, dynainic local communiD,' health organizadon. Bolt, however, found liimself increasingly distanced from the acdvities of the Child Hygiene Secdon as the decade advanced."''"

Members of the Child Hygiene Section created programs and crafted recommendations for communit}' child health beginning in the womb. They uniformly considered prenatal development the first stage in normalized chUd development. Some members went so far as to advocate then-fashionable "racial hygiene" principles. While child health "theoretically" began with conception, Richard Bolt summarized at one point, it "has its background in the health of father and mother and the stocks from which they have sprung.™

Members blamed poor obstetrical care, particularly in the largest maternit)' hospitals, for a large share of maternal deadis. Hospital care for expectant mothers remained fraught with considerable danger. American hospitals were much less successful than their European counterparts in containing septic infections. Puerperal fever remained a great danger despite abundant research on the importance of aseptic and antiseptic practice. Hand washing, sterilization, and chemical disinfection were all neglected in American hospitals for many

reasons, but foremost among them was the mistaken belief that "hospital fevers" arose in

crowded hospitals with litde ventilation. Less crowded American hospitals, unlike the largest

European hospitals, were long thought immune to such dangers. This conclusion was bolstered

^^^l^chard Arthur Boh, "Maternal and Cloild Welfare Work in Russia," American Journal of Public Healflj 24 (1934): 406-8; idem, "What Can We Learn from Cliild Health Conditions in Europe?" American Journal of Public Health 24 (1934): 951-6; idem, "Effects of Unemployment on Cliildren and Young People in Belgium," American Journal of Public Health 23 (1933): 1091-2; idem, "Child Welfare in Germany," American Journal of Public Health 24 (1934): 77-9; idem, "The Effects of Unemployment on Children and Young People in Germany," American Journal of Public Health 23 (1933): 744-7. ^^^Bolt, "The Infant Before, During, and After Birth," 843-50. 145 by significantly lower pueqDeral fever death rates in the rural countn'side. American hospital staff did not awake to these dangers until the late 1920s when statistics began to show that the septic infection rate of European hospitals had declined precipitously while the American rate had only marginally improved. By 1928, the United States bore an ignoble distinction for the second highest puerperal fever rate in the world.

The dangers of hospital deliver}' were especially embarrassing to health professionals considering the low maternal and neonatal death rate among practicing midwives. Infants delivered by midwives died much less often than those delivered in hospitals. In 1928, hospital mortality was nearly four times as high, 21.8 per thousand compared with only 5.6 per thousand among midwives. Some of tliis difference was explained as the natural gravitation of women carrying difficult pregnancies to trained obstetricians.""'

Other "tendencies of modern life" creeping into obstetrical practice were also thought partially responsible for high maternal and neonatal death rates. Forceps, general anesthesia.

Cesarean sections, and use of the drug pituitrin were all blamed for high hospital mortality'.

Physicians, it was thought, had capitulated to the woman's desire for the alleviation of pain, and the results had been devastating. Forceps in particular wrought all sorts of havoc upon the infant: bruises on the face and scalp, injury to the brachial plexus and subsequent paralysis, and fractured femurs."'"^'

The acknowledged skiU of the midwife played a substantial role in lessening mortalit)'.

Strict regulation and training of midwives, demanded by most state boards of health and state medical societies, gave them definite advantages over male obstetricians in many places.

^^''Le\T, "Maternal and Infant Mortalit)'," 227-8. ^^^Lev)', "Maternal and Infant Mortality'," 226; Nicoll, "Maternit)' as a Public Health Problem," 966. ^^^Le\7, "Maternal and Infant Mortalit}-," 227; Nicoll, "Maternit)- as a Public Health Problem," 966-7; Walter R. Ramsev, "Effect of Intranatal Care Upon the Ininni" American Journal of Public Heahh 20 (1930): 271-2. 147

placed the countr)' among the worst in the world. Infant mortalit}' in urban areas topped

sixt)'-eight per thousand, though this rate was among the lowest ever attained.

Members of the Child Hygiene Section agreed that infant health was a problem

particularly suitable for public health because both sanitarj' and environmental factors played such a large role. "It is futile to argue which has the more influence, hereditj' or environment,"

explained Chairman Bolt. "Both are integral parts of the whole individual and act and react, one

upon the other." These factors depended solely upon general communit)' provisions for public

health. Infant health was a complex problem demanding a coordinated response. Infant health

demanded, in the words of one Section member, "intense awareness of the characteristics

special to maternit)' and childhood within a total family health ser\'ice."''^"

Poor communit)' coordination diminished the qualit\' of ser\ncc provided to infants. 5"

X 8" child record cards and larger family record cards were kept by pubhc health nurses

monitoring the health of individuals within the family group. Birth and death certificates, as well

as standardized causes of death reduced "masses of meaningless data" to uniformit)' and made

information more accessible by aU health workers. Coordinated, generalized seiTices ensured a

balanced, proportionate response to infant health problems."'^'

The preschool child was recognized by child health authorities as the most neglected

segment of the population where health was concerned. Charles Wilinsky, a Boston health

commissioner, likened the preschool years to the "plastic age" then dawning, one opened up by

289Le\T, "Maternal and Infant Mortalit)'," 225; "Infant Mortalit)' in Our QXnz.'i'' American Journal of Public Health 19 (1929):'l351. "590 Wiehl, "Tlic Correction of Infant Mortalit)' Rates for Residence," 495; Leonard Blumgart, "Some Aspects of the Mental H)'giene of the Child," Annals of the American Academy of Political and Social Science 98 (November 1921): 50; Bolt, "Tlie Infant Before, During, and After Birth," 845; Hilbcrt, "Nursing Sen'ices for Mothers and Children," 875-9. ^"c.A. Sargent, "A Plan to Obtain More Accurate Records of Infant Hygiene Field Work," American Journal of Public Health 23 (1933): 677; Hilbert, "Nursing Services for Mothers and Children," 875-9. 148 the manufacture of flexible consumer products like acetate and rayon. Richard Bolt agreed:

"The years before school entrance are those in wliich many habit and behavioral difficulties occur." The preschool years were the years when traits and habits were formed, and character solidified. Personal traits lasting a lifetime—suspicion, cruelt)', jealousy, timidity, curiosit}-, conscientiousness—were aU confirmed in the preschool years."^"

Where health was direcdy concerned, proper posture, eadng habits, and essendal morality' were all locked in, Wilinsky asserted, before age five. The preschool years also were the years where potentially debilitating injuries and sicknesses could be prevented. Measles, whooping cough, diphtheria, and scarlet fever all plagued preschool children, threatening to destroy their abilit)' to lead productive adult lives. Endangering any aspect of normal health and development interfered with the totalit)' of functioning of children as individuals within groups.

Normal preschooler digestion was impossible without normal excretion and vice versa.'^^

Nourisliing development assured the appropriate community-enhancing activity and reactivity in the child:

A balance between extravert and introvert . . . obviously is more advantageous than an extreme expression of either one of these personalit}' trends. The preschool cliild who is allowed to cultivate his independence, who is encouraged in attention, persistence and coordination; who is aided in the establishment of habits of order and regularity in function . . . has the finest opportunity for building up normality in health to the time of school entrance."^"*

Parents, however, seemed to exhibit much indifference as it was popularly understood that mortality' was greatest among children in the first year of life. Preschoolers did indeed

^^"Wilinskv, "The Communit)- Health Program as It Applies to the Cliild of from One to Six Years," 851-4; "Mental Hygiene," Annah of the American Acadmy of Political and Social Science 98 (November 1921): 54-5. ^^^Wilinsky, "The Communit}- Health Program as It Applies to the Child of from One to SL\ Years," 851-4; Bolt, "Child Hygiene," 1162; idem, "Health of the Preschool Chi\A" American journal of Public Health 2\ (1931): 1162; William Alanson Wliite, "Cliildhood: The Golden Period for Mental Hygiene," Annals of the American Academy of Political and Social Science 98 (November 1921): 54-60; 54-5; Esther L. Richards, "Are the 'Nerves' of Badness of Cliildhood of Any Importance to the Field of Public Health?" American journal of Public Health 23 (1933): 198. "'''ira Solomon Wile, "Mental Health of the Preschool Child," American journal of Public Health 23 (1933): 191. 149 exliibit a much lower mortality rate than infants under one )'ear of age. Still, preschoolers caught colds easily and were prone to debilitating accidents during play. Parents also harbored the belief, to the detriment of proper nutrition, that preschoolers could and should eat anything and ever)'thing."'^^

The Depression only exacerbated the problem of providing health semces to preschoolers. In 1929, for instance, only four hundred cliildren in the boroughs and suburbs of

New York City were reached by a single free clinic. Most free clinics, Hke that established by the

Child Hygiene Section of the Akron (Ohio) Health Department gave little or no medical attention to children or provided specific diagnoses to avoid offending private practitioners.

These clinics were manifesdy referral mills for children, largely born to immigrants or blacks, and with no doctors of their own. Parents did not, or could not, always take the advice of clinic workers to seek assistance for their cliildren among the private practitioners. Some of the most indigent cases were eventually sent to hospital dispensaries, but the depressingly low rate of defect correction exhibited in clinic children testified to the inadequacy of the clinic referral process.296

Child health programs in the Depression tended to focus narrowly on what could ideally be done in carefully circumscribed local communities rather than divide meager funds among the too many needy children. "Most of our efforts in tliis field have been either spasmodically intensive or consen-atively prolonged," explained Richard Bolt. Many organizations funded child health demonstrations in needy njral counties and urban cores, concentrating thek efforts to avoid a dilution of prestige in the public eye. The Milbank Fund set up the only operating

"'^Shirlev \V. Wynne, "Free Clinics for the Preschool Child," jAmerican joiirna/ of Public Health 20 (1930): 264-5; Bolt, "Child Hygiene," 1162. ^'^Huenekens, "Tlie Well Baby Clinic at the Office of the Family Physician and Pediatrician," 746-9; Eldred Tliiehoff, "Report of a Preschool and Infant Welfare Clinic," American journal oj Public Health 21 (1931): 1164-5. 150 preschool clinic in New York in 1929. The Commonwealth Fund sponsored a Child Health

Demonstration Committee to set up such programs as early as 1925 in Clarke Count}', Georgia, and Rutherford Count)', Tennessee, where tlie black and poor white population was substantial.

The child health demonstradon in Marion Count)', Oregon, launched by the Commonwealth

Fund in 1925 was t)'pical of the majorit)' of child health demonsuadons. The Commonwealth

Fund cooperated with local health officials for a period of five years, after wliich responsibilit)' for continuing the program fell to a new locally-conu-olled count)' health board."^^

The liiTiited scope of preschool child health demonstration projects also reflected the recognition by public health authorities that, as Bolt put it, "It is comparatively simple to oudinc a broad program for child hygiene. It is, however, quite another matter to fit such a program to the diverse needs of various t)'pes of localities." Each communit)' had its own distinct personalit)' that contributed to die larger whole American communit)'. Thus, the norms of behavior for children varied greatiy from local communit)- to local communit)'. "Personalit)' as a unit consists of the interaction of numerous trends," noted one APHA hygienist. "For example,

Iving would be regarded by one family as an evidence of mental Ul health and by another as namral, normal, and expected.""'^^

School health authorities understood that normal mental and physical fitness in individual children—revealed in self-control, temperament, and inhibitions—translated later in life to social fitness as a whole. The uneven health of preschool cliildren was, then, a matter of much dismay. "Children, at the time of school entrance, are ver)' unequally conditioned physically, mentally, and emotionally," wrote one school health inspector. "This difference

^^^Nicoll, "Maternit)' as a Public Health Problem," 965; Wynne, "Free Clinics for the Preschool Child," 268; Bolt, "The Infant Before, During, and After Birth," 843; "Child Hygiene Work of a Count)' Department of Health," American Journal of Public Health 22 (1932): 427. "^^Bolt, "The Infant Before, During, and After Birth," 843; Wile, "Mental Health of the Preschool Child," 191. 151 arises primarily from hereditan- factors, modified by social environment, numtion, infections, and various handicaps dues to accident or disease." The solution was to encourage each school child to do his best to exercise originalit)% inidative, and responsibilit}' as a member of a social group. AD children became more normal by cooperadng with others.""''^

Much of the necessar}' public health initiatives planned in the 1930s were st}^mied, however, by the sheer poverty' of information concerning the prevalence of sickness and retardation of normal development among school children. The Child Hygiene Section deferred to the APHA's Comnnittee on Record Forms for the construction and evaluation of appropriate forms for determining the health of school aged children. School sickness charting by the

Committee on Record Forms, in turn, was modeled after the Appraisal Forms for certif\'ing the progress of local public health associations being constandy created and modified by the

Committee on Administrative Practice."^""

Tight-fisted cconomy demanded that public health authorities give school teachers and nurses more power as a first line of defense against the maladies of childhood than ever before.

I'eachers heretofore were litde trusted by public health authorities who thought such responsibilities for child health were beyond the capabilities of those who had little or no education beyond high school. Now, the teacher became an indispensable helpmate of

professional health workers. "The doctor needs to have an intimate knowledge of the problems

of the schoolroom, and the teacher needs to have a larger concept of health education than is

now hers, and both doctor and teacher need more knowledge of the homes from which school

cliildren come," reported one school nurse. Teachers were to inspect tlieir charges for anything

"'^White, "Cliildhood: The Golden Period for Mental Hygiene," 58-9; Frederic H. Knight, "The Behavior Problems of Atypical Cliildren," Annats of the American Academy of Political and Social Science 98 (November 1921): 67; "Child Hygiene: Health of the School Child," American Journal of Public Health 21 (1931): 1278-9. ean Downes, "Sickness Records in School Hygiene," American jonrnal of Public Health 20 (1930): 1999; Brown, "The Communir\' Health Program as It Applies to the Child from Si.\ \'ears to Adolescence," 857. 152 out of the ordinan-, and report any changes to the closest available medical personnel. Specially trained "visiting teachers" and "home and school visitors," heirlooms from the 1910s, were also occasionally employed to seek out the deficiencies of children. Yet, the teacher proved not interested in the particular diseases afflicting her charges. They remained in the sole the pun'iew of the physician. "She is interested only in determining the presence or absence of any deviation from normal which indicates that the child may be suffering from some acute disease," explained one school health administrator."^"'

The great weight of school healdi during the Depression, then, fell upon the scant supply of school nurses. Nurses were responsible for showing teachers how to look for any conditions regarded as deviations. Their other chief duties were to conduct periodic inspections of children, administer first aid, and conduct home visitations where necessar)'. The child was supposed to be considered as a "whole," that is, not a collection of "tonsils, teeth, eyes, ears, etc." School nurses were to look for cuts and abrasions on children; evidence of impetigo, pediculosis, and scabies; and toothaches. Signs of communicable diseases were to be reported to school inspectors and local physicians immediately upon discover}'. Thermometers, medicine droppers, bandaging material, ointments, disinfectants, and soap were all supposed to be found in the basic first aid cabinet of any school nurse worth her salt. Home visitation was especially valued, because remedying some problem in an individual child usually required remedying a problem in the whole family of which the cliild is a part. The school nurse, observ^ed one

Section member, "senses as the go-between for the school and the health department in making

Charles Christopher Wilson, "First .\id Cabinet of a School Nurse, Her Standing Orders for First Aid, and Her School Nursing Procedure," Amrican journal of Public Health 20 (1930): 151; Culbert, "Tlie \'isiting Teacher," 81-3. Some teachers fed smdents out of their own pockets. In Cliicago, 11,000 hungrj' school cliildren were given food by teachers who were themselves financially embarrassed by the failure of the Board of Education to pay them in 1932. See "Child Hygiene: Childhood and the Depression," American Journal of Public Health 22 (1932): 872-4. 153 use of community resources in the interest of cluldren, and in carrying out special directions in times of emergency."^""

The nutritive qualities of the diet of youth were iinportant components of the school health projects of the Depression, bolstered by the discover)' of various vitamins by E. V.

McCollum at Johns Hopkins Universit)'. Many communit}' summer programs for preschoolers and school children sought to correct abnormal nutritional deficiencies and restore children to their appropriate developmental group. LoweU, Massachusetts, established one such summer camp for malnourished children. The camp was located within the cit)' limits of Lowell, but provided something of a pastoral landscape for children debilitated by the deforming effects of industrial Life.'^"'^

The main ser\''ices provided by the Lowell camp were regular feedings, recreadon, and rest. Weight-gain was the chief determinant of success though regular examinadon and a regularized diet fordfied with vitamins A, B, and C. Bananas were sensed daily because they contained essential vitamins and were easily digested. Milk and ice cream provided vitamin D.

The children attending the camp boasted an average weight gain of seven pounds. Playground • equipment was donated by the Lowell Gas Light Company, but as Lowell's director of school hygiene John McNamara explained, "These children, undernourished and undei-weight, need rest rather than strenuous exercise." Rest periods lasted 24 hours at times. Punishment for insubordination also took the form of lengthened rest periods.

302Wilson, "First Aid Cabinet of a School Nurse, Her Standing Orders for First Aid, and Her School Nursing Procedure," 148-54; Elma Rood, "Part the School Nurse Plays in the School Health Education Program," American Journaloj Public Health (1935): 1215-20. McCollum, "Nutrition as a Factor in Physical Development," Annals of the American Academy of Political and Social Science 98 (November 1921): 34-7, 41; John J. McNamara, "Lowell Fights Undernourishment Among its School Cluldren," American Journal of Public Health 19 (1929); 605-10,15; H.C. Sherman, "The Problem of Sweets for Children," American Journal of Public Health 19 (1929): 1205. 304 McNamara, "Lowell Fights Undernourishment .^mong its School Children," 610-19. 154

The Social Security Act of 1935 restored several initiatives begun under the defunct

Sheppard-Towner Act and kept alive by child health experts in the Depression. Title I\' of the

Act provided money to needy dependent children in need of social protection because of death or incapacitation of parents. The Social Security Administration stressed the "mutuality and cooperation" aspect of all child health programs at all jurisdictional levels. One fundamental objective was "development of a fully balanced and correlated national plan of program and procedure, with each of the three elements of government (federal, state, and local) assuming full responsibilit)' for the functions it is best situated to perform." Again, an imaginar)' line was drawn in the sand. The Administration pledged to cooperate with local private and public medical, health, nursing, and welfare groups, and granted funds to the Children's Bureau and state child health organizations. It also hoped to make a career in public health "as attractive, lucrative, and permanent as any other professional field.^"^

Unfortunately, Aid to Dependent Children under Social Security represented a drop in the bucket when compared against Old-Age Assistance programs. Federal aid to dependent child rose from less than a million to S7 million dollars between Januar}' 1936 and Januaty 1938.

Disbursements to the aged, by comparison, rose in the same period from $4 million to more tlian $31 million. A disproportionate share of the benefit of Social Security where child health was concerned went to rural families in western states. Six of the top eight child recipient rates

^"^E.L. Bishop, "Public Health at the Cross-Roads," American journal of Public Health 25 (1935): 1175-80; C.E. Waller, "The Social Securit)- Act and Its Relation to Public HcsXth" American Journal of Public Healllj 25 (1935): 1186-94; Katharine F. Lenroot, "National Aspects of the Social Securit)- Program as they Pertain to the Cliildren's Bureau," American Journal oJPublic Health 25 (1935): 1327-33. On tlie historiography of Social Securit)- see Arthur j. .-Mtmeyer, The Formative Years of Social Securi^' (Madison: Universit)- of Wisconsin Press, 1966); and Roy Lubove, The Struck for Social Security, 1900-1935 (Cambridge; Har\'ard Universit)' Press, 1968; reprint, Pittsburgh; Universit)- of Pittsburgh Press, 1986). 155 in January 1938 were found in states west of the Missouri River; Oklahoma, Utah, Idaho,

Washington, Arizona, and Colorado.

ADC payments in 116 urban areas which had slowly risen from slightly under $2 million in 1929 to about $3 million in 1937, rose more rapidly to 54 million the next year. Assistance to urban retirees, however, rose much more quickly and to significantly higher funding levels. All supplementary payments to the elderly were already in the neighborhood of $6 million when

Social Securit)' engaged. By 1938, over §15 million was pouring into eldercare programs. These funds were distributed to 1.6 million urban aged Americans and almost six hundred thousand urban children in the single month of Januan-1938.'^"^ The Social Securit}' Adininistration hired

nutritionists for its fledgling school lunch program. Some of these nutritionists were immediately dispatched to the larger school systems in the countty where they operated within

the interdependent matrix of communit}' child health activity.'^"''

• • •

The Social Securit)- Adminisu-ation echoed the spiiit of the Child Hygiene Section in

1935 by promising that "the most far-reaching contribution [child health workers] can make to a

county- or communit)- program is through developing local resources for continuing

participation in die work of the local unit."'^"'^ The community remained the locus for child

health efforts and all interested parties were tied together into a dynamic network of

responsibilities. Physicians, sanitarians, public health nurses, school health nurses, parents, and

taxpayers coordinated their efforts in a holistic way, perceiving the normal development of the

^^^From Chart IN' & N'lII, Table 7 in the Social Security Bulletin 1 (Match 1938); 45, 50-1. ^""'prom Chart III in tlie Social Security Bulletin 1 (March 1938): 61. •jno Marjorie M. Heseltine, "Nutrition Ser\nces in Maternal and Child Health Programs Under the Social Securtt)' Act," American Journal of Public Health 28 (1938); 813-7. 156 whole child as the product of the careful manipulation of a sometimes bewildering number of external and internal shaping forces. Expiration of the Sheppard-Towner Act dramatically reduced the number of federal doUars available to child health activists, but did not significantly alter the conception of group involvement in cliild health. 157

CHAPTER VI. INDUSTRIAL HYGIENE

In 1936, the American CoUege of Surgeons sur\'eyed the employees of 116 companies operating throughout the countr\'. The CoUege wanted to know why the average American worker missed so much work, almost a week and a half each year. Reports collected from

350,000 workers revealed that, on average, a worker lost just over half a day to on-the-job injur)' per year, but less than one-one hundredth of a day to occupation-induced diseases. Workers lost fifteen times as much time it appeared, fully nine days, to injuries and illnesses (the largest share: respirator)' diseases including the common cold) unrelated to their activities in factories, retail establishments, and mines.^'" Two years later, Clarence D. Selby, chief medical consultant to the

General Motors Corporation, figured that GM employees on average spent twent)'-five percent of each day at work, but acquired only sL\ percent of their illnesses and injuries there.^"

The American College of Surgeons and GM studies confirmed what health professionals already generally knew about the intertwined, interpenetrated nature of human experiences.

Injuries and diseases suffered in the homes of workers affected the efficiency and profitabilit)' of

modern indusuial and commercial America. "We arc beginning to realize," explained J. J.

Bloomfield of the USPHS, "that industrial health forms an integral part of the health of the

communit)'." Loyal Shoudy, president of the American Association of Industrial Physicians and

^'"Melx'in N. Newquist, MedkatService in Industty and Workmen's Compensation Laws (Chicago: American College of Surgeons, 1938): 32-3; C.O. Sappington, Essentials of Industrial Health (Philadelphia: J.B. Lippincott Compan)', 1943), 43; J.]. Bloomfield, "Development of Industrial Hygiene in the United American Journal of Public Health 28 (December 1938): 1394; Harold G. Tobey, "Common Colds in Relation to Industrial Hymens" Journal of Industrial Hygiene 3 (March 1922): 333-8; Orlen J, Johnson, "Public Health and Medical Relationships in Industrial Health," American Journal of Public Health 32 (October 1942): 1157-63; National Industrial Conference Board, Inc., Medical Supervision and Service in Industty (New York: National Industrial Conference Board, Inc., 1932), 99; A.J. Lanza and Jacob A. Goldberg, eds., Industrial Hygiene (New York: Oxford Universit}' Press, 1939), 11. ^"clarence D. Selby, "Health Maintenance in Industty," American Journal of Public Health 28 (November 1938): 1328. 158

Surgeons, echoed this view. "Factor)- health and communit}- health are so closely related that they cannot be separated," he concurred, "but must be carried on together." More importantly, he assumed that industrial medicine and hygiene had the obligation and right to do something about it.^'-

The ideas and ideals of "industrial"-^'^ physicians, hygienists, and nurses, then, flowed with the main currents of communit\- health as tliey postulated the inseparabilit)- of domestic and industrial health matters. "Industrial hygiene is concerned with even* phase of the health of the man behind the machine," explained James Townsend, "whether it is the industrial dust in the air he breathes or the food his wife has packed in his dinner pail." Workers' health influenced not only industrial productivit)', but the producdvit)' of aU the members of their families. The health and safet)' of family members also weighed on the minds of employees. "If there is uncared for illness at home," suggested C.-E. A. Winslow, "his worrj' and distress may gravely impair his efficiency."^''* One industtial hygienist idenufied this home effect in a female employee forced to leave her children with a "perverted" sister. "She wanted the children to be decent, and her distress over the home simadon was seriously interfering with her efficiency in the factoiy," he explained. "In industrial hygiene, it is as impossible to separate the home from the factory, as it is in school hygiene to divorce the school from the home."-^'^

''"Sappington, Essentials of Industrial Health, 36; Bloomfield, "Development of Industrial Hygiene in the United States," 1388; Loval A. Shoudy, "Annual .Address of the President of the .-American .\ssociation of Industrial Physicians and Surgeons," Journal of Industrial Hygiene 6 (September 1924): 169-'^3. accordance with coiuemporar}- sources, I use the term broadly to include anyone engaged in the production, distribuuoii, or sale of goods and services. As Lanza and Goldberg put it in the preface to their widely cited texbook, "Industr)' is an all inclusive term; within its confines are to be found all the different kinds of labor which furnish us svith everj'thing we use in our present complex life." See Lanza and Goldberg, eds.. Industrial Hygiene, v. ^'''james G. Townsend, "The Problem of Industtial Hygiene," New Orleans Medical Surgical ]ountal95 (May 1943): 505; Charles-Edward Amor\- Winslow, "Industry' in Medicine," American Journal of Public Health 23 (May 1933): 453. "^''Charles MacFie Campbell, "Mental Factors in Industrial Hygiene," of Industrial Hygiene 5 (.-Xugust 1923): 130-7. 159

This interconnected view of home and work encouraged industrial hygiene workers to establish health ser\'ices not only for workers, but for spouses and their children. The modern workplace sprouted with pre- and post-employment clinics, well baby stadons, prenatal care lectures, and first aid stadons. Industr}' liired thousands of physicians and nurses to staff these facilides. Even where the enterprise was small, experts encouraged owners and managers to participate and contribute to the efforts of the local healdi and medical establishment and draw upon tliis resource for advice and support regularly.'"^'

Health professionals gained unprecedented access to die American workplace between the world wars. The union of public health and industr)- seemed not only a natural consequence of communit}'-oriented thinking, but a necessar)' and immediate response to the cosdy yet preventable industrial problems of absenteeism, fatigue, morbidit)-, and mortalit)'. These problems invariably led to higher rates of labor turnover which in turn destabilized production and caused "maladjustment between the requirements of industr)' and worker." The health problems of indusuy, in other words, were tangible and expensive when viewed from the standpoint of corporate managers or of health professionals. Management and health experts, then, could see eye to eye and agree that the "maintenance of a productive group which can turn out tlie products of the company on a reasonable schedule" was of paramount importance.^''

Emery R. Hayhurst, one of America's foremost industrial hygiene experts and a consultant hired by many factories, noticed membership changes in his profession concomitant with the reorientation of industrial hygiene as a communit}' health problem. He noticed that an

"old guard" in the Industrial Hygiene Section of the American Public Healtii Association had

^"'See recommendations of the National Industrial Conference Board, Inc., in Medical Care ofliiduslrial Workers (New York: National Industrial Conference Board, Inc., 1926); and Medical Supervision and Service in hidtistij (New York: National Industrial Conference Board, Inc., 1932). "^"La\'ona Babb, "Industr5''s Challenge to the Nurse," American]oHriial of PMic Health 29 (September 1939): 1026; Lee Kaufer Frankel and Alexander Fleisher, The Human Factor in Industiy (New York: The Macmillan Company, 1920), 15; Sappington, Essentials of Industrial Health, 93. 160 become disaffected. This disaffection stemmed, Hayhurst argued, from deliberate attempts on the part of die old guard to isolate themselves from other APHA sections. This old guard industrial hygiene, he complained, represented a specialized "st}'le" not in vogue because it artificially separated itself from otlier generalized activities. Industrial hygiene as practiced before and during the first World War, it seemed to him, resisted integration into the larger universe of public healdi programs. Now it had to be belatedly brought back into the fold by a younger generation of industrial hygienists who took a broader, more inclusive, approach.^'"

It is unrewarding to evaluate the old guard Hayhurst identifies for their resistance to or ignorance of modern trends. More worthy of scrutiny is die long tradition of industrial health liistor)'-making that has focused more upon toxicological problems, admittedly a staple of "old guard" practice, tlian that of industrial health's integration into the wider field of conununit)' health. Toxicological hazard identification remained an important, even crucial part of industrial hygiene practice in postwar professional practice, but became an adjunct to other equally important inquiries into ventilation, lighting, noise, and employee relationsliips. Preference in documenting the abuses, effects, and controls placed on poisonous substances illuminates only a

thin slice of the activit)' of the modern industrial h)'giene expert. One industi'ial hygiene expert's

comment speaks volumes in diis respect: "The great majorit)' of persons engaged in industry and

commerce do not so much need protection from their work as they need adjustment to the

industrial civilization of wliich they form an integral part."^''^

R. Hayhurst, "The Industrial Hygiene Section, 1914-1934," Americun Joiinml of Public Health 24 (October 1934): 1041. ^"Leonard P. Lockhart, "Modern Problems in Industrial Medicine," Jowr/w/ of Industrial Hygiene 14 (March 1932): 81. See also Christopher C. Sellers, "Factor\' as Environment: Industrial Hygiene, Professional Collaboration, and the Modern Sciences of Pollution," Eiiuironmental Histaty Revieiv 18 (Spring 1994): 55-83; idem, Hat^ards of the Job: From huhistrial Disease to Eniiironmental Health Science (Chapel Hill: Tlie Universirj- of North Carolina Press, 1997); idem, "The Public Health Serxice's Office of Industrial Hygiene and the Transformation of Industrial Medicine," Bulletin of the History of Medicine 65 (1991): 42-73; William Graebner, "Hegemony Tlirough Science: Information Engineering and Lead Toxicolog)', 1925-1965," in Dji/ig for Work; Safety and Health in Twentieth-Centuty America, eds. David Rosner and Gerald Markowitz (Bloomington: Indiana Universit)- Press, 1987), 140-59; Claudia Clark, Radium Girls: Women 161

Indeed the toxicological laborator)-, so useful in isolating offending workplace toxins,

could not easily describe or measure quantitatively newer industrial health problems like

"fatigue," "comfort level," or "glare." Scientific methods also seemed insufficient in fully

describing and harnessing workers' mental creativit}', and indeed were sometimes thought to have

"handicapped" this industrial resource. C. O. Sappington delimited laborator)' methods as

"largely chemical and physical in nature," good cliiefly for analyzing air samples, testing

protective clothing and apparatus, and examining worker body fluids for signs of chemical

exposure. As a consequence, places like the Industrial Hygiene Laboratory in the Connecticut

State Department of Health limited its responsibilities to gathering samples for comparison

against exposure standards set by the USPHS, the United States Bureau of Mines, universities,

and other toxicological laboratories.""

Industrial hygienists exploited the advantages of communit)' health perspectives best

when thev engaged their faculties in "social laboratories," that is, out in the nation's factories,

offices, and department stores. There they found namral communities in the homogeneous

groups engaged in exactly the same tasks day in and day out, varying litde in mental and physical

capacit}', and laboring under the same environmental and social conditions. "Ever}' large factor)'

ami Industrial Health Reform, (Chapel Hill: Universirj'of North Carolina Press, 1997). The toxicological slant is compounded by comparing the whole of modem industrial hj-giene to the carcer of Alice Hamilton. See Barbara Sicherman, "Working It Out: Gender, Profession, and Reform in the Career of Alice Hamilton," in Gender, Class, Race, and Reform in the Progressive Era, ed. Noralce Ftankel and Nancy Schrom Dye (University' Press of Kentucky, 1991); Wilma Ruth Slaight, "Alice Hamilton; First Lady of Industrial Medicine," Ph.D. diss., Case Western Reser\'e University, 1974; Madeleine Parker Grant, Alice Hamilton: Pioneer Doctor in Industrial Medicine (New York: Abelard-Schuman, 1967); Barbara Zichtxmv.n, Alice Hamihon: A Ufe in Letters {C^mbndgc, Mass.: Harvard University Press, 1984); Angela Nugent Young, "Interpreting the Dangerous Trades: Workers' Health in America and the Career of Alice Hamilton, 1910-1935," Ph.D. diss., Brown Universit)', 1982; William T. Moye, "BLS and Alice Hamilton: Pioneers in hidustrial Health," Monthly Labor Review 109 (June 1986): 24; William K. Beatry, "Alice Hamilton: Pioneer in Industrial Medicine," Proceedings of the Institute of Medicine of Chicago 32 (April-June 1979): 120; and Don Rhodes and Carlton Blauton, "Alice Hamilton: Occupational Safety and Health Legend," Professional Safety 35 (August 1990): 11-5. ^-^Henrj' B. Elkind, ed.. Preventive Management: Mental Hygiene in industry (New York: B.C Forbes Publishing Company, 1931), xii; C.O. Sappington, "Tlie Control of Occupational Diseases by Laboratory Mediods," Journal of Industrial Hygiene 17 (januaiy 1935): 21-6; Warren A. Cook, "The Industrial Hygiene h^hoxMor)''' Journal of Industrial Hygiene and Toxicolog)' 18 (November 1936): 623-36. 162 is a communit)' in itself and presents the public health problems of a small village," remarked one industrial health worker. Natural communities simplified the task of experts because they did not require individualized health planning, but instead flexible group planning."'

Because their job requirements had expanded to include all the health semces of the communities where employees lived, hygienic experts reached a sudden and stunning consensus: industrial physicians, nurses, and allied personnel suffered under the burden of inadequate and narrow training. "The industrial physicians of today have too much of a one sided training," complained lago Galdston, professor of public and social health at Fordham Universit}'. "The majority are well versed in the science and technique of their specialt)', but rather neglectful of the sociologic and economic aspects of their realm." The National Industrial Conference Board, established to redress these perceived inadequacies, recommended that industrial hygiene workers have experience in general practice, industrial relations, applied preventive medicine, occupational diseases, psychopathic medical investigation, recreation, accident prevention, employment methods, housing, physical examinations, transportation, and education. Others experts recommended knowledge of ventilation, iUumination, and posture. To surmount these numerous hurdles, training and retraining in industrial hygiene necessitated invitations to and enlistment of assistance from engineers, chemists, nurses, personnel directors, and attorneys. In tliis manner industrial hygienists might become more that just "first-aid men," a common misapprehension.'"

'"'lames Dominick Hackett, Heahh Maiiitenaiue in hidiisliy (Chicago: A.W. Shaw Company, 1925), 39; W. hinng Clark, |r., "Industrial Medicine in \922'']oiimalofImliistria/HjffetteA (March 1923): 474-9. '"Comment by Galdston recorded in response to paper by W.S. Bean, "Tlie Role of the Federal Government in Promoting Industrial American Jotirnci/of Piib/ic Hea/lh \5 (|uly 1925): 629; National Industrial Conference Board, Inc., Medical Supervision and Service in Indusliy, 12; A.J. Lanza, "Obser\'ations on Industrial Hygiene," American journal oJ'PublicHealtb 21 (May 1931): 531; Milton H. Kronenberg, "Undergraduate Training of Industrial Hygiene American Journal of Public Health 1>1> (1943): 545-9; Robert T. Legge, "Relation of Industrial Medicine to Public American Journal of Public Health 11 Qanuar)' 1921): 62-4. 163

Han-^ard University established the first program leading to a degree in industrial hygiene in 1918. Students holding the medical or public health degree worked in the occupational disease clinic of the Massachusetts General Hospital and took School of Public Health classes in industrial toxicology, factor)' sanitation, safety engineering, physiology of respiration, vital statistics, nutrition, industrial health administration, orthopedic surgety, general circulatoty physiology, and neuromuscular physiology to achieve this certificate. Har\'ard's industrial hygiene graduate program also launched the professional Jottma! of Industrial Hygiene. The next year, in 1919, the University of Cincinnati Medical School inaugurated a one-year series of courses that granted a certificate of public health in industrial medicine. The school offered field work experiences in cooperation with the National Safety Council. Many other universities quickly followed in establishing new industrial hygiene courses and certification programs, exploiting the gap between workplace realities and potentialities. Columbia University's College of Physicians and Surgeons offered eight industrial hygiene lectures to fourth-year medical students enrolled in public health administration. Columbia also offered field service to graduate students. At Yale, students in introductoty' public health classes listened to three lectures in industrial hygiene, attended two discussion sessions on the subject, and obsen'ed the industrial hygiene apparatus of a large factoty. Graduate students engaged in an additional thirty hours of lectures and field investigations. Ohio State University' required all senior medical students to take six hours of industrial hygiene lectures and laboraton- demonstrations. An elective industrial hygiene course also existed for advanced students in medicine, engineering, education, business, and art. The University' of Pennsylvania developed an elective twelve week course of lectures, demonstrations, and field work for its medical students. Many obsei-\'ed patients in the

Occupational Disease Clinic of the University Hospital. Graduate students interested in 164 industrial hygiene spent a half-day each week for a semester conducting surveys of industrial

hygiene and hazards of cigar manufacturers, felt-hat makers, organic color mixing plants,

ball-bearing factories, and stove foundries. Ohio State Universit)', Rush Medical School, tlic

universities of Wisconsin, Michigan, and California, Albany Medical College, and Howard

Universit}' all added industrial hygiene to tlieir curriculums.'^"^

The many young industrial hygiene programs born in American universities around 1920

all stressed tlie inclusiveness of industrial hygiene principles and practice. Industrial hygiene

never stood apart from the main intellectual currents of public health and social medicine, and

indeed de^'eloped largely to reinforce it. The birth of industrial hygiene marked not only the birth

of a new specialt)' in medicine and public health, but a radical rejection of heretofore the intuitive

defmition of "specialit)'" itself. "The majorit)' of specialties in medicine tend to develop along

some specific line to the exclusion of the other branches of practice," announced Harr)' E. Mock.

"This new specialt)- of industrial medicine and surgen- includes everj' scientific branch of

medicine and in addition requires a keen understanding of practical sociology."^"''

These programs also taught industrial hygienists to act ideally as intermediaries between

industrial offices and their agents, and local healdi officials. They were to coordinate the

resources of tlie communit)- and apply them to meet the health needs of workers and their

families. "The indusmal physician," explained C. O. Sappington, "is really a public health officer

in industn' and, dierefore, should cooperate with all of the official health agencies in his

communit\'." Industrial hygiene experts also worked as coordinators and cooperators inside the

factor)' walls. Here they acted to integrate the work of emergency surgeons, industrial nurses,

^"•^Lanza, "Observations on Industrial Hygiene," 532-3; George Martin Kober and Emer)' R. Hayhurst, eds., IndustrialhUahh (Pliiladelphia: P. Blakiston's Son & Co., 1924), xlvi-.\lviii; R.R. Sayers and J.J. Bloomfield, "Industrial Hygiene Acti\'ities in the United States," American Journal of Public Health 26 (November 1936): 1087-96; Sappington, Essentials o f Industrial Hea/th, 16. "^"''Harn' E. Mock, "Industrial Medicine and Surger)-: .-V Resume of its Development and Scope," Journal of Industrial l (May 1919): 1-7. • 165 clcrks, ambulance drivers, safety engineers, and refuse collectors. They also ideally played a central role in the routine activities of die hiring department, group insurance agency, and sociological department.-^'^

This charge to husband the resources of the communit)' to protect and improve worker health rested heavily on the expert's shoulders. Speaking in mechanical metaphors, industtial nursing leader Violet Hodgson noted that '"too much play between the teeth of the meshing gears', 'stripping of the gears,' 'lack of care in operation,' and 'unrelated gears,' each, in turn, produces a condition in which 'coordination and proper sequence' are interfered with, resulting in lost energy and interruption of power transmission from tiie motor to the drive wheels."

Caught between a multitude of agencies, offices, and constituencies, industrial hygienists had to appear at aU times not make intemperate decisions or to take sides. Balance or evenhandedness, in other words, was required.^''^'

They needed to avoid the appearance most often of being employer's lackeys, though owners almost invariably paid the hygienist's wages. They had to maintain strict confidentiality in their relationsliips with individual workers and dieir health problems, avoid charges of malicious troublemaking in pointing out particular hazards to plant managers, and balance the health expenses of the workplace with the fiscal-mindedness of owners. Sometimes the industrial health officer played the role too well, seeing no evil, hearing no evil, and unfortunately, acting on no evil.

'•'Sappington, Essentials of hidiislrial Health, 97, 338; John J. Prendergast, "Industrial Medical Department Otgamzanon," American journal oj Public Health 29 (June 1939): 641-2. '•''^'iolet H. Hodgson, "The Industrial Nurse in Gear with the Machinery' for Human Adjustment," American journal of PubJicHealth 20 (December 1930): 1327; comment by Galdston recorded in response to paper by Bean, "The Role of the Federal Government in Promoting Industrial Hygiene," 625-9; Hackett, Health Maintenance in Industry, 77. On the organo-mechanical metaphor in early twentieth-centur)' thought see Cecelia Tichi, Shifting Gears: Technolo^', Uterature, Culture in Modernist America (Chapel Hill: The Universit)- of North Carolina Press, 1987). 166

In many ways, industrial hygienists had fewer free hands wirii which to do their work, even as other health professionals and laypeople threw up more balls for diem to juggle. As

United States Public Health Ser\'ice Reserve Surgeon William J. McConneil noted,

The task of the industrial physician is by no means easy. He occupies the position of liaison, as it were, between management and employees. His dudes toward the former are to increase die efficiency of the workers, in order to secure and maintain a high rate of production; to prevent wastage; to ininimize labor turnover; and to interpret the workers to the management, by pointing out causes of dissatisfaction among them and suggesting remedies for it. His duties toward the employees are to promote health, sanitation, personal hygiene, and contentment; to maintain cleanliness and order; to lessen the possibiHt)' of accidents and disease to protect against dust, industrial poisons, inadequate ventilation and illumination, over-fatigue, draught, extremes of heat and cold, danger of fire; to advise in the selection of jobs suitable to the physical capacit)- of individuals; to improve the morale; and to interpret die management to the workers.^"'

The industrial hygienist also had to fend off intemperate physicians in private practice who saw community-oriented occupational hygiene as a threat to their livelihood. "The family

practitioner sees nothing, as a rule, in plant medical work but a loss of patients," noted J. D.

Hackett, former manager of the medical department of the Nichols Copper Company in New

York, even though "the sphere of the [industrial] medical department ends where that of the

familv doctor begins." Finding the dividing line between indusuial and family practice still could

be difficult. Fences could often be mended by communication and cooperation. The situation

became compounded where community ser\aces already existed outside the plant for the

emergency treatment of workers injured on the job. Industrial hygienists hired as salaried or

wage-earning workers threatened to upset an older balance achieved by fee-for-senace contracts

between employers and private practitioners or between employers and insurance companies.

Regardless "however weU founded or erroneous the workers' suspicions of the industrial

•^"'vvilliam i- McConneil, "The Industrial Physician and the Qualifications Essential to His Success" Journal of Industrial Hygiene 3 (August 1921): 130-4. 167 physician may be," emphasized Columbia University sociologist Bcrnhard Stern, "such attitudes are real factors in limiting the effectiveness of his work."^"''

Industrial hygiene leaders routinely recommended cultivation of a pleasant personality as an essential lubricant in the reorganization of individual assets (even recalcitrant private doctors) into a network of interacting and responsive ser\''ants of industrial health. The power of personalit}' could not be overestimated in measuring the potential success of industrial hygiene personnel. "The medical department in the industrial plant," wrote medical officer M. Burnett

Franklin of Philadelphia's E.F. Houghton and Company, "must haA^e human personality and the spirit that inspires confidence in the human element with which it deals." Personality included not only the habits, appearance, integrity, and humor of the indusuial hygienist, but even his mental acuity, training, and skills. It allowed the industrial health department to gain the confidence of the workers it shepherded and the trust of plant officers it advised. Effective industrial health workers possessed a liberal education, tact and judgment, upright bearing, and ability to work in a variety of professional contexts demonstrated through experience in city health departments, community dispensaries, and private practice. "The character of a man's work is the best advertisement which he can have," argued South Manchester, Connecticut, physician C. C. Burlingame. "And as long as you are a doctor, and as long as you are a nurse, remember that you have a medical obligation to smile, smile, smile."^"^

^"^Comment bv Giildston recorded in response to paper by Bean, "The Role of the Federal Government in Promoting Industrial Hygiene," 625-9; Hackett, Health Maintenance in hidiistiy, 77; Bernhard J. Stern, Medicine in Indiistiy (New York; Tlie Commonwealth Fund, 1946), 160,167. ^"'M. Burnett Franklin, "Tlie Successful Industrial Medical Department: Essential Cooperation of Executives and Employees Gained by Proper Methods," yo«r/;a/ ojlndiistrial Hygiene 2 (May 1920): 24; Carey P. McCord, "Industrial Health Promotion in Small Plants," ]onnml of Public Health 15 (April 1925): 299-302; Frankel and Fleisher, The Human Factor in Indiistiy, 190; C.E. Ford, "Health Education in Industry," American Journal of Public Health 11 (lune 1921): 489-97; C.C. Burlingame, "The Art, Not the Science, of Industrial hltdicinc," Journal of Industrial Hygiene 2 (February-1921): 371. 168

Inside large businesses, industrial hygiene experts divided their time between the plant dispensar\' or health and safet)' office and the plant floor. Their first responsibilities to employees and employers alike usually came with the pre-employment interview. Industrial physicians and nurses examined all job candidates for signs of preexisting injur)', cardiac condition, mental instability, or communicable disease. These exams varied widely. Prospective employees could expect anything from chest tapping for signs of tuberculosis to a complete workup including x-rays and culture sampling. Some hygienists required complete undressing, others mere shirt untucking. Many hygienists also checked mental acuit)' from normal conversation in order to ascertain the candidate's personality' as well as whether or not they might "fit in with the 'Spirit of the Hive.'" As a practical measure, health examinations protected the employer from invalid medical claims and fragile candidates from exacerbating their conditions. But there did exist another important motive. Hygienists used exam results to help employers place new hires in jobs matching their physical and mental attributes, and thereby avoiding "fitting the square peg to the round hole." This helped to prevent costly accidents and reduced labor's desire for insurrection.'^"

Candidates who did not pass the pre-employment exam might still be hired by enlightened plants with strong industrial health sentices. Miriam Lincoln in the Social Ser\dce

Department of Massachusetts General Hospital spoke for many when she noted that "the economic securit)' of the community' requires that ever)' member be a contributor to its maintenance and welfare and not a drain upon its resources." Frankel and Fleisher echoed this view when they noted that "the purpose of die entrance examination should not be to reject or

•'^"pord, "Health Education in Industr)-," 493-4; W.H. Rand, "Missing Links in the Chain of Evidence Concerning Occupational Diseases," American Jotirnal of Public Health 7 (October 1917): 835; Dudley R. Kennedy and Richard M. Neustadt, "The Proper Executive Function of the Industrial 'Physician" Jotmial of Indus/rial 1 (Januar)' 1920): 429-30; Frankel and Fleisher, The Human Factor in Industiy, 53; Selby, "Health Maintenance in Industr)'," 1329. 169 discharge the great number of applicants or employees who are physically imperfect, but to prevent their employment in particular kinds of work for which they are disqualified." Rather, work should be found that was "fitted" to them. Hygienists argued that "defective" workers suffered fewer accidents than their apparently "normal" coworkers when properly married to a particular job. This was because, as one expert explained it, "the defective worker knows his limitations and will not overstep them, while the normal worker will expose liimself to dissipation and excesses of various sorts." And once the candidate was on the job, rehabilitation regimens for physical and mental diseases could begin, a boon not only to industr}' but to the communit)' as a whole.^^'

Industrial hygienists agreed that debilitated candidates ideally should not be refused employment solely on the grounds of their afflictions, but instead placed in jobs where their handicaps no longer mattered. They found, for instance, many occupations where cardiac

patients could contribute their skills rather than simply drain community' resources.'"

Architectural firms could hire cardiacs as draftsmen, blue print filers, and plan estimators with

litde danger of stress or strain. Automobile manufacturers could hire them as battery and

steering wheel assemblers, tinsmitlis, supply clerks, and salesmen. Bakeries could place cardiac

patients in packing, labeling, or wrapping departments depending on the severit)' of their

conditions. Clothiers might hire cardiacs as buttonhole makers, headers, or embroiderers where

physical exertion was at a minimum. Industrial hygiene experts found them jobs in department

Miriam Lincoln, "Industrial Aspects of Heart Disease; A Study of Eight)' Industrial Workers from the Cardiac Clinic of the Massachusetts General Hospital, Boston, },biSS," Journat of hidustria/Hygiene b (May 1924); 1-13; Frankel and Fleisher, The Human Factor in Industry, 169; Frank Leslie Rector, "Wliat O'Clock is it in Industrial Hygiene?" American Journal of Public Health 19 (December 1929); 1327-33. '^^"A disease Hackett described as "non-industrial in origin, arising as it usuallj- does, from arteriosclerosis, rhcumatic fever, or syphilis," but nevertheless of major importance to the industrial physician. See his Health Maintenance in Industry, 138-9. 170 stores, theaters, banks, fountain pen factories, hotels, jeweky stores, dental offices, and pencil factories.'^"

Once hired and on the job, industrial hygienists justified continued focus on worker health and safet)' and the amelioradon of hazards as influendal components in increasing producdvit)'. Natural times for reevaluating employee health came when workers transferred between departments or returned to work after long absences. Hygienists remained especiall)' vigilant for those diseases that, reladvely speaking, plagued the enterprises they super\dsed.

Hygienists employed in the glass industry- kept a war}' eye for workers with eye disorders

(glass-blowers' cataract a common disease in diis respect), syphilis (from shared blowpipes), and lead and arsenic poisoning. In the garment industr)' hygienists looked especially for diabetes (a disease prevalent among the many Jews employed in this work) consdpadon, flat foot, varicose veins, and respirator}' infections. H}'gienists in potten' factories watched for signs of carbon monoxide and lead poisoning, pneumonoconiosis, and persistent headache (from turpentine odors). In post offices they looked for flat feet, exposure, and cardiac disease."""

Plant hygiene professionals looked in general for those diseases of occupation associated with the kind of work employees performed. Still, because modern industrial hygiene in principle and practice had widened the circle of focus, it behooved them to seek out the home and communit}- contributions to plant diseases. This effectively rendered occupational diseases nonoccupational. As Hackett explained, "occupational diseases are those of ordinar}' origin when aggravated by industtial conditions." In modern America industrial hygienists magnified their assault on diseases that made it harder for workers to do their jobs, but discounted (but of

'^•'Ida M. Duggan, "Industries and Occupations in Which Cardiac Patients Have Been Successfully Placed According to Cardiac Chssi^icadons," Jomialof liidHslria/His/or)' 5 (October 1923): 200-4; Hackctt, Health Maintenance in Industiy, 138-9; Lincoln, "Industrial Aspects of Heart Disease," 12. ^^''Selby, "Health Maintenance in Industrj'," 1330; RoDo H. Britten and L.R. Thompson, "A Health Study of Ten Thousand Male Industrial Workers: Statistical Analysis of Sur\'eys in Ten Industries," Public Heaiti} Bulletin 162 (June 1925): 1-170. 171

course did not entirely ignore) those diseases cciiised by factory or workplace. Occupation in this way became what Truesdell called a "double factor, made up of direct hazards, which affect only the worker" and "of the attendant living condidons, which affect both the worker and his family.'""

The new perspective increased interest in diose diseases, regardless of source, that affected the life of the modern worker because they not only reduced efficiency and drained the resources of American business but also threatened the pool from which workers were drawn, that is, the communit)'. Chronic syphilis and tuberculosis became two of the greatest threats to industr)' on this account. Syphilis came from virtually nowhere to become a "prolific source of industrial inefficiency." Success in prophylactic treatment of social diseases with neosalvarsan in the Allied Expeditionar}- Force in the late Great War raised the profile of hygienic experts in preventive efforts against syphilis. Yet, it had "just dawned upon the profession" at war's end that the ranks of the army and rank-and-file of industi7 might appear as equivalent groups for the elimination of syphilitic infection.™

Industrial and social hygiene experts estimated that one percent of the adult population of the country was under treatment for syphilis at any given time in the 1920s and 1930s. One industrial hygienist claimed in a popular treatise that "ten million Americans have it." Physicians recognized that fuUy ten percent of all workers had some kind of venereal disease. One pinned the blame on venereal infections of all t)'pes for rendering ineffective sevent)' percent of all

"^^'Theodoie C. Waters, "Administration of Laws for the Prevention and Control of Occupational Diseases," American joiiriial of Public Hea/lh 29 (July 1939): 728-37; Hackett, Hcallh Mciiii/enmice in liiiliislry, 150; Leon E. Truesdell, "The Outlook for Mortalitj- Statistics by Occupation," American Journal of Public Health 19 (June 1929): 620-6. ''''Hackett, Hea/th Maintenance in Industry, 150; Alec N. Tliomson, "S)-pliilis and Indxistvy" Journal of Industrial Hygiene 3 (july 1921): 99; Page Edmunds, "llie Role of Syphilis in Industrial Disablement: Analysis of 291 Physical Surveys," Journal of Industrial Hygiene 4 Qanuar\' 1923): 380; Harr}- E. Mock, Industrial Medicine and Surgery (I'liiladelphia: W.B. Saunders Company, 1921), 197; George Walker, I 'enereal Disease in the American E.^.'peditionaiy Forces (Baltimore: Medical Standard Book Co., 1922); Percy Moreau Ashburn, "Factors Making for a Low Venereal Record in the American E.vpedidonan' Foices," Journal of the American Medical Association 73 (1919): 1824; Edward A. Oliver, "Syphilis, and Inestimable Factor in Industrial Incffxcicncy," Journal of Industrial Hygiene 1 (September 1919): 246-50. 172 employees. Sypliilis complicated other diseases, and sped to conclusion many degenerative disorders. It worsened preexisting conditions like angina, apoplexy, Bright's disease, epilepsy, and cirrhosis. Syphilis accounted for ten percent of all mental hospital admissions and fifteen percent of aU diagnoses of organic heart disease."'

Syphilis undermined the health of the communit)', and diffused slowly but insidiously into the workplace. It invaded the working population by sexual intercourse between family members. It invaded by sexual intercourse with prostitutes. It in\'aded through hereditarj' affliction from mother to child. Rarely, though at the time it seemed an important source of infection, it invaded by incidental contact as in the exchange of sputum from shared drinking glasses or by stabbing accidents with sharp objects. Despite the curative value of neosalvarsan,

Walter Clarke, director of the Division of Medical Measures of the American Social Hygiene

Association, computed syphilis' toU at eighty-four million dollars annually.

Syphilis came not only from the wider community', but also found refuge witliin the natural industrial order. It was assumed that syphilis spread easily between workers, reducing tlie efficiency and output of the plant in general. The seeming communicabilit}' of syphilis between

"people working in close contact, with common tools or utensils" made it doubly dangerous inside the plant. Hygienists worried especially about social contacts between workers, the intimacy of their relations in the locker room, and the uncouthness of theii' behavior in the lunch

^^'Walter Clarke, "Dealing with S)'pliilis and Gonorrhea as Industrial Vcoh\ems" Jotinia/ of Imliis/rial Hy^ie/ie 15 ()anuan-1933): 79-80; S. William Becker, Ten MUHon Americans Ham It (I^hiladelphia: J.B. Lippincott Company, 1937); Ray H. Everett, "The Cost of \'eneteal Disease to Indnsxry," Journal of I mluslrial Hygiene 2 (September 1920): 178-81. ^'®Clarke, "Dealing with Syphilis and Gonorrhea as Industrial Problems," 82. The spriochete requires moisture to survive for more than a few minutes outside the body. Hygienic experts swapped coundess anecdotal examples of extragenital transmission of syphilis, but as with the contemporar)- case of AIDS this mode is relatively insignificant. Hygienists blamed such tilings as kissing and wet nursing, and shared cigars, nails, pencils, pipettes, needles, and coins as ways to spread the disease. See Kober and Hayhurst, eds., IminslrialHealth, 9; and Charles C. Dennie, Syphilis: Acquindand Heredo^philis (New York: Harper & Brodiers, 1928), 295-304. By 1940, it had become clear that syphilis was almost exclusively a disease caused by sexual contact or in utero for children. See Joseph Earle Moore, "Syphilis and \JnQ.mp[o\'mtnx" Journal of Industrial Hygiene and Toxicolo^' 19 (May 1937): 189-90, 192. 173 room. Fully eleven percent of a group of raikoad employees sun'eyed for syphilis infection

tested positive for the disease, making the disease appear culpable at least in part for rocketing accident rates in the industry. Coal miners breathing the same fetid air and using the same tools

expressed itself in annual rates of infection topping ten percent. But syphilis had more insidious

effects on the mental stabilit}' of workers. Hygienists and managers complained that syphilitic workers caused unrest on the job. Cerebral syphilis, they claimed, produced delusions of

grandeur. This condition not only resulted in disastrous accidents, but could cause otherwise

balanced minds to follow the deranged into absenteeism, dereliction of dut}', strikes, and

desertion. "Employees who possess exalted ideas as to tiieir importance are quite liable to stir up

labor troubles," explained Michigan Centtal Railroad Company chief surgeon W. Louis Hartman,

"whereas if their mentality is normal they will not think of it.""'^

Factories and shops, industrial hygienists asserted, reintroduced syphilis infection to the

wider communit}'. It spread to customers receiving certain types of ser\'ices provided by

undiagnosed syphilitics. Food preparers, hotel housekeepers, barbers, beauticians, and porters all

handled items tiiat might infect unsuspecting individuals. In one famous case, a fruit vendor who

spit-polished his apples transmitted syphilis to several girls. Syphilis destroyed relationships in

the home for workers with syphilis-induced mental deterioration. Explained one syphilologist,

"Many men have developed softening of the brain and have squandered the savings of a lifetime

in a verj' few days, leaving their families destitute."^'"'

Physicians diagnosed syphilis by physical examination, but had at their disposal the more

accurate blood and spinal fluid Wassermann tests, the Kahn precipitation test, or

^'"'Thomson, "Syphilis and Industn-," 99-101; Hackett, Health Mainlenance in Industry, 145; Clarke, "Dealing with Syphilis and Gonorrhea as Industrial Problems," 80; W. Louis Hartman, "The Economic Viewpoint upon Syphilis in laduBtry," journal of Industrial Hygiene 5 (Januar)' 1924): 341-6. Sayers, "Sypliilis Control in Indnsir;," American Journal of Public Health 28 (Februar\' 1938): 155-61; Clarke, "Dealing with Syphilis and Gonorrhea as Industrial Problems," 80; Dennie, Syphilis: Acquired and Heredo^'phiiis, 303-4; Becker, Ten Million Americans Have It, 181. 174 complement-fixation tests for the presence of antibodies. However, routine testing of employees remained far too expensive in the 1920s and most plant experts first discovered syphilis by looking for outward signs. These included open sores and lesions, ataxic gait, rapidly degenerating hearing, distinctive vocal abnormalities, or irrationally inflamed temper. Still, syphilis gained a reputadon as the "great mimic" becausc it often manifested symptoms distinctive of other diseases. Chemotherapeutic treatment regimen against had changed but litde since the discover)' of salvarsan 606 by Ehrlich. By the 1930s arsenical preparations remained the treatment of choice, though continuing chemical manipulation in the laborator}' (into dierapeutic agents Like neosalvarsan 914) made them more effective and less toxic.^'"

Tuberculosis, unlike sypliilis, had long been a perennial problem in public health. Yet, like syphilis, its sources and modes of infection presented no easy way to separate home from mercantile communit)'. Experts admitted that few cases of tuberculosis in modern America could be direcdy linked to specific occupations, even as the disease represented a "staggering economic loss" to the countr)'. "It is almost impossible to determine in any individual case how important a part has been played by occupation," stated Francis A. Craig of Philadelphia's Phipps

Institute, "and to what extent home environment and mode of living has been responsible for the development of the disease."^"*'

"^'"Tliomson, "Syphilis and Industn-," 99; Edmunds, "The Role of Syphilis in Industrial Disablement," 380; Mock, iiulmlrial Mfdiciiw and Siirgciy. 197; Mackett, Heahb Maintenance in Indmtiy. 147, On the most popular tests and treatments for sypliilis see Reuben Leon Kahn, "The Wassermann Test in the Public Health Laborator}-," American joiintal of Public Health 11 (1921); 410; idem. Serum Diagnosis ofSypljilis by Precipitation: Governing Prindpks, Procedure, and Clinical Application of the Kahn Precipitation Test (Baldmore: Williams & Wilkins Company, 1925); idem, The Kahn Test: A Practice Guide (Baltimore; The Williams & Wilkins Company, 1928); S. Ide and G.J. Smith, "Comparative Study of Wassermann and Kahn Tests for Syphilis," Archives of Dermatology and SyphiloloQ< 6 (1922): 770; J.F. Anderson and E.E. Fisher, "A Comparison of the Wassermann and Kahn Tests in Tliree Hundred and Twenty-Nine Cases," Neiv '5 'ork MedicalJonrnal 118 (1923): 490; and B.S. Kline, Microscopic Slide Precipitation Tests for the Diagnosis and Exclusion of Syphilis (Baltimore: The Williams & Wilkins Company, 1932). On contemporar)- methods for treatment see Joseph Ead Moore, The Modern Treatment of Syphilis (Springfield, 111,: Charles C. Thomas, 1933); John H. Stokes, Modern ClinicalSyphilolog}- (Pliiladelpliia; W.B. Saunders Compan)-, 1934; and J.S. Sartin and H.O. Pern', "From Mercur}' to Malaria to Penicillin; The Histon- of the Treatment of Syphilis at the Mayo Clinic, 1916-1955,"/owrW of the American Acader/iy of DermatoloQ' 32 (1995): 255. ^''"Bernard S. Coleman, "The Tuberculosis League, the Sanatorium, and Industrj'," journal of Industrial Hygiene 11 175

Despite this hygienists insisted that tuberculosis was a peculiarly industrial disease because the workplace harbored and exacerbated the disease. A contributor)' role seemed clear.

Industrial policy holders of the Metropolitan Life Insurance Company died of tuberculosis at nearly twice the rate of policy holders generally. But longtime AMA Council of Physical Therapy steward Harrj' E. Mock and others absolved the employer of direct culpabilit)', but because of his indirect role found him in a positive "strategical position" to wipe out the disease in the ver)- place where the diseased congregated. "The seeking out of the tuberculous employee and removing him from the presence of liis fellows, placing him under proper conditions for recover}', have resulted in decreasing botli the morbidit)' and mortality rate," claimed Mock. "But the employer alone cannot be blamed for these deplorable conditions which make the disease so prevalent." He suggested oudawing on-the-job consumption of alcoholic beverages and moderating plant temperature and humidit}' (presumed to be predisposing factors), and ventilation systems to control dust.^''^

Though pulmonar)' tuberculosis could be diagnosed by x-ray examination, sputum study, and skin-reacting tuberculin testing, there was no cure before streptomycin. Employers and industrial hygiene experts defended themselves against this liighly contagious disease by isolating infected workers in hospitals and sanatoria, but communit}' reinfection easily subverted attempts to keep the disease out of the workplace. Some exasperated employers resorted to ineffective cold vaccines. One paper manufacturer dispensed one such preparation to its 2,400 employees eveiy fall, hoping to hold down the number of tuberculosis infections.^"'''

(September 1929): 217; Frank A. Craig, "Tuberculosis a.s Ir.\ffecrs the Industrial journal of Jndiistricjl Hj^iene 4 (August 1922): 170-6. ^""•^Donald Budd Armstrong, "The Framingham Health Demonstration and Industrial Journal of Indus/rial Hygiene 3 (October 1921); 183; Charles W. Bergquist, "Tlie Tuberculosis Worker and His Placement in Industrj'," American Journal of Public Health 19 (March 1929): 270; Louis Israel Dublin, "Incidence of Tuberculosis in the Industrial Populations," American Journal of Public Heallh 22 (March 1932): 281 -9; Mock, Industrial Medicine and Surgery, 429-31, 433-4. ^"'''National Industrial Conference Board, Inc., Medical Supervision and Service in Industry, 52. 176

Industxial hygienists addressed more dian specific occupadonal diseases. They also adopted functions described as "social engineering" today, but better described at the time as human management, composed of those sciences dedicated to producing individual physical and mental equilibrium and social tranquillit}'. ?Iygienists became interested in interwar America in the communit)' problems of industrial health, but they also saw the factor}- itself as a communit)' in microcosm. Some of the representative "social," or better "associational," problems included worker fatigue and malingering, but also what appeared (on the surface at least) as cliiefly technical problems related to illumination and assembl)' line practice.^"*'

The question of fatigue, once we get past the progressive political question of the "eight hour day," designed in the first decades of the twentieth centun- primarily for women and children, demonstrates tlie importance hygienists ascribed to interdependent, dynamic, associational relations within the plant and with the wider communit)' beyond. The most serious questions facing modern industrial hygienists with regard to fatigue was definitional. What exacdy was fatigue and could it be measured? The second question was one of relevance. Was it an inevitable product of the frenetic pace of modern production or a preventable propert}- heretofore unscrutinized by hygienists? Or perhaps it didn't exist at all as a relevant object. Rex

Hersev, associate professor of industry at the University' of Pennsylvania, summarized the issue of

fatigue with particular concision. "The chief difficult)- facing one in such a study [of fatigue] is

the indefiniteness of tiie feeling," he noted. "Can it be taken for granted when such a person says he feels tired, that he is reaUy fatigued?"''"^'

^''^Carl Scheffel, "The Mental Hygiene of Industrial ^oikeis" Journal of Induslrial Hygiene 2 (September 1920): 182-8. ^"""On prewar developments in industrial fatigue sec Joseplune Goldmark, Fatigue and EJjicieng: A Study in Industry (New York; Sur\'ey Associates, 1912), and Frederick S. Lee, The Human Machine and Industrial Efftcienij (New York, 1919); Re.v B. Hersey, "The Subjective Side of Fatigue in Indnstrj^" journal of Industrial Hygiene 13 Qune 1931): 185-7. See also Richard Gillespie, "Industrial Fatigue and the Discipline of Physiology'," in Physiolo^' in the American Context, 1850-1940, ed. Gerald L. Geison (Bethesda, Md.: American Physiological Societ)-, 1987), 237-62. 177

Hersey tried to quantify the "feeling of tiredness," but the subjectivit}' of fatigue as a categor)' eluded objective analysis. The problem, he concluded, is "expressed in [the following] mathematical relationship; the amount of energ\- available at the moment divided by the amount of energy demanded at the moment equals feeling of pleasure or feeling of fatigue." This, he admitted, gave relative dimensionality- to the problem, but did not capture or define fatigue dissociated from human social science.^'*'

Difficulties calibrating fatigue to personal health complicated the analysis further.

Fatigue, most industrial hygiene experts presumed, was (and alwa\ s had been) normal and not a functional disease. Indeed, it could be beneficial. Eugene Lyman Fisk, medical director of the

Life Extension Institute, considered fatigue "a part of the normal rhythm of life and a condition to be welcomed as one necessar}- in maintaining the balance of mental and physical health."

Fatigue did not precipitate illness or Hi-health, though "excessive fatigue" produced by the modern pace of industry might. But what was excessive? Hygienists were unsure. Clearly, fatigue could not be represented in a binar}' way where employees tested positive or negative, but rather only in a continuous way as described by a specti-um or scale. Finding the positions demarcating the unhealthy-fatigued and the healthy-fatigued proved especially difficult because of individual human variabilit)'.-^''"

These problems aside, projects for identifying sources of excessive fatigue in the plant

and ameliorating them arrested the attention of modern industrial hygiene experts. Hersey

proposed many possible factors contributing to fatigue in the plant; physical activit)', emotional

tension, bodily tension, mental activit)', colds and other diseases, the physical environment,

malnutrition, boredom, and futile effort. Emen' Hayhurst, professor of hygiene at Ohio State

^''^Hersev, "The Subjective Side of Fatigue in Industn'," 188. ^""^Eugene Lyman Fisk, "Industrial Fatigue," journal of Public Health 18 (December 1928): 1465-9, 178

University, blamed excessive fatigue on "spurt work . . . disharmonious rhythm . . . fault)' illumination, faulty ventilation, and many forms of distraction such as jarring or jiggling processes and noise." Others fingered poor lighting and ventilation, noise, vibrating floors, monotony, speed, poor posture, overcrowding, overtime, Sunday shifts, and unsanitan' conditions.^'"

Conditions and activities outside the plant contributed to excessive fatigue at work at least as much as internal factors. }. D. Hackett blamed dancing, movies, routine family affairs, and public transportation and infrastructure. E. E. Southard, professor of neuropatholog}' in the

Harvard Medical School, accused family, housing, and drinking. Hersc)' identified man)' non-industrial sources of worker fatigue, many identical to those found inside the factoty: recreation and entertainment, physical activity-, emotional tension, bodily tension, colds and diseases, physical environment, malnutrition, climate, and too much sleep. All could be identified as the cominon stresses of modern life. He noted that recreation, family responsibilities, and sleep habits (aU external or community factors) were the most important factors contributing to industrial fatigue.""

That Hersey and others discovered many of the same factors influencing fatigue inside and outside the factoiT is important. It suggests, and suggested to them, that fatigue was not only an occupational disease, but a disease of the whole community. Its home and work causes were

inseparable in many instances. Philadelphia Housing Association director and former consulting

hygienist with the USPHS Bernard J. Newman, in fact, credited "a compound of plant activities

^""Hersey, "The Subjective Side of Fatigue in Industr)'," 199; Emerj' R. Hayhurst, "Points in the Detection of Industrial Fatigue and Measures for its Possible Complete 'E&imnanon" Jomial of Industrial Hj^iene 2 (November 1920): 257; Frankel and Fleisher, The Human Factor in Industry, 113. ^'°Hackett, Health Maintenance in Industry, 390; Elmer Ernest Southard, "The Modern Specialist in Unrest: A Place for the Psychiatrist in Industn'," journal of Industrial Hygiene 2 (Ma)' 1920): 11 -9; Hersey, "1 he Subjective Side of Fatigue in Industry," 199, 203. 179 and home or other environmental conditions" for producing fatigue. Home and factor)-, in sum, both were places for toil and rest.^^'

Industrial hygienists attempted to correct excessive fatigue in many ways. Many hygienists endorsed the "eight hour day" as a way to reduce excessive fatigue. Others altered the flow of assembly lines or bench work to equilibrate muscular or mental effort. Hayhurst noticed tliat when walls and machines were painted white "the whole tone of workmansliip is better." As an added benefit a bright factorj^ tended to remain clean because workers noticed accumulating dust, oil, grease, and trash.^"

Remedying poor plant illumination in particular reveals an especially clever way industrial hygiene experts confronted the unquantifiable problem of fatigue in terms of a continuum with a solution at least as unquantifiable and continuous. Hygienists worked closely with illumination engineers to alleviate fatigue and other health hazards in plants across modern America. Both groups asserted that the illumination problems of industry were not the simple result of inadequate lighting. That is to say, they noticed the troubling phenomenon tliat adding more and more bulbs over a particular factor)' floor might improve lighting on an absolute scale of foot-candles, but did not necessarily translate directiy into less fatigue. In fact, intense beams of high candlepower became irritating if not blinding. Instead, hygienists and engineers answered worker fatigue with hard to measure but eminentiy satisfactor)' terms like illuminar)' "continuit)',"

"diffusion," and "comfort." They often grouped diese terms in modern industrial practice under the umbrella problem of "glare."'^'

•'^'l-Ietsev, "The Subjective Side of Fatigwe in Industr\^" 199, 203; Bernard J. Newman, "Work Environment as a Factor i)i the General Health of Workers," Journal of Pnb/ic Health 21 (December 1931): 1355. •^^"Reynold Spaeth, "The Problem of journal of Industrial Hygiene 1 (May 1919); 22-53; Ha)'hurst, "Points in the Detection of Industrial Fatigue and Measures for its Possible Complete Elimination," 256-8. •^•"^Miles A. Tinker, "Hygienic Lighting Intensities," journal of Industrial Hygiene 17 (November 1935): 261; McConnell, "Tlie Industrial Physician and the Qualifications Essential to His Succcss," 133. 180

Glare, like diffusion, comfort, and fatigue, existed as an airy, continuous, quality' rather tlian discrete concrete quantit)'. Glare became pronounced when engineers increased candlepowcr to that hard to isolate nexus where "brightness" became intolerable, and where considerations of fatigue and eye strain still had not been satisfactorily eliminated. Glare captured the essence of what happened when a large number of nonspecific factors came together unsatisfactorily. Eliminating glare, then, involved intertwining aU the relevant factors or quaUties into a networked, hygienic, and gleaming visual whole.-^^''

Improving the luminosit}' of workplaces while simultaneously reducing glare became one of the foremost preoccupations of industrial hygienists in the interwar period. They justified their efforts on the grounds that proper illumination increased productivit}', reduced fatigue and accident rates, and improved general health. In cooperation witli illumination engineers, hygienists modified the position of fbctures above working surfaces. They learned that lamps mounted well overhead produced more evenly distributed and more comfortable "general" illumination than individual "local" lamps, and exploited the fact that creating reflective surfaces improved Ughting indirectly without increasing candlepower requirements. They altered the shape and frosting of glass bulbs to mimic diffused natural sunlight, or replaced artificial lighting

altogether with solaria or banks of exterior windows.-^^^

Shading, filtering, and curtaining of bare incandescent lamps—so mundane

today—appeared to modern industrial hygienists as miraculous innovations for reducing glare.

These devices advantageously modified and redirected raj's of light for occupational purposes.

Shades reduced violent contrasts and the dark spots of vision created when workmen looked

"^'''Brunon A. Nowakowski, "The Measurement of Glare," American J ouma/ of Hygiene 6 (januan' 1926); 1-2; Joel I. Connolly, "Engineering SerNnces in Industr)' Other Than Control of Occupational Diseases," American journal of Public Health 31 (|anuar)-1941): 22. ^^^C.E. Clewell, "Industrial American journal of Public Heahh 9 (March 1919): 196,199. 181 directly into lighting fixtures in plain view. Indeed, bulb frosting was just one t)'pe of shade, albeit a built-in one. Shading, filtering, curtaining and frosting also alleviated visual disturbances associated with brighter gas-filled and fluorescent bulbs.^^'^'

General Electric lighting researcher Percy W. Cobb, like many of his compatriots, noted

that industrial hj'gienists occupied with the problems of hygienic illumination "must consider

such intangible 'mental' influences as comfort and the maintenance of good spirits generally."

However, it would be a mistake to pigeonhole iUuminadon hygiene as merely subjective and thus

unsciendfic. The Illuminating Engineering Societ)' clearl)- thought of glare as an authentic

problem, as did the industrial hygienists. Indeed, Matthew Luckeish, modern America's foremost illumination engineer, called the field devoted to lighting the "science of seeing."-^'' Foot-candle

measurements did not disappear, and in fact photometric equipment used in gauging adequate

lighting proliferated rapidly. Alongside the old standard candle-power lamps and illuminometers

for measuring light intensit)- engineers developed devices for measuring the speed of vision

recognition, examining die optical behavior of aii' contaminants, and calculating light distribution

cun-^es.""

The Industiial Accident Commission of die State of California codified remarkably

precise rules for illuminating workplaces. Order 1505 demanded that lamps be shaded where

"suspended at elevations above eye level less than one-quarter their distance from any positions

at which work is performed." Order 1506 limited local lighting "in such a manner that the

•^^^Louis Bell, "Industrial Lighting Codes," Jounta/ of Imhistria/Hjgiene 2 (August 1920): 133-5; Connolly, "Engineering Sen'ices in Industn- Other Than Control of Occupational Diseases," 22; Tinker, "Hygienic Lighting Intensities," 258-62. ^^'See his Artificial Light: Its Influence Upon Ci»ilis;atio>i (New York; The Centut)- Co., 1920); Light and IForA'A Discussion oJQualit)' and Quantity of Light in Relation to Effective Vision and Efficient Work (New York: D. Van Nostrand Company, 1924); and the work co-authored with F.K. Moss, The Science of Seeing (New York: \'an Nostrand, 1937). •^sSpejcy w. Cobb, "Lighting in the Industries," Journal of Industrial Hygiene 7 (May 1925): 185-98; Philip Drinker, "Laboratories of \'entilation and Illumination, Harvard School of Public Health, Boston," Journal of Industrial Hygiene 6 (Iunel924): 57-66. 182 intensity of the brightest square inch presented to view from any position at which work is

performed" to no more than three candles. Order 1507 defined standards for general lighting where local lighting was the primary' source of illumination so that the "contrast to die surrounding darkness" did not precipitate eye strain, general fatigue, or accident.'^'^

Malingering was another tough nut industrial hygienists attempted to crack. Industrial

hygiene experts divided malingering into two categories of behavior, first those employees who

thought they could not work (at least at full capacit)') and suffered legitimate neuroses, and a

second dishonest group of "fakirs" (fakers) who suffered no illness or injur)'. Professional

industtial hygiene attempted to explain and solve both problems. It quicldy became apparent to

experts that modern malingering, like fatigue, represented a continuum. Malingering in

moderation, in fact, appeared requisite to the proper socialization of employees. And, what

sometimes appeared as malingering on the part of the employer could often be ascribed to

employee ambition for attention or sympathy.""'

Excessive malingering, however, led to inefficiency in the plant and social dislocation and

crime in the community'. Committed malingerers tended to be unsafe, unhealthy, and disheveled

in appearance. They bred accidents, disease, and embarrassment. Hardened malingerers filled

their idle time plotting revenge against their employers, imitating or impersonating managers and

experts, and feigning hysterics. Some of the most disturbed malingerers loitered in factory

washrooms and on street corners looking for easy marks for confidence games.

"'•''Bell, "Industrial Lighting Codes," 137-8. •^'"ludson C. Fisher, "Malingering: Involving the Problem of Getting the Sick or Injured Empoyee Back to Work," Jounia/ofhidnslria/Hj^iene 1 (December 1919): 408-14; F.VX^. Dershimer, "Further Studies in Mental Hygiene in Industrj'; Mahngenng,"jot/r/jalof}iidus/ria/H}igiene5 (December 1923): 293-8; idem, "The Prevention ofTraumatic Journal of Industrial Hygiene 16 (|anuar\' 1934): 40-51. ^^'Mock, Industrial Medicine and Surgery, 732-4; F.W. Dershimer, "Practical Mental Hygiene in Industry'," journal of Industrial Hygiene 5 (May 1923): 1-2. 183

Industrial hygienists dwelt less on the hardened malingerer than on those employees who exercised acceptable conduct most of the time. These workers, identified as quiet, shy, and conscientious, that is, usually steady and hardworking caused a disproportionate share of plant disturbances. Hardened malingerers were considered "ver)' rare." These malingering neurotics, more numerous than the isolated but hardened malingerers, cost employers real time and money.

Malingering neurotics had diagnosed or diagnosable physiological or mental illnesses of -varj'ing intensit)'. Some were "comnjlsionists," having epilepsy or other seizure disorder. Some were manic-depressives whose exaggerated behaviors surfaced occasionally or regularly. Others had paranoid delusions or hysteria. Many took refuge from the world in day dreams. Others evinced symptoms of neurasthenia, hyperstimulation by modern civilization. A few suffered head traumas and their associated bizarre behaviors. Some were feebleminded idiots, imbeciles, and morons.-^'^^"

Whatever of the source of their malingering, industrial hygienists tried to modify- the work and home environment of workers as well as their unhealthy behaviors. The modern workplace and home, they found, exacerbated malingering behavior. In the factory, monotonous work dulled the senses making workers "duUer and duller" so that many became "near-morons."

"Habits of introspection" developed by boring work led to "self-pit)'" and "dissatisfaction" that could spread Uke wildfure to the "mass-mind." Hazardous occupations produced hypochondria, self-consciousness that produced very real illnesses. Discontented workers took their discontentment home, wreaking havoc in family and civic life, which created even more stresses on the job. Those repressed employees with "strong religious feeling" fared especially poorly,

"'"Dershimet, "The Prevention of Traumatic Neuroses," 41; Fisher, "Malingering: Involving the Problem of Getting tlje Sick or Injured Employee Back to Work," 410-1; Lanza and Goldberg, eds., Industrial Hj^ie/ie, 243; Scheffel, "The Mental Hygiene of Industrial Workers" 183; Dershimer, "Further Studies in Mental Hygiene in Industry': Malingering," 304. 184

alienating their coworkers on the job and stimulating neurotic behaviors that surfaced in diatribes in defense of their minister, priest, or rabbi. Other men of "high ideals" but little interaction with

others also suffered this sort of disillusionment and resultant neurosis. Anytliing that established

team play among these repressed or high-minded individuals might prevent general industrial

unrest. Mock preferred exposing the malingerer to liis family and relatives, the social group to

which he or she was most responsible. Others advised employers stimulate group pride without

giving up authorit)'. As New York Cit)' industrial insurance expert Judson C. Fisher put it, "the

employer should be kind, gende, courteous, and joUy, but firm and not unwisely generous."^'^^'

Employers and industrial hygiene experts worried tliat normal but neurotic malingerers

might trigger strikes. Malingering led not only to accidents and expensive or unscheduled work

stoppages, but could bring owners to their knees. Fear of strikes justified hygienic activities in

tlie minds of many plant managers. As Hackett put it, "a sick man is a discontented man; a

discontented man is a potential striker."-^^'''

Industrial mental hygienists attempted to address concerns about malingering and

discontent by "adjusting" worker minds. Mental hygiene activities dwelt on the human

personalities involved, the sources of maladjustment and monotony, and the psycholog}' of the

industrial group. Mental hygiene reduced both the envii-onmental preconditions surrounding

plant problems like fatigue and malingering. Industrial hygiene workers complained that earlier

efficiency studies had ignored the most important aspect of American production: the human

worker. At best, they thought, efficiency experts treated employees as just so much "muscle," or

simply as "hands" or "foot-pounds of energy."'^"^"

^''•^Scheffel, "Tlie Mental Hygiene of Industrial Workers" 183; Dershimer, "The Prevention of Traumatic Neuroses," 41; Mock, Industrial Medicine and Sufgety, 732-4; Fisher, "Malingering: Involving the Problem of Getting the Sick or Injured Employee Back to Work," 412-3. "^''•'Scheffei, "The Mental Hygiene of Industrial Workers" 186; Hackett, Health Maintenance in Jndiistiy. 10. ^""^Elkind, ed. Preventive Management: Mental Hygiene in Industry, 28. 185

Instead, indusuial hygienists elevated humans, their thoughts and emotions, and dieir daily existence in and out of the plant to the most important position in factor)' work. Not content with simply improving the fortune of the individual, however, hygiene experts widened the circle to consider the group or mass mind as the most fundamental unit of production.

Humans did not work efficiendy as isolated "automatons." Efficient work involved the mobilization of all the workers and their managers into a "working parmership." No employee could any longer be thought of as "number so-and-so" but instead as part of the "corporate group." Only by choreographing their labors did the factor)' become a modern, organic powerhouse, an example for the world to emulate.^^'^'

Mental hygiene was frankly inseparable from industrial hygiene, and from public health generally. In almost ever)' way, industrial mental hygiene intersected and overlapped with other professional activiues in the plant, especially industrial psycholog)' and psychiatr)', and industrial human reladons. Like industrial hygiene, die mental hygiene of workers included scrutinizing dieir lives outside the plant. Mental hygiene was the joint responsibiUt)' of the job and the communit)' as a whole. The communit)' akeady supported a "large arm)' of misfits" through welfare programs supported by churches, family, religious agencies, and ethnic social insdtudons.

Why should the modern factor)' be any different in supporting, supplying, and most of all adjusting these potential contributors to communit)' and industrial life?^*^^'

The physical, mental, and social problems of fatigue and malingering folded nicely into the wider world view of the modern industrial hygiene expert. They were both problems of the whole and could not be solved by simple alteration of the part. They were continuous, organic

'^^Dershimer, "Further Snidies in Mental Hygiene in Industr)-: Malingering," 293-8; idem, "Practical Mental Hygiene in Industn'," 1-2. "^''Campbell, "Mental Factors in Industrial Hygiene," 130; Henn* B. Elkind, "Industrial VsychiMxyjonrna! of Industrial Hjigieiie 6 (October 1924); 251-8; Hackett, Health Maintenance in Industiy, 118,123-4; Elkind, ed., Preventive Management: Mental Hygiene in Industry, 169, 182. 186 problems expressing themselves only as the melding of body and mind, individual and group.

They required complex reacdons depending on the variabilit)- of the individual worker, the objecdves of the entire plant, and the wishes of the communit}'. Proper illumination did not single-handedly solve the problem of fatigue, yet it most surely affected plant malingering.

Mental hygiene practice in the shop equilibrated the mind and softened neurological disorders, but also lessened the incidence of fatigue. White paint applied to factor)- walls reduced fatigue in the home as surely as malingering in the home caused strikes at the factory.

The famous Hawthorne experiments, conducted in the Hawthorne Works of the Bell

System's Western Electric Company between 1924 and 1933, demonstrated the significance of industrial hygiene widiin die larger context of industrial management in modern America. The

Hawthorne experiments were the brainchild of experts, many in the social sciences, but were largely coordinated by two researchers from the Fatigue Laboratory of the Harvard Business

School, Lawrence J. Henderson and Elton Mayo. Henderson and Mayo wanted to determine the variables most and least material to worker happiness and productivit)' at Hawtiiorne. They were driven, like the industrial hygienists, by the problems of fatigue and monotony and potential for absenteeism, labor turnover, and strikes among the company's workers.

Henderson, Mayo, and other experts investigating die Hawthorne Works conducted several sets of experiments designed to isolate the various factors driving worker fatigue and plant productivit)'. Hawthorne's workforce, primarily female, assembled relays and bank wiring systems for automatic telephone switching. These relays and systems contained many parts, some quite small, and the experts concluded that most fatigue probably developed out of eye and

^''^Lawrence J. Henderson and Elton Mayo, "Tlie Effect of Social Env'nonment," Jotirnalof Imlustrial Hygiene and Tax/coJo^)' 18 (September 1936): 401-16; Elton Mayo, "The Maladjustment of the Industrial Worker," in W'ertbeim Lectures on IndustrialBx/ations, 192S (Cambridge, Mass.: Har\'ard Universit)' Press, 1929), 165-96; Elton Mayo, The Social Problems of an Industrial Civili:;ation (Boston: Havtad Universit)', Graduate School of Business Administration, Division of Research, 1945), 87-112. A verj' insightful account of these experiments is found in Richard Gillespie, Manufacturing Knowledge: A History of the Hawthorne Esferinmts (Cambridge, Mass.: Cambridge Universit)- Press, 1991). 187 mental strain coupled with the monotony of endlessly repeated steps in assembly. Industrialists generally agreed witli this idea since boosting lighting was a relatively cheap solution promising manifold returns on the primaiT investrnent. General Electtic, specifically, akeady recommended turning up the lights to resolve fatigue problems, directing that productivit)' could be boosted fifteen percent by increasing light intensity from two to eleven foot-candles. That increased lighting improved worker behavior and output seemed a reasonable, intuidve hypothesis, but testing showed it simply was not the case.^*^^'^

Illumination experiments, paid for by the National Research Council, began innocuously in November 1924 among relay assemblers, coil winders, and inspectors. The tests, conducted in three separate series, lasted more than two years. In none of the cases did producdvit\' correlate with light levels. In fact, increases in producdvity in control groups matched those seen in the experimental groups. The difference, researchers concluded, seemed to be the presence of the researchers themselves. Workers, knowing that they were being monitored, consciously or unconsciously increased their output for their observers. Lighdng had little to do with it. Even one group working in as litde as 1.4 foot-candles of light managed to match its production levels under normal lighting condidons.""

A second series of experiments began in 1927, modeled after the iUuminadon tests.

These relay assembly test room experiments were designed to isolate many other variables implicated as causes of industrial fatigue. They lengthened and shortened rest periods, moved

around eating times, altered the length of the working day and week, changing or rotating

positions in the test room, special pay rates, and even group pay systems. The results were (and

^""'Gillespie, Mamtfachtring Knowledge, 38-9; F.J. Roethlisberger and William J. Dickson, Management and the Worker. An Account of a Kesearch Program Conducted /j' the Western Electric Company, Hawthorne Works, Chicago (Cambridge, Mass.: Harvard Universit)' Press, 1949), 15-19, 90-127; Elton Mayo, The Human Problems of an Industrial Civilitiation (New York: Tlie Macmillan Company, 1933), 1-54. ""Gillespie, Manufacturing Knowledge. 41-6; Roethlisberger and Dickson, Management and the Worker, 15-19; Mayo, The Human Problems of an Industrial Citiili^a/ion, 55-76. 188

for many in the social sciences, stdll are) astonishing. Regardless of the arrangement of the work environment, changes introduced into the daily schedule, or t}'pe of payment for work, worker

productivit)' almost invariably itureased. Between April 1927, and Februar)- 1932, average hourh"

relay output increased inexorably from 49.6 to 54.5 to 66.5 to 72.4. This occurred despite

twent)'-three separate changes in specific variables.^"

The results of the illumination tests and relay assembly tests convinced many experts,

among them the MIT health educator Clair Elsmere Turner who briefly attended the

experiments, that individual environmental variables did not matter, but rather all the variables

acting together witli intangible human factors of individual physiolog)' and psychology and

collective worker relationships Kke "morale" and "social order." Future experiments were

designed to reflect these changed assumptions.^''

These landmark conclusions, that factors impinging upon workers could not be examined

independendy and that environment and worker cannot be separated and should instead be

thought of as coextensive have been questioned endlessly ever since. One interpretation

circulating today maintains that Henderson, Mayo, and their entourage of scientists merely

proved what they wanted akeady assumed to be true, or at the ver)- least what they came to agree

was true. Many others describe the various experiments as flawed and worthless. One argues

diat productivit^' increases in either the illumination or relay assembly tests might simply be

attributed to the learning cur\'e of employees.

Yet this misses the point. Henderson and Mayo's arguments dramatically confirm the

social and associational spirit of modern industrial hygiene principles and practice, albeit in

'^'Gillespie, Mamifacliiriii^ Knowledge, 48-57, 64-5; Roethlisberger and Dickson, Management and the Worker, 19-89. ^'"Gillespie, Manufacturing Knowledge, 69-15], Roethlisberger and Dickson, Management and the Worker, 161-188; Mayo, The Human Problems of an Industrial Civilit^lion, 99-121. Gillespie, Manufacturing Knowledge, 1-6. 189 different ways. Where industrial hygienists generally worked to reduce serious mental and eye fatigue by reducing the tangle of variables causing glare, Hawthorne experimenters discovered that fatigue and illumination had no direct relationship. Both essentiaUy denied the utilit}' of the foot-candle as a separable and independent variable in industrial life. Similarly, though the

Hawthorne experiments never really rigorously examined the effects of home and communit)' life on operations in the plant, it did establish the positive effects of collaborative worker effort in plant. Ever)'thing was interrelated; nothing existed apart."''

Outside the plant industi-ial hygiene experts advised employees in matters of personal hygiene and domestic sanitation, but also attended to those problems of a more personal nature like relationships with family members, financial problems, and moral lapses. They encouraged such virtues as thrift, domesdc bliss, and sobriet)'. "To conserve human values is their common purpose," explained A. ). Lanza and Jacob Goldberg in their introduction to Indnslrial Hygiene

(1939)."'

Educating workers played an crucial part in the sum total of industrial hygienic activit)'.

The percepdon of inadequate worker education was pen'asive among industrial hygienists. "The workers of today now know more about banking, unemployment, insurance benefit societies, etc., than thev do about health work and industrial work," complained USPHS surgeon W. S.

Bean. Indusuial hygiene experts warned employees of specific safet)' hazards and dangerous chemicals, but broadened their entreaties to cover general health in the home and communit)' as

well. Experts dwelled on proper nutrition and food sanitation, exercise, dental hygiene, and the

virtues of clean water at least as much as they warned workers of the dangers of arsenic, benzol,

•^'•'Lawrence ]. Henderson, T.N. Whitehead, and Ehon Mayo, "The Effects of Social Environment," in Papers on the Science of Administration, eds. Luther Gulick and L. Urwick (New York: Columbia Universit)', Instiaite of Public Administration, 1937), 143-58. ^^^Kober and Hayhurst, eds., Industrial Health, 124; Lanza and Goldberg, eds.. Industrial Hygiene, 11-2. 190 or mercuty exposure. They clid this through lectures or (more popularly) "health talks," poster campaigns, brief and attractive plant journals, motion pictures, and blackboards upon which daily

messages were placed. Sappington enjoined employers and experts to sell general health and safet)' principles, instilling in them "the idea that the safe way is the best way" to guarantee a long and profitable career with the company. Industrial health management failed unless employees

appreciated the benefits of their own good health. Thus, "it is not enough to inform and

instruct," related W. A. Evans of the Chicago Tribune's Health Department. "The habits of the

people must be changed.""'^'

For employers, industrial health educadon paid dividends in rising plant efficiency.

Isjiowing this, many companies had extensive education programs. General Electric's National

Lamp Works sponsored thirteen annual health talks for its employees. The Remy Electric

Company issued pamphlets on such topics as rheumatism, blood-poisoning, pneumonia,

constipation, "tobacco heart," and of course syphilis and tuberculosis. The Eastman Kodak

Company, Colorado Fuel and Iron Company, Brooklyn Rapid Transit Company, Dennison

Manufacturing Company, and Norton Company all sponsored extensive model health programs

for tlieir workers. Many offered lectures in several (sometimes dozens) of languages.

Professionals also enjoined employers to actively support health projects outside the plant

and occasionally lead in the development of communit)' facilities. Depending on the existence or

nonexistence of community' centers and services, employers could become enmeshed in the

building of playgrounds, parks, gardens, hospitals, schools, stores, and clubs. Hygienists favored

^'^National Industrial Conference Board, Inc., Medical Supervision and Service in Industry, 103; Sapptngton, Essenlia/s of Industrial Health, 131; Rector, "Wliat O'Ciock is it in Industrial H)'gicne?" 1332; Bean, "The Role of the Federal Government in Promoting Industrial Hygiene," 629; C.E. Ford, "Some Considerations for the Physician in Indnstiy," Journal of Industrial Hygiene 4 (May 1922): l;John A. Turner, "Practice ofPreventive Medicine in Industrj'," American Journal of Public Hea/th 17 (November 1927): 1127-8; Lockiiart, "Modern Problems in Industrial Medicine," 82; W.A. Evans, "Health Education in Industr)%" Journal of Industrial Hjgiene 1 (December 1919): 398-400. •^'^Evans, "Health Education in Industry-," 398-400; Lanza and Goldberg, eds., Industrial Hygiene, 603; Frankel and Fleisher, The Human Factor in Industij, 197-9. 191

"group exerciscs" over games played by individuals bccausc these acdvides stimulated evenly developed muscular development and mass participation, both useful to industrial employees.

Charities also benefited from pressure placed on employers by industtial hygienists. Employers, as the experts constantly retninded them, had a vested interest in "the domestic environment, recreation habits, and [even] dietaiy customs" of their workers/^'"

Male physicians trained in the principles and practice of industrial hygiene oversaw these activities in larger plant facilities and in their surrounding communities. In smaller plants, public health nurses working as industrial health nurses often maintained the facilities and led as crusaders for health initiatives. Their devotion to communit)' health principles and practice remained as great as that of the industrial physicians. Industrial nursing sel•^'ice, in fact, shows in microcosm the public health nurse acting as a cooperating, coordinating, communit)' health leader. Violet Hodgson of the New York State Department of Health defined industrial nursing as "the application of nursing skills and procedures to the sick or injured worker, and the sharing of information on the fundamental principles of healthful living as applied to the needs of the worker." Industr}' presented the industrial nurse with a social laboratory producing public health improvements in a fashion similar to rural demonstration projects. Nurses interpreted their ser\'ice in private factories as nurses looldng from without also viewed them; as experiments of interest to the wider communir\' health.^'''

Industrial nurses like industrial physicians saw their sendee as inextricabl)' linked to the larger communit}'. Nurses did have to overcome a "disdnct handicap" (namely their subser\dence to physicians) in communicadng their needs to other professionals. Still, industrial

"^'^Frankel and Fleisher, The Human Factor in Industty, 260, 282-3; Babb, "Industr}''s Challenge to the Nurse," 1025-8; Kober and Hayhurst, eds.. Industrial Health, 124; Schcffel, "The Mental Hygiene of Industrial Workers," 182-8; Rector, "W'liat O'Clock is it in Industrial Hygiene?" 1329. ^''^'iolet H. Hodgson, ?uhlic Health Nursing in Industry (New York; Tlie Macmillan Company, 1933), 28-9,49. 192 nursing depended on close cooperation with allied heakh ser\'^ants and plant foremen. Nurses reached out as part of the "social aspect" of their duties to experts and laypeople in both public and private organizations for help. Nurses enlisted the aid of physicians and other health professionals from the outside world. They also engaged the attention of plant owners and studied the health programs of various other plants.'^""

Still, nurses did not mistake themselves for physicians or engineers, for they recognizcd that they were neither one. Indusuial nurses placed dramatic limits on what they could do for employees injured on the job. They functioned mainly to treat minor injuries, scrapes, abrasions, contusions, and the like. Much of their time was spent keeping careful records of sickness and absenteeism, and in the dressing and redressing of wounds. Many times they accompanied industrial physicians as tliey examined female workers to avoid "unfavorable criticisms." Some industrial nurses acquired special skills through training in x-ray machine operation and routine laboratoiT analysis. In the smallest of enterprises, they might even hold janitorial functions keeping toilets and sinks adequately disinfected, referred to occasionally as "factor)' housekeeping." Serious injuries demanded the attention of a trained medical practitioner whether a full- or part-time industrial physician or physician engaged in private practice.

FuO-timc physicians always remained on call for just such eventualities, though they might not always be stationed in tlie plant dispensaiy.-^"'

Industrial nurses took their coordinating function seriously. Coordination meant acting in the full interest and with the fuD understanding of all people working in the plant. "The acid

•'""M. Gray MiicDonald, Handbook of Nursing in Inchisliy (Philadelphia: W.B. Saunders Company, 1944), 41; National Industrial Conference Board, Inc., MedicalSupervision and Service in Industry, 101; Hodgson, J^ubHc Health Nursing in Industiy, 28-9, 49; BethelJ. McGrath, Nursing in Commerce and InduslQ' (New York; The Commonwealth Fund, 1946), 303-7. ^^'McGrath, Nursing in Commerce and Industry, 303-7-, Prendergast, "Industrial Medical Department Organization," 641-2; National Industrial Conference Board, Inc., Medical Care ofhiduslrial Workers (New York: National Industrial Conference Board, Inc., 1926), 12-16; Mar)' Beard, "Public Health Nursing and Industrial Hygiene,"/owr/Wof Industrial Hygiene 1 (August 1919); 197. 193 test of a good nursing 'contact' in industiy," noted Hodgson, "is a one hundred percent cooperation from all economic levels—from the watchman to the president—all nationalities, and all degrees of cultural background prevailing in the plant." It also meant connecting the factor)' to the communit}' with her social sen'ice work. Hodgson emphasized "knowledge of and cooperation with the communit)' macliiner)-" as "prerequisites for the proper relationship of the gears in the machinet)' for such human adjustment." The National Organization for Public

Health Nursing recommended a wide variet)' of education experiences to reinforce this cooperative function, from courses and field work in public health administradon, family social work, factor)' psycholog)' and industrial relations, as well as basic courses in industrial hygiene, safet)', and sanitation.^""

Care for members of the worker's family was a professed goal for industrial nurses.

Factory personnel and their dependents represented an artificial family for industrial nursing practice, much as the school nurse superintended the health of children. "So closely can her teacliing in the fundamental principles of personal and plant h)'giene coincide with those of the visiting nurse and school nurse," noted Hodgson, "that we can truly speak of the joint efforts of aU public health nurses in terms of a family and communit)' health program." Industrial nurses often required home visiting to discover the interconnected phenomena that led to the ill-health of the worker. They were sometimes under pressure from management to seek out employees in

their homes for no otlier reason than to root out malingerers and fakers, but this they were never

to do. Visits were instead to be made only in the "spirit of friendship, never of spying."'^"'^

^^"Hodgson, Public Health Nursing in Induslry, 66; Clark, Jr., "Industrial Medicine in 1922," 478; National Industrial Conference Board, Inc., Medical Supervision and Service in Industry, 15; Hodgson, "The Industrial Nurse in Gear with the Machiner}' for Human Adjustment," 1324-6. ^®^Hodgson, Pub/ic Health Nursing in Jiidiistiy, 3; MacDonald, Handbook of Nursing in Indnshy, 110; Hodgson, "The Industrial Nurse in Gear with the Machinery' for Human Adjustment," 1325; Bethel J. McGrath, Nursing in Commerce and Industiy, 41; Kober and Hayhurst, eds.. Industrial Health, 137-42. 194

Generalized seivice, here as elsewhere, became the favored plan of organization. "The field is wide," remonstrated one industrial nurse. Industrial nurses called for many and varied technical skills and a wide understanding of the particular needs of individual workers. Nursing education for future factor)' nurses stressed the same core curriculum applied to other public health nurses. Industrial nurses, like their peers, needed more flexibilit)' than they received in diploma programs in hospitals. "The nurse needs a pioneer spiiit," argued Bethel McGrath of the National Organization for Public Health Nursing. "She needs energ)' to experiment and explore, courage to risk mistakes if necessaiy, and judgment not to make the same mistake twice." Traditional nursing schools were just not inculcating this spirit in the minds of many public healtli nursing leaders. Industrial nurses desperately needed courses in the theor)' and application of psychology and sociolog)'.'^"'*

As with industrial physicians, personabt)^ also turned the wheel of progress in coordinating industrial nursing. Personalit)' development facilitated good relations between aU the various parts of the plant. As the industrial nurse M. Gray MacDonald explained, she

should be a woman of culture and refinement, mature in mind if not in years,... a woman of poise and personaht}'. . . . She should ask herself, "Do I like people? Do I like them even when they are dirt}' and have to come to me reeking of unpleasant odors, so often a part of their daily labors?" The industrial nurse must be broad-minded, especially regarding race, color, religion, and social beliefs, remembering always that she must suppress personal prejudices in the interest of both the management and the employee.^"^

A pleasant personalitj' sensed particularly well among workers who did not fully understand

American language or culture.'^"'^'

•'"''MacDonald, Handbook ofNiirsh!g in Industiy, v; McGrath, Niining in Commerce and Industry, 45, 303-7. ^''^MacDonald, Handbook ofl^nrsingin Indus/Q', 5-6. ^^^Prendergast, "Industrial Medical Department Organization," 641-2; MacDonald, Handbook of Nursing in Industry, 5-6; Walter S. Leathers, et al., "Desirable Qualifications of Nurses Appointed to Public Healtli Nursing Positions in ItidMstiy" American Journal of T'ublicHeallb 29 Quiy 1939); 789-90. 195

No place existed for partisanship in industrial nursing ser\'ice. At all times a "misU'ess of tact," professional dctachment kept industrial nurses in good stead. Nurses avoided becoming embroiled in labor disputes and steered clear of union activities, confining diemselves to those activities that could "in no sense jeopardize the employer-employee relationship." Industrial nurses also refused gifts from employees for ser\aces for fear of creadng embarrassment or a competitive atmosphere on the factor)' floor that discouraged the truly needy from seeking medical attention.'"''

Clearly, the profit motive and die production and sale of goods and services generally

remained of preeminent concern in American industn* throughout the period 1915 to 1940.

Health matters always took a back-seat to the bottom line whenever belts were tightened. Yet

experts also surmised that industrial health serxtice and education itself supported the expansion

of business. The pure water campaign bolstered the sales of pipe and fixtures manufacturers.

The pure milk campaign increased demand for sanitary' daily equipment and outbuildings. Other

health campaigns stimulated purchases of soap, disinfectant chemicals, hot water heaters, and

laundries. Yirtuall}' no manufacturer or retailer could argue diat they had not directiy or

indirectly reaped benefits from rising public health awareness; some depended upon public health

for their very existence. "It seems to me," reasoned Paper Cup and Container Institute public

health expert Homer N. Calver, "that we should have no hesitancy in requesting an industry to

aid us in a program without which that industr)' might never have come into being."'""

By 1940, Memphis healtli department superintendent L. M. Graves and others could say

with confidence that the "term industtial hygiene" had been "stripped of some of its highly

'^'Hodgson, Piihlic Health Nursing in Industiy, 54-5, 68,165; MacDonald, Handbook of Nursing in Indusliy, 7-8, 28; Bethel |, McGrath, Nursing in Commerce and Industiy (New York: The Commonwealth Fund, 1946), 31-4. ^®^Rudi W. Hubbard, "Use of Existing N'isiting Nurse Services for Industrial Work in Small Plants," American journal of Public Heal/I.i 31 (JanuaiT 1941): 27-33; Momer N. Calver, "Resources of Industry' for Health Educauon," American journal of Public Heahh 34 (May 1944); 489-93. 196 specialized meaning."^"'^ Yet despite this, industrial hygienists strove throughout the period 1915 to 1940 to carve out a niche for themselves and exhibit their indispensabilit)' to the rest of communitj' health. Industrial hygiene sections sprouted everywhere in the landscape of modern public health to conduct scientific research in the particular problems of industrial hygiene, disseminate knowledge derived from laboratory, clinical and field investigation, train and retrain its professional workforce, and tout the value of the industrial hygiene perspective. Experts worked through the American Public Health Association, American Medical Association,

National Organization for Public Health Nursing, American Chemical Society, American College of Surgeons, Conference of State and Provincial Health Authorities of North America, the

National Industrial Conference Board, National Safet)' Council, American Standards Association,

American Association for Labor Legislation, Association of Government Labor Officials,

American Management Association, American Societ}' of Heating and Ventilating Engineers,

Illuminating Engineering Societ)', and National Tuberculosis Association, and various

manufacturing associations and insurance organizations to promote themselves. The APHA

Industtial Hygiene Section entertained committees on the issues of lead poisoning, workmen's

compensation, volatile solvents, skin irritants, and ventilation.^'^'

Sometimes they started entirely new organizations, most notably the American

Association of Industrial Physicians and Surgeons founded in Detroit, Michigan, in 1916, the

Conference Board of Physicians in Industry, and in 1939 the American Industrial Hygiene

Association. Nurses formed the American Association of Industrial Nurses in 1942. Industrial

Graves, et al, "Integrating Industrial Hygiene with Local Health Service," American Journal of Public Health 30 (May 1940): 493-4. Bloomfield, "Industrial Hygiene; Retrospect and Prospect," Journal of Public Health 29 (November 1939): 1216-7,1222; Rector, "What O'Clock is it in Industrial Hygiene?" 1331-2; Bean, "The Role of the Federal Government in Promoting Industrial Hygiene," 625-9; Mock, "Industrial Medicine and Surgerj': A Resume of its Development and Scope," 1-7; Leverett D. Bristol, "Industrial Hygiene; What Ever)' Health Officer Should Know," American Journal of Public Health 28 (September 1938): 1080-2; Newquist, Medical Service in Industty and Workmen's Compensation Lam, iii. 197 hygienists also stood in the vanguard of the Air Hygiene Foundation of America, in Pittsburgh, founded in 1935 bv the Mellon Institute to ameliorate the heating and ventilation problems of industr)-.-^'^'

Valuable leadership came from industrial hygiene experts placed at the federal level in the

Division of Industrial Hygiene of the United States Public Health Service, the Bureau of Mines in

the Department of the Interior, the Children's and Women's bureaus, the Bureau of Labor

Statistics in the Department of Labor, and the Navy and War departments. T\vent)'-t\vo state

departments of health, conscious of growing authorit}' and prestige accorded industrial health

sen'ice, created industrial hygiene divisions.''^"

Long considered a specialt)' devoted to the emergency treatment of injured workmen, the

moment of modernization in industrial health ser\'ice, with its concomitant dedication to

communit}' health, had arrived.

^"Bloomfield, "Industrial Hygiene: Retrospect and Prospect," 1216-7,1222; Rector, "Wliat O'Clock is it in Industrial Hygiene?" 1331-2; Bean, "Tlie Role of the Federal Government in Promoting Industrial Hygiene," 625-9; Mock, "Industrial Medicine and Surger)-: A Resume of its Development and Scope," 1-7; Bristol, "Industrial Hygiene: What Ever)' Health Officer Should l

CHAPTER VII. MENTAL HYGIENE

A large share of professional discourse in industrial hygiene examined the physiological bases for absenteeism and labor turnover. Psychological and social problems of workers, though, appeared in industrializing America to be a large and growing source of danger to worker health and to business efficiency and profitability. Many obser\'ers Enked this mental hazard to the pace of twentieth centur)' life, including psychiatric social worker Margherita Ryther, who remarked to colleagues,

the increasing complexities of modern life demand an ever-increasing "speeding up" of the mental faculties in order to meet the requirements of the times. The result of this high-pressure activit)' upon the people is demonstradng itself in many ways, of which incomplete adaptation to environment is the most conspicuous.'^'^'

C.-E. A. Winslow stated that "this [mental health] problem is clearly not only a dominant problem in the field of public health, but it is going to be the dominant problem in the field of public health and human relationships.

More and more in modern communit)' health, experts began examining employee mental processes, relating them to the patterns of group or social "adjustment" and grounding them in a newer conceptualization of the "normal" hygienic mind.^'^' Mental hygiene, the profession which cr)'stallized around tiiis equation of health with normalit}', represented an eclectic collection of

Margherita Ryther, "Place and Scope of Psycliiatric Social Work in Mental Hygiene," Mental Hygiene 3 (October 1919): 637. ^'•"President of the Connecticut Society' for Mental Hygiene in 1928. Quote reprinted in Norman Dain, Clifforil IF. Beers: Advocate for the Insane (Pittsburgh: Universit)' of Pittsburgh Press, 1980), 239-40; Charles-Edward Amor)' Winslow, "Twent)' Years of Mental Hygiene," Mental Hygiene 12 Quly 1928): 510. ^'^This can be observed even in a cursor)' survey of book titles: William H. Burnham, The Normal Mind: An Introduction to Mental Hygiene and the Hygiene of School Instmction (New York; D. Appleton and Company, 1925); Elsie M. Smithies, Case Studies of Normal Adolescent Girts (New York: D. Appleton-Centun* Co., 1933); Douglas A. Thom, Eveiyday Problems of the Evetyday Child (New York; D. Appleton & Co., 1927); Douglas A. Thom, Normal Youth and Its Everyday Problems (New York: D. Appleton-Centur)' Company, Inc., 1932). 199 individuals often drawn to the subject as an interrelated extension of their primar)- fields of interest; psycholog)% psychiatr)', sociolog}', social work, neurolog)- and physiology, and the many professions of public health. Downplaying what they perceived as obsessive interest in disturbed or criminal individuals, "mental hygienists" (as those interested in such matters occasionall)% but not always or with regularit}% referred to themseh-^es) refused to bisect society into the apparendy normal (adjusted) and abnormal (unadjusted). Instead, they cultivated a gestalt view of the hygienic individual mind and body, composed of coexisting cooperating and conflicting native and conditioned traits totaling a "personaht}'," and an associational view of societ}', integrated or dissociated by the mental attitudes of its members.^'^'^'

Most students of mental hygiene credited Clifford Whittingham Beers, a businessman and

Yale graduate, for founding the mental hygiene movement in America. In 1907, Beers published

A Mind that Found Itself, documenting a personal "mental civil war" he fought against insanit)'.

Beers decried many aspects of the treatment he received and leveled damaging criticisms (overuse

of restraints, abusive attendants and physicians, and unsystematic and unscientific research

agendas) against custodial institutions. He called for the adoption of a "Bill of Rights for the

Insane," guaranteeing that they be treated widi the same sympathy accorded sane people. The

book, carefully balanced to avoid the impression of polemic, launched a fuestorm of interest,

especially among psycliiatrists, psychologists, and physicians.

Solomon Wile, "The Mental Hygiene Approach to Public Health," Menial Hygiene 17 (|uly 1933): 385; Elmer Ernest Southard, "The Modern Specialist in Unrest: A Place for the Psychiatrist in \\vh.\nry" journat oflndiislrial Hygiene 2 (May 1920): 12; Lewellys F. Barker, "The First Ten Years of the National Committee for Mental Hygiene, with Some Comments on its Future," Menial Hjgiene 2 (October 1918): 579; Paul Lemkau, Menial Hygiene in Public Heahh (New York; McGraw-Hill Book Company, 1949), 10; Clara Bassett, Mentat Hygiene in the Community (New \'ork: The Macmillan Company, 1934), 3, 11; William H. Bumliam, Tije Wholesome Personality: A Contribution to Mental Hygiene (New York: D. Appleton and Company, 1932), 205; Frank E. Howard and Frederick L. Patn', Menial Health: Its Principles am! Practice (New York: Harper & Brothers Publishers, 1935), 36. For exaustive accounts of the development of personality' theory in the social sciences see Kimball Young, Personality and Problems of Adjustment (New York: F.S. Crofts & Co., 1940); and Donald W. MacKinnon, "The Structure of Personalit)'," in Personality and the Behavior Disorders, ed. J. Mc\^ Hunt (New York: The Ronald Press Company, 1944), 3-48. ^''See Clifford Wliittingham 'Qee.ti, A Mind That Found Itself: An Aiilobiograpl)y (London: Longmans, Green, and Co., 1907); Dain, Clifford IP'. Beers: Admcafe for the Insane, .\.\iii; Frankwood Ear! Williams, "Is There a Mental Hygiene?" 200

Beers enlisted the assistance of a large cast of characters impressed by his own account drawn from firsthand experiences. Supporters included Adolf Meyer/''" dii-ector of the prestigious Ward's Island, N.Y., Psychiatric Institute; the philosopher and psychologist WUliam

James; Anson Phelps Stokes, Yale Universit)''s influential secretary; William H. Welch, pathology professor at Johns Hopkins and chairman of the Rockefeller Institute for Medical Research; Julia

Latlirop, lately of Hull House; Livingston Farrand, then of the National Tuberculosis

Association; Jacob Riis; and many others. Together they advised or oversaw first the organization of a Connecticut Societ}- for Mental Hygiene (1908),^'^'^ and the following year along the same plan a more encompassing National Committee for Mental Hygiene."""'

The acceptance oi A Mind that Found Itself, with its account of abuses and indiscretions, did much to stimulate interest in humanizing inmate life in America, but did not presage the

broader mental hygiene movement that followed. An enlarged communit)- focus for mental hygiene, as described in the first paragraph of this chapter, did not emerge until many years later.

Indeed, the original goals set by the National Committee and its growing constellation of affiliate state mental hygiene societies were directed simply to "correct abuses" occurring among

institutionalized and recendy released inmates. And, as Beer himself later admitted, "work

previously done had made it easier to formulate part of the plans of the National Committee,

namely, those features relating to State care and to aftercare of the insane, in both of which fields

P^'cboanalylicQuarterlj \ (April 1932): 113-20. ''^For an interpretation of the early relationsliip bettt'een Beers and Meyer see Eunice E. Winters, "Adolf Meyer and Clifford Beers, 1907-1910," Bulletin of the Histoiy of Medicine 43 (September-October 1969): 414-43. •^''The preliminar)' consdrutioii of the Connecticut Societ}- is reprinted in Twentj Years of Mental Hj^iene, 1909-1929 (New York: National Committee for Mental Hygiene and American Foundation for Mental Hygiene, 1929), 11-6. •'""Letter from Charles Macfie Campbell to Clifford WTiittingham Beers reprinted in A Mind Tijat Found Itself: An Atilobiography, rev. ed. (Garden Cit)', N.Y.: Doubleday, Page, and Company, 1923), 257-9; Howard and Patrj', Mental Health: Its Principles and Practice, 484; Beers, A Mind That Found Itself: An Autobiography, rev. ed., 265-86. 201 the New York State Charities Aid Association had done pioneering work so far as this countr)- is concerned.'"""

The mental hygiene movement as it developed in the 1910s and early 1920s owed much to the enthusiasm of its cliief salesperson Clifford Beers, but derived its inteUectual focus and

(more importandy) its expert authority from others. The psychiatrist Adolf Meyer, not Beers, coined the term "mental hygiene" to describe the new reform movement ^&tAMind that Found

Itself\izd sparked. Meyer, Beers' early champion and chief critic, noted diat the new term incorporated a preventive element into an otherwise curati^'e specialt)', much as the public health movement had extended medicine into previously uncharted somatic territor)'. His early writings and practice, though, do not suggest that he considered extending mental hygiene activities

outside the bounds of the psychiatric hospital. Instead, Meyer advocated, as contemporar)-

sanitan,' scientists did, rigorous adherence to systematic and scicndfic research, classification,

record-keeping, and clinical treatment. The National Committee chiefly concerned itself with

collecting and collating statistics of mental illness in America, surveying conditions in specific

institutions, and smveying laws related to these institutions.'"'"

By 1917, though, with the inauguration of Mental Hygiene, official organ of the National

Coinmittee for Mental Hygiene, mental hygiene became transformed into a profession devoted to

the mental prophylaxis of all people, well and unwell. The journal exposed a "general realization

... coming into existence tliat mental factors underlie not only inability to make a living and the

gross disorders of conduct, but all the social activities of man." Committee members agreed the

"""Letter from Charles Macfie Campbell to Clifford Wliittingham Beets reprinted in^I Mind That Found Itself: An Autobiography, rev. ed., 257-9; George K. Pratt, "Twent)' Years of the National Committee for Mental Hygiene," Mental Hygiene 14 (April 1930): 399; Howard and Patrj', Mental Health: Its Principles and Practice, 484; Beers, >I Mind That Found Itself: An Autobiography, rev. ed., 265-86; Arthur H. Ruggles, "Twent)'-Fifth Anniversarv- Celebration of the National Committee for Mental Hygiene," Mental Hygiene 19 Qanuan-1935): 1. A Mind That Found Itse^: An Autobiograply, rev. ed., 265-8; Tiventy Years of Mental Hygiene, 1909-1929, 6-9; Dain, Clifford W. Beers: Advocate for the Insane, 79-80,101,185-6; Pratt, "Twentj- Years of the National Committee for Mental Hygiene," 400-7, 417-20. 202 journal addressed the need "to present non-technical articles on the practical management of mental problems in all relations of life.'"*"'^ By the 1920s even Clifford Beers could only remark that die greatest failing of the messengers of mental hygiene (including himself) so far had been not demonstrating that "the mental hygiene movement is of vital concern to evetyboclj [his emphasis].'"'"''

Mental hygiene in this way became modern, now devoted to protecting the health of communities, families, and their constituent individuals. The mentally ill belonged to societ)' even when they themselves felt withdrawn, and could not simply be excised like a bruise from fruit. Feebleminded, depressed, and criminal individuals posed a threat to societ)' by malicious destruction or by indiscriminately spreading communicable diseases, but they also burdened societ)' materially and emotionally in state and private institutions. The mentally unstable, reminded social sen'ice director Jessie Taft of the New York State Charities Aid Association,

"belongs to a home whose love for him and belief in his possibilities will have to be taken into account in any plan we may formulate." Mental hygiene experts more and more hoped to restore the ill to productivit)', as well as increase the efficiency of the apparentiy well. "More and more of these inild cases were coming to be recognized," remembered George K. Pratt, assistant medical director of the National Committee, "as psychiatric knowledge widened its boundaries to include, under the term 'mental disorders,' numerous conditions heretofore not considered as falling within its precincts." Mental hygiene, then, became community hygiene, addressing itself to "these non-institutional or 'communit)'' t)'pes of problem [s]," and its adherents dedicated tliemselves to exploring and adjusting social situations to ideally bring or restore order and mental health to the many and the few. "The group has two interests in the individual, to

articulated in the prefator)- to the first volume of Mental Hygiene (1917), edited b)' Frankwood Earl Williams. "'"•'"Forward," Mental Hygiene 1 Qanuaiy 1917); 1; Charles MacFie Campbell, "Mental Hygiene in Industiy," Mental Hygiene 5 (July 1921): 468-78; Beers, A MindThat Found hselj: An Autobiography, rev. ed., 301, 370. 203 suppress wishes and activities wliich are in conflict with the existing organization, or which seem the starting point of social disharmony, and to encourage the wishes and actions which are required by the existing social system," explained psychologist William I. Thomas. "Ever}- new invention, ever)- chance acquaintancesliip, every new environment, has the possibilit)' of redefining the situation and of introducing change, disorganization, or different type of organization into the life of the individual or even of the whole world.'"""

Disciples of this "new" mental hygiene objected strenuously to an obsession with the abnormal perpetrated by the last generation of scientists. Studies of criminals, the wicked, the disoriented, the insane, and the pathological did nothing, they generally agreed, to further an understanding of normal individuals, nor did they reveal the overwhelming natural correspondences between the abnormal and normal. "Those who like to stamp persons in an

'either-or' dichotomy of 'normal' and 'abnormal' t)'pes are uninformed or unwholesomely biased with respect to facts of individual differences and individual likenesses," concurred two mental hygienists. "There is nothing in the abnormal that is not in the normal, potentially, latently, or acmally." Human personalities instead wavered between states of relative normality and abnormalit)', establishing as the battleground for academic debate the location and enumeration of factors responsible for that dynamic balancing act at work in the individual, as well as its place amid fluctuating human conventions and societal norms."""'

''"'lessic Taft, "Supen'ision of the Feebleminded in the Communit)'," Mental Hygiene 2 Quly 1918): 435, 442; Haven Emerson, "Tlie Place of Mental Hygiene in the Public Health Movement," Mental Hygiene 6 (April 1922): 228-9; Pratt, "Twent)' Years of the National Committee for Mental Hygiene," 409; George S. Stevenson, "Organizing the Communit}' for Mental Hygiene," Proceedings of the National Conference of Social Work 54 (1927); 417-24; idem, "A Suggested Communit)' Mental Hygiene American jotmtai of Public Heai/h 2\ (December 1931); 1301-7; William 1. Thomas, The Unadjusted Girl, With Cases and Standpoint for Behavior Analysis (Boston: Little, Brown, and Companv, 1923), 70-1,151,213, 233-4; Howard and Patrj', Mental Health: Its Principles and Practice, 6; \'. May MacDonald, Mental Hygiene and the Public Health Nurse: Practical Suggestions for the Nurse of Today (Philadelphia: j .B. Lippincott Company, 1923), 3; Eduard C. Lindeman, "Some Mental Hygiene Aspects of Communit)' Process," Mental Hygiene 15 (October 1931): 729-38; idem, "Some Mental Hygiene Factors in Communit)' Processes," Proceedings of the National Conference of Social Work 58 (1931): 305-14. '•"^William Alanson Wliite, "Underlying Concepts in Mental Hygiene," Mental Hygiene 1 Qanuar)' 1917): 7-8; Burnham, The Wholesome Personality: A Contribution to Mental Hygiene, 8, 77; Charles MacFie Campbell, Present-Dery 204

The qualities of "normal" mental health remained in dispute throughout the intervvar period, but hygienists ascribed to one common denominator: integration, or said another way, the possession of wholeness. Mental hygienists agreed that normal individuals were connected to themselves,'"" understood their own needs and desires, and acted on them in concert with the needs and desires of communities. Their mental and physical funcdons betrayed a fundamental

"unit}- in action."'""' As public health nurse and psychiatric social worker Julia Weld Huntington extrapolated in the poem "Integration,"

My fingers pattern a symphony. Whimsical, quaint, of industr)'; The shining needle slips in, sUps out Like a silver horn; the cymbal's shout Of dissonance clangs from pan against pan; The thud of the iron sounds round about.

My irrelevant mind constructs a plan.

Apart from this surfacing melody Of design and task, the essential me Yields itself to the ecstacy Of complete experience, suffers, sings. Broods; atuned, is questioning Enveloping worlds; is absorbed, remote . . .

I am synthesized by a single note From without! In sudden harmony. Thought and feeling and act are bound Into one response; swift chords resound, In released progression, triumphant, free!

Is the master key To inner music realit)'?'"''^

Conception of Mental Disorders (Cambridge; Harvard Universit)' Press, 1925), 16, 53-4; Karl A. Menningcr, T/je Human Alind, 2nd ed. (New '^t'ork; Alfred A. I'Cnopf, 1937), viii; Howard and Patr}', Menial Health: Its Principles and Practice, xi. """Said anodier way, they possessed good physical health as a precondition for good mental and emotional functioning, good mental health as a precondition for good physical and emotional health, and good emotional health as a precondition for good physical and mental health. ''"^John Dewey, "Body and Mind," Mental Hygiene 12 Qanuarj' 1928): 4. ''"'julia Weld Huntington, "Integration," Menial Hygiene 15 (October 1931): 838. 205

The Columbia philosopher John Dewey described integration as the touchstone of civilized life; integrated accomplishment allowed individuals to "accomplish something beyond themselves."'""

This is not meant to suggest that conflict or discord did not exist in normal personalities.

Ideally, the well-adjusted always carried (though tidily tucked away most of the time) this impetus along with them in life. Integration, it was agreed, emerged only out of the success of individuals in tlieir struggle to maintain equanimity in sometimes hostile natural and societal contexts.

Conflict advanced the personalit)' to new levels of integration when used in a consttucdve way.

Conversely, disrespect for power of conflict in the personalit}' led to disintegration and dissolution of normal personality'.'"'

Mental hygienists more or less uniformly termed these dissolved personalities

"maladjusted." The qualities of the maladjusted also formed a locus for dispute in mental hygiene circles, but again revolved around a core conception of disintegration, or disharmony.

Maladjusted personalities possessed, relatively speaking, little or no aptitude for maintaining internal or social cohesion. Again, as in the normal personalit)', maladjusted individuals always possessed some mechanism for integration or wholeness, but appeared incapable of mastering (or remastering) that mcchanism in adhering to the rules for the game of life, or of bending those rules in socially acceptable ways. Maladjusted mental processing caused disintegration of intellectual functions, but also perpetrated bodily and emotional harm as well.'"'

Personalit}', then, was a pliable thing beyond its hard hereditarian core. It sprung from shifting and cumulating native and acquired mental patterns. Indeed, personalit}' proved much

"Dewey, "Body and Mind," 6. 'john Chynowedi Buniham, "Mental Health for Normal Children," Mental Hygiene 2 (Januat)-1918): 19-22; Burnham, The Wljolesome 'Personalis: A Contribution to Mental Hygiene, vii-xiii, 77,176,188-9,191. ""'Edward K. Strecker, "Tlie Non-Specificit)' of Mental Disease," Menial Hygiene 7 (April 1923): 278, 280; Thomas, The Unadjusted Girl, Wit!) Cases and Standpoint Jar Bebanior Anajysis, 255; MacDonald, Mental Hygiene and tite Public Health Nurse: Practical Suggestions for the Nurse ofTodc^', 14-5; William Alanson Wliite, "Tlie Behavioristic Attitude," Mental Hygiene 5 Qanuarj' 1921): 17-18; Burnham, The Wholesome Personality: A Contribution to Mental Hygiene, 247-9, 286-7, 359; Howard and Patr\', Mental Health: Its Principles and Practice, 20, 494. 206 more ephemeral than tliat, for mental hygienists found that they could only obsen^c its impression upon others, and not the thing itself direcdy. "Personalit)'," noted Stanley P. Davies of the New York State Charities Aid Association, "is the veiy stuff out of which social relationships are made, and from which what we know as human societ)' is built up." Yet, obsen^ed Clarke University professor of education and school hygiene William H. Burnham,

"both personality' and character are largely social evaluations." The eminendy human desire to understand the world required integration for its fulfillment, but an understanding of personaUt)' as a social artifact meant that integration ultimatel}- derived from interaction witii others. The role of the practicing clinical mental hygienist, then, involved "adjusting" personalities by reacquainting them with societal conventions and appropriate outlets for individuaUsm.""'^

The social evaluation of Jewish mental life, to cite one specific and lively debate, illuminates just how professionals constructed appropriate mental hygienic problems and solutions. The problem of the Jewish mind had long vexed scholars. Many late nineteenth and early uventietii centuiy academicians, particularly in Germany but in America as well, explained that the Jewish race manifested significandy higher rates of mental illness and maladjustment than non-Jews. As late as 1939, Johns Hopkins researchers in the Eastern Health District of

Baltimore reported a rate of personalit)' disorder among Jews twice that of Gentiles living in the same neighborhoods. This debate, of course, contributed to tlie loathsome proposition of Jewish racial and cultural inferiorit}', but to be fair, the most outspoken in modern American mental hygiene circles disagreed with this conclusion, and the methodology' and data by which it became established.""

•"^Stanley P. Davies, "Mental Hygiene and Social Progress," Metita/ 13 (April 1929): 226; Burnham, T/ie Wholesome Personalily: A Con/ribtitioii to Mental Hygiene, 122; Howard and Patr)', Mental Health: Its Principles and Practice, 19, 26,32. Abraham M. Myerson, "The 'Ner\'ousness' of the Jew," Mental Hygiene A Qanuarj' 1920): 65-6; Bernard iSI. Cohen, et al., "Statistical Contributions from the Mental Hygiene Study of the Eastern Health District of Baltimore: Personalirv' Disorder in the Eastern Health District in 1933," H/iman Biolo^' 11 (Februar)' 1939): 112-29; idem. 207

Setting aside the posturing and concentrating on the subtleties of the textual debate, however, highlights the relevance of personal and social adjustment to the Jewish question.

Hygienists postulated that a peculiarly Jewish personalit)' might account for excessive mental instabilit)' in American life. This personalit}' stemmed in part, these experts argued, from liistoric conditions, sometimes termed their "social heredit)-." The Jews for example, argued the Freudian psychoanalyst Abraham Brill, thought of themselves as "Jehovah's only and favored" children.

Favorite or coddled children, though, being spoiled, developed as poor competitors in the

"struggle for existence." Jews raised soft in a hard world became predisposed to mental and nen'ous diseases. BriU and others also tendered the idea of historic isolation, both self-imposed and enforced, as contributor)' to Jewish mental instabilit)'. They argued that Jews ver)- early on exhibited "voluntar)' clannish exclusiveness." Abraham Myerson argued that this came from a conviction that the religion was "superior to those of the nations with whom he came in contact" and "because he refused in any way to acknowledge tlie potency or the realit)' of the gods of the people amongst whom he lodged." Tliis condition, compounded by well-founded suspicion and

fear of outsiders, created die entirely introverted and disconnected Jewish group found in

modern American cides. Tliis also explained why Jews made incompetent "mixers" at parties.

"He who tended to become introspective became deeply so," pronounced Myerson, "and this

introspection was deeply apprehensive and melancholy."""^

"Statistical Contributions from the Mental Hj'giene Study of the Eastern Health District of Baltimore; Further Studies in Personalit}' Disorder in 1933," Human 11 (December 1939); 485-512; Benjamin Malzberg, "'Rie Prevalence of Mental Disease Among Jews," Menial Hygiene 14 (October 1930): 926-46; Jacob .\. Goldberg and Benjamin Malzberg, "Mental Disease Amongjews," PiychiatricQiiarterlyl (April 1928): 194-213; Benjamin Malzberg, "Mental Disease Amongjews: A Second Study with a Note on the Relative Prevalence of Mental Defect and Epilepsy," Mental Hygiene 15 (October 1931): 766-74; idem, "New Data Relative to Incidence of Mental Disease in lews," Mental Hygiene 20 (April 1936): 280-91; Jacob A. Goldberg, "Incidence of Insanit)' Amongjews," Mental Hygiene 6 ()uly 1922): 598; Elisha M. Friedman, "Tlie Jewish Mind in the Making: A Layman's Essay in Mental Hygiene," Mental Hygiene 7 (April 1923): 349; Abraham Brill, "Adjustment of the Jew to the American En\'ironment," Mental Hygiene 2 (April 1918): 219-21. See also I.S. Wechsler, "Nervousness and the Jew," in TIJC Neurologist'.! Poinl of View: Essays on P^'cbiatric and Other Subjects L.B. Fischer, 1945), 13-43. ^'^Brill, "Adjustment of the Jew to the American Enwonment," 220-1, 223-5; Myerson, "The 'Nervousness' of the Jew," 66,69,71. 208

The pressures created by Jewish social heredity surfaced in a variet)' of detectable ways.

Neuroses, arteriosclerosis, diabetes, alcoholic insanity, and general paresis all emerged out of

Jewish isolation and persecution. The "ininutiae" of Mosaic dietar)' laws threw Jewish housewives into hysterics. The lethal combination of monotonous traditional Jewish work

(pushing of carts, pressing of pants, banking and trading) and intellectual rigors of Talmudic education led inevitably to derangement. Social heredit)', in sum, created a Jewish race defiandy resisting fitting to the normal statistical cun'e. Instead, they exhibited only the extremes of human behavior. "They have a larger percentage of deaf mutes and of musically gifted, more geniuses and more idiots," explained New York psychologist Elisha M. Friedman.""^

Jews, maladjusted as they were, did not always react to these internal and external social stresses in beneficial ways. Mental hygienists who noted that Jews evinced excessive mental malady critiqued American Jewish life along a broad front. Some objected to the Jewish proclivit)' for cerebral activities and their disavowal of sport and play, causing progeny to grow up

"ver)' serious, ver)' earnest, too early devoted to mature efforts." Some objected to an apparent inflexibility in the keeping of the Sabbath and other Jewish holidays running "counter to the imperious demands of twentieth-centur}' life." Others complained that ner^'ous Jews unwholesomely dissipated excess energ}' by talking loudly.'"'

Mental hygienists did more than complain. They had some concrete suggestions about how to adjust and assimilate Jews. Many recommended the Americanization of Jewish religion, that is, the abandonment of orthodoxy in favor of reformed Judaism. Reformed Judaism de-emphasized the intricacies of ritual, obviated the need for exclusiveness, and generally created

'"^Myerson, "The 'Nervousness' of the Jew," 70; Friedman, "The Jewish Mind in the Making; A Layman's Essay in Mental Hygiene," 347, 349,354. ""'Myerson, "The 'Nervousness' of the jew," 67-9, 72; Friedman, "The Jewish Mind in the Making: A Layman's Essay in Mental Hygiene," 349-52. 209 a denominationalism familiar to non-Jews. Others recommended athletic competition and intermarriage as solutions to Jewish mental problems/'"

At the same time, mental hygiene experts uniformly rejected conversion as a viable strateg)- for diffusing Jewish mental maladjustment. Conversion harmed Jews because it subverted identit)' and personality as essential products of nature and nurture. Jewish traditions supplied a source of strength when the individual personality failed. Jews cut off from their religion, or cast adrift on a sea of Christianit}', faced the prospect of utter dissolution. "The sensitive Hebraic nature, formed through centuries, cannot be transformed into that of a well adjusted western individual without being subjected thereby to profound and even dangerous modifications," stated Brill. Better to go slow and succeed, than make "desperate efforts to move in non-Jewish circles" and fail.'"'''

Again, the Jewish mental hygiene debate illustrates just how mental hygienists juxtaposirioned "insiders" and "outsiders" to demonstrate the effect of communit)' upon personalit)' adjustment. Jews suffered mental maladjustment because they had withdrawn from societ}' and because they had been rejected by societ}'. Lack of integration created mental problems, and the Jewish reaction to lack of integration caused still more. The solution involved adjusting the Jewish faith to meet the realities of modern life, not spurning the only natural communit)' they had ever had. Then mental hygienists could quit referring privately to the diagnosis, "Judaism."'*'"

"Adjustment of the Jew to the American Emaronment," 224-5; Myerson, "The 'Nervousness' of the jew," 72; Friedman, "TheJewish Nlind in the Making: A Layman's Essay in Mental Hygiene," 352-3, 356. ""'Brill, "Adjustment of the Jew to the American Environment," 224-5, 227, 230-1; Friedman, "TheJewish Mind in the Making: A Layman's Essay in Mental Hygiene," 351-2. ''""Elmer Ernest Southard and Mar)' C. Jarrett, The Kingdom of Evils: Psychiatric Social Work Presented in One Hundred Case Histories Together with a Classification of Social Divisions of Evil York: The Macmillan Company, 1922), 328-32. 210

Another way to explore personalit}' and its social adjustment involves unpacking the

methods of the so-called "architects of adjustment," in this case those individuals closely

associated widi the developing modern mental hygiene movement. Some of the most influential of these architects included William A. White, Karl Menninger, as well as Adolf Meyer himself.

Though each identified different personalit)' t)'pes and disorders and explained the role of

adjustment in different ways, all conformed to die basic tenets of modern mental hygiene

illuminated above. Interestingly, mental hygiene maintained its coherence as a valid disciplinary'

approach even as professional language and terminology resisted con form t)'.''"'

Adolf Meyer's wridngs underscore the transformation that took place in a profession he

helped found along different lines. Meyer, a recognized leader of mental hygiene and long time

professor of psychiad.y at Johns ?Iopkins (1910-1941), evinced an intellectual breadth treasured

in mental hygiene circles. That breadth sometimes causcd confusion, but also sen'cd to welcome

potential recnoits to die fold. "The difficult)' in understanding Meyer came from a number of

sources, one of which, at least, was his tendency to assume that we had a background and frame

of reference comparable to liis own," one of Adolf Meyer's students recalled after his death. "He

would often express liimself by a series of oblique references to concepts imbedded not only in

psychiatry, but also in psycholog)', in sociolog}', in anthropolog)', in philosophy, in histor)', and in

Greek literature." Modern mental hygienists identified him as not only the dean of American

psychiatr)', but as an organicist who ravenously assimilated European and American thought

about the mind's hygiene and assembled them into a usable whole. He did not choose sides

easily, but rather encouraged an open cross-disciplinar)' approach to the mental hygiene problem.

One commentator has since said that Meyer practiced "nonadherence to any theory in

particular," and yet drew together "the sum total of the cultural heritage which a current

''"'white, "The Behaviorisdc Attitude," 18; Howard and Patrj', Menial HeaJlh: Its Principles and Practice, 19. 211 civilization represents" to explain how "man stays healthy or becomes ill, depending upon the interaction of his total personality' with tlie world he is called upon to meet.'"'"

This broad methodology for understanding personalit)- and social adjustment, however, is not readily apparent in Meyer's early writings. Rather, Meyer initially possessed a fairly functional vision for mental hygiene. He originally supported a number of specific projects; (1) sun'cys of mental institutions, (2) correction of their abuses in accordance with scientific and systematic principles, (3) founding of new specialized "psychopathic" hospitals for scientific research, treatment, and training, (4) prophylaxis for certain susceptible classes of the public not yet institutionalized, (5) "aftercare" of released patients, (6) cultivation of an enlightened public attitude towards the mentally iU, and (7) legislation guaranteeing all of the above. The objective of all of these projects (all of which the National Committee for Mental Hygiene substantially undertook), as Meyer saw it, was to protect the mentally ill and societ)' from one another by super\'ising and shepherding individuals in and out of institutions constructed specially for that

task."'-^

Meyer began extending mental hygiene to include all personalities, not just the chronic or

recoverable insane, as legitimate subjects for study around 1915. The National Committee

reflected this change by inaugurating sur\'eys of "extra-institutional" groups (those outside mental

institutions) like school children, jailhouse inmates, college freshmen, and factor}' employees.

"'""GtegoiT Zilboorg and George W. Henr)', A Histoij of Medical P^xlmlogf (New York: W.W. Norton & Company, Inc., 1941), 503-4; Ale.xander H. Leighton, "Introduction," in The Collected Papers of Adolf M^'er, vol. 4, ed. Eunice E. Winters (Baltimore; The Johns Hopidns Press, 1952), xiii. ''•'.•\dolf Meyer, "Modern Psychiatr)-: Its Possibilities and Responsibilities," State Hospitals Bulletin 2 (1909-10); 323-57; idem, "A Mind that Found itself; A Review," P^rholo^icalBulletin 5 (1908); 283-4; idem, "Reception Hospitals, Psychopathic Wards, and Psychopathic Hospitals," American Journal of Insanity 64 (1907-8); 221-30; idem, "Aftercare and Prophj'laxis and the Hospital Physician," Journal of Nervous and Aienfal Disease 3A (1907); 113-6; idem, "The Birth and Development of the Mental Hygiene Movement," Menial Hygiene 19 (1935); idem, "Organization of Communit)' Facilities for Prevention, Care, and Treatment of Ner\'oiis and Mental Diseases," in Proceedings o/ the Firs/ International Confess onMental Hygiene, vol. 1 (VC'ashington, D.C., 1932); 237-57; idem, "The Problem of the State in the Care of the Insane," American Journal of Insanity (>5 (1908-9); 689-705. 212

This second period came to synthesis in his "psychobiologic""'"'' approach to mental health, an approach that saw personality as inextricably intertwined with the societ}' it inhabited. Three

tasks preoccupied the normal, healthy personalit}' in psychobiology, or what Meyer often simply

called "mental health work." The first task involved "self-organization" or saUsfaction of "inner continuit)'." The second task was "integration of the physiological." The third task was die development of "sociological assets." Furdier, psychobiology treated mental "disease as a variant

of potentially normal functioning" which logically called for the creation of research "centers for

the study of the average," and treatment centers for "readjustment in a solid setting of the more socialized and 'normal' dependables of life.""*"'

Meyer grouped personalities into three categories that reflected his new concern for the interrelatedness of individual and societj'. The normal personalit)' he termed "koinotropic" (from

the Greek koinos, common) or "syntropic." Tliis t}'pe of individual displayed "we" tendencies,

that is, wholesome societal interactions. Deviant personalities formed out of "conflict," an

inabilit)' of the individual to reconcile a "complex" of incompatible emotion-colored impulses

with the "total personalit)'." The "egotropic" personalit}- displayed harmful "I" tendencies.

"Dystropic" personalities displayed bizarre, socially unacceptable tendencies, and often an

unhealthy preoccupation with "the other." Hobos, criminals, mad scientists, and sexual deviants

could be egotropic or dystropic.''"^'

''•"'Meyer often referred to the practice of psychobiologic psychiatrj- as "ergasiatr)-," that is, the study of "integrated mental activit)-." """'Adolf Meyer, "Where Should We Attack the Problem of the Prevention of Mental Defect and Mental Disease," Proceedings of the National Conference ofCI)arilies and Correction 42 (1915); 298-307; idem, "Organization of Community Facilities for Prevention, Care, and Treatment of Ne^^'ous and Mental Diseases," 237-57; Adolf Meyer, "The Contribution of Psychiatry' to the Understanding of Life Problems," in P^vhiatric Milestone (Wliite Plains, N.Y.; Bloomingdale Hospital Press, 1921), 21-54; Pratt, "Twent)' Years of the National Committee for Mental Hygiene," 424-5. ""^^See esp. Leo Kanner, "The Significance of a Pluralistic Attitude in the Study of Human Behavior; Introduction to Some of the Leading Principles of Dr. Adolf Meyer's 'Objective PsychobiioXQ^','" journal of Abnormal and Social P^'choloQ' 28 (April-June 1933); 30-41; and Wendell Muncie, P^chobioloQ' and P^chiairy (St. Louis: Mosby, 1939). Adolf Meyer, "Tlie Psychobiological Point of \'iew," in The Problem of Mental Disorder, eds, Madison Bentley and E.\'. 213

Meyer did not see the categories, termed "reaction types," as discrete entities, but rather as relative positions between wliich personalities might freely pass. As his Hopkins colleague

Frederick L. Patrj' described them, they respected "the concept of 'more or less' and 'allied to,' of multipolarity and mid- and border-zones as well as extreme deviations in t}'pe, which, however, never appear in absolute pure culture." Egotropic individuals, in fact, could manifest what appeared to be dystropic personalities, and vice versa. Indeed, Meyer never fully accepted reaction types as possessed of objective realit}', but merely as useful experimental contrivances.''"'

William A. White, superintendent of the U.S. Government Hospital for the Insane

(renamed St. Elizabeth's Hospital) in Washington, D.C., from 1903 to 1937 and another dominant figure in mental hygiene in the interwar period, contributed to the new social and associarional view by "rather radically" (Meyer's words) redirecting attention away from adults to die more impressionable, more dynamic, minds of children. Older physicists and astronomers, he argued, had difficult)- accepting physics' relativit)' theor)', but "young, plastic, adjustable minds, unhampered by the prejudices of yesterday, wiU grasp these new concepts quickly, as they ha^'e in the past." Moreover, where before World War I social scientists and health and medical professionals mistakenly assumed that inheritance of traits predetermined the fate of children's minds as adults in the present. White and other child guidance experts now understood that careful inculcation of healthy mental habits and socialization might prevent deviant mental development today and tomorrow. The child, most literally, was "the father to the man." White

Cowdn' (New York: McGraw-Hill, 1934), 51-70; idem, "The Scope and Teaching of Psychobiolog)'," of the Association of American Medical Colleges 10 (1935): 93-8; Adolf Meyer, "Leading Concepts of Psychobiologj' (Ergasiolog)') and of Psychiam- (Ergasiatrj-)," in Proceedings of IheFoitrli) Conference on Ps}

White's guidance plans emphasized childhood (particularly before age five) as the critical period of habit formation. If good mental habits could be instilled in infancy, White reasoned, children might grow up with powerful adjustment mechanisms for emotion and reason, a healthy respect for order, and a desire for moral and wholesome living. White often called mental hygiene clinics set up for children "habit clinics." These habit clinics captured mental energy otherwise lost by undiscovered defiant outflows, mental maladjustments that grew to riverine proportions in adulthood. Familial relationships, ideally, supplemented and su-engthened expert direction of the child's mental growth, but in practice bore the onus of childhood mental development.'*"'^

Childhood represented the critical juncture for the formation of acceptable social habits, because in this developmental period children faced the delicate task of differentiating "self from "not self," then having to go about reconciling the two. White considered this a laborious process for any normal child, and required an "increasingly complex series of integrations" where personaUt)' might become derailed. Other mental hygienists built on White's idea of child guidance. New York physician Ira S. Wile, for instance, described child guidance as a way to

am particularly indebted to Hamilton Cravens on tliis point. See liis article "Applied Science and Public Policy: The Ohio Bureau ofjuvenile Research and the Problem of Juvenile Delinquency, 1913-1930," in P^'cbolo^ical Tcsling and American Society, 1890-1930, ed. Michael M. Sokal, 158-94 (New Brunswick, N.J.; Rutgers University Press, 1987), esp. pages 158-60; Meyer, "Organization of Communit)' Facilities for Prevention, Care, and Treatment of Nervous and Mental Diseases," 237-57; William Alanson Wliite, "Tlie Frontier of the Mind," Mental Hygiene 19 (Januar)- 1935): 84-5; N'ictor \'. Anderson, P^v/jia/r)' in Ediicalion (New York: Harper and Brothers, 1932); William Alanson Wliite, "Psycliiatr)' and the Social Sciences," Bulletin of the St. EUt^beth's Hospitall Quly 1931): 26, 28; Smith Ely Jelliffe, "William Alanson Wliite," Mental Hygiene 21 (April 1937): 291-3. See also VVliite's autobiography, William Alanson White (Garden Citj-, N.Y.: Doubleday, Doran & Company, Inc., 1938) and a collection of some of his lectures. Twentieth Century P^chiatiy: Its Contribution to Man's Knowledge of Himself York: W.W. Norton & Company, Inc. 1936). ''"^William Alanson White, The Principles of Mental Hygiene (New York: The Macmillan Company, 1923), 267-70; idem, "Tlie Mind of the Child," in An Introduction to the Study of the Mindfor the Use of Medical Students, Beginners in P^chiatiy, Social Workers, and All Those Interested in Mental Hygiene (Washington, D.C.: Nervous and Mental Disease PubUsliing Company, 1924), 63-8. See also Wliite's The Mental Hygiene of Childhood (Boston: Little, Brown, and Company, 1924). 215

understand die child "as the center and the peripher)' of its own ciirlc of acdvides." In other words, as a participant and an obser\'^er of tiie communit)-, the child conformed to "habits of

social relationships, whether bound up in mere conventions or in powers of initiation and

leadersliip or willing submissiveness and acceptance" which determined "familial welfare and

communal life."'""

White also articulated an elaborate approach to the social and internal unit)' of the

adjusting human organism. White put together the dynamic and gestalt conceptions floating

around in psychology, claiming that "the organism in all its various parts, including the mind,

works as an integrating mechanism, each part of which is related to ever)' other part." He called

this understanding "das Es," the "It," perhaps a subtie reference to the platonic concept of "the

One." Das Es for White encapsulated "the precipitate of functional tendencies, dynairuc urges,

witii which ever)' living human being is endowed and which are fundamentally the same in all

because they are the result of millions of years of experience and have comc to be what they are

because these millions of years of experience have proven them to have sur\'ival value."

Moreover, das Es suggested that "all men are alike, and if we knew the qualities of this nucleus of

our personalit)' in theii' totalit)', we would have given to us a definiteness with which we could

approach the study of the human psyche with much greater certainties dian we have at present."

No room remained in liis vision of mental hygiene for individual renegade "faculties" as his

teachers suggested in an older meme White called "facult}' psychology." He compared the unit

approach to understanding human personalit)' with a stor)' he remembered from his own

childhood. A playmate suggested that he could master at least the rudiments of a foreign

language in only one year simply by learning a new word eveiy day. Such a scheme White now

found preposterous, because it left out any consideration of the intricacies of "the grammar of

"The Mental Hygiene Approach to Public Health," 388; White, "Tlie Mind of the Child," 63-8. 216 the language, the significance of prefixes and suffixes, the qualifj-ing words and the mechanism of sentence formation, dependent and independent clauses, and the whole problem of the relationship, of synthesis.'"'^'

White continued this line of reasoning by pointing out that the discover)' of simple units in psychological understanding provided few clues to understanding personaht)', perception, or otlier life processes. He compared this situation to what he considered a particularly disconcerting idea in modern quantum theor)'. How could electrons jump from shell to shell in their orbits about the nucleus without passing through the inten'^ening space? Wouldn't it be better. White asked, to see tlie process as continuous instead of raising anxieties by dividing the problem into a sort of Zeno's paradox of infinite regress? An understanding of the "organism as a whole" and its abilit)' to actively create associations and become dissociated demanded that the mental hygienist conceive of the world in all its relations as a "syncretistic conglomerate," much as the fumbling, learning child apparendy did. The mind did not grow simply by a "process of addition" as previously assumed.'''^" This syncretistic view suggested to White a new way to understand die maladjusted as well as the adjusted. Maladjusted personalities exhibited conduct suggesting that they were entirely self-absorbed, with no contacts to their surroundings. Only

"'"''William Alanson \X%ite, "The Adjustments and Unit)' of the Organism," P^cbc25 (]uly 1926): 5-18; idem, "The L'nir\' of tiic Organism," P^'choanalytk Review 7 Qanuan' 1920): 71-8; idem, "The Adjustments and Unit)' of the Organism," in Modern Science and People's Health (VC'.W. Norton Company, 1926), 141-79; idem, "Das E.s," Bulletin of the St. Elit^aheth's Hospitall (]uly 1931): 7-10; idem, "The Language of the Psychoses," Bulletin of the St. Eli::^abetbs Hospital 6 Ouly 1930): 1-12. ''^^The theor)' of "emergent evolution," by contrast, held a particular appeal. White liked the idea that each stage in evolution represented a "new forward integration" with "entirely new possibilities which cannot be forecast by the understanding of the previous state." In equation form, A + B A -t- B because in the process of manipulating the factors a third factor of unknown quality' C crept in, making A + B = A + B + C. See also William Alanson White, "Psychiatry and the Social American]ournalofP^'chiatiyl (March 1928): 729-47; and idem, "The Social Significance of Psychiatr)'," in Twentieth Centuty P^xbiatry: Its Contribution to Man's Knowledge of Himself York: W.W. Norton & Company, Inc. 1936): esp. pages 90-1. 217 maladjusted minds saw the world as discrete units growing additively. Narcissistic minds, put another way, produced their own disintegrations by synthetic incapacit}'/^^

Mental hygiene came closest to synthesis and popularization in the interwar period in the hands of Karl A. Menninger, cofounder with his physician-father of the influential Menninger

Clinic in Topeka, Kansas, in 1919.''^'' Menninger identified the psychiatrist Elmer Ernest

Southard and neurologist Smith Ely Jelliffe as his greatest teachers, and claimed the pioneer criminologist and child psychiatrist Herman Adler, Adolf Meyer, William A. White, and Menial

Hygiene editor Frankwood E. Wiiliams as important influences in his inteUectval development.

Menninger's formal mental hygiene education began under Southard, an old-school descriptive psychiatrist who shepherded Menninger through liis neuropsychiatry residency at the Boston

State Psychopathic Hospital in 1918. Southard taught Menninger to look for physical abnormalities by photographing and correlating autopsied brains. This was the "descriptive method" that Southard later thought of as "superficialism." Jelliffe was one of Freud's few close

American friends, and with Abraham Brill first introduced the theon-' of psychoanalysis to New

York's mental hygiene circles. Still, Jelliffe refused to be theorj'-driven, and has since been described as an adherent to an "American eclectic tradition" in psychiaO.7 and mental hygiene, preferring openness to disciplinar)- orthodoxy. It has sometimes been said that Menninger developed his professional orientation by rejecting Southard and accepting Jelliffe. Menninger referred to it once as a "conversion" of sorts. Menninger, like Jelliffe, refused to make Freud dogma wliile recognizing its usefulness, and placed no constraints on who (that is, from what specialt}') could practice analysis as long as they belonged to an "approved" professional

"Das Es," 7-10; William Alanson White, The Meaning of Disease: An Inquitj in the Field of Medical Philosophy (Baltimore: The Williams & Wilkins Company, 1926), 175; idem, "Tlie Language of the Psj'choses," 1-12. '"''A descriptive narrative of the founding of the Menninger Diagnostic Clinic as the mental health equivalent of Rochester's Mayo Clinic is found in Walker Winslow's The Menninger Story (Garden Cit)', N.Y.: Doubleday & Company, Inc., 1956). Menninger contributed a popular column in the pages of The hlouseholdMagat^ne in 1929, and Ladies Home}onntal itom 1931 to 1932. 218 organization (like the National Committee for Mental Hygiene or the American Psychoanalytic

Association) and endured sufficient "training," an unclear standard for much of the intenvar period, but governed in practice by die master-apprentice system. Yet, Menninger presen'ed much that he had learned from Southard, especially his insistence that the mind was a medical problem, and as such involved an equally important somatic component.'*'^^ This conviction became strengthened as he joined his father in private practice back in Topeka and began talldng about the importance of "healthy-mindedness" and the "totalit)' concept.'""^'

Menninger defined personalit)' as "the indi^adua] as a whole, his height and weight and loves and hates and blood-pressure and reflexes; his smiles and hopes and bowed legs and enlarged tonsils." This personalit}', composed of a fusion of inherited material and environmental influences, adjusted itself to individual life acts Menninger called "situations."

Situations could be resolved in only three possible ways: success, failure, or compromise.

Menninger called personalities successfully adjusting to situations "adjusted." The failed or frustrated, "attacked" simations and became "maladjusted." Healthy maladjusted individuals overcame failure by creating a "constructive compromise," and entered the ranks of the

"readjusted." The unhealthy maladjusted suffered one of two fates: (1) a "broken personalit)-"

"'•^^Menningcr himself had been an indifferent student at the Harvard Medical School, and a surgical intern in Kansas Cit)', before becoming distracted by n burning interest in neuros)'philjs, n disease with both somatic and psychic components. •'^''Karl A. Menninger, The HmfianMind (New \'ork: Alfred A. Knopf, 1930), x-xi; J.E. Carney, "The Psychoanalytic Education of the Dean of American Psycliiatr)': Karl Menninger and Smith Ely Jelliffe," Pgcbobisloiy Review 19 (Fall 1990); 71-87; John Chynoweth jelliffe: American P^'choana^'st ami Physician z? His Correspoiiele/ice with Si^miml Freud and C.G. jnng (Chicago; University- of Chicago Press, 1983), 117; Sydney Smith, "A Renaissance Man of Psychiatr\'," in The Human Mind Revisiled: Essays in Honor of Karl A. Menninger, ed. Sydney Smith (New York: International Universities Press, Inc., 1978), i-17; B.H. HiXi, A P^chiatrisl's World: The Selected Papers of Karl Menninger, M.D.. vol. 2 (New York: 1959): 815, 850; Lawrence J. Friedman, Menninger. The Family and the Clinic (New York; Alfred A. Knopf, 1990): 28-47; Karl A. iNfenninger, "Tlie Totalitj' Concept in Medicine," in Man Against Himself (New York: Harcourt, Brace, and Company, 1938), 353-61. See also Frederick P. Gay, The Open Mind: Elmer Ernest Southard, 1876-1920 (Normandie House, 1938). The professional correspondence to and from Menninger is presented in The Selected Correspondence of Karl A. Menninger, 1919-1945, eds. Howard J. Faulkner and \'irginia D. Pruitt (New Haven, Conn.: Yale Universit)' Press, 1988). 219 leading to breakdown or suicide, or (2) a "broken situation" like criminal activit)-, violence, or even murder.

The unhealthy maladjusted, at least when not suffering organic mental disease, reti'cated from normal life by "flight." Menninger called the eccentric, withdrawn, and unsociable the

"isolation t}'pe." These people suffered breaks in personalit)' for many reasons, including provincial parenting, lacking siblings, home schooling, and by reason of extremes in povert)- and wealth, or religious conflicts. The "scliizoid t}'pe" collected together the queer, the odd, the silent, and the serious, all of whom suffered "a break or split in the internal harmony of the personalit)-" such that they grew up "noticeably out of tune with the rest of the world." These personalities, though, often harbored brilliant minds. Menninger recalled that many of the world's great thinkers and leaders came out of the ranks of the readjusted schizoid. Menninger ciixumscribed the "cycloid t}'pc" as those personalities moody or predisposed to fits of deep melancholia. He included in this category' those individuals suffering dramatic swings in temperament, that is, rapidly from "up" to "down" or vice versa. The cause of this r}'pe of reaction to a situation Menninger described as exaggerated introspection. The "neurodc t)'pe," literally those suffering from excessive ner\'ousness, included those "whose primitive insdncts have been modified to meet social demands only with painful difficult}'." Neurones could harbor troubling doubts, fears, anxiedes, obsessions, compulsions, hypochodriacal complaints, and addicdons. One of the particular dangers of neuroses was their communicabilit}'. Menninger himself once witnessed an epidemic of "hysterical aphonia" (speechlessness) among fourteen telephone switchboard operators. Finally, Menninger grouped a final fraction of unresolved

''^'Menninger, The Htmmn Mind, 21-6. 220 mental breaks into the "antisocial t)'pe." These included the per\'erse, the habitually criminal, and the itinerant. These personalities held to no anchor in societ)', and instead raged against it/^'*

Menninger claimed that even the most hard-boiled of broken personalides could be salvaged. They represented only the "intolerable extremes" of normal personalities. The maladjusted types did not represent differences of kind altogether, only differentials in land.

Menninger, for instance, prefaced liis second edition of T/je Hw/ui/i Mi/id (1937) with the comment,

Many readers have said to me; "I was afraid I would find myself in your book," or "I almost imagined I had some of those abnormal conditions myself." To such persons I usually reply quite gravely; "I hope so." For if one has a mind at all, his mental processes are subject to some of the faults and failings that characterize the human mind. If someone does not find himself at all in this book, it is either that he is not human or that some pages have been left out (or torn out)."*^'^

The first step in resolving breaks in personalit)' was to determine symptoms leading to the classification of tj'pe. Classification determined treatment regimen. Regardless of classification

(or diagnosis), ti-eatment could only be effective when it involved change or dynamism as its preferred tool. The patient might be changed with drugs, by surgical procedure, physical therapy, or using psychotherapy. The patient's environment might also be changed by hospitalization, reorientation of living arrangements, through team play and sport, or crafts and hobbies.

Menninger disliked holidays or vacations because they reinforced "flight," the cause of mental affliction in the first place. All of the various non-organic personalit}' breaks could be prevented simply by cultivating social contacts, recognizing evasions of social responsibilities, and always assuming "that the unhappy are always wrong." The importance of the social group, the

''^^Menninger, The Hriwaii Mind, 56-151. ''^'Menninger, The Humau Mind, 2nd ed., viii. 221 community of humanity, in prophylaxis cannot be overstated, as Menninger wrote, "Tty to make even'body think I'm feeling good, and pretty soon I am."'*''"

• • •

Mental testing of WW I draftees, conducted by a new U.S. Sanitaty Corps-commissioned

Psycholog)- Committee of die National Research Council and chaired by Robert M. Yerkes, lent a sense of urgency and purpose to otherwise esoteric mental hygiene studies. The Psychology

Committee's Army Alpha tests for the literate, Beta tests for the illiterate, and the Woodwortli

"Personal Data Sheet" for measuring temperament revealed appalling numbers of mentally deficient Americans. Almost fifty percent of one million young men tested during enlistment drives possessed intellects no better than tliose of seventh graders. Mental testing immediately eliminated more than 72,000 men, all victims of neuropsychiatic disorders, epilepsy, inebriety, and mental defect. Taken as a whole, the Army rejected over fifteen percent of all draftees as, in the words of one mental hygienist, "actual hindrances to civilization." Many more were dismissed from certain types of work for various mental and personality- weaknesses that threatened to outweigh any strengths.'*'"

''"'"Karl A. Menninger, "Social Techniques in the Ser\'ice of Reconstruction," in Man Against HimselJ (New York; Harcourt, Brace, and Company, 1938), 457-71; idem, ".\djunctive Therapy Modalities," in A Manuct/ forP^vhiatric Case SIMIJ (PICWYoik: Grune & Stratton, 1952), 331-2; Menninger, The Hitman Mind, 149-151, 359-95, and esp. pages 150, 362. See also liis brother's contribution (who also practiced in the Menninger Clinic): William C. Menninger, "Play and Mental Health," in The Heahliy-Minded Child, ed. Nelson Antrim Crawford and Karl A. Menninger (New York: Coward-McCann, Inc.), 148-67, esp. page 154 where William writes, "There is a constant effort and a necessit}' to supplant T with 'wc'; to coordinate T with 'you'. It is a struggle to become social, to learn propert)' rights, to become aware of other opinions than one's own, to play the game as others phiy it, and to play it happily and agreeably with them." '''"Pratt, "Twent)' Years of the National Committee for Mental Hygiene," 411-6; Shepherd Ivor\' Franz, "Mental Tests," Mental Hygiene 1 (April 1919): 258-65; H.E. Garrett and M.R. Schneck, "A Study of the Discrimination N'alue of the Woodworth Personal Data Shest," Journal of General P.ycholo^' 1 (1928): 459-71; Bailey, "War's Big Lesson in Mental and Nervous Diseases," Neiv York Times (September 14,1919): sect. IV, 9. See also Arthur S. Otis, "An Absolute Point Scale for the Group Measurements journal of Educational P^choh^'') (1918): 239-61, 333-48; Robert Mearns Yerkes, ed., "Psychological Examining in the United States Army: Part II, Methods of Examining," Memoirs of the National Academy of Sciences 15 (1921): 293-546; Clarence S. Yoakum and Robert Mearns Yerkes, Army Mental Tests (New York: Henrj- Holt, 1920); Robert Mearns Yerkes, "Psycholog)' in Relation to the War," Psychological Revieu'2b (1918): 85-115; idem, "The Measurement and Uulization of Brain Power in the Army," Science 44 (1919): 221-6, 251-9; idem, "Report of the Psycholog)' Committee of the National Research Council," P^'chological Review 26 (1919): 83-149; idem, "The Role of Psycholog)' in the War," in The New World of Science: Its 222

The stoiy of the Psycholog)' Committee, elevated from its immediate prewar status as a special preparedness committee of the American Psychological Association is well-documented in the secondar)' literature/'*" Much less well known is the work performed during WW I by a new Army Medical Corps Division of Psychiad.7, Neurology, and Psychology, representing the militarization of the War Work Committee of the National Committee for Mental Hygiene, and the aspirations of prominent members Thomas W. Salmon, Pearce Bailey, and Stewart Paton.

The Psycholog)' Committee screened the young men of America for mental defects. The

Division of Psychiatr}', Neurolog}', and Psychology worked to adjust the minds of those accepted into ser\dce, hoping to dramatically reduce mental afflictions and personality' maladjustments among the troops."*"'^

The Division super\''ised the adjustment of new recruits to life in the barracks by organizing morale-building activities. It helped the War Camp Community Ser\''ice replace harmful traditional leisure pursuits of army and nav}' personnel, reducing venereal disease rates by chaperoning dances and organizing sporting events and other entertainments for instance."'''"' In

Development Diiriiig the ll'ar, ed. Robert M. Yerkes (New York: The Centur)' Company, 1920), 351-89; idem, "Eugenic Bearing of Measurements of Intelligence in the U.S. Army," Eugenia Review 14 (1923): 223-45; and Frederick E. Terman, "The Use of Intelligence Tests in the Army," P.ycbnlogical Biillelin 15 (1918): 177-87. "'"'"See for example J oAnne Brown, "The Great War," in The Definition of a Profession: The Aiilhoritj of Metaphor in the History of Intelligence Testing, 1S90-1930 (Princeton, N.J.; Princeton Universit)- Press, 1992), 109-25; James Reed, "Robert M. Yerkes and the Mental Testing Movement," in Psychological Testing and American Society, 1890-1930, ed. Michael M. Sokal (New Brunswick, N.J.: Rutgers Universitj' Press, 1987), 75-94; Richard T. von Mayrliauser, "The Manager, the Medic, and the Mediator: The Clash of Professional Psychological Stj'les and the Wartime Origins of Group Mental Testing," in P^chologtcalTestingami American Society, 1890-1930, ed. Michael M. Sokal (New Brunswick, N.].: Rutgers Universitj- Press, 1987), 128-57; Henn- L. Minton, "Off to the Army, 1917-1919," in LewisM. Terman: Pioneer in Psychological Testing (New York: New York Universit)' Press, 1988), 62-76; Thomas M. Camfield, "Psychologists at War: The Histor}' of American Psycholog}' and the First World War," (Ph.D. diss., Universit}' of Texas-Austin, 1969); Joel H. Spring, "Psychologists and the War: The Meaning of Intelligence in tlie Alpha and Beta Tests," Histoty of Education Quarterly 12 (1972): 3-15; Daniel Kevles, "Tesung the Army's Intelligence: Psychologists and the Militar}' in World War \'' Journal of American HistoQ- 55 (1968): 565-81; and Franz Samelson, "World War I Intelligence Testing and the Developmeni oCPsychology," Journal of the History of the Behavioral Sciences 13 (1977): 274-82. ''''^National Committee for Mental Hvgiene, War W^ork and Other Activities of the National Committee for Menial Hygiene, Inc. (New York: Ir\'ing Press, 1918), 5-10. "'''•'C.F. Weller, "Permanent Values in War Camp Communitj' Sers'ice," Surv^' 41 (December 7,1918): 295-8; A.L. Dahl, "Communit)' Life for Our Soldiers and Sailors," Overland 12 (October 1918): 306-8; P.R. Jacques, "W'liat We Ate Doing For the Boys in Camp," Country Life 35 (November 1918): 59-61. 223 the trenches, the Division of Psychiad.y confronted a new disease, called "shell shock," already reported as epidemic among British and French troops. Shell shock, as the Division's mental hygiene experts came to understand it, was a mental disease peculiar to modern soldiers who came to the ser\dce poorly adjusted by their experiences in civilian life to foresee the prospect of exploding shells.

Men who had received no wounds were paralyzed. Some with apparendy normal organs were deaf, dumb, and blind. . . . Then followed the experience in the camps. Men who had not been exposed to shell fire developed the same symptoms. Soldiers who had not been under fire became paralyzed, mute, lost flesh, developed fears and curious insanities, recounted Salmon. The Division of Psychiatr)' treated these men by evacuating them to field neurological hospitals where mental hygienists reminded the soldier that he was intact, and that his "love of countr}'" and "desire to retain the respect of the people at home" overrode normal feelings of fear. The Division stressed the quick return of the shell shocked to their units, where camaraderie strengthened these desires and sen'^ed as examples to others. Almost eight)' percent of the men brought to the hospitals with concussion-related disorders were returned to their units in less than three days. The Division alleviated the effects of "gas neuroses," the product of a modern soldier's worr}' about chemical warfare agents, in a similar manner. In case the war

proved longer than expected, the Division also sponsored programs among America's youth to

replace unhealthy "personal preoccupation" with "the idea of cooperation, of working together

to an end, of patriotism," and encouraged the efforts of boys' clubs, the Boy and Girl Scouts, and

playground development groups. All of these activities apparendy paid dividends. General

Persliing's AEF suffered a lower suicide rate than the army in peacetime, less crime than that of

the French countrj'side, and fewer shell shock cases than any other army in Europe. Pershing 224 credited the mental testing and special neuropsychiatric units accompanying the doughboys for acliicving these astounding results.'*'''

Civilian uses for group mental testing blossomed after the war. Mental hygienists constructed a whole host of "personality tests" and "personaEt}' inventories" for use in the workplace, elementary and secondary schools, colleges, and other places where maladjustment interfered with socialization or social engineering. They designed the tests to do a great variet)- of things; provide vocational guidance, supplement employment interviews, capmre ardstic or musical aptitude, measure motor skills, etc. Some tests purported to measure single personalit)'

"capacities," like imaginativeness, suggestibility, or association. The Bernreuter Personalit}'

Inventor}', consisting of 125 "yes"-"no" questions, determined one's relative levels of neurotic tendency, self-sufficiency, introversion or extroversion, and dominance or submissiveness. The

"P.Q." or Personalit)' Quotient Test measured five aspects of the personalit)', extroversion, social aggressiveness, self-determination, economic self-determination, and adjustment to the opposite sex. The Wisconsin Scale of Personalit)' Traits measured emotionalit)', introversion, persistence, and seclusiveness.'*""^'

''''•^.\bout 3,000 men returned from abroad with neuroses unresistanr to therapy. Pratt, "Twent)' Years of the National Committee for Mental Hygiene," 413-4; Wile, "Tlie Mental Hygiene Approach to Public Health," 392; Winslow, "Twenn,- Years of Mental Hygiene," 509; Bailey, "War's Big Lesson in Mental and Nen'ous Diseases," sect. I\', 9; Ruggles, "Twent)'-Fifth Anniversarj' Celebration of the National Committee for Mental Hygiene," 2; Thomas W. Salmon, "The Neuroses and Their Lessons," New York Medical journal 109 Qune 7,1919): 993-4; idem, "The Future of Ps}'cliiatr)- in the Arm)'," Military Surgeon 47 (August 1920): 202; Frank Parsons Norbur}', "Mental Hygiene and the War," journal of the Iowa State Medical Society 9 (September 15,1919): 305; Frank Garm Norbur}-, "The Relation of Defective Mental and Ner\-ous States to Militan- Efficiency," MiUtaty Surgeon A1 (July 1928): 20-37; [acob Gould Schurman, "The Crnxst," Mental Hygiene 19 Qanuar)-1935): 13. ''''^References and descriptions of personalit)' tests are found in Gertrude H. Hildreth,^^ Bibliography ofMentalTests and Rating Scales, 2nd ed. (New York: The Psychological Corporation, 1939); and Charles K.A. Wang, An Annotated Bil>liography of MentalTests and Scales, 2 vols. (Bejing, Cliina: Catholic Universif)' Press, 1939. An excellent source for periodical literature on personality' testing is Earl Bennett South, An Index on PeriodicalLjterature on Testing: A Classified Selected Bibliography of Periodical Literature on Educational and Mental Testing, Statistical Method, and Personality Measurement, 1921-1936 (New York: llie Psvchological Corporation, 1937). R.G. Bernreuter, "The Theot)' and Construction of the Personality InycnXovy," Journal of Social Psychology 4 (1933): 387-405; idem, "Validirj' of the Personalit)' Inventor)-," Personnel journal \\ (1933): 383-6; H.C. Link, "A Test of Five Personalit)- Traits of Adolescents and a Statistical Theor)- of Personality-," P^chological Bulletin 33 (1936): 774; idem, "A Test of Four Personalit)' Traits for Adolescents," journal of Applied P^cholo^ 20 (1936): 527-34; R. Stagner, "The Wisconsin Scale of Personalit)- Traits." journal of Abnormal and Social PQ'chohgy 2>\ (1937): 463-71. 225

Shell shock and gas neuroses also yielded useful therapies in civilian life. Mental hygienists agreed that the stresses felt by the soldier were not so dissimilar to the stresses faced in everj'day life. The youngster who broke a window with a baseball, the gendeman who misplaced his hat, the pilot whose plane had crashed, and the bewildered tourist in a foreign land all suffered reactions varj'ing from war neuroses only in cause and intensit)'. Indeed, many of the men who survived the greatest stresses in the war found themselves unsuited to or unassimilable by life back home, remaining unemployed and unemployable in large numbers. This maladjustment re\^ealed well the synchronicit)' of war and civilian neuroses. They bodi ser\'ed the same purpose, fulfilling a need to "escape from an intolerable simadon." Mental hygienists associated with the Division of Psychiatr)', it should not surprise, thus recommended after the war new psychiatric treatment centers all along the front lines in urban and rural America.''""

The effects of the Depression gave mental hygiene renewed relevancy in 1929. Some confronted the poor national economic picture with healthy action. Exercises of self-improvement, as shown by massive increases in librarj' lending, showed what those providentially equipped with good mental equilibrium could achieve under great duress. Many odiers did not, some from sheer lack of an adequate diet, others from family pressures. Most of these depression-maladjusted, however, evinced tendencies already harboring below the surface before the markets slipped. "Individuals who now show signs of mental illness were in realit)' no better adjusted before the depression than now," explained psychiatrist Miriam Dunn of the

Catholic Charities of Washington, D.C. The maladjusted refused to pay even a fraction of their rents, parent (or even conceive) children, spent hard earned wages extravagantiy and recklessly,

''''^Norbur)-, "Mental Hygiene and the War," 303-6; Salmon, "War Neuroses and Their Lesson," 993-4; F.H. Sexton, "\'ocational Rehabilitation of Soldiers Suffering from Nen'ous Diseases," Menial Hygiene (April 1918): 265. 226 or committed suicide. Preexisting personalit)' maladjustment, reinforced by petrified habits, caused these individuals to remain unresponsive or behave irresponsibly in a changed world/''"

The explosion of interest in the new communit)' mental hygiene was nowhere more in evidence than in the establishment of vast numbers of mental health, neuropsychiatric, behavior, and child guidance clinics, springing up like new grass all across the countr)' in the 1920s and

1930s. Minnesota by 1932 had child guidance clinics in Minneapolis and St. Paul, a division of mental health at the Universit)' of Minnesota Students' Health Sendee, and neuropsychiatric clinics at Minneapolis General Hospital and at the Universit)' Hospital Dispensar)' of the

Universit)' of Minnesota. Pennsylvania in the same year had three regional chapters of a state

Mental Hygiene Committee operating under the auspices of the Public Charities Association based in Philadelphia. Mental health clinics opened their doors daily in AUentown, Altoona,

Bedford, Bethlehem, Bloomsburg, Buder, Carlisle, Chambersburg, Chester, Coatesville, Danville,

Doylestown, Easton, Erie, Franklin, Gett)'sburg, Greensburg, Harrisburg, Hazleton, Huntingdon,

Indiana, Jenkintown, Lancaster, Lebanon, Lewistown, Lock Haven, Mansfield, Meadville,

Monti'ose, Mount Carmel, Nanticoke, New Brighton, New Casdc, Norristown, Pahnerton,

Philadelphia, Philipsburg, Pittsburgh, Pittston, Pottsville, Reading, Scranton, Shamokin, Sharon,

Sunbur)', Towanda, Uniontown, Warren, Washington, West Chester, Wilkes-Barre, Williamsport,

Windber, and York. Child guidance clinics operated in Erie, Philadelphia, and Pittsburgh.

Philadelphia had over a dozen neuropsychiatric clinics, and Pittsburgh almost half as many.'*'''^

'''"^Douglas A. Tliom, "Mental Hygiene and the Depression," Mental Hygiene 16 (October 1932): 564-76; Miriam Dunn, "Psychiatric Treatment of the Effects of the Depression: Its Possibilities and Limitations," Mental Hygiene 18 (.\pnl 1934): 279-86; Henrj- C. Schumacher, "The Depression and Its Effect on the Mental Health of the Child," Mental Hygiene 18 (April 1934): 287-93. See also Herman M. Adler, "Unemployment and Personality': Study of Psychopathic Cases," Mental Hygiene \ ()anuary 1917): 16-24. '''"National Committee For Mental Hygiene, Division on Community Clinics, Directoty of Psychiatric Clinics (New York: The Commonwealth Fund, 1932), 5, 73-4,134-50. 227

Clinics for mental hygiene dispensed aid with the help of mental hygienists, child hygienists, physicians, public health nurses, psychiatrists, psychiatric social workers, psy chologists, and clerg)'. Cases came referred from children's aid societies, public health nurses, youth clubs, police courts, school principals, physicians, friends, and other private and public social and health agencies. Children and adolescents, by virtue of their mental plasticit}' especially tractable and responsive, usually formed the majorit)' of clinic patients. Patients submitted to a batten' of physical, psychological, and neurological tests to determine the extent of the injury or personality- malformation. Diagnoses ranged from moral imbecilit)' to subnormal mentalit)' to paranoia.

Clinic workers forwarded those suffering organic diseases, such as lesions on the brain or pituitan' malfunctioning, to hospitals.

Psychiatric social workers occupied the core of the communis,' mental hygiene agency.

The psycliiatric social worker, usually female, represented the chief coordinator and cooperator, the integrator of effort, "an intermedian' body who deals with transportation among the ideas" in the mental hygiene movement. By tradidon, the fu'st psychiatric social worker is said to have been Mar}' Potter Brooks, who after marrj'ing Adolf Meyer, began visiting his subjects at home.

Meyer appreciated liis wife's help, as home visidng established a "broader social understanding of our problem" by "reaching out to the sources of sickness, the family and the communit)'." He defined psychiatric social work as general "social work plus work on man's social organ itself," the social organ being "the integrated personalit}'.""*^'

Malctz, "The Placc of the Mental Hvgienc Clinic in the Communit)'," Mental Hygiene 23 (.-Kpril 1939): 196-214; Simon Stone, "W'l-iat Mental Hvgienc Means to a Communiri,'," Mental Hygiene 19 (July 1935): 416-28; Bassett, Mental Hygiene in the Community, 40-2, 58. "'^'jessie Taft, "Mental Hygiene and Social Work," in Social Aspects of Mental Hygiene (New Haven, Conn.: Yale Universit)' Press, 1925), 125-45; ,-\do]f Meyer, "A Historical Sketch in Outlook of Psycliiatric and Social Work," Hospital Social Service 5 (1922): 221-5; Gay, The Open Mind: Elmer Ernest Southard, 1876-1920, 163; Christine C. Robb, "The Problem of Meeting the Needs of the Social Worker Who Refers Cases to a Psychiatric Clinic," Proceedings of the National Conference of Social Work 54 (1927): 399-408. 228

Interest in psychiatric social work, and social psychiatr}' generally, increased dramatically in the late 1910s. The National Conference of Social Work established a mental hygiene scction in 1917. Psychopathologist E. E. Southard, Menninger's mentor, and Maiy C. Jarrett, chicf of social sen'ice at die Boston Psychopathic Hospital, organized the first training course for psychiatric social workers in the Smith College for Social Work in 1918, partially as an expediency in meeting the mental hygiene needs of war. Soudiard and Jarrett agreed that psychiatric social work represented "the focusing of various recent influences leading to more attention to the mind in social practice, under pressure from psychiatr)' demanding more attention to social needs in medical practice." Psychiatric social workers received about two years' academic training in a variet)' of subjects, contributing to the whole of their education, including psycholog)', social psychiatr)', sociolog)', and biology. The National Committee for Mental Hygiene underwrote this

first effort to regularize the training of psychiatric social workers, and about fift)' of the first

graduates of this program signed up for service in Red Cross army hospitals. Other psychiatric

social work programs popped into existence soon after the Smith CoUcge experiment began,

including those started at the New York School of Social Work, the Pennsylvania School for

Social Ser\tice, Simmons College School of Social Work, National Catholic School of Social

Ser\tice, the School of Social Sentice Administration of the Univcrsit)' of Chicago, the School of

Applied Social Sciences of Western Reserve Universit)', and Tulane Universit)' School of Social

Work. The American Association of Psychiatric Social Workers followed in 1926 as a profession

for any worker having "an adequate working knowledge of mental hygiene," generally applied as

at least one year's experience (not formal academic study) in psychiauic social work.''^"

""^Southard and J arrett, The Kingdom of EuHs: P^cbiatric Social Work Presented in One Hundred Case Histories Together with a Classification of Social Divisions of Evil, 517-62; Sarah H. Swift, Training in P^chiatric Soda! Work at the Institute for Child Guidance, 1927-1933 (New York: The Commonwealth Fund, 1934), 2; Mrs. H.S. Mallor}', "Psychiatrj-, Social Service, and Societ\'," Hospital Social Sen'ice 12 (1925): 283-7; Ryther, "Place and Scopc of Psychiatric Social \Vork in Mental Hygiene," 636-45. 229

The functions and responsibilities of the psychiatric social worker were manifold, but were usually restricted to work with children and immigrant families. On a practical level, they collected sociological data on patients, put together social ease records (sometimes called

"personalit}' pictures") similar to the family folders of the public healdi nurse, and helped patients follow the prescriptions of mental hygienic diagnoses. Anything to establish "a dynamic treatment relationship" and "make Johnny socially competent." Psychiatric social workers helped physicians locate schools, camps, and hobbies appropriate to the personalities of maladjusted children. They assisted public health nurses in assessing die mental hygiene and educational needs of malnourished children under the local health center's care. "The potentialities of the collaboration of psychiatrists, psychologists, and social worker were early recognized in some centers," wrote one psychiatric social worker later. "The value that results from a smoothly working and essentially mature team work relation, in helping a cliild achieve a more harmonious adjustment to life still seems to many clinicians, at tliis stage of tlierapeutic advancement, a factor of the greatest importance." Smaller numbers of psychiattic social workers represented mental hygienists in the homes of chronically unemployed men and poor housekeepers. Wherever psycliiatric service was necessar)' in the home, though, it demanded

"fitting psycliiatric ser\'-ice to the communit)'" as a "biological unit." Psychiatric social workers were enjoined to understand their service to individuals as it related to the whole, to the communit)- as "a growing, adjusting, evolving thing, which needs at times certain treatment."'"^

•"^"^Frances Taussig, "A Family Case Work Organization," Proceedings of the National Conference of Social Work (1924): 442-7; Robb, "Tlie Problem of Meeting the Needs of the Social Worker Wlio Refers Cases to a Psycliiatric Clinic," 399-408; Rebecca H. Boj'le, "Psychiatric Social Work in a Family Agency," Hospital Social Service 4 (1921): 209-13; Margaret L. Wirt, "Psychiatric Social Work in the Boston Children's Hospital," Hospital Social Service 16 (1927): 29-37; Marie L. Donohoe, "Psychiatric Social Work in the Field of Public Health," Hospital Social Service 20 (1929): 223-33; Ruth Lloyd, "Psychiatric Social Work in Relation to a State Mental Hygiene Program," Hospital Social Service 13 (1926): 54-8; Swift, Trainin^in 'Psychiatric Social Work at the Institule for Child Guidance, 1927-1933, 6-7,10-1; George S. Stevenson, "Fitting Psychiatric Ser\'ice to the Community," Proceedings of the National Conference of Social Work 58 (1931): 362-70. For more on the "minutiae" of psychiatric social work see Porter R. Lee and Marion E. Kenworthy, Mental Hygiene and Social Work (New York: The Commonwealth Fund, 1929). 230

Psychiatxic social workers also held positions related to research. Some participated in

"State Nursery" programs where they obsen^ed children, collected data, conferred with psychiatrists, psychologists, and child hygiene and child welfare experts, and treated problems of intellect and behavior. On a day to day basis they prevented children from manipulating one another—biting and fighting and teasing—instead inculcating collaborative habits and behaviors in the group. Hospital social ser^'•ice worker Grace Corwin Rademacher summarized this kind of activit)' as "habit training, an interpretation of the cliild's behavior, and an evaluation of his personalit)' and behavior manifestations." The Judge Baker Foundation in Boston, the Palmer

School in Detroit, the Hull House Branch of the Institute for Juvenile Research in Chicago, and the Iowa Child Welfare Station in Iowa Cit)' all employed psychiauic social workers in this capacit}'. Much research, as well as practice, occurred in government mental hospitals; communit}' child guidance, psychiatric, and mental hygiene clinics; state departments of mental hygiene, public health nursing organizations, and family welfare agencies."'^''

The shape of the new communit)' mental health profession reflected the ideas of its diverse constituency. Mental hygiene appealed to psychologists interested in the acquisition and formation of habits. Behaviorists used mental hygiene to further their understanding of the complex human mechanisms of adjustment to stimuli. Psychiattists working in mental hygiene studied the evoludon of personalit)' defects (psychoneuroses) from social traumas and inherent natural factors. Educators contributed to the discourse of social interaction and student socialization. Physicians, physiologists, and neurologists puzzled over the role of endocrine and neiTous functions amidst the complex sociological and psychobiological workings of human

Grace Corwin Rademacher, "The Psychiatric Social Worker and the Period of Early Childhood," Hospital Social Service 15 (1927): 156-63; Lois Meredith French, P^xbiatric Social Work (New York: The Commonwealth Fund, 1940), 1-74. See also the recent monograph by Hamilton Cravens, Before Head Start: The Iowa Station & America's Children (Chapel Hill: Universit)- of North Carolina Press, 1993). 231 physical, emotional, and mental adjustment. Public health workers wanted mental health to expand die horizons of child hygiene, industrial hygiene, and communit)' health organization work.'^^

The National Committee for Mental Hygiene acted as clearinghouse for the interchange of information between these professions. Mental Hygie/ie's first editor, Frankwood Williams, called the field "too extensive to be occupied or preempted by any one professional group."

Clifford Beers called it a "sanctuar}'" for people with conti'asting ideas, a "sort of Switzerland, in the field of social welfare, health work, and related activities." No less than fift)- American professional, voluntar)', and government associations and agencies sent representatives to the furst

International Congress on Mental Hygiene in 1930. Out of this amalgam two things became exceedingly clear, that mental hygiene work demanded the tearing down of the artificial barriers constructed around specialties, and the demolition of the "sharp line" supposedly separating the mentally ill from the mentally weU."'^'^'

Ferenczi, "Freud's Importance for the Mental Hygiene Movement," Mental Hygiene 10 (October 1926), 673-6; MacDonald, Mental Hjgiene and the Public Health Nurse: Practical Suggestions for the Nurse of Today, 10-1,17; Bassett, Mental Hygiene in the Community, 1; White, "Tlie Behavioristic Attitude," 1-3, 5, 10-17; Lemkau, Mental Hygiene in Public Health, 4; Milton C. Winternitz, "A Physician Looks at Mental Hygiene," Mental Hygiene 16 (April 1932); 221-32; Wile, "Tlie Mental Hygiene Approach to Public Health," 389-90; ^liltonj. Rosenau, "Mental Hygiene and Public Health," Mental Hygiene 19 (Januaq-1935): 8-10. "'^''Frankwood Earl Williams, "Mental Hygiene: An Attempt at a Definition," Mental Hygiene 11 QuU' 1927): 485-6; Clifford Whittingham Beers, "Some Intimate Remarks," Mental Hygiene 19 (January 1935): 22-3; Winslow, "Twent)' Years of Mental Hygiene," 505-6. 232

CHAPTER VIII. SELLING HEALTH

Charles-Edward Amor)- Winslow noted that the new communit)' health and the activities of all of its constituent professions could be best defined by tlieir concentration on popular education. This modern crusade for health education of the masses, he said, created a new need for all kinds of carefully choreographed publicit)' campaigns. "An elaborate technique of health bulletins, health news sen'ices, health lecture bureaus and institutes, health cinemas, health exhibits, and health radiograms has been created to meet this need," he noted. Publicit)' helped reform individuals, families, and the communit)' at large by providing an opportunit)' for the public to hear, learn, and apply the facts of health)' living, providing lifest)'le choices that the professions of health did not adequately provide for before. Publicit)', coupled with broad-based health education programs, helped bridge the artificial gap born of the earlier shearing off of sanitaiy scientific expertise from common wisdom in health matters."'"

Winslow encouraged all health professionals to enthusiastically take on this general challenge of effusing the knowledge derived from scientific investigations into popular circles.

Lavpeople, in fact—at least according to the experts—seemed to demand that the general knowledge of proper hygiene be suitably delivered up. "What the college student wants and needs in this field of community hygiene," wrote two Cornell Universit)' assistant professors of hygiene in the preface to their textbook Community Hjgiene (1929), "is perhaps not so much a specific knowledge of the exact steps which must be taken to protect adequately a communit)'

""'Charlea-Edward Amoiy Winslow, The Evohilion and Significance of tije Modern Public Health Campaign (New Haven: Yale Universit)' Press, 1923), 55; Dean Franklin Smiley and Adrian Gordon Gould, Community Hygiene (New York: Tlie Macmillan Company, 1929), 8; Ira \''aughan Hiscock, et al., IFays to Community Health Education (New York: The Commonwealth Fund, 1939), 5-6. 233 from n-phoid fever or malaria or to reduce its infant mortalit)' as it is a knowledge of what in general the science of public health has to offer toward the solution of common communitj' health problems.""'"

Communit}' health authorities viewed sanitar}' science's attempts to arouse the interest of the public as generally misguided and incomplete. "When the public health movement was still ver)' young and the lion's share of official activit}' was directed to the sanitary improvement of the environment," remembered Yale public health professor Ira V. Hiscock, "public health education was not regarded as a particularly important administrative function—if, indeed, it was thought of at all." The health educator of earlier days, he suggested, was like a "prophet crying in the wilderness." Indeed, the attitudes of some communit)' health leaders toward earlier popular health education initiatives bordered on contempt.""'^

Communit)' health professionals complained about the authoritarian, preach)', and overl)- competitive manner by which the earlier brand of healtli education operated. Sanitarians, they concluded, approached the public health problem Eke sanitar)' police, a relic derived from eighteenth- and nineteenth-century notions stirred up by J ohann Peter Frank, David Hosack,

John C. Griscom, and others.''^'" Public health legislators and enforcers destroyed the angel of

pestilence in the decades around 1900 with theii- regulations and punishments against the

Winslow, The Evo/ulion and Significance of the Modem Public Health Campaign, 55-60; Smile)' and Gould, Community Hygiene, v, 7-8. '"'Hiscock, et al., to Community Health Education, v. '"'"On the medical and sanitan- police function in public health see J ohann Peter Frank, ^ System of Complete Medical Police, l''"^9-181"' (reprint, Baltimore: )ohns Hopkins Universit}' Press, 19''6); David Hosack, Observations on Febrile Contagion and tite Means of Improving ll)e Medical Police of the City ofNewA 'ork (New York: Elam Bliss, 1820); David Hosack, "Observations on the Means of Impro\'ing the Medical Police of the Cit\' of New York," in Essc^s on Various Subjects of Medical Science, vol. 1, 9-86 (2 vols., New York; Seymour, 1824); John C. Griscom, "Improvements of the Public Health and the Establishment of a Sanitar)- Police in the Cit)- of New York," Transactions of the Medical Society of the State of New York (1857). See also George Rosen, "Cameralism and the Concept of Medical Police," Bulletin of the Histoty of Medicine 27 (1953): 21-42; idem, "The Fate of the Concept of Medical Police, 1780-1890," Centaunis 5 (1957): 97-113; Brenda White, "Medical Police, Politics, and Police: The Fate of John Robertson," MedicalHisto/y 27 (1983): 407-22. 234 production of noxious wastes and germs. The public, in the estimation of community' health leaders, however, had ver}' litde to do direcdy with public health progress. They merely complied. Compliance, though, had its limits. Sanitary laws prevented the worst abuses of the public—improper garbage disposal, obsttucting the flow of drainage systems, poor plumbing, and overflowing cesspools—but shackled the public imaginadon against as yet unrealized possibilides for health advance."*^''

Police tactics found their way into the schools too. "Many schools," explained health educator Lawrence AveriU, "subject their small patrons to a torturing series of mongrel lessons in physiology, anatomy, and hygiene" where "formal drill" replaced the formation of a

"trustworthy" healtli attitude. Further, favoring of "health knowledge" over "health practice" led students astray of "healthful living."""^^"

Communit)' health leaders deplored the scare tactics employed in past health education initiatives. "The most frequent appeal in the past has been fear," wrote one health worker.

"Horrible pictures of smallpox victims, horrible statistics of deaths from preventable diseases, horrible reminders of aches and pains, horrible portraits of rickety children." Communit)' health professionals worried that such tactics might unduly stimulate "hypochondrias," a perpetual health lifestjde characterized by deep phobia or panic. "To demonstrate the effectiveness of the appeal to fear we can point to the thousands who no longer shake the hands of those they meet, who never kiss those they love, who polish the tableware in hotels and restaurants with their napkins."'"^^^ Overemphasis on the negative side of public health also inevitably led the public to

'lago Galdston, "Health Education," American JoHrnai ofPHh/ic Heahh 23 (April 1933): 338; J ames Mace Andrcss, Heahh Education in Rural Schools, rev. ed. (Boston: Houghton Mifflin Company, 1925), 35-6. ''^"Lawrence Augustus Averill, Educational Hygiene (Boston: Hougliton Mifflin Company, 1926), 24, 28; Howard L. Conrad and [oseph F. Meistcr, Teaching Procedures in Health Education (Philadelphia: W.B. Saunders Company, 1938), 11,21,26. ''^^Benjamin Charles Gruenberg, "Motivation in Health Education," American Journal of Public Health 23 (Februarj' 1933): 114-5. 235 ciy "wolf." Thus, public health leaders began favoring pictures of beautifully healthy people over the monsters of nature.''^'''

Many also condemned all kinds of combative "health contests" as ill-considered and counterproductive. Contests pitting babies or whole families against one another at state faiis in order to discover the "perfect" or "fittest" ones, athletic matches where only the Olympian had a chance of success, and schoolroom weight and height charting games where children were publicly singled out for falling behind were all considered misguided health education methods.

"The striving to outdo the other fellow is bound to react unfavorably on the emotional stabilit\- of each competitor," explained the same health educator, "and may lead to feelings of superiorit)' in those who win and of inferiorit}' and inadequacy on the part of those who frequently or habitually bring up the rear." Competitions held without opportunit}- for normal people to reach reasonable goals were also not in the best interests of health education. "As those whom we urge to attempt the impossible become aware of the futilit)- of aspiring to the 100 per cent score they become indifferent or even hostile."'"^'^

Specialism created its own problems communicating knowledge to experts in other fields and to lavpeople. In 1916 Hibbert Winslow Hill, Professor of Public Health at Western

Universit)-, stated flatlv that "health departments are police bodies, not preachers or teachers."

Teachers taught, he claimed, not sanitarj' scientists or hygienists."*^'^'

•"'''Gruenberg, "iMotivation in Health Education," 114-5; WAV. Peter, "llie Psycholog}- of Public Health Education," American jotmial of Public Heahh 17 (May 1927): 488; Burr Ransom llickards, "Discussion: Local Publicity Use of Statistics from National and State Sources," joiinial of Public Heahh 24 (April 1934): 334; Evart Grant Routzahn, "Health Education and Publicity," journal of PMic Heahh 13 (March 1923): 249. Bauer and Thomas G. Hull, Heahh Education of the Public: A Practical Manual of Technic (Philadelphia: W.B. Saunders Company, 1937), 185; Marguerite M. Hussey, Teaching for Health (New\'ork: Prentice-Hall, Inc., 1939), 86-7, 276-8; Gruenberg, "Motivation in Health Education," 115-6,121. See also Daniel J. Kevles description of the "Fitter Families" contests at the Kansas Free Fair in the 1920s in his hi the Name of Eugenics: Genetics and the Uses of Human Heredity (Berkeley: Universit}' of California Press, 1985), 61-2. '"'''Hibbert Winslow Hill, The New Public Heahh (New York: The Macmillan Company, 1916), 47-8. 236

There may have been some txuth to communin- health's charge that sanitan' scientists had

failed to weigh carefully the problem of popular hygiene. One of the famous founders of sanitary science, Providence Superintendent of Healdi Charles V. Chapin, assigned education only 80 out of 1,000 possible points among all the "reladve values" of public health departments as late as

1917. By comparison, he assigned pri^')• sanitadon 100 points and tuberculosis sen-ice 140

points. This dearth in emphasis deeply troubled health authorities after the war.'"^^"

Despite the extravagant claims of communitj' health professionals, though, sanitary science had done much to encourage the disseminadon of knowledge to the public.'"^" Ernest C.

Le\7, health officer of Richmond, Virginia, noted that "education of the public is one of the

most fundamental necessities in all public health work." Indeed, expert research and demand catapulted hygiene and physiologj' into tlie curriculum of public schools as early as 1882.

Physical education became a required subject in many states around the turn of the centur)'.'"^^''

The importance of a sanitar\' meat and milk supply, the so-called "pure food" movement,

had long been a staple of public hygienic education. The Consumer's League, Woman's

Municipal League, and the Housewives' League, as well as the federal government and state and

local health departments all played useful roles in disseminating food hygiene information.

Leaflets on proper food handling, along with lists of punitive fines for lawbreaking moved from

the hands of health experts to producers and consumers.''^"

"""'Charles N'alue Chapin, "The Relative \'alues of Public Health Procedures," journal of the American Medical Association 69 (1917): 90. '"''^Indeed, one communit)' health worker believed that "health education has suffered from over-stimulation in early infancy." See Emma A. Winslow, "Stimulating Health ^ducanon" Journal of Home Economics 19 (December 669. ''^'Ernest Coleman Lev)-, "Advantages and Difficulties of Publicit}- in Connection with Municipal Public Health Work," Journal of the American Medical Association 52 (February' 27,1909): 683; llichard Arthur Bolt, "Health Education," American Physical Education Reuieu'26 (Match 1921): 113; Clair Elsmere Turner, Principles of Health Education, 2nd ed. (Boston: D.C. Heath and Company, 1939), 9. """Donald Budd Armstrong, "Educational Work in Sanitar)- Food N'alues in New York Cit)'," American Journal of Public Health 5 (1915): 347-53. See also James Har\'ey Young, Pure Food; Securing the Federal Food and Drugs Act of 1906 (Princeton, N.J.: Princeton Universitj- Press, 1989). Ill

All else aside, though, the dynamism of modem societ\' demanded in the eyes of health experts a break from older popular health models and a concerted search for new ones. Prior hygienic campaigns, in fact, appeared most awkward and misguided because they resisted updating. Explained the Chicago Tribune's hczlth officer W. A. Evans, "Last year I had the opportunit)' of seeing a health exposition in which there were shown a number of old methods of presentation that were exceedingly valuable and effecti\'e in the Chicago Health Department some ten years before, but were just as useless in 1921 as they were useful in 1910." Datedness alone defined unpopularit}'. "How is curiosit}' aroused?" asked Fordham universit)' professor of health lago Galdston. "The answer is simple—by the extraordinary, by the novel, by the new.'"*^'

Good public and personal sanitation and concerted public action, sanitar)' experts generally agreed, rationally flowed from discover)' and disseminadon of sanitar)' scientific knowledge. That is to say, good health was fact-driven. The more facts afloat among the public, the better their potential for health. The more inclusive goals of communit}' health principles and practice, however, demanded more zealous and less passive efforts to mold public opinion. The well-used platitude, "public health is purchaseable,""*^" or some variation thereof, motivated a generation of communit)' health workers to view health education in terms of good

"salesmansliip," rather than as an exercise in objectivity.'*'^

'"'W.A. Evans, "Wliat Can Be Done at tlie Next Convention to Advance Efficient Work in Health Education and Publicit)'?" American journal of Public Health 12 (April 1922): 288; lago Galdston, "How to Tell Wliat in Popular Health Instruction," American Journal of Public Health 20 (Februar)-1930): 173. ""•Appropriated from comments first made by Hermann Michael Biggs in the October, 1911, issue of Monthly Bulletin of the Department of Health of the City of New York, but repeated elsewhere. A summar)' of the first conversation involving the statement (or "slogan" as Biggs reportedly called it) along with its import to community health professional culture is found in Frank Ernest Hill, Educating for Health: A Study of Proffams for Adults (New York: American Association for .-Xdult Education, 1939), 1-6. •"^Charles F. Rogers, "Commercial Salesmansliip Applied to Public Health Work," American Journal of Public Health 15 (October 1925): 892; Ralph G. Beachley, "Selling Public Health," American Journal of Public Health 16 (June 1926): 617. 238

Public health experts directly and indirecdy borrowed the motif of salesmanship from

private commerce and advertising. The object of diis work, though, was selling health scr\'icc,

not commercial products. Salesmanship could "break down the walls of ignorance and

prejudice" over matters of health. "Your real purpose is in persuading people to change their

habits," explained one health officer to his peers. "That can't be done, save as it is 'sold' to the individual." The overweening goal of selling health education and ser\'ice, indeed, inspired

Charles F. Wilinsky, a healtii leader in Boston, to nickname the community health center a

"Department Store of Health." The health center, he explained, like the department store sold

the public even'thing needed to live a healthy life all under one roof. Health ser\nce, noted

another expert, represented the "saleable commodit)-" of the health worker. Advertising suidies

seemed to confirm the value of this commodit)'. In terms of sheer "pulling power"—the

influence certain ideas had on product selection—"healthfulness" and "cleanliness" ranked first

and second, far stronger than appeals to "scientific," "efficient," or "modern" goods.

The commodification of health, the selling of "ideas" and "attitudes" tested the

professions of health in ways that demanded a reconfiguration of their own professional aims and

objectives. Health salesmanship illuminated in novel ways supply and demand relationships as

well as aggregate costs. Product qualit)' was also thrown into starker relief. Public health became

interpenetrated by and embroiled in the wider community' concerns for business and the politics

of business. Commercial advertising, and hence health salesmanship, stressed the "sensational"

use of "subject matter . . . presented in predigested, easily swaUowed capsules." This shattered

^'"'Rogers, "Commercial Salesmanship Applied to Public Health Work," 892; Beachley, "Selling Public Health," 617; Evans, "What Can Be Done at the Next Convention to Advance Efficient Work in Health Education and Publicity-?" 288; Charles F. Wilinsky, "The Department Store of Health," Stm^ 57 (March 15,1927): 790-1; Herman N. Bundesen, "Selling Health: A ^'^ital Dut)-," American Joiiriial of Public Heahb 18 (December 1928): 1452-3; Louise Franklin Bache, "Health Education Program in a Cit)' of 100,000," American journal of Public Health 18 (May 1928): 581. See also Harrj' Tipper, et al.. Advertising: I/s Principles and Practice (Chicago: The Ronald Press Company, 1919). 239 allegiance to disinterestedness and rationality in mundane human affairs stressed by the older public health model of sanitary science and state medicine.""'

The impulse to sell health ser\'ice to the public occupied much of the discourse in modern health education and publicity. Health salesmanship involved persuasion rather dian the presentation of cold, hard facts to a passive audiencc. "Motivation of the individual into improved health behavior depends majorly upon die choice of ideas, images and emotional appeals which, utilizing his innate drives, will influence his mental attitudes and behavior," explained one health educator. Thoughtful professionals noted that the public could not be motivated to acquire a healthy attitude solely by carrot or stick or by an appeal to reason.

"Appeal to some want," explained Hiscock. "Enlistments for the fight for better health will not come through argument." Some historians have labeled tliis tendency in modern America "social engineering," an obviously provocative concept today. Such functions at the time, though, merely highlighted more inclusive acts common in the human (as well as scientific) art of persuasion. Informing, instructing, and advising the public, communit)' health professionals felt, did not always win the day. Active appeals to emotion possessed a singular potential for permanendy modif\'ing individual human behavior.'''''

The efficient, capable health salesman understood human potentialities as well as he (or she) understood his scientific evidence. The centralit)'^ of human emotion in health education

H. Everett, "Publicit)' and the Campaign .^gainst Venereal Disease," American journal of PMic Health 9 (November 1919): 854; Rogers, "Commercial Salesmanship Applied to Public Health Work," 893; Oscar Dowling, "Publicit)' in Health Matters a Public American Journal of Public Health 8 (May 1918): 342. ""^As Walter H. Brown, the Stanford Universit)' professor of Hygiene and Physical Education put it, "\'ou [the health worker] must fight a terrific battle against indifference and stupidit)' among people who have demonstrated over and over again that they can be roused and controlled by catchwords and appealed to through simple emotions." See Walter H. Brown, "Adult Health Education," American Journal of Public Health 22 (October 1932): 1063. Hussey, TeacbingJ'or Health, 50; Bertrand Brown, "A New Deal in Health Education," American Journal oj'Public Heahh 24 Quly 1934): 745; Hiscock, et al., Ways to Community Health Education, v, 2; Peter, "The Psychology' of Public Health Education," 487; Galdston, "Health Education," 271-2, 338; Rogers, "Commercial Salesmanship Applied to PubUc Health Work," 893. 240 campaigns meant that communit)' health leaders had to understand human instincts, behaviors, and personalities in all their rich and myriad forms. "Educational endeavors, of whatever sort," explained Galdston, "can be successful only as they are adapted to the native and individual capacities of the person." Public health, to paraphrase another oft-quoted cliche of the communit}' health movement, represented both science and Manipulation of human emotion placed great demands on the "art" half of the equation.''^" The health salesman, whether nurse, physician, administrator, or specialist,

will inform his prospect that the sendee of which he stands in need is in existence. He will also point out the value of that service to him, indicating both the benefits to be derived through his acceptance of the service and the ill results which are liable to accrue if he does not take advantage of it. In the doing of all this he will address himself to the individual's mind. However, there comes a time in ever}' sales process when the salesman ceases addressing his remarks to the mind of the prospect and goes past the mind and into the heart, not for the purpose of getting more ideas into the mind, but with the direct intent of getting "old feelings" to move out of the heart. It is at this point that salesmanship actually enters. It is the creation of desires which lead to action that completes the sales process.''™

Health salesmen lived by example, putting their own sound minds and bodies and even theii" hale children on display. Their work demanded "an attractive personal appcarance," abundant energy, and an alert mind. The personality of the health worker played an increasingly important role in the daily life of communit}' health practice. Necessar}- endowments included

"courtesy," "cheerfulness," "confidence," and "patience." Personable health salesmen became efficient and practical health managers, further strengthening health education campaigns.'"'" "He

""'BV Charles-Edward Amor)- Winslow. Tlie full definition, repeated in many of his writings, reads: "Puiilic health is the science and the art of premnlin^ disease, prolonging life, and promoting physical and mental health and efficiency through organized communit}' efforts toward a sanitar}' environment; the control of communit}- infections; the education of the indi\'idual in principles of personal hygiene; the organization of medical and nursing service for tlie early diagnosis and treatment of disease; and the development of the social machiner)' which will ensure to ever\' individual in the communit}- a standard of living adequate for the maintenance of health." '"'lago Galdston, "The Psychophysics of Health Education," Transac/ions of tfje National Tuberculosis Association 28 (1932); 273, 276-7; Galdston, "How to Tell What in Popular Health Instruction," 171-2. ""'Rogers, "Commercial Salesmanship Applied to Public Health Work," 893. '''"Bundesen, "Selling Health: A ^'ital Dut}-," 1453; Rogers, "Commercial Salesmanship Applied to Public Health Work," 892; Dorthy Deming, "Selling Health Through Washing Machines," Surv^' 57 (Februan-15,1927): 632. 241

[or she] must be scientific, specific, optimistic," explained Chicago Daily News health editor

Herman N. Bundesen. More than that, his (or her) associates had to be pillars of the communit}'.

Health salesmen (and women) could not be seen frequenting taverns, appear disheveled, or neglect the health of their own families/"'

Male health officers, voluntar}- association secretaries, family physicians, and medical journal editors acted as the quintessential salesmen of health. Communit)- health nurses, in complementary manner, described themselves as health saleswomen. Each became, explained

National Health Council secretar)' Dorothy Deming, a "public health sales-nurse." Communit)' health nursing bent itself easily to tlie selling of health. "The nurse has become a dean of women in business," admitted one public health officer. Public health nurses became intensely interested in "selling" sen'ices produced in the laboratories, clinics, welfare agencies, and health departments. Nurses saw themselves as linking producer to consumer, much as the butcher filled a demand for meat. Public health behaved as a commodity to be consumed in the home. The nurse as saleswoman became simply another way of coordinating and cooperating in the communit)'. Selling public health priorities to laypeople involved "transferring the enthusiasm and convictions of the professional group," creating in the process "greater community consciousness and financial support of the service." Selling also extended to the professions who might otherwise underutilize communit}' health nursing sendees. Bringing together all the key health groups into a unified whole was sometimes even referred to as "closing the sale."'*"'

'""Bundesen, "Selling Health: A Vital Dut}'," 1453; Rogers, "Commercial Salesmanship Applied to Public Health Work," 892-3. ''^"Deming, "Selling Health Through Washing Machines," 632; Lloyd Sherrill, "Getting Along with People," Public Health Nursing 30 (1938): 385-9; Jose Bosley, "Selling Ser\'ice," Public Health Nursing 24 (1932): 449-51; \'iolet H. Hodgson, "Have You 'Sold' Your Board?" Public Health Nursing 24 (1932): 611-5; Violet H. Hodgson, "The Industrial Nurse in Gear with tlie Machiner)- for Human Adjustment," Journal of Public Health 20 (1930): 1323-7. 242

Deming recommended that communit)' health nurses study sales in other areas of the economj'. She herself recommended the "thrilling" wasliing machine business. Nurses could even use fundamental business principles in the evaluation of theii- own profession. "Character, capacit)^ and capital," wrote nurses Grace L. Anderson and Mabelle S. Welsh, "will determine the success of the public health nurse; the will to give of her abilit)', the capacit}' to learn from experience, and a capital constantly increased to meet the exigencies of changing situations and new and varied experiences."''"'^

Community health nurses demanded, though, diat their sen'ice rise above petty advertising campaigns and the degrading effects of the simple assembly line. Communit)' health nurses, in general, did not identify the "povert}' of abundance" plaguing commerce and trade with their own professional problems. "The economic world has cramps because it cannot sell all the things it can make," explained one nurse. Public health did not. Public health resources had never been that abundant. Rather, nurses found rationing and tempering over-enthusiasm a central occupation. Nurses advertised themselves to distribute their talents more evenly, not necessarily to sell more service. They chafed at those who called them "peddlers."''"''

The application of social science sti-ategies to the business of health education helped health authorities construct useful ways to sell health to the public. The social sciences, a branch of inquir)' dedicated to discover}' of human laws, informed and helped articulate those psychological, sociological, and pedagogical tools useful in popular health appeals. Health experts hoped that knowledge gleaned from the social sciences, when applied, might unmask root causes of human indifference in health matters. The professions of health along with their

''^^Deming, "Selling Healtli Through Wasliing Macliines," 632; Grace L. Anderson and Mabelle S. Welsh, "Family Health Needs and Nurses' Service," Public Heahh Nursingl)!) (March 1941): 137-41. '^^''David Cushman Coyle, "The Changing Order of Today," Public Health Nursing 26 (1934); 365-71; \'iolet H. Hodgson, "Study of Nurses in Commerce and Industry'," Public Heahh Nursing 23 (1931); 87-9. 243 adjunct cadres of social scientists, worked to discern the behavioral and material influences at work inside human society, in order to reorient and motivate humankind to take advantage of the wisdom of accumulating knowledge about health.""''

Social scientists, particularly psychologists, helped unearth the startling fact that rational, stepwise forms of instruction lacked sufficient integrative educative power. Excessively factual and logical presentation of public health knowledge, after all, was responsible in part for the failure of sanitarj' science education. "Progressive" health teachers relied instead, then, on dynamic, illustrative, experiential, and "psychological" factors to drive their lessons home.'""^'

As we have already seen in the case of mental hygiene, health professionals also exploited the concept of "personalit)'" as a particularly useful epistemological construct emerging from social science study. Sociologists traiiied workers "to consider human beings as persons having personalities wliich are products largely of their group relations." The subtle art of health salesmanship required that health professionals recognize the complex interplay of human relationships and capitalize upon them. "The art of persuasion," remarked one nurse, "depends on one's knowledge of people." The study of individual and group personalities provided valuable grist for that mill.'"''

Health workers came to see each member of the public as a distinct bundle of personalit)'

attributes, genetic traits, mental capacities, and organic potentialities. "An individual's features,

the Unes of his figure, his skin coloring, his expression (whether happy or discontented, gay or

'"^^Hiscock, et al., to Community Health Education, 2; lago Galdston, "Debunking Health Education," Journal oJ the American Medical Association 91 (October 6,1928): 1056; Gruenbetg, "Motivation in Health Education," 118; Galdston, "The Psychophysics of Health Education," 273-5. ''^''Conrad and Meister, Teaching Procedures in Health Education, 34-9; Wiliard Walter Patr\', Teaching Health and Safety in Elementary Grades (New York: Prentice-Hall, Inc., 1940), 79. '"^l.L. Gillin, "Restatement of the Objectives of Social Work Education from the Point of View of a Teacher of Social Science," Journal of Social Forces 2) (March 1925): 408-13; Deming, "Selling Health Through Washing Macliines," 633. 244

sad, winning or unresponsive, alert or dull)" all contributed to person-ness. Decoding these appearances helped reveal the complex whole upon which health salesmanship worked/'*''

Groups of people also had distinguishable personalities with which to contend. Knowing the "normal t)'pes" occurring in the sea of humanit)' helped health workers quickly form their strategies. These t)'pes coalesced around racial and environmental considerations, intelligence quotients, general physique, age, and gender. "Tears appeal to emotional Italians," suggested one manipulative visiting nurse.""'''

The utility' of personality' theorj- extended beyond stereotyping individuals and groups.

Personalit)' and health acted in concert as self-reinforcing or self-attenuating entities. Personalit)' affected human maintenance of health habits as surely as health habits affected human personality. There existed, for example, a linkage between health and happiness, and between sickness and fatalism. The normal personality was attuned to the message of health, and health education diminished communicable disease and promoted safet)-, thereby nourishing the normal personality'. The "healthy personality" by most definitions expressed self-confidence, activity, happiness, wholesomeness, responsibility, and engagement.'*'^"

The personalities of professionals also helped determined the success or failure of health salesmanship. Personality blocked the efforts of egotistic experts, as surely as unselfishness generated positive community health relationslaips. The companionability of expert and public personalities in communities played a defining role in determining health outcomes.'''^'

''^^Hussev, Teaching fur Hea/th, 142-76. ""^''Deming, "Selling Health Tlirough Washing Machines," 633. ^'"WiUiam E. Burkliard, "An Analysis of Educational Objectives and Outcomes in the Field of Health Education," Ph.D. diss., Universit)' of Pennsylvania, 1927, 9-10; Averill, Educational Hygiene, 9; Thomas D. Wood, et al.. Health Education: A Program for Public Schools ami Teacher Training Institutions (New York: Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association, 1924), 24. ""'Hiscock, et al., Ways to Communit)' Health Education, 16. 245

The marketing of health transformed the health education curricula of public and private elementar}' and secondar}' schools, and these schools reached one-fifth of the population. The statement by one health teacher that "boys and girls are just as much interested in health as we strive to make tliem" demonstrates just how far the modern popular health campaign had come.

Schools moved beyond the esoteric study of human anatomy and physiology, instead stressing practical communit}- and personal hygiene so as to "close the wide gap between scientific knowledge and the application of this knowledge to daily life." Practical and personal hygiene, moreover, improved the general communit)'^ standard of living and strengthened moral fiber, and therefore represented "the cornerstone of good citizenship.'"''''"

Schools also sought the participation of all members, teachers, administrators, and staff, in investigating the problem of health promotion. The 1924 /«>;/ Report of the American Medical

Association and the National Education Association, which elevated student health to the number one priorit)' of public schools, reflected in part this enlarging sphere of practice and responsibilit)'. Home economics instructors, the principal, science teachers, and even janitors

played essential roles in purchasing healthy schools and teaching by "correlation" the various

aspects of health in different classrooms. Histor}- could be taught as the storj- of "man's striving

for and achieving a better life." English classes could read of the health horrors of

nineteenth-century London in Dickens' novels. Music and art could contribute to good mental

health by selecting appropriate instruments and media."*'^^

""'Ira Solomon Wile, "Public Health Publicit)- and Education Tlirough Public Schooh" American journal of Public Health 8 (Maj" 1918): 336; Sally Lucas Jean, "Creating a Demand for Health," Proceedings of lbs National Conference of Social W^ork 47 (1920); 15; Andress, Health Education in Riiral Schools, rev. ed., 2-7; Hiscock, et al., ll^ays to Community Health Education, 1,3. ^'^Wood, et al.. Health Education: A Program for Public Schools and Teacher Training Institutions, see esp. pages 76-7; Bolt, "Health Education," 113; Andress, Health Education in Rural Schools, rev. ed., 36-7; Winslow, "Stimulating Health Education," 671; Frank Kiernan, "Health Education Demonstrations in Massachusetts High Schools," Transactions of the National Tuberculosis Association 28 (1932): 254; Hussey, Teachingfor Health, 17; Ruth M. Strang and Dean F. Smiley, The Role of the Teacher in Health Education (New York: 'File Macmillan Company, 1941), 84-6; Lynda M. Weber, Educational Health Teaching Syllabus (Boston; Ginn and Company, 1941), 17, 28; Kathleen Wilkinson Wootten, >1 246

Again, the health and personalit}' of the educator played an important part in establisliing effective public health lessons. "When the teacher practices good health behavior regularly," wrote one nurse, "many pupils will follow her example." Teachers blessed with qualities like

emodonal maturit)', humor, poise, and sincerit)- formed a bond with students hastening the

adopdon of hygienic practices. Likewise, irritable, sarcasdc, and nagging teachers generated

negative health consequences.'''^''

Health educators conscientiously and consistently packaged their messages for mass

consumption. They wanted health education to reach all students, converting outmoded

attitudes toward health and establishing proper habits. At the same time, educators remained

cognizant of the inherent diversit}' of human capacities, attitudes, and desires. The human

equation complexified seemingly simple recommendations for rest, work, nutrition, and exercise.

"What is meat to one is poison to another," noted Columbia professor of public health

administration Haven Emerson. Many paths led to normal health.'*'^^

It should come as no surprise, then, that the changing tastes of young, plastic minds,

coupled with progressive hygienic discover)' and invention, bred fluidity and malleabilit)' into

health pedagogy. Educational media, noted one social hygienist, "is experimental material which

we are ready to scrap" when warranted. It needed to be, explained an editor of Avmican Medicine,

Health Education Procedi/re (New York: National Tuberculosis Association, 1926), 256-9; E. George Payne and Louis C. Schroeder, Health and Safety in the New Curriculum (New York: The American Viewpoint Societ)', Inc., 1925), 47-165. '"''Ruth E. Grout, ed.. Handbook of Health Education: A Guide for Teachers in Rural Schools (New York: The Odyssey Press, 1934), 5; Strang and Smiley, The Rok of the Teacher in Health Education, 284-9; Hussey, Teaching for Health, 69-74; Patty, Teaching Health and Safetj in Elementa^i Grades, 8-36; \Vootten,y4 Health Education Procedure, 14-9;Jesse Feiring Williams and Fannie B. Shaw, Methods and Materiah of Health Education (New York: Tliomas Nelson and Sons, 1936), 300-26. '"^Hiscock, et al.. Ways to Community Health Education, 24; Gruenberg, "Motivation in Health Education," 114,120; Huntington Williams, "Selling Health Department Members First on Health Education," American Journal of Public Health 25 0une 1935): 715; Haven Emerson, "Making Health Knowledge the Propert)- of the Community," Proceedings of the National Conference of Social Work 48 (1921): 67. 247

"dynamic" and have "vitalizing qualities." Fluidit)' in health education technique blossomed as public health became enmeshed in the routine of a wider communit)- that it ser\-iced."''^^'

One of the most repeated necessities of school health education involved the stimulation of proper "health habits." Hand washing drills, individual drinking cups, toilet and handkerchief lessons, and table manners all stimulated positive habits. Students were encouraged to give up candy between meals, tea and coffee, and nail biting. Daily classroom charting of progress reinforced these tendencies. Habits formed the core matter from which sprang "realizations,"

"motives," and "attitudes" sening community- needs. Pupils realized "the sacrifices of others made necessary' by the illness of one of the family group," and understood the "motive of desiring to avoid causing inconvenience and disturbance in the life of others."'''^'

Class projects reinforced the lessons of health. Students created health posters, pasted together health scrapbooks of drawings and pamphlet material, wrote papers on health subjects, sang catchy tunes, and dressed up bulletin boards. Model habitations were constructed on sand tables. Children's posters were sometimes collected and distributed in wider publicity campaigns outside the schools.

Teachers sometimes resorted to "briber)'" when school programs selling health failed to deliver the desired effect on students. Moderate use of souvenirs and trinkets made these

'"''Hiscock, et al., to Community Health Edimthn, 4; Bauer and Hull, Health E-diuatioii oj the Public: A Practical Manna! of Technic, 189; Beachley, "Selling Public Health," 616; W.F. Snow, "Wliat is Being Done to Study Methods in Health Education and Publicity* for Adults and Cliildren?" Journal of Public Health 12 (April 1922): 282; Wile, "Public Health Publicity' and Education Tlirough Public Schools," 340. '"'Avetill, Educational Hygiene, xi; Grout, ed., Handbook of Health Education, 4-5; Andress, Health Education in Rural Schools, rev. ed., 38, 51; Clair Elsmere Turner, "Maiden Studies in Health Education: A Preliminary- Report," American Journal of Public Health 15 (May 1925): 410;Burkard, "An Analysis of Educational Objectives and Outcomes in the Field of Health Education," 204-5. ""^See especiaUy Theresa Dansdill, Health Training in Schools: A Handbook for Teachers and Health Workers, 2nd ed. (New York: National Tuberculosis Association, 1923). Averill, Educational Hygiene, 47, 58; Hussey, Teaching/or Health, 16, 111-4; Bache, "Health Education Program in a Cit)- of 100,000," 585; Conrad and Meister, Teaching Procedures in Health Education, 74-90,109-10; Wiliiams and Shaw, Methods and Materials of Health Education, 238. 248 diminutive health customers pliant. Buttons, ribbons, baubles, balloons, and loUipops all proved useful in "getting things done."'''^'^

Awards and certificates for weight gain or proper habits formalized a "technic of buying and selling" that troubled (but also rescued) many health workers. They also artificially linked

health habits to extrinsic goals. Limited use of material rewards seemed acceptable to most, but

carried with them die potential for "snobbery" on the part of die "star-bearers" against the

"untouchables" in the classroom.^""

Long term acquisition of proper health habits did not come without their general

insinuation into daily life. "Health education of the school child is the joint responsibiUt)' of school, home, and communit)'," explained one nurse. "If health is to function consistendy

throughout the twent)'-four hours, there needs to be an integration of purposes and actions

among these groups." Health education, agreed one school health director, "must be studied not

from the viewpoint of a school alone, but as a communit)- problem, when attempting to alter the

practices of a group."""

The connectedness of existence also meant that parents would be drawn in and exposed

to health education and publicit)'. Children became, in other words, health messengers and

propaganda ministers to their parents and friends as much as they themselves were brought to

task by parents and teachers.^""

""^Bauer and Hull, Heci/llj Education of the Public: A Practical Manual of Technic, 178-9; Wootten, A Health Education Procedure, 196-7. ^""Sauer and Hull, Health Education of the Public: A Practical Manual of Technic. 183-4; Gruenberg, "Motivation in Health Education," 117; Hussey, Teaching for Health, 278-9. Grout, ed.. Handbook of Health Education, xviii-xi.\, 9; Don W. Gudakunst, "A School Health Program as an Educational Acrivit)'," American journal of Public Health 25 (April 1935): 463; T.D. Wood and Hugh Grant Rowell, Health Supervision and Medical Inspection of Schools (Philadelphia: W.B. Saunders Co., 1927), 36; Strang and Smiley, The Role of the Teacher in Health Education, 3-4; Clair Elsmere Turner, "The Communit)- Program of Health Education," American journal of Public Health 25 Qune 1935): 725-9. '"^Wile, "Public Health Publicit)- and Education Through Public Schools," 338. 249

Community health salesmanship outside the schools relied in large measure on publicity.

Some city health departments hired full-time publicity- directors with experience in advertising or newspaper column writing to carty' out this work. Charles F. Rogers, field agent with the

And-Tuberculosis League of Cleveland, called advertising that which "sows the seed," and health education that which "cultivates the soil." Publicity was designed ideally not to impose the will of the professions upon the public, but to guide them along a path satisfactoty in light of expert knowledge.'"^

Amusements and advertising bombarded Americans, and professionals attuned thcii- publicity work to this reality. Laypeople, wrote one college health educator, suffered from

"fashions, fads, and crazes,. . . and the blandishments, allurements, and catchwords of commercial interests" in their ever)'day lives. Health programs in this competitive environment needed to operate along similar lines to be effective.^"''

Publicity drives consciously encouraged the development of a monolithic front behind which a diversity of public health ideas might be entertained. "All truth is relative," C.-E. A.

Winslow intimated, but "our facts should be facts." Professional dissonance, in other words, did nothing to create an atmosphere of trust among laypeople.^"^

Public health publicists also avoided alienating technical jargon. They favored simple language over complex forms of speech and writing. Indeed, the "right person" for a publicity position should possess, besides a penchant for "diplomatic salesmanship," the "ability to translate technical material into popular terms." Health publication editors trimmed or

^"•^Rogeis, "Commercial Salesmanship Applied to Public Health Work," 891-2; Grace Amundsen, "Public Health Education," American journal of Public Health 12 (October 1922): 815-6; James Alner Tobey, "Progress in Health Education and Vvh'^aty," American Journal of PublicHealth 16 (February' 1926); 106-8. ^"''Lloyd Ackerman, Health and Hygiene: A Comprehensive Study of Disease Prevention and Health Promotion (Lancaster, Penn.: The Jaques Cattell Press, 1943), 2; E.G. Burrows, "Newspaper Puh]ic\ty" American Journal of Public Health 15 (April 1925): 317. ^"'Hiscock, et al., W^ajs to Community Health Education, 17; Charles-Edward Amorj' Winslow, "Steps in Planning a Health Education and Publicity' VrogiAm" American journal of Public Health 19 ([une 1929): 647. 250 eliminated tedious tables of vital statistics and the complicated calculations accompanying them.

Figures were rounded off where possible. Layout designers "buUeted" main ideas and issues otherwise buried in columns of text. "You will find in various parts of the country how weaiy people are with the tremendous amount of work they already have on their shoulders," explained one child health worker, "and if we can get our point across quickly and ver)' simply so that the mind and the eye, in the presentation of actual material, is not wearied or bored, it seems to me we have made great progress."^'"^

Experts used "publicity' calendars" to choreograph their sales campaigns. Publicit)' calendars were designed by health departments and official and voluntar}- associations as road maps to effective public health ser\ace. Health workers divided their duties into days, weeks, and months devoted to particular aspects of health work. When reassembled into a coherent whole these healtii "drives" gave the year a natural flow and purpose.'"'

Traditional holidays and seasonal activit}- carried many health publicit)' programs along.

Community health workers all over the counU-y used May Day to focus attention on child health.

Mother's Day signaled a focus on maternal mortalit)'. Heart disease could be tied to Valentine's

Day. New Year's resolutions promoted healthy habits. Seasonal winter topics included pneumonia, colds, and heating. Workers associated spring cleaning and sanitation; summer and sunstroke; fall and allergies. Not all drives were tied to obsei-ved holidays. Public proclamations launched some healtii campaigns. The Wayne Count)' (Detroit) Medical Society in 1924 launched a "Cancer Week" to highlight the utilit)' of roentgen rays against malignant tumors.

The Society enlisted newspapers to publish more than fift)' articles about cancer risk and

'"^Bundesen, "Selling Health: A Vital Dut)'," 1453; Hiscock, et al, lFa}'s/o Communilj Health Education, 53-4; Donald Budd Armstrong, "Vital Statistics for Educarional Uses" Ameriian journal of Public Health 15 (March 1925); 217-9; Hilton 1. Shelley, "Local Publicit)' Use of Statistics from National and State Sources," American Journal of Public Health 24 (May 1934): 331-4; Bache, "Health Education Program in a Cit}' of 100,000," 582-3; Marie L. Rose, "Problems to Be Solved in Health 'Ed'acMxm" American Journal of Public Health 12 (April 1922): 286. '"^Bauer and Hull, Health Education of the Public: A Practical Manual of Technic, 64,193-9. 251

txeatment. Eleven hundred subsequendy presented themselves at the hospital for examinadon.

In May, 1928, the Nadonal Tuberculosis Association kicked off die "Let Your Doctor Decidc" campaign for early detecdon of tuberculosis. The Nadonal Health Council put together a

"Rotary Health Week" to "sell" health to businessmen. Schools, too, established publicit)'

calendars to focus attention on important issues, including health. Schools launched "sunshine"

and "child labor" days, and "baby" and "safet)' first" weeks.^""

The newspaper provided the most immediate and cost-effective mouthpiece for selling

health. Almost ever)' community' of any note possessed tliis "important social agency" read

religiously by many people. Health professionals enlisted editors as sympathetic allies in their

health campaigns, relying on them for advice as to the "news-worthiness" of health activities and

as active proponents of their work. The health departments of Boston, Bridgeport, Chicago,

Columbus, Fall River, Flint, New Orleans, and Providence all tried to get out health stories to the

papers on a daily basis, and many more published on weekly schedules.^"'^

Editors and health workers came to favor human interest stories over less subde forms of

health propaganda in community' news reporting. Stories of personal or community' triumph

over sickness created lay interest by their sheer immediacy. People, explained one journalism

professor, "are interested primarily in themselves." Local events could be used to build stories

redoubling the health resolve of the communit)'.^"'

^"^Richard Arthur Bolt, "Education for Home and Farruly Life," American journal of Public Heahh 21 (April 1931): 438-41; Bauer and Hull, Health Education of the Public, 193-9; Harrj- C. Saltzstein, "Publicit}' in Cancer," journal of the American Medical Association 82 0une 28, 1924): 2140-1; H.E. Kleinschmidt, "A Publicit)' Campaign of National Scope," American journal of Public Health 18 (November 1928): 1369-74; Lawrence Marcus, "VWiat Can Be Done Cooperatively During Tliis Year to Studj' Methods and Materials?" American journal of Public Health 12 (April 1922): 287-8; Wile, "Public Health Publicit)' and Education Through Public Schools," 337; Savel Zimand, "The Campaign Calendar of the Public Health Organization," MUbank Memorial Fund Quarterly Bulletin 9 (October 1931): 165-78. '"'Bauer and Hull, Health Education of the Public, 110; Hiscock, et al., \l'''ci)'s to Community Health Education, 45-6; Beachley, "Selling Public Health," 617; Amundsen, "Public Health Education," 819; Bache, "Health Education Program in a Cit)' of 100,000," 583. ^'"Burrows, "Newspaper Publicit)'," 317; Bauer and Hull, Health Education of the Public, 110; Hiscock, et al., Wctys to Community Health Education, 45-6, 85. 252

The physicians and public health statesmen James Barton, Logan Clendening, In-^ing

Cutter, Morris Fishbein, and lago Galdston all produced regular health columns for newspapers in the 1930s. They became masters of a difficult media for health workers who argued for free professional thought and expression. "Categorical affrrmadon is the stj'le of the newspaper story," commanded Ira V. Hiscock. "Qualifying phrases and hypothetical questions should be reserved for the professional journal." Health educators discouraged dissent even in the editorial columns. Letters to the editor, furthermore, needed to be succinct, genial, and constructive.'"'

Other types of print media helped health professionals sell health. Healtl:i magazines, reports, bulletins, leaflets, and pamphlets all disseminated the emotional appeals of the professions to other professionals and to the public. The American Medical Association published Hjgeia, the Health Maga^ne, for a national audience of interested professionals and laypeople. Thirt}' state departments of health issued popular bulletins, as did thirt)' more cit)' health departments. Their circulation varied from as few as eighty-five copies in Washington,

D.C., to as many as fift}' thousand in New York City. One of the most widely circulated of these bulletins, with a circulation of nineteen thousand, was the Health News of the New York State

Department of Health. Some publications made the rounds almost entirely in industrial establishments or school systems. The United States Public Health Ser\dce distributed almost eighteen million such pamphlets in 1920 alone. State tuberculosis and mental hygiene associations also issued their own promotional health literature. "Dodgers," slips included in pay envelopes, also contributed to the paper blizzard of health serials.^'"

" 'Hiscock, et al., IP'ajs to Community Health Education, 53-4; Bauer and Hull, Health Education of the Public, 113-4; Edward McKernon, "How the Health Officer May Obtain Newspaper PuhUciry," American Journal of Public Health 17 (September 1927): 913; William Ford Higby, "Public Health Education Technics of Special Experiences: Newspupeis," American Journal of Public Health 25 (May 1935): 605-8. ^'"Clair Elsmere Terrj' and F. Schneider, Jr., "Public Health Education and the Family Magazine," American Journal of Public Health 8 (May 1918): 345-8; Bauer and Hull, Health Education of the Public, 90, 96,149,151-4; Hiscock, et al., Wa)'.' to Community Health Education, 71; Burt Ransom Rickards, "What Should be the Policy of the Monthly Health Bulletin?" American Journal of Public Health 12 (April 1922): 286; B.L. Carlton, "Publicit)' as a Means of Promoting 253

Professionals made palatable the popular consumption of health-oriented literature by careful design. Health workers learned new techniques from clinics with art school directors, printers and publishers, and direct mail advertisers. The public, health workers learned, preferred clean, slick publications over haphazardly, organized ones. The public hated oppressive gray and blue circulars replete with capitalized words and phrases. Health professionals paid scrupulous attention to presenting legible tj'pe fonts, unobstructed margins and gutters, kerning, and simple charts and graphs much in the same way Lalique and other contemporar)- industrial designers

"streamlined" and "cleanlined" automobiles and household appliances.^'^

Charts and graphs also became staples of health exhibits and health museums. Visual elements, attractive to public viewing, brought together in these exhibits and museums became another way professionals sold communit)' health. Photographs, maps, models, dioramas, suitcase theaters, window displays, and posters, usually arranged into "an impressive, instructive, attractive whole," lent instant clarit)' to the important work of health professionals and to communit)' responsibilit)' for public health.^'''

Traveling exhibits, of van'ing ephemeralit)\ went to schools, state fairs, expositions, conventions, and anniversaries. Workers assembled health exliibits at the Centur)' of Progress

Exposition and Texas Centennial Exposition, the California-Pacific Exposition and the Great

Lakes Centennial, and on college campuses. Science museums in Buffalo, Chicago, Philadelphia,

Efficiency in Health Work," American City 23 Quly 1920): 57; James Alner Tobey, "Pamphleteering and Public Hszhh," American journal of Public Health 12 (Februar)' 1922): 149; Amundsen, "Public Health Education," 816-8; Bache, "Health Education Program in a Citj' of 100,000," 585-6. ^'"^Hiscock, et al., ll^a)'f to Community Health Education, 66-7, 73-4; Jules Schevitz, "Advertising as a Force in Public Health Education," American Journal of Public Health 8 (December 1918): 916-21; Routzahn, "Health Education and Publicit^^" 248-50; Marj- Swain Routzahn, "The Clinic on Printed Matter," American Journal of Public Health 14 (Ianuar\-1924): 43-50. ^'^Hiscock, et al., Ways to Community Health Education, 104,108,112,115,116,118-9; Evart Grant Routzahn, "Sources of Material," Journa/ of Public Plealtb 16 (March 1926): 268; Bauer and Hull, Health Education of the Public, 68-9, 71-2, 75; James Alner Tobey, "Selling Health by Window Exhibits," American City 25 (September i921): 232. 254 and New York all gave over space to exhibits. Chicago's health department constructed a birth registration exliibit, and Washington, D.C., one on the venereal diseases. A small town in Ohio put on the exposition "Let Health Rule in Bethel," complete with demonstrations of Schick tests, poster contests, mechanized exhibits, and sermons and speeches on matters of health. These exhibits displayed all manner of health articles, including toothbrushes, fly ttaps, nutritious foods, first aid kits, sterile instruments, pharmaceuticals, sputum cups, microscopes, and x-ray machines.

"Healthmobiles" and converted railroad cars also toured the countr)'side carrying the message of health to the public.'"

Educational exhibits also infiltrated professional health meetings. "Scientific exhibits" began showing up at the Semicentennial American Public Health Association meeting in 1921.

In 1933, the APHA seated a permanent Committee on Scientific Exhibits, which promptiy put together the "large and remarkable" exhibit "Public Health and Eugenics in New Germany."

Judging began in 1936, following four general rules: (1) the "effectiveness of die exhibit in attracting attention," (2) its "effectiveness in holding attention," (3) its "clarity in expressing its message, and (4) whether "the message is . . . pertinent for presentation to a group of public health workers." A Motion Picture Program, initiated separately in 1936, became part of the

Scientific Exhibit in 1941.^"^'

Interest in the permanent housing of exhibits generated two attempts to create health museums. Members of the American Public Health Association organized a Committee on

American Museum Hygiene in 1931 to construct a "House of Health." By 1939, the Museum

'''Bauer and Hull, Health Education oJthe Public, 62-3, 179; Bleecker Marquette, "A Small Town Health Exposition," American Journal of Puhlii: Health 13 (May 1923): 396; Averill, Educational Hygiene, 45. "^Homer N. Calver, et al., "Scientific Exliibits," journal of Public Health Yearbook (1937-8): 42-3; idem, "Scientific Exhibits," American Journal of Public Health Yearbook (1941-2): 54-60; Milton S. Rose, et al., "Exhibit A^9.tAs" American Journal of Public Health Yearbook (1941-2): 60-1. 255

Committee had collected together exhibits, many from the German Hygiene Museum/'' at the

New York World's Fair. Over 11 million visitors later, the museum by 1941 still had not found a permanent abode, and began loaning out its exhibits for traveling shows. Independently, a

Cleveland Museum of Health and Hygiene, incorporated in 1936, opened its doors to visitors in

1940 as a "center of communit)' health education."®'"

Health professionals studied the effect of their exhibit and museum sales pitches in detail.

They found that seventy-five percent of visitors walked around mazes of displays always tending to die right and rearranged them to fit this ambulator)' pattern. Professionals found crowding of the exhibits an important cause of "museum fatigue." New labels for displays, developed from lengthy research, increased patron engagement by up to one-tiiird. Moving parts (as in mechanical dioramas) built energy and interest into otherwise immobile sales messages.

Health shows, plays, pageants, and parades further shattered the static aura of health exhibits and museum displays. Children played most of the key roles in these dramatic and dynamic presentations as players and as a core audience. Puppet shows, singalongs, poetry and

inspirational museum described in one place as proceeding "on the assumption that an entire subject could be demonstrated visually and that various messages could not only be made clear in themselves, but could be related to each other." See Hill, Ednailiii^ for llen/lli: A Sliiily of Programs for Acln/ls, 188. ^'"Benjamin Charles Gnienberg, A Museum of Health (New \'ork: American Public Health Associauon, 1937); N'ictor G. Heiser, et al., "Committee on American Museum of Hygiene," American jotirnal of Public Health i 'earbook (1936-7): 38-40; Louis Israel Dublin, et al., "Association Committee on American Museum of Hygiene," American journal oj Public Health Yearbook (1938-9): 30-1; idem, "American Museum oiHy^cnc" American journal of Public Health Yearbook (1939-40): 45-6; idem, "American Museum of Hygiene," American journal of Public Health Yearbook (1940-1): 60; idem, "American Museum of Hy^cne" American journal of Public Health Yearbook (1941-2): 52-3; American Museum of Health, Proceedings oftije Dedication of the Aiuseum, june 17, 1930, in the Medicine and Public Health Buildings New York World's Fair, 1939 (New \'ork: American Museum of Healtli, 1939); Hill, Educating/or Health: A Study of Programs for Adults, 186-92. See also Bruno Gebhard, "The Changing Ideology- of Health Museums and Health Fairs Since 1850," BuHetiu of the History- o/Aledicine 33 (March-April 1959): 160-7; idem, "From Cincinnati's Western Museum to Cleveland's Health Museum," Ohio State Archaeological and Historical Quarterly 59 (1950): 371-84; idem, "From Medicine Show to Health Museum: Historical Aspects of Public Health Education in the United States of America," Ohio State Medical journal 5\ (1955): 145-7; and idem, "From the Dresden Hygiene Museum to the Cleveland Health Museum," Ohio State Medical journal M (1968): 1004-8. '"Edward S. Robinson, "The Psychology" of Public Education," American journal of Public Health 23 (February 1933): 126-8; Mary Swain Routzahn and Evart Grant Routzahn, Publicilj for Social Work (New York: Russell Sage Foundation, 1928), 289-90; Homer N. Calver and Bertrand Brown, "Marketing Mass Education," American journal of Public Health 22 Qanuan' 1932): 56-7. 256 stoiy readings, dramas and comedies, all ser\'^ed as health distribution mechanisms to children and their parents. Cho-Cho the Health Clown (sponsored by the American Child Health

Association), and dramadzations derived from the text Cho Cho and the Health Fahy, delighted school pupils with humorous sketches involving proper and improper health habits.'-"

Professionals used parades to bring together a whole communit)' in one place to engage in a shared expression of faith in the health crusade. Children, dressed as fruits, vegetables, and toothbrushes, some carr^'ing signs and banners, marched down Main Street or rode atop floats with tombstones carrying inscripdons like "1,054 Children Killed in Accidents in New York Cit}',

1921," as their parents looked on. Pageants also sen'^ed this cotnmunit)- building function. "A

Visit from Mars," first put on in Mansfield, Ohio, in 1923, introduced visiting healtli officers

from the red planet to the robust children of "Healthy Town.""'

Radio represented a relatively new and growing medium for public health salesmanship.

Six hundred stations blanketed the United States by 1939 and 23 million families possessed radio

receivers. Advertisers paid over 572,000,000 for radio spots nationwide. Critics called radio "the doorknob which gives entrance to the intimate privacy of the home."^~

The American Societ)- for the Control of Cancer used a Denver station to broadcast die

first known radio health show in 1921. Regular, continuing health broadcasts began the same

year by the United States PubUc Health Sen'ice over naval radio. The Connecticut State Board of

Health initiated a health drama involving the "Smithson Family" in 1931. The New York

'•"Bauer and Hull, Health Edticalion of the Public, 182; Grace Taber Hallock, Dramalit^ng Child Health: A New Book of Health Plays, with Chapters on the the Producing, and the Educational I 'alue of Dramatics (New York: American Child Health Association, 1925), 3-4, 6, 79. '•'Bauer and Hull, Health Education of the Public, 187; Routzahn and Routzahn, Publicity for Social Work, 269-71; Hallock, Dramativjug Child Health, 259, 262-75. '"^Hiscock, at al., to Community Health Education, 92; Bauer and Hull, Health Education of the Public, 43; Alan Blanchatd, "Health Information on the Air," American fournal of Public Health 25 (October 1935): 1081. On the culture of radio see Susan Smulyan, Selling Radio: The Commerciali^tion of American Broadcasting 1920-34 (Washington, D.C.: Smithsonian Institution Press, 1994). 257

Academy of Medicine aired the fifteen-minute program "Highways to Health" each week beginning in 1932. The New York State Department of Health jumped aboard in 1934 with its regular show about "The Health Hunters." The National Life and Accident Insurance Company broadcast two serials in 1934 and 1935 entided "Man's Fight to Live," and "The Strong Family."

In 1935 and 1936 the National Broadcasting Company and the American Medical Association cooperated in the production of "Your Health.""'^

Selling health on the radio was not without its dangers. Radio advertised pharmaceuticals and beaut)' aids of marginal value, including "J.R. Brinkley's Goat Gland Treatment," the

"Neurometer," and Norman Baker's cancer cures. The New York Academy of Medicine and

Department of Health began broadcasting health shows in 1922 in response to a radio address on the prevention and treatment of cancer by a "food faddist." Reputable commercial establishments also blanketed the airwaves with commercial health messages. The drug company

Sharpe and Dohme sponsored programs on health and disease. The Cream of Wheat

Corporation put on chats about mental hygiene and child training. The Metropolitan Life

Insurance Company, Horlick's Malted Milk, and Stanco, Inc., all put their own health messages on the radio. Health professionals worried that in this environment unsophisticated radio listeners might lose (or worse, confuse) theii- health message amid the cacophony."''

^•^Bauer and Hull, Health Education of the Public, 40-1. Hie content of radio health talks is documented in Henn' Copley Greene, Listen In: Radio Health Talks (Boston: American Red Cross, Department of Health Scrvicc, Boston Metropolitan Chapter, 1923); J.D. Dowling, Health bj Radio: A Series of Radio Lectures on Personal and Public Health Presented over Station WAPI (Birmingham, Ala.: Jefferson Count}- Board of Health, 1931); Baltimore Cit)' Hcaltli Department, Bureau of Public Health Education, Keeping Welh The First Hundred Radio Talks (Baltimore: Baltimore Cit)' Health Department, 1937); Baltimore City Healtli Department, Bureau of Health Information, Keeping Well: The Second Series of Radio Talks (Baltimore: Baltimore Cit)' Health Department, 1937); Monroe Count)' Medical Societ)', Radio Health Broadcasts (Rochester, N.Y.; Jefferson Count)' Board of Health, 1940). '"''Hiscock, et al., 11''^'/ to Community Health Education, 95; Blanchard, "Health Information on the Air," 1085-6; Donald Budd Armstrong, et al., "Radio Broadcasting: Critical Snidy of Health Education," in Radio in Health Education (New York: Columbia Universit)- Press, 1945), 1; Brown, "Adult Health Education," 1065; Clair Elsmcre Turner, et al., "Effectiveness of Radio in Health 'EdncMoa," American Journal of Public Health 25 (Maj' 1935): 593. 258

Certain subjects otherwise palatable to laypeople also becamc taboo on the radio, at least at certain times of the day. Americans listened to the radio copiously, and sometimes all day.

Health professionals learned to avoid scheduling talks on venereal disease, sewerage systems, and horrific epidemics at meal times, or when children might be listening. Moreover, all of the national radio networks classified as off limits certain words commonly used within the professions. The "objectionable" words bowels, breast, discharge, pregnancy, pus, rectum, syphilis, urine, uterus, womb, and even abdomen could never be used. Topics entirely avoided included birth control and social (venereal) hygiene."^

As with other media, health professionals discovered that st)'le contributed to the selling of substance in othenvise "dull and uninteresting" radio health talks. Most health broadcasters, often health officers, educators, and physicians, found themselves in unfamiliar tcrritor)' on the radio, unable to squeeze their "cluttered" addresses into short spots designed for a popular

audience. They lacked what was called the nccessary but unquantifiable "psychology of address."

Radio speakers strove to compensate in several ways. Simplicit)' helped, as did appeals to common sense. A variet}' of approaches to educational material, lecmres, dramas, and stories for

example, kept shows fresh. Colloquial, conversational speech created unique feelings of security

over the airwaves, as did the soothing male baritone voice. Musical inti'oductions signaled regular

listeners to begin paying attention and bred familiarit)-.^"'^

Motion picture projectors represented another modern mechanical technolog)' applied to

health salesmanship. Motion picmres breathed life into otherwise esoteric health subjects,

'""^Hiscock, ct ill., to Comnnmity Health Education, 99; Bauer and Hull, Health Education of the Public: A Practical Manual of Technic, 50-1; Armstrong, et al., "Radio Broadcasting; A Critical Study of Health Education," 2. ^"^\rmstrong, et al., "Radio Broadcasting: A Critical Study of Health Education," 1, 11, 21, 30; lago Galdston, Critique of the Objectives and Techniques in Health Education," in Radio in Health Education (New York: Columbia University- Press, 1945), 40-4; Frank Ernest Hill, "On Forming a Program," in Radio in Health Education (New York: Columbia Universit)' Press, 1945), 47; Alan Gregg, "Basis, Purpose, and Method," in Radio in Health Education (New York: Columbia Universit)- Press, 1945), 68; Hiscock, et al., U^ajs to Community Health Education, 97-8; Bauer and Hull, Health Education of the Public: A Practical Manual of Technic, 46. 259 bundling them (when done properly) for mass consumption. Motion picture producers compressed the essence of action, the dynamism of modern America, into their 16 and 35 mm film stock. Experts showed these films in schools, factories, theater houses, at Chautauquas and churches, wherever audiences could be naturally collected together."' Health workers incorporated film into their traveling exhibits by utilizing continuous-automatic mechanisms for repetitive performances.""

Health experts, especiallv the Societ\- for Visual Education's Committee on Health and

Sanitation,"'^ formulated rules for producing and showing health pictures. Good health films had several virtues. Simplicit)' was one. Too many rules or messages placed in motion pictures confused audiences. One or two major themes was enough for any film. Another virtue was the condition of the film. A scratched film distracted and diminished interest in the message. Films that evoked powerful emotions also worked magic in publicit)' campaigns. One particular picture about hookworm, for instance, "makes the Southern cotton planters get the willies when they sec it."""

Popular health films roughly fell into three groups: films demonstrating the work and commitment of health agents and agencies, films explicating the mechanics of biolog}' and health, and films advocating particular health habits. Films in the first categoiy included those showing

the work of the United States Public Health Seivice or of the visiting nursing association, immunization drives, or health campaigns and parades. The nvent)' minute film "The Juice Bowl:

^"'Bauer and Hull, Health Education of the Public, 121; Evart Grant Routzahn, "Health Education and Publicit)' Round Tahiti" American journal of Public Health \1 (June 1927): 573. '"''Bauer and Hull, Health Education of the Public, 124. '"^Members included N'ictor C. N'aughan, chairman, Simon Flexner, F.M. Gregg, Ludwig Hektoen, E.O. Jordan, Wickliffe Rose, M.j. Rosenau, and Clair Elsmere Turner. ''°Clair Elsmere Turner, "Should There Be Any Difference in the Type of Picture Produced for Classroom Use and That for Popular Education?" American journal of Public Health 12 (April 1922); 270-1; Stanley Osborn, "What Standard Should Be Set for the Pictures Used by Health Agencies?" American journal of Public Health 12 (April 1922): 272; Ernst Christopher Meyer, "What are the Needs in Health Motion Pictures that are Not Met at Present?" American journal of Public Health 12 (.\prii 1922): 275. 260

Is it a Menace to Public Health?" recorded tlie experiences of two health experts tcsdng samples taken from unsanitarj' drink booths at the 1933 Minnesota State Fair. Films in the second category included the "Science of Life Series" on reproduction, personal hygiene, disease prevention, and such matters. "Getting Acquainted witli Bacteria," produced by the Societ)' for

Visual Education, used shots made through the microscope to illustrate its points.'^'

Films in the last categorj^ those involving health habits, sold health to the public by direct appeals to the heart and head. A motion picture funded by the Kern Count)' (California) Health

Department entitled "Sells Heakho Circus" showed the live action of a health circus put on b)' pupils of Wasco Grammar School. Children dressed as Mother Nature, Miss Cleanliness, Miss

Rest, Mr. Exercise, Miss Sunshine, and Mr. Whole Wheat. Others wore costumes approximating fruits and vegetables. Dancing, marching, and vigorous tooth brushing are all depicted. The message of the picture is that good health brings happiness. The eleven minute film "The Road to Health and Happiness" advised viewers to live a healthy life by sleeping well, exercising in fresh air and sunlight, brushing the teeth, and getting immunized. Good mental hygiene is stressed through reading, listening to the radio, swimming and roller skating, and going to church.

Cho Cho the health clown got his own motion picture debut in "Cho Cho the Clown School

Teacher: A New Method of Teaching Children" (1919).'^"

Competition from commercial film productions also diminished the novelt}' and hence usefulness of motion pictures selling health. Commercial films raised the bar substantially between 1920 and 1940, creating a sophisticated audience that no longer tolerated amateurish

"'"The Juice Bowl: Is it a Menace to Public Health?" 16mm/b&w (1933); Clair Elsmere Turner, "Motion Pictures as Used in Health Education: \''isualized Truth Carries its Own Argument and Calls Forth Immediate Response," Nation's Health 4 (Ianuar\' 1922): 17-9; H.E. Kleinschmidt, "\Vlio Shall Make the Motion Picture, the Health Worker or the Professional Motion-Picture Man?" American Journal of Public Health 12 (April 1922): 276. On the eugenic import of some of these health films see Martin S. Petnick, Black Stork Eugenics and the Death of "Dejktive" Babies in American Medicine am! Motion Pictures Since 1915 (New'i'ork: Oxford Universit)' Press, 1996). "•Guynoir Kratka (director), "Sells Healtho Circus," 16mm/b&w (1933); R. David Bennett Hill (director), "Tlie Road to Healtli and Happiness," 16mm/b&w (1937). 261 productions shot on shoestring budgets. Commercial productions moved into the territor)- of health professionals too. Audiences willingly paid to see Anvwsmith, The Country Doc/or, Life of

Lanis Pasteur, The White Angel, and Yellow Jack. Professional filmmakers, despite their tendency to

"burlesque" serious subjects, increasingly took the place of health experts in the producdon of films. Experts continued to monitor their content. Animated shorts represented another response to the inadequacy of novelt)' as a drawing card. "How Life Begins," an animated film by the American Social Hygiene Associadon, brought the unfilmable to the screen. Producers also used animadon for the army and na\y training film "Venereal Diseases."^^"^ Despite the effecdveness of these flickering images, motion pictures by the 1920s had not replaced other projecdon devices used in producing popular health messages. Stereopdcons or lantern slides, in fact, made a comeback in the 1930s and 1940s as a useful adjunct to lecmres and shows."''

All of these publicity devices for selling health meant Utde without the active pardcipadon of a willing public. OrdinaiT cidzens formed the clay from which the professions of health formed their programs. Health professionals targeted the fundamental social units of societ)', families, in dieir health advertising and publicit)' campaigns. Experts encouraged parents and their children to provide "unlimited support" to the modern communit}' health movement.

Health workers charged parents with the responsibility for their children's normal development by immunizing them and carefully monitoring their diet, sleep, play, and mental habits.^'^'

Laypeople could also be trained by health professionals as able and efficient salesmen for health themselves. Perhaps the largest share of the brute front-line work of the modern

^'•^Hiscock, et al., U-'ajs to Community Health Education, 124; Bauer and Hull, Health Education of the Public, 123; Strang and Smiley, The Rale of the Teacher in Health Education, 249; W.P. Shepard, "Recent Progress in Health Education," American journal of Public Health 27 (May 1937): 456; Meyer, "What arc the Needs in Health Motion Pictures that are Not Met at Present?" 275. ^^''Hiscock, et al., to Community Health Education, 134; Bauer and Hull, Health Education of the Public, 131; Patt)', Teaching Health and Safety in Elementary Grades, 173. ^'^Grout, ed.. Handbook of Health Education, 9-10; Beachley, "Selling PubUc Health," 616; Hussey, Teaching/or Healtij, 203-5. 262 community health campaign fell to ordinan' citizens and civic leaders. "If further progress in healdi is made," noted lago Galdston, "the people must be taught to do things for themselves."

Health experts entertained representatives of social, religious, educational, business, and recreational associations as potential agents in health commerce. In successful health campaigns, explained one health authority', "there was always some public spirited citizen in even- community who was looked upon to take the lead." Tight budgets in tlie 1930s redoubled efforts to enlist the aid of laypeople. While prohibited from engaging in the development of new immune sera or disinfectants, laypeople could keep track of the budgets of voluntary health agencies or negotiate solutions to identified problems.'^^'

Individual laypeople often worked through preexisting community' associations, chambers of commerce, or community chests. All brought to die table a considerable natural network of community resources. Potent community' associations enlisted to sell health included fraternal orders like the Elks Club or Knights of Pythias; social and educational groups like the Grange and the PTA; and voluntaty' health alliances like the many local Red Cross chapters and

Federated Mothers' Clubs."'

Health salesmanship, education, and publicity all depended on teamwork in the accomplishment of community health goals. Selling always benefited by reinforcement. As one social welfare worker put it, "United we stand, divided we fall." Experts coordinated official and

voluntaty' health and welfare associations, and folded members of disparate social, religious, and

educational groups into coherent wholes. Throughout, however, professionals preferred "careful

"''Deming, "Selling Health Through Washing Machines," 633; Galdston, "Health Education," 338; Hiscock, et al.. Ways to Community Health Education, 30-33. ^^'Sleecker Marquette, "\'oluntar\' Agencies' Activities in a Cit\' Health Education Program," American journal of Public Health 19 (October 1929): 1123-8; Mabel Traer Harding, "Rousing Interest in Health," Survey 43 (March 13, 1920): 742; Hiscock, et al.. Ways to Community Health Education, 34; Elma Rood, "Participation of Lay People in the Promotion of a Rural Child Health Program," American Journal of Public Health 22 (October 1932): 1027-32; Amundsen, "Public Health Education," 823. 263 blending" over domination. Health salesmanship remained an interdependent function of communit}' health principles and pracdce.'^"

The most dramatic difference between the earlier sanitar)' scientific model of popular education and later communit)' health efforts involved the charismatic, emotive attempts to sell healdi to the masses. Experts drew business people, publicists, editors, writers, ministers, broadcasters, directors, actors, and even laypeople into tliis new web of communit)' health relationships. Professionals and the public in the age of communit)' health sold health much the same way other goods and sen'ices were sold."'^

Still, the professions did acknowledge limits to the commodification of sanitary and communit)' health knowledge. The manipulative qualit)' of public health work enhanced by health salesmanship generated what seemed to be some distincdy negative consequenccs.

Self-promotion deflated expert objectivit)' established by a long histoiy of neutral obsen'ation and disinterestedness. It inflated the egos of some. Selling health also blurred the boundar)' between quacker)' and authenticit)'. One cit)' commissioner of health worried that "technics in public health education and in salesmanship and advertising are developing, if anything, a little more rapidly that they may be safely assimilated."^'"'

'^'^Brown, New Deal in Health Education," 743; Harding, "Rousing Interest in Health," 742; Winslow, "Stimulating Health Education," 670; John W. Trask, "Heahh Publicity' an .Vid to Cooperation Between Health Department and Citizen," American Journal of Piiblii: ]-\ealth 8 Qune 1918): 417-20; Pauline Brooks Williamson and Fanny Movchine, "School Health Needs as Described by .-Vdministrators," Edmalion 57 (Alay 1937).- 522; Strang and Smiley, The Kok of the Teacher in Health Education, 257. '^'Lendol Calder, Financing the American Dream: A Cultural History oj Consumer Credit (Princeton, N.J.: Princeton Universit}' Press, 1999); William Leach, Land of Desire: Merchants, Power, and the ?Jse of a Neiv Consumer Culture (New York: Pantheon Books, 1993); Roland Advertising the American Dream: Making for Modernity, 1920-1940 (Berkeley: Universit)- of California Press,1985). See also Warren I. Susman, Culture as His/or)': The Transformation of American Society in the Twentieth Century (New York: Pantheon Books, 1984), esp. pages 122-8. ^""^Hiscock, et al., W^'s to Community Health Education, 51; Bauer and Hull, Health Education of the Public, 21 Galdston, "Debunking Health Education," 1055; Williams, "Selling Healdi Department Members First on Health Education," 718. 264

Some authorities bemoaned the continued disease of "hypochondriasis" fostered among overly willing customers succumbing to health propaganda. lago Galdston noted tliat the health giving qualities of fruits and vegetables had become "oversold" to some people, resulting in

"hypermotile colons" irritated by too much cellulose. Others worried simply about making people too "self-conscious" of their health defects and personal inadequacies.^'"

Sinclaii'Lewis' nove\ y\n-ommi/h (1925), written with the expert assistance of Paul de

Kruif, details the foibles of health professionals pushing health salesmanship too far. The character Roscoe Geake, budding bacteriologist Martin Arrowsmith's hated professor of otolaryngology at the Universit}- of Winnemac, delivered the following diatribe annuall)' to his classes:

Knowledge is the greatest thing in the medical world, but it's no good whatever unless you can sell it, and to do this you must first impress your personalit)' on the people who have the dollars. Whether a patient is a new or an old friend, you must always use salesmanship on him. . . . The graduates of tlie Universit}' of Hard ICnocks judge a physician as they judge a business man, not merely by his alleged "high ideals," but by the horsepower he puts into carr)'ing them out and making them pay!

Tucked within the speech, Prof. Geake recommends the fictional book How to Put Pep in

Salesmanship.

Sinclaii-'s character Dr. Almus Pickerbaugh, director of the Zenith (Iowa) Department of

Public Health, also evoked re^'ulsion in the chief protagonist Arrowsmith. "1 assume,"

Pickerbaugh tells Arrowsmith,

you agree with me, or you will when you have had an opportunit)' to see the effect our work has had on the cit}% and the success we have in selling the idea of Better Health, that what the world needs is a really inspired, courageous, overtowering leader—say a Billy Sunday of the movement—a man who would know how to use

^•"Williams, "Selling Health Department Members First on Health Education," 718; lago Galdston, "Hazards of Commercial Health Advertisements," American Jotiriial o/Piibtic Heatth 21 (March 1931): 246; Wood, et al., Heahtj Education: A Program for Pubtic Schools and Teacher Training Institutions, 85. '"'"Sinclair LcwAi, Arrowsmith (London; J onadian Cape, 1925; reprint, Chicago: Harcourt, Brace, and Company, 1945), 86-9. 265

sensationalism properly and wake the people out of their sloth.

Pickerbaugh considered himself such a man, favoring "good health, good roads, good business, and the single standard of moraUt)'" by founding the local Rotan' Club, superintending over a

Sunday school, presiding over the Moccasin Ski and Hiking Club and the West Side Bowling

Club, and cheerleading for a half dozen other communit)' organizations. A selection of his speeches included "Health Maxims for Trolly Folks," "More Health—More Bank Clearings," and

"Health First, Safet)' Second, and Booze Nowhere A-tall."^'*-^

The young Martin Arrowsmith rebelled against both Geake and Pickerbaugh. He preferred practical research, "working in a laboraton' at night, alone, absorbed, contemptuous of academic success," over commercial health salesmanship. Of Pickerbaugh, Martin thought "that to a civilized man the fact that Pickerbaugh advocated any reform would be sufficient reason for ignoring it.'"''''

Part of die appeal of Sinclair's novel, though, is Arrowsmith's revelation of the necessit}' for tlie Geake's and Pickerbaugh's in modern health work. Though he himself is not intrigued by such activit)', at one point Arrowsmith remarks tliat "this pep and heartiness stuff of

Pickerbaugh's is exactly the thing to get across to the majorit}' of people the scientific discoveries." Arrowsmith's long suffering and somewhat naive wife Leora corrals die business of health salesmanship best. "I get it," she exclaims to Arrowsmith one day. "Your job will only take about twent)'-eight hours a day, and the rest of the time you're perfectly welcome to spend in research, unless somebody interrupts you."^"*^

"^Ibid., 203-6. ^•'''ibid., 12, 207. ''''Lewis, Arromm'tih, 207-8. For other obseivations on Arrommith see H.L. Mencken, "Arrowsmith," American hUrmty^ (April 1925); 507-9; T.K. Wliipple, "Sinclair Lewis: Arrowsmith," Nw Republic A2 (April 15,1925): 3-5; Haven Emerson, "A Doctor Looks n Arrommith," Surv^-b'^ (May 1,1925): 180; Lyon N. Richardson, "Arrommilk Genesis, Development, ^'ersio^s," American Literature 27 (May 1955): 225-44; T.R. Fyvel, "Martin Arrowsmith and His Habitat," New Republic 133 Quly 18,1955): 16-8; Charles E. Rosenberg, "Martin Arrowsmith: Tlie Scientist as Htzo" American Quarterly 15 (1963): 447-58; and James M. Hutchisson, "Sinclair Lewis, Paul de Kruif, and the 266

CHAPTER IX. COMMUNITY HEALTH DEMONSTRATIONS

The professions of health used educational publicity campaigns to can'^e out their own ideal markets in which to "sell" health ser\'ice. They called them "health demonstrations."

Health demonstrations became an important way experts and laypeople solved communit)' health problems together. The National Tuberculosis Association, Milbank Memorial Fund,

Commonwealth Fund, Rockefeller Foundation, and the United States Public Health Sen^ice sponsored some of the most influential professional health demonstrations in modern, interwar

America. These agencies secured experts in private and public employ to direct and carr)' out health work in natural communities. Defenders considered demonstrations cooperative ventures, shared experiences between public and private funding sources and administrative agencies, and between professionals, local health authorities, and citizens. Each constimency contributed its talents to the whole, but all bore together the tribulations and exuberancies of the demonstrations.^'"^'

Professionals did not intend that the demonstration be a "laborator}' of experiment" as delineated by the ethos of sanitar)' science. The application of already known facts eclipsed (but never replaced) discover)' of new progressive and scientific hygienic laws. Experts designed

Composition oi Amwsmith," SIndies in the Novel2A (Spring 1992): 48-66. Many of these essays are collected in Robert J. Griffin, ed., TweiUieth Century Interpretations o/"Arro\vsmith (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1968). ^"""George C. Ruhland, "Health Demonstrations," journal of Public Health 19 (March 1929): 287; Livingston Farrand, "The Philosophy of Health Demonstrations," American Journal of Public Health Supplement 17 (February 1927): 1-4. For the historiography of health demonstration philanthropy see Howard S. Berliner,^ System of Scientific Medicine: Pi}ilanthropic Foundations in tise Flexner Era (New York: Tavistock, 1985); E. Richard Brown, Rockefeller Medicine Men: Medicine and Capitalism in America (Berkele)': Universit}' of California Press, 1979); Raymond Blaine Fosdick, The Stoy of the Kockefeller Foundation (New York: Harper, 1952); A. McGehee Har\'ey and Susan Abrams, For the Welfare of Mankind: The Commonwealth Fund and American Medicine (Baltimore: Johns Hopkins Universit)' Press, 1986); and Warren Weaver, U.S. Philanthropic Foundations: Their Histoiy, Structure, Management, and Record (New York: Harper & Row, 1967). 267 demonstxations, rather, to bring together authentic knowledge derived in laboratories and field sur\^e)'s and opportunities for application. "About the most difficult thing with wliich the world has to contend is the lack of applicadon of knowledge which is akeady in possession of the experts," explained Livingston Farrand. "Most of our victories over disease are traceable to some careful, painstaking pieces of scientific research in the laboratory or with limited and carefully controlled groups and conditions outside it," explained Courtenay Dinwiddie, director of the

Commonwealth Fund demonstrations. "The number of variables is greatly increased when the knowledge tliat has been gained in laboratories or in strictly controlled experiments is carried into the field. There has been a wide gap between tlie accumulation of scientific knowledge of how to control disease and to build up health, and the application of this knowledge to the daily health problems of the public."''*'

Administration, salesmanship, methodology, and finance occupied the minds of many professionals in health demonstrations. "The demonstration is something between research and education," noted C.-E. A. Winslow, a program designed to take expert ideas and strategies out into the real world for further refmement. "The demonstrations," wrote Walter H. Brown of the

Commonwealth Fund, "are acting as research stations for the discover)' of improved methods of communit)- organization for health." George C. Ruhland, Health Commissioner of one Milbank

Fund demonstration agreed, "There is nothing experimental about health demonstrations except in the technic of establishing modern health procedure in a given communit)', and in so far as the relationship of humans to one another is always experimental."^''"

^""^Livingston Farrand, ".Annual Meeting Minutes," Milbank Memorial Fund Quarterly Bulletin 1 (januar)' 1924): 30-1; Courtenay Dinwiddie, Child Health and the Community: An Interpretation of Cooperative Effort in Public Health (New York: The Commonwealth Fund, 1931), 58. '"'^Farrand, "The Philosophy of Health Demonstrations," 1-4; Homer Folks, "Financial Aspects of Health Demonstrations," Journal of Public Health Supplement 17 (February' 1927): 6; Charles-Edward Amor)' Winslow, "The Liwng Hand: Elizabeth Milbank Anderson," in Milbank Memorial Fund: A Meeting Commemorating ll)e Twenty-Fifth Anninersaiy (New York: Milbank Memorial Fund, 1930), 34; Walter H. Brown, "Organization of Health Demonstrations," American journal of Public Health Supplement 17 (Februar)' 1927): 15-6; Ruhland, "Health 268

The cenaal goals of dcmonsttations involved coordinating health resources, publicizing

the fruits of public health research, and educating the public. Health experts and their sponsors agreed that energetic public "demonstrations" of effective public health tools cultivated curiosit)-,

immediacy, and the formation of healthy habits. Professionals, in other words, saw

demonstrations as lessons given on a mass scale to raise communit)- consciousness.

At the same time demonstrators worked hard to create a harmonious environment for

local officials, experts, and volunteers. Public health professionals entered demonstration

communities with discretion. "They must," explained Walter Brown, "hax'e the rare abilit)' to

become temporarily a real part of the communit}'." Personalities and relationships were crucial

aspects of demonstration work. Professionals listened carefully to the voices of laypeople, just as

they shepherded them to good health. Further, these professionals found solutions to the

problems of communit)' health generaUy,^'*'^

Great variation existed in the choosing of appropriate territories for individual

demonstrations, but professionals searched mainly for "typical" or "ideal" American

communities. Health education and activities involving the population of one communif\'

needed to be applicable, at least in part, to other similar communities. "A health demonstration

is not intended, primarily, so far as those giving outside aid is concerned, as a benefit to the

people of that one localit)-," explained Homer Folks, secretary of the New York State Charities

Aid Association. "It is intended to benefit the people of many localities through what that

particular localit}' may learn, or, in current phraseology, may demonstrate." The plan of

organization and execution of demonstrations needed to be elastic enough for use elsewhere.""

Demonstrations," 289, 291. ''"Brown, "Organization of Health Demonstrations," 16-7. ''"parrand, "Tlie Philosophy of Health Demonstrations," 1-4; Folks, "Financial Aspects of Health Demonstrations," 6; Dinwiddie, Child Health and the Community, 14. 269

Health experts and their sponsors selected appropriate communides by a process of applicadon and eliminadon. They encouraged local leaders in communities to submit requests for pardcipadon in the programs, then sent out representatives to sur\'e\' these candidate communities, peruse public records, and assess the receptivit)' of the public to a health demonstration. Still, local circumstance always demanded adaptation in demonstration motives.

An inflexible program," noted Brown, "no matter how perfect or desirable, is impossible."^''

Lessons drawn out of one demonstration, experts understood, could never be applied in their entirety' everywhere, since each communit}' possessed its own distinctivenesses along with its commonalities. Explained Cornell Universit}' President Livingston Farrand, active in the demonstration movement, "It is nowhere more apparent tiian in the field of public health that you cannot with confidence draw lessons from one place and apply them to all of the sections of the countn'." Demonstration sponsors encouraged the production, then, of generalized knowledge and generalizable practices in demonstration organization.""

The general purpose nature of health demonstrations clashed with collective, progressive memon' of health experts who tried to track down the origins of demonstrations programs.

Many of them agreed in the 1920s and 1930s that die Framingham (Massachusetts)

Demonstration, begun in 1916, launched the movement that followed. Most, however, missed

the prominent discontinuit)' lodged in the Framingham program, dividing it into two parts: origin and progress as a sanitaiy scientific program, and resolution into community health

principles and practice. From its specialized root as a disease-prevention mechanism, the

Framingham demonstration broadened out into a "social" movement complete with

collaborative participation between experts and laypeople. The Framingham demonstration

'"Brown, "Organization of Health Demonstrations," 15. ^'"Farrand, "Tlie Philosophy of Healtli Demonstrations," 1-4. 270 ended as an experiment in selling general health senacc to communides, but it surely did not begin as one.

The National Associadon for the Study and Prevendon of Tuberculosis (convendonally, the Nadonal Tuberculosis Associadon) launched the Framingham demonstration. The source of the demonstration idea might be traced to Lee K. Frankel, chair of the Welfare Division of the

Metropolitan Life Insurance Company. Frankel, worried about the declining but still excessive expense of tuberculosis mortalit}' among company policyholders, penned a letter to Edward

Baldwin, then president of the National Tuberculosis Association. Insurance claims on 14,325 dead policyholders, he calculated in the letter, cost four million dollars each year. Tuberculosis deaths generated sixteen percent of all claims in the company's Industrial Department. Frankel proposed that the National Tuberculosis Association conduct a field study demonsttating the most effective of the new methods for mberculosis control. He promised generous funding, about one hundred thousand dollars, from his company. "It is our hope," he wrote, "that this experiment wiU be a practical contribution towards the study of the etiology of tuberculosis and that the results obtained may indicate a method for die prevention and elimination of the disease."'^'^

The Framingham Demonstration more than fulfilled Frankel's vision. Originally conceived as a three year program, but lasting seven, Framingham organizers focused almost exclusively upon the conquest of tubercular disease. "Is it possible to discover and to place under adequate medical, nursing, and relief super\'ision all of the cases of tuberculosis, incipient and advanced," cliief executive and supentisor of the demonstration Donald B. Armstrong

'^^Quoted in Louis Israel Dublin,^ 40 Year Campaign Against Tuberculosis (New York: Metropolitan Life Insurance Company, 1952), 81-2; Donald Budd Armstrong, et al., Framingham Community Health and Tuberculosis Demonstration of the National Associolion for the Study and Prevention oJTuberculosis: The Program, Framingham Monographs, no. 1 (Framingham, Mass.: Community- Health Station, 1918), 9. 271 wanted to know, "in a normal industrial communit)'?" Organizers designed the Framingham

Demonstration to answer this question conclusively. They also wanted to know how much it would cost. "To know die unit costs of production and distribution is one of the fundamentals in any entci-prise," noted the Commonwealth Fund's Walter H. Brown reflecting on the experience of Framingham, "whether this be the manufacture and disti-ibudon of Fords or the

'selling' of a health program to a communit}'." Framingham generated numbers from which organizers extrapolated the necessary minimum health expenditure levels for such a purpose.'''*

The National Tuberculosis Association selected Framingham, a cit}' of about 17,000 residents twent)' miles southwest of Boston, not out of concern for any special characteristics, because of its t)-picalit)'. It was an "average communit}'." Experts sun'eyed two hundred communities in Massachusetts and New York as possible Demonstration hosts. Armstrong explained why Framingham beat out the competition. The cit\', he wrote, "recommended itself to the committee because it possessed certain average qualities, being an industrial community', with mixed industries, ^'aried racial groups, a good local health organization backed up by an excellent

State Department of Health, a normal amount of disease, well trained physicians and good hospitals, and sufficient promise of cooperation from medical, industrial, commercial, and social organizations." The general mortality rate had also fluctuated little since 1907, with no evidence of great improvement.^'''

''"'Ruhland, "Health Demonstrauons," 291; Donald Budd Armstrong, "The Framingham F-lealth and Tuberculosis Uemonsttaaon," Jotirna! of Public Health 1 (March 1917): 318; Brown, "Organization of Health Demonstrations," 14. ''^Armstrong, et al., Framingham Community HeaM and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program, 12-3; Ruhland, "Health Demonstrations," 291; Armstrong, "The Framingham Health and Tuberculosis Demonstration," American Journal of Public Health 1 (March 1917): 318; Brown, "Organization of Health Demonstrauons," 14; Donald Budd Armstrong, et al., ¥ramingl)am Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Vital Statistics, Framingham Monographs, no. 3 (Framingham, Mass.: Communit)- Health Station, 1918),12-4, 22. 272

The National Tuberculosis Association's National Committee organized the Framingham

Demonstration, but other contributors of time, money, and expertise secured for the work included the Massachusetts State Department of Health, Massachusetts Board of Labor and

Industr}', Massachusetts Bureau of the Census, Massachusetts Trustees of Hospitals for

Consumptives, United States Public Health Semce, United States Bureau of Labor Statistics,

United States Bureau of the Census, United States Children's Bureau, John Hancock Life

Insurance Company, Prudential Life Insurance Company, Russell Sage Foundation, American

Museum of Safety, International Health Board of the Rockefeller Foundation, Massachusetts

Institute of Technology, Har\'ard Medical School, Siinmons College, Mt. Holyoke College,

Cincinnati Social Unit Organization, New York State Commission on Ventilation, Connecticut

Tuberculosis Commission, Health Department of the DcAm/Zo/'magazine, other private anti-tuberculosis organizations, and of course the Metropolitan Life Insurance Company."''

Health experts dictated the course of action followed in Framingham, not laypeople. The

National Tuberculosis Association secured the expertise of many sanitar)' authorities, including

Livingston Farrand, Homer Folks, Lee K. Frankel, Victor C. Vaughan, and C.-E. A. Winslow,

These experts and the National Committee selected Armstrong as the demonstration's chief

executive officer because of his demonstrated talents for public organizing as director of the

Department of Social Welfare of the New York Association for Improving the Condition of the

Poor. They also selected P. Challis Bartiett as chief medical examiner and Mar)' A. Abel as

educational assistant to round out the executive staff. Other staff members, most paid for out of

local funds, included full-time tuberculosis, school, indusuial, and district (public health) nurses;

'^''Armstrong, "The Framingham Health and Tuberculosis Demonstration," American journal of Public Health 7 (March 1917): 318-9; Dublin, A 40 Year Campaign Against Tuberculosis, 84-5; Armstrong, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Stucly and Prevention of Tuberculosis: The Program, 5; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention ofTiiberculosis: Vital Statistics, 6. 273 infant welfare clinic and tuberculosis sanatorium workers; a public health dentist; and numerous

physicians hired on a part-time, full-time, or voluntar)' basis."^

Real work on site in Framingham began iii December, 1916. Armstrong spent a couple

of weeks meeting local authorities, chatting with local physicians, assessing personalities, setting

up committees, and plotting strateg)-. Once setded, Armstrong and his staff launched a campaign of health publicit)' and education, presenting factual evidence in English and Italian on proper personal hygiene, disease prevention regimen, and the restriction of tuberculosis. Staffers

trumpeted the Demonstration as "Framingham's Opportunit}," and demanded "united

community action" against tuberculosis. The National Tuberculosis Association distributed

leaflets with dties like "Advice to Consumpdves," "Framingham Keep Fit," and "Healthy Homes

Make Happiness." Demonstradon organizers also linked tuberculosis control to war

preparedness. The Massachusetts State Normal School, located in Framingham, assisted in

educating the public with lectures on domestic science, economical food preparadon, home

economics, and of course tuberculosis prevention and control. "Communit)- houses," placed in

poorer districts, provided similar instruction. The National Tuberculosis Association also

organized a "medical club," mostly tuberculosis lectures and clinics, to gather support among

local physicians.^''*

^"Armstrong, "The Framingham Health and Tuberculosis Demonstration," Journal of Public Health 1 (March 1917): 319-21; idem, et al., Framingbam Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention ofTuberciilosis: The Program, 3, 8,17. ''^Armstrong, "The Framingham Health and Tuberculosis Dcmonsmrion" American Journal of i^uhlic Health 1 (March 191"'): 319-21; idem, et al., Framingbam Community Health and Tuberculosis Demonstration of the National Association for the S tudj and Prevention of Tuberculosis: The Program, 1,12-13,17, 22; idem, et al., Framingbam Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Vital Statistics, 4; idem, et al., Framingham Communis Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Medical Examination Campaigns, Framingham Monographs, no. 4 (Framingham, Mass.; Communitj' Health Station, 1918), 45; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Sickness Census, Framingham Monographs, no. 2 (Framingham, Mass.: Communit)' Health Station, 1918), 9. 274

The next step involved organizing local advison* conamittees composed of both experts and laypeople. Demonstration staff recruited communit\- leaders and "sympathetic" citizens, selected from every block in Framingham, for these committees. The National Tuberculosis

Association placed local government officials and members of pri\'atc associations on its

National Committee. Demonstration organizers brought together these citizens with experts into committees for education, sickness reporting, recreation, hygienic swimming pools, and infant welfare. The National Tuberculosis Association also organized a special "exclusion committee" to root out the "migrator)' consumptive" invading from without.^^'^

Armstrong inaugurated a "sickness census" in the spring of 1917 to sur\'ey local levels of sickness and disabilit)' and to establish a base line from which to measure tiie Demonstration's effectiveness against tuberculosis morbidit}' and mortalit)'. Nurses and trained agents of the

Metropolitan Life Insurance Company collected and tabulated information on 6,582 individuals in 1,455 families. Together they found more than four hundred defects in health, including sixteen cases of tuberculosis. This culminated in medical examinations of as many people as possible at the WUsonia Building (later dubbed the "Communit}- Health Station"). Citizens registered for the exams by sign-up sheets kept by canvassing nurses and life insurance agents, or by mailing in a newspaper or leaflet "cut-out slip." Physicians offered the first five hundred applying families exams for free in their homes. The rest paid a small fee. Medical examiners collected sputum samples and took chest x-rays for laborator)' analysis. Physicians also administered von Pirquet tuberculin skin tests to five hundred children, one-third of whom tested positive, including fully fifty percent of aU the children of Italian descent.®""

'''.•\rmstrong, "The Framingham Health and Tuberculosis Demonstration," American journal of Public Health 7 (March 1917): 319-21; idem, ct al., Framingham Communis Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program, 8,14,16. ^"""Armstrong, "The Framingham Health and Tuberculosis Demonstration," American Journal of Public Health 1 (March 1917): 319-21; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association {or the Study andPremition of Tuberculosis: The Sickness Census, 9-12,19; idem, et al., Framingham Community Health and 275

Five thousand examinations later, the Demonstiation had checked one-third of the total population for signs of tuberculosis and found mnet}'-six cases. When added to tlie number of cases already previously known, about one percent of the population suffered active or "open" tuberculosis. One in a hundred, in other words, were contagious. Armsti'ong found tliis result

"approximately representative of similar urban and semi-urban communities elsewhere," calling it the "Framingham yardstick." He worried that mbercular residents might flee Framingham during the canvass for cases, spreading disease more widely, but found litde evidence. Only eleven cases moved on to unknown places. The sickness census and medical inspection drives had instead formed a "non-penetrable sieve." The Irish and Irish American districts of Framingham evinced

the highest rates for tuberculosis (almost five percent), while the Italian showed the lowest (less

than half a percent). Demonstrators explained the puzzling figures for Italian children and adults in terms of the hardiness of this race.^*^^'

Demonstrators insdtuuonalized most of the acdve (contagious) cases of tuberculosis

discovered by sur\''ey and inspection. They quarantined adult cases in several local and state

institutions. The tuberculous found treatment at the Cambridge Tuberculosis Hospital, Lakcville

State Sanatorium, Rutiand State Sanatorium, Westfield State Sanatorium, Westboro Insane

Asylum, and a few other places. The demonstrators sent "pretuberculous" minors to the

Children's Health Camp where workers exposed them to large quantities of fresh air and

Tiiberailosis Demonstration of the Nationa/ Association for the Study and Prevention of Tuberculosis: Medical Examination Campaigns, 7, 22-4, 45; idem, et al., Framingham Community Htaltb and Tuberculosis Demonstration of the National Association for the Studj and Prevention of Tuberculosis: The Program, 7,12-13,17, 22; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Assoaation for the Study and Prevention o f Tuberculosis: Tuberculosis Findings, Framingham Monographs, no. 5 (Framingham, Mass.: Communit)- Health Station, 1919), 29-32. ^^'Armstrong, "The Framingham Health and Tuberculosis Demonstration," American journal of Public Health 7 (March 1917): 319-21; idem, "Four Years of the Framingham Demonstration," American Review of Tuberculosis 4 (Februar)' 1921): 913; idem, et al., Framingl)am Community Health and Tuberculosis Demonstration of tl)e National Association for the Study and Prevention of Tuberculosis: The Sickness Census, 9-12, 19; idem, et al., Framingham Communily Pleahh and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Medical Examination Campaigns, 7, 22-4,45; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program, 7,12-13,17, 22; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Tuberculosis Findings, 6-7, 21. 276 sunshine. Staff at tliese institutions witnessed an arrest in the disease in over half of the inmates by the end of 1919. Ten percent had died.^'^'-

Nadonal Tuberculosis Associadon organizers almost immediately began teaching and training local authorides to take up the reins of the demonsti'ation's e.xecudve committee.

Armstrong and his staff weaned these local experts away from temporar)' outside control and taught them to become adept at routinizing newly introduced health measures.

Finally, Framingham organizers kept careful records of their work and other statistical diagnostic evidence throughout the demonstration in order to proA'e or dispro'\'^e theii- own management of the tuberculosis situation. So diat the stausdcal evidence gathered in the demonstration might be corroborated, researchers also collected evidence from seven "control" cities in Massachusetts of similar size and social and economic composition. Compared against the mortalit)- figures of American communities generally, health experts considered the

Framingham Demonstration a success. Tuberculosis mortalit)' declined by two-tliirds in the first five vears of the Demonstration, against declines of an\'where from ten to fift\' percent recorded elsewhere. The general mortalit)' rate fell sixteen percent.^"

The National Tuberculosis Association put together a traveling exhibit to bring the results of Framingham to other communities. Demonstration staffers found the "expert advisor)- consultation seivice" one of the most useful fruits of Framingham. The expert consultation sen'-ice developed after the start of the fu'st medical inspection dri-\'e. Many ph)'sicians rooting

^''"Armstrong, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Stuclj and Prevention of Tuberculosis: Tuberculosis Findings, 8-9,15,18, 29-31; Armstrong, "Four Vears of the Framingham Demonstration," 911,916, ''"•^Donald Budd Armstrong, "The Framingham Health and Tuberculosis Demonstration," joiinial of Public Health 7 (March 1917): 319-21. ^^''Armstrong, "Tl:e Framingham Health and Tuberculosis Demonstration," American journal of Public Health 7 (March 1917): 319-21; idem, "The Tuberculosis Demonstration Plans of the Milbank Memorial Fund," American Journal of Public Health 13 Qanuar)' 1923): 14; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program, 23; Armstrong, "Health Equipment in Framingham: Then and Now," Nation's Health 5 (March 15,1923): 125. 211 out infections, particularly respirator}' infections, found themselves unsure of giving proof-positive diagnoses. Armstrong hired a tuberculosis expert to field inquiries about respirator)' diseases at the Communit)' Health Station. He called the ser\'ice a "triple link, connecting up the patient with early diagnosis, the tuberculous individual with prompt and adequate treatment, and the physician with expert facilities and scientific knowledge." The sendee averaged three hundred calls from area physicians each year. It also boosted the number of tubercular cases found in the general population.^''^

The National Tuberculosis Association and its allies designed the Framingham

Demonstration as a novel social experiment against the white plague. Frankel's original statement of purpose revealed the program as "a practical contribution towards the study of the etiology of tuberculosis" from which experts might derive a "metliod for the prevention and elimination of the disease." They looked for no help outside what a normal communit)' an)'where might be able to provide if given "average equipment" and adequate funding.^''^'

Nonetheless, by April, 1918, Armstrong liinted that he hoped Framingham would

"broaden out into a general health demonstradon."^'" Midway through the Framingham

Demonstration the National Tuberculosis Associadon began promoting health activities outside

the limits of tuberculosis sun'eillance and control. Infant welfare, school health, industrial health,

and education began occupying an increasing share of the Demonstration's burden. Armstrong

persuaded Franz Schneider, Jr., of the Russell Sage Foundation to conduct an investigation of

Charles-Edward Amor}- Winslow, "Discussion," American journal of Public Heahh Supplement 17 (Februan' 1927): 21-2; Armstrong, "Four Years of die Framingham Demonstration," 910, 915; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Tuberculosis Findings, 7; Armstrong, "Health Equipment in Framingham: Then and Now," 127, ^^'"Quoted in Armstrong, et al., Framingham Communit)' Health and Tuberculosis Demonstration oftlje National Association for the Study and Prevention of Tuberculosis: The Program, 10; .\rmstrong, "Health Equipment in Framingham: Then and Now," 125. Armstrong, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program, 12. 278

Framingham's "general sanitar)' conditions." Schneider looked at health in schools and factories, the sanitary state of the food and milk supply, and the condition of sewers and water supply.

Schneider and a graduate student from MIT studied heating, ventilation, and lighting systems in the schools of Frainingham, as well as the state of school equipment, particularly student seats, drinking fountains, and bathroom facilities. They also inspected 29 of 37 local factories. With the help of the New York State Commission on Ventilation they sampled and analyzed dust samples and air flow. The New York Museum of Safetj' conducted a special safet}- study in the factories, making recommendations on machine hazards, lighting, fire emergency procedures, and first aid stations. The Massachusetts State Board of Labor and Industr}' also provided material assistance.

Armstrong became convinced by tliis widening circle of investigation of the "necessit)' for recognizing the comprehensive nature of an effective antituberculosis program."

Tuberculosis conttol, to be effective, necessitated general improvements in the health of the whole communit}-. Armstrong elaborated on this aspect of the demonsttation in a 1920 lecturc at

johns Hopkins. "Tuberculosis is not merely a medical problem; it is not merely a health problem," he lectured. "It is a social problem, in the broadest sense, requiring a comprehensive communit}' engineering plan, if the possibilities for disease control are to be realized to the

fuU."'''''

Armstrong and his staff began collecting together outside "correlative agencies" to accomplish this broader mission in Framingham. The Civic League, the Park Commission, and

the Framingham Women's Club all became active participants by 1922. The Civic League built a

'^^Armstrong, "Four Years of the Framingham Demonstration," 911-2; idem, et al., Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention o f Tuberculosis: Schools and Factories, Framingham Monographs, no. 6 (Framingham, Mass.: Communit)' Health Station, 1919), 4-40. ^""'Armstrong, "Four Years of the Framingham Demonstration," 919. 279 swimming pool and g)-mnasium facilities open to the public. The Park Commission built and maintained five new playgrounds. The Women's Club organized "Mother Craft" programs in the schools. By the end of the demonstration, the expert consultant on tuberculosis questions had widened his trade to addressing all manner of general health questions.

Still, for most of the demonstration advances in the general health of the population operated mainly as a byproduct of a more specialized aim: tuberculosis control. Health experts who pointed to Framingham for their own inspiration merely ascribed community- healtii dimensionalit}' to the entire demonstration. The Milbank and Commonweakli Fund demonstrations, however, bore the stamp of community- health principles and practices start to finish.

The Milbank Memorial Fund, created to "improve the physical, mental, and moral condition of humanit)'," began sponsoring demonstrations in 1922. The fund's founder,

Elizabetli Milbank Anderson, already had a long histoiy as a contributor to New York social and health initiatives. Milbank gave money so that Edward Livingstone Trudcau could construct the first ever tuberculosis research laboratory' in 1891 alongside his famous Adirondack Cottage

Sanitarium at Saranac Lake. In 1894, she started giving millions of dollars to cash-strapped

Barnard College for women. She paid for the construction of model public baths in the lower

East Side tenement district of New York in 1904. In 1909, she gave to the Children's Aid Society a Home for Convalescent Children at Chappaqua, New York. She also funded the establishment in 1912 of a Department of Social Welfare in the New York Association for Improving the

Condition of the Poor, the ver%' same department out of which Donald B. Armstrong emerged.

'^".-Vrmstrong, "Health Equipment in Framingham; Tlien and Now," 126-7. 280

Starting from a small personal donation in 1905 and several larger ones thereafter, the Fund grew to $10,000,000 by the time Elizabeth Milbank died in 1921.'''

By that year, explained C.-E. A. Winslow, "it had become clear that sound progress in the field of public health must depend on a balanced communit)' program under competent permanent expert leadersliip." The Milbank Fund's officers seized upon this opportunit}' to advance general health in American communities. Milbank Fund officers described the New

York Health and Tuberculosis Demonstrations as "an attempt to demonstrate, by cooperation with three tj'pical communides embracing a population of half a million people, whether by intensive application of known health measures the extent of sickness in the United States can be materially diminished and mortalit)' rates further reduced, and whether or not these practical results can be achieved in a relatively short period of time and at a per capita cost which communities will willingly bear.""'

John A. Kingsbmy, chief executive of the New York State Charities Aid Association, made the announcement pledging Milbank sponsorship for three comprehensive health demonstrations in May, 1922, at a meeting of the Association's Committee on Tuberculosis and

Public Health. The Milbank Fund earmarked $325,000 a year for the demonsu-ations, but gave over administrative and super\'isor)' powers to the State Charities Aid Association. Isjngsbun' and Milbank executives lured Donald B. Armstrong away from the National Tuberculosis

Association and made liim secretary of the Milbank Fund Technical Board based on his

experience at Framingham.^'^ His Advison' Council, a large body of experts called together at

^"Edward W. Sheldon and .-Mbert G. Milbank, "Milbank Memorial Fund: Twent}-Fifth Anniversary^" In MiJbaiik Memorial Fund: A Meeting Commemoraling the Twenty-Fifth Anniversary (New York: Milbank Memorial Fund, 1930), 6; Winslow, "The LiN-ing Hand: Elizabeth Milbank Anderson," 11-5,18-9, 27-8; Armstrong, "The Tuberculosis Demonstration Plans of the Milbank Memorial Fund," 15. "Hvinslow, "The Living Hand: Elizabeth Milbank Anderson," 37; Milbank Memorial Fum!Quarterly Bulletin 1 (April 1924): 1-2. ^'\\nnstrong resigned late in 1923. He was succeeded by Bernard L. Wyatt. See "Recent Progress in the 'De.monsximons" Milbank Memorial Fund Quarterl}' Bulletin 1 (January' 1924): 37-41. 281 irregular inter\'als, and Technical Board, for handling day to day activities, included such public health luminaries as Hermann M. Biggs, Louis I. Dublin, Ha\''cn Emerson, Livingston Farrand,

Homer Folks, Lee K. Frankel, L. Emmett Holt, Veranus Moore, M. Adelaide Nutting, William

H. Park, T. Mitchell Prudden, Theobald Smidi, Pliilip Van Ingen, William H. Welch, and C.-E. A.

Winslow. Together, they worked out a plan to use an unprecedented pool of $2,000,000 in available Milbank funds for three five-year demonstration efforts"" inside New York State, placed in "t}'picar' communities of widely varjing populations. The Fund settied on Cattaraugus

Count)' as representati^'e of a normal rural communit)', Syracuse as an ordinar)' urban city, and the Belle\aie-Yorkville District of New York Cit)' as a t)'pical metropolitan neighborhood.

Typicalit)- and variet}- were particularly important, as Milbank officials hoped that demonstrations

"planned on a sufficiently extensive scale" and covering "a wide enough variety of circumstances" might ser\'e as "evidence of the practicability of the development of communit)' health work and of sickness control, not only in the areas where the demonstrations are being conducted, but in similar environments ever)where." A Milbank Committee for the Selection of

Conti'ol Towns chose Rochester, Utica, and Yonkers as "controls" for the Syracuse demonstration, and Steuben, Jefferson, and Chatauqua as "control counties" for the Cattaraugus demonstration.'^^

"''None were completed on schedule. The Cattaraugus Count)' and Syracuse demonstrations began in 1923 and were not finished until the winter of 1930-1. The Belle\ne-Yorkville demonstration was started in 1923 and finished in 1934. Sir Arthur Newsholme, who visited the Cattaraugus Count)' demonstration twice during lecture tours of eastern universities, remarked that such work with expectation of significant results could not possibly be fmished in only five years. Milbank Memorial Fund, MUbank Memorial Fund: Tbirty-Five Years in Rei/iew (New York: Mibank Memorial Fund, 1940), 15; MUbank Memorial Fund Quarterly Bulletin 1 Qanuar)' 1924): i; MUbank Memorial Fund Quarterly Bulletin 4 (April 1926): 13; "Sir Arthur Newsholme Revisits the New York Health Demonstrations," MUbank Memorial Fund Quarterly Bulletin 6 Quly 1928): 53-66; "Sir Arthur Newsholme's Comments on the New York Health Demonstnaons" Milbank Memorial Fund Quarterly Bulletin 6 Quly 1928): 67-75. ^^^Armstrong, "The Tuberculosis Demonstration Plans of tlie Milbank Memorial Fund," 15; "Organization of the Milbank Memorial Fund," Milbank Memorial FundQuarterly Bulletin 1 (March 1923): 2; "Activities of Boards and Committees of Counsel," MUbank Memorial Fund Quarterly Bulletin 1 Quly 1923): 6; "The Scope of the Demonsuaaons," Milbank Memorial FundQuar/erfy Bulletin 1 (October 1923): 1-4. 282

The Milbank demonsttations followed the course of the earlier Framingham demonstxation in seeking to closely tie themselves to the chosen communities and create as nearly as practicable a harmonious relationship. Demonstration activities, explained Homer

Folks, "should be thoroughly grounded in the insdtutions and the life and public affairs of the communit)' . . . and should not be regarded as a strange sometliing imported into the community." Cooperation for communit}* healdi meant, wrote John A. Ivingsbur)', that "there is general participation, every organization, both public and private, and ever}- individual in the demonstrations [is] included." Moreover, the Milbank Fund did not want demonstrations to operate solely by extra-local agency. Instead, die Fund hoped that money could be distributed to public and private agencies already in existence and working in the selected communities.^^''

One of the goals of the Milbank program was to eliininate mberculosis. It was after all still the "captain of the men of death," but it was not the single overriding objective as it had been in early Framingham. "Effective mberculosis work in a communit)' usually stimulates the

development of measures to advance the public health in general," a report issued by the

Cattaraugus Count)' Bureau of Tuberculosis put it. "The inauguration of ser%'ices for the

promotion of general communit)' health, however, does not necessarily lead to special activities

for the prevention and control of mberculosis." Instead of a specialized focus, "general health"

was the most important consideration. The Milbank Fund encouraged in this way public health

education, medical examination, occupational therapy, infant health, school health, and industrial

healdi, among other initiatives. It was also hoped that local experts, local funding sources, and

local lay efforts might gradually take over the work sponsored by the Milbank Fund.^'^

''^William Henn' Welch, "The New York Health Demonstrations: The Principal Grant," in MUbank MemorialFimd: A Meeting Commemorating the Twenty-Fifth Anniversa^' (New York: Milbank Memorial Fund, 1930), 63-70; Homer Folks, "Annual Meeting Minutes," MUbank Memorial Fund Quarterly Bulletin 1 Qanuarj' 1924): 10-3; John A. Kingsbur)', "Two Yeats of Public Health Demonstration," MUbank Memorial Fund Quarterly Bulletin 3 (April 192.5): 2. ^^'Armstrong, "Tlie Tuberculosis Demonstration Plans of the Milbank Memorial Fund," 15-6; "The Scope of the Demonstrations," MUbank Memorial Fund Quarterly Bulletin 1 (October 1923): 6; "Work in the Control of Tuberculosis 283

The Cattaraugus Count)' Health Demonstration lasted seven 3'ears, from 1923 to 1929, several years longer than initially proposed. Cattaraugus Count}' at the time had a population of about 74,000, engaged primarily in farming and dairj'ing, with some light industn'. The two largest cities were Olean, with 21,752 residents, and Salamanca, with 9,570. Forty-six village and towns dotted the landscape, as did approximately 54 other unincorporated agglomerations of houses. C.-E. A. Winslow described the area as "highly tj'pical" compared against other counties in the region. Milbank officers commended it for its "normal economic and social conditions" as well as its "representative" morbidity and mortality history.""

Typicalit)' was not the only requirement for a Milbank Memorial Fund demonstration.

Milbank officers also identified "local desire for the demonsti'ation and local assurance of cooperation, harmony, and coordination of effort; local responsibilit)' for participation in, and leadership of, the demonstration . . . ; and local assumption, in the beginning or as early thereafter as possible, of financial and operating responsibilities." Leaders in Cattaraugus County had already tried to secure demonsti'ation funds for themselves, failing in 1921 to secure a demonstration that was eventually awarded to Mansfield and Richland counties in Ohio. Now four counties—Cattaraugus, Dutchess, Jefferson, and Saratoga—became Milbank rural demonstration fmalists. Each count)' was subjected to special sur\'-eys to ferret out unusual mortality rates and, abnormal population distributions, and odier deficiencies. Tliis time, thanks in part to "unusual cooperation between public and private social and health agencies," and to the persistent lobbying efforts of Lilla C. Wheeler, a Red Cross nurse in Port\^ille, Cattaraugus

Count)' won its demonstration.^^'^ in Cattaraugus Count)'," Milbank Memorial Fund Quarterly Bullelin 4 (April 1926): 1. '^^Stephen Douglas, "The Rural Health Demonstration," Milbank Memorial Fund Quarterly 'bulletin 2 Qanuar)' 1925): 5; Charles-Edward Amor)' Winslow, Health on the Farm and in the V'illaff (New York; The Macmillan Compan)', 1931), 1, 28-30, 34; "Tlie Scope of the Demonstration," Milbank Memorial Fund Quarterly Bulletin 1 (October 1923): 1-2. ^"vvinslow. Health on the Farm and in the Village, 1, 36,43-4. 284

The Milbank Fund left the administration of the Cattaraugus Count)' Health

Demonstration to the New York State Charities Aid Association, then under the secretan'ship of

Homer Folks, in keeping with its policy of working only dirough preexisdng organizadons.'""

Cattaraugus Count}- at the time of the demonstradon's inauguration had no count)' health department at all. The cides and larger towns had part time health officers and school medical inspectors, but their responsibilit)' was mainly the rooting out of communicable diseases. The count)' did have a recendy constructed tuberculosis sanatorium. The cit)' of Olean had the most extensive health organization. There the school medical inspector had fashioned out of school, local board of health, and Red Cross funds a loose organization of four public health nurses and a dental hygienist.^"'

The Milbank Fund goal of securing general health for the populace provided the road map for putting together the demonstration. The Cattaraugus Count)' Board of Supen'isors fu-st organized a count)' "general health district" bringing together all of the health and medical professionals in the count)' into a single web of health. To this end, the State Charities Aid

Association organized a new Cattaraugus Count)' Department of Health headquartered at Olean, within which they created six bureaus and two auxiliary programs, each designed to attack the public health problems of the communit)' from a different angle. The six bureaus were for communicable diseases; tuberculosis; laborator)' diagnosis; statistics collection; maternit)', infancy, and child hygiene; and health education and publicit)'. The two auxiliary programs involved social hygiene and sanitation. The county board of supen'isors liired Leverett D. Bristol, former

Maine state commissioner of health and current professor of public health at the University of

Minnesota as its full-time count)' health commissioner and demonstration director.^"- Bristol

'®°Ibid., 39, 236. '®'lbid.,35. ^^"Latet succeeded by Stephen A. Douglass and Reginald M. Atwater. 285

hoped the Cattaraugus demonsu-ation would show "that the count)' is the logical unit for carrying on rural health work." Indeed, the creation of a general health district in Cattaraugus Count)' represented the fu'st use of WiUiatn H. Park's 1921 state law allowing for count)' health units.

The State Charities Aid Association further subdivided Cattaraugus County to ensure, as

C.-E. A. Winslow put it, "decenttalization of ser\''ice." So-called "district centers" for "general

health activities" were placed in Cattaraugus, Ellicott\'ilIe, Franklinville, Randolph, Salamanca, and Olean to this end. The local communit)' paid for their physical accouterments. Each district center building contained three rooms: one room an office for the one to four public health

nurses assigned to each center, another sening as a waiting/meeting room, and the third for examinations and clinics. The State Charities Aid Association placed two more "substations" in

South Dayton and Delevan, and scattered mobile clinics and consultation centers (with the help of P. C. Bardett, the "expert consultant" in Framingham) around to achieve proper coverage of

the entire count)' so that no count)' resident might have to travel more than a township or two

for advice or assistance.^"''

The main activities of the Cattaraugus Count)' Department of Health were the

provisioning of generalized nursing sen'ice; tuberculosis case-finding, both human and bovine;

school health inspection, and popular health education campaigns. An experiment in generalized

^''•^Indeed, the Cartaniugus Count)- demonstration prompted New York Governor Alfred G. Smith to remark in his annual address to legislators that "the unit for local public health work should be the count)', with a full-time qualified count)' health officer who should be made responsible for the conduct of local health matters within his jurisdiction, with only such supervision as the State may be required to give in an advisor)' capacit)-. Such an organization has been possible under the law for several years; yet only one count)', namely Cattaraugus, has seen fit to take advantage of it, and with tlie ver\' best results in promoting the physical welfare of the inhabitants." Quoted in the Milbank Memorial Fund Quarterly Bulletin 4 (April 1926): 13. Winslow, Health on the Fanti and in the Village, 2, 44-5, 82; "Progress of the Demonstration Units," Milbank Memorial Fund Quarterly Bulletin 1 (March 1923): 3; "Recent Progress in the Demonstrations," Milbank Memorial Fund Quarterly Bulletin 1 (luly 1923): 2-4; Leverett D. Bristol, "Annual Meeting Minutes," Milbank Memorial Fund Quarterly Bulletin 1 (januarj' 1924): 17; "Recent Progress in the Demonstrations," Milbank Memorial Fund Quarterly Bulletin 1 (October 1923): 6-10. ^^•'"Recent Progress in the Demonstrations," Milbank Memorial Fund Quarterly Bulletin 1 Qanuarj' 1924): 42-4; "The Rural Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 2 (April 1924): 3; Winslow, Health on the Farm and in the Village, 85-7; "Recent Progress in the Demonstrations," Milbank Memorial Fund Quarterly Bulletin 1 (july 1923); 2-4. 286 countywide nursing was launched coincident with the beginning of the demonstration. The size of the nursing staff of the Bureau of Public Health Nursing in the Cattaraugus Count)'

Department of Health was doubled over the course of the demonstration to sixteen. Field training of new public health nurses was conducted in Cattaraugus Count)' after 1926 under a program inaugurated by Teachers' College, Columbia Universit)'.^"^

The campaign against tuberculosis, choreographed by the local voluntar)' Tuberculosis and Public Health Association and the count)' health commissioner, turned up an alarming number of previously unidentified tuberculosis cases. Newly purchased equipment and scholarships for local physicians to study at the Trudeau School of Tuberculosis at Saranac Lake paved the way for this case finding. Portable x-ray machines and tuberculin testing revealed many more active and arrested cases of the disease than had previously been found. Thousands of x-rays and sputum samples were processed over the course of the demonstration. Case finding efforts among the resident Indian population of 1,400 were also beefed up with Milbank funds. Where before the institution of the demonstration physicians discovered about 70-80 new cases each year, now they found over 300. Demonstrators consigned active cases of tuberculosis to Rocky Crest Sanatorium, just across the river from Olean. They also sent children at risk for tuberculosis, identified by physical examination or as household associates of active cases, to the

Health Camp in Allegany State Park for 42 days of salubrious environmental exposure and exercise. Here "the boys and girls find themselves members of a large family, where the acquisition of 'good health habits' is made a matter of serious moment."^"'^'

'^'WINSLOW, Health on the Farm and in the Village, 171,186. '^''Winslow, Health on the Farm and in the \ 'illage, 47-9, 57, 79-80,126,133; "Progress of the Demonstration Units," Milbank Memorial Fund Quarterly Bulletin 1 (March 1923): 3; "Recent Progress in the Demonstrations," Milbank Memorial Fmd Quarterly Bulletin 1 (October 1923)'. 6-10; "The Cattaraugus Count)' Health Camp in Allegany State Park, New York," Milbank Memorial Fund Quarterly Bulletin 5 (April 1927): 36-42. 287

The State Charities Aid Association considered bovine tuberculosis in otherwise bucolic

Cattaraugus Count)- an important source of human tuberculosis infection (about five pcrcent of all human cases according to contemporaneous studies). A spccial advisor)' committee led bv

Veranus A. Moore, dean of Cornell's New York State Veterninar)' College, reduced herd infection rates (as determined by tuberculin testing) from thirteen percent in 1920 to 7.7 percent in 1923, and 2.55 percent in 1924. By 1926, less than half a percent of cattle in the count)' reacted positively to the tuberculin test. Experts pegged the net gain in catde value to local farmers at one million dollars.'""

The District Committee on School Hygiene coordinated primar)- and secondan- physical examination and sanitation efforts. The Committee was composed of the Olean and Salamanca school superintendents, five rural school district super\'isors, and the count)' health commissioner. Cattaraugus Count)' had 293 public schools in demonsu-ation days, 228 of them one-room rural schoolliouses. The fourteen thousand school children in the count)' were subjected to annual exams by local physicians. Each child was obsen'ed about six to ten minutes each. School medical inspection uncovered large numbers of "defects" in children, 15,372 in all among 7,944 school children by the end of 1924. Headng and ventilation of schools was also an important issue taken up by the demonstration. Count)' health officers, aware of the results of the New York Commission on Ventilation, strove to keep die temperature of rooms in the healthy range between 70 and 73 degrees.'"" Health officers also encouraged Cattaraugus County children, though of good preexistent nutritional habits, to put more butter in their diets.''"'''

Rural Health Demonstration in Cattaraugus Count)', New York," MUbank Memorial Fund Oiiarlerly BuHe/in 3 (januan-1926): \2)-, MUbank Memorial Fund Quarterly Bulletin (t (April 1928): 34. ^ "The New York Commission on \'entilation Renews Studies of ^'cntilation in School Rooms," MUbank Memorial Fund Quarterly Bulletin 5 (July 1927): 65-70; Thomas J. Duffield, "The New York Commission on \''entilation," MUbank Memorial Fund Quarterly Bulletin 1 Quiy 1929): 67-74; Winslow, Health on theFarm and in the Village, 50-1, 66, 80,151,156. 589 A strange conclusion given the importance of the local daily industr}'. See Winslow, Health on the Farm and in the I 'illage, 162. 288

Selling health semce to the public was of prime importance to MUbank demonstrators in

Cattaraugus Count}'. Health education and publicity' efforts ran the gamut. The count)- health commissioner published weekly "health letters" in the local newspapers, and other tidbits wherever unused column space could be found. The Count)' Board of Health used Milbank money to establish a health librar)' open to all. It showed the health filmstrip "Working for Dear

Life." The Milbank Fund purchased a Trans-Lux opaque projecting machine "with a special dayUght screen" for use by any count}' health organization. The Count}' Tuberculosis and Public

Health Association constructed a health float for the Farmer's Picnic at Litde Valley. An enterprising public health nurse put together a cliild welfare exhibit for the Count}' Fair. Even

Lee K. Frankel, who stimulated the specialized origin of the Framingham Demonstration, now came to see the wider implications of communit}' health education. "One of the primar}' objects of these demonstrations," he explained, "will be to bring the subject of health right down to the people, to show them in their own terms what scientific medicine means, what the health movements are, and, in other words, to cultivate a health habit among them."^'^"

Demonstrators enlisted both local experts and laypeople in the health education and publicit}' drives. Town and village chambers of commerce, local medical societies, farm and home demonstration bureaus, and granges all donated theii- time to spreading the gospel of health. The local communit}' chest supported prenatal and child health clinics. May Day became an in-senj^ice day for the promotion of chUd health and the reinvigoration of local voluntar}'

"vigilance committees."^'^'

^'""Progress of the Demonstration Units," Milbank Memorial Fund Quarterly Biillelin 1 (Match 1923): 3; "The Rural Health Demonstration," MUbank Memorial Fund Quarterly Bulletin 2 (April 1924): 9-10; "The Rural Health Demonstration," MUbank Memorial Fund Quarterly Bulletin 3 (April 1925): 18; "Recent Progress in the Demonstrations," MUbank Memorial Fund Quarterly Bulletin 1 (October 1923): 6-10; Lee Kaufer Frankel, "Annual Milbank Memorial Fund Quarterly Bulletin 1 Qanuar)' 1924): 27-8. ^""Recent Progress in the Demonstrations," Milbank Memorial Fund Quarterly Bulletin 1 (July 1923): 2-4; "The Rural Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 2 (April 1924): 5-6. 289

A mral demonstxation demanded pardcular attention to the necessit)' for cooperative interaction between "outside" experts, local experts, and interested laypeople. The aim of cooperation and coordination sought in all of the Milbank demonstrations became compromised in 1926. The Cattaraugus Count)' Medical Societ}', apparentiy, had tired of its role in the demonstration. Some societ}' members complained of the arbitrar)' manner by which tlie New

York State Charities Aid Association ran tlie demonstration. Some complained about a loss of fees from private practice, an attempt at medical "pauperism" on the part of tlie public health authorities. Others complained that they misapprehended the original intent of the demonstration as tuberculosis case-fmding only. The County Medical Society passed resolutions

"condemning" the demonstration, especially the "ineptitude of lay bodies," and distributed booklets to the public advising against cooperation with demonstrators.^'^"

Physician opposition is intriguing considering the level of integration already achieved by

1926. Two physicians had positions on the Count)' Board of Health. J. P. Garen, the president of the count)' board of health in 1925, was both a local physician and director of the count)' laborator)' and bureau of communicable diseases. He launched an offensive against the demonstration even as he drew a salar)' from his demonstration offices. C.-E. A. Winslow blamed the breach on a "lack of tact" on the part of Milbank experts and administrators and inherent "psychological difficulties" found in an imperfect attempt to reorganize and reorient local physicians to the cause of health.^"

The year 1928 brought more trouble to Cattaraugus demonstrators. That year witnessed

"disastrous" epidemics of enteritis, dysentery, typhoid fever, and diarrhea in the cit)' of Olean.

The source was traced to the auxiliar)' water supply, a series of wells located too near the

^'"Winslow, Health on the Farm and in the Village, 3-4, 240-51. "•^Ibid., 3-4, 240-51. 290

Allegheny River, into which only a little way upstream the cit}' dumped its untreated sewage. In all, 2,500 cases of gastroenterius, six cases of dysenterj', and 238 cases of t\-phoid amounting to

1350,000 in unanticipated medical bills were recorded in Olean. In the follow-up investigation,

Matthias Nicoll, Jr., the New York State Commissioner of Health, unearthed evidence that the

health officer of Olean had improperly recorded chlorine levels daily when they had in fact been performed much less often. Chlorine levels in the towns water supply, as a result, were insufficient to ward off a breach into the filtration system. Furdier, the local water superintendent, acting on a report from a man fishing on the AUeghen)' who had heard a strange sucking sound as he floated near the wells, had shut off the suction pump to one of the wells without informing local authorities of the problem. The pipe turned out to be broken, polluting

the drinking water system with untreated creek water and sewage from an Olean oudet located

upstream. No one noticed die resulting fluctuations in the volume and pressure of water flowing

through the system because no one took daily obser\'ations of chlorine used to treat the water.

The mayor fu'ed both the offending health officer and his board of water commissioners. The

disaster, all told, sti'etched the credibilit}' of the local health organization and reflected poorly on

the demonstration itself The reaction involved the hiring of a full-time count)' sanitar}'

engineer.S04

Opposition and conti'oversy lengthened the Cattaraugus demonsu-ation from three to five

years. Arguing that the health programs established by the Milbank Fund and State Charities Aid

Association would not be supported solely by countj' funding after 1927, the last "planned" year

of the demonstration, members of the Count)' Board of Health appealed to the Milbank Fund to

continue at least partial funding for an indeterininate number of years. This the Milbank Fund

''''"Olean, in Cattaraugus Count)', Experiences a Typhoid Fever Epidemic," Milbank Memorial Fund Quarterly Bulletin 7 Qanuar)' 1929): 13-20; Winslow, Health on the Farm and in the Village, 62-5. 291 did, providing a limited amount of money for 1928 and 1929 before ending formal funding entirely. Some money continued to be spent for Milbank-sponsored health research projects into the 1930s.''''

Despite these problems health experts considered the rural demonstration operated in

Cattaraugus Count}- a success. The communit)''s score as measured by the Appraisal Form developed by the American Public Healdi Association skyrocketed from fort)'-one percent in

1923 to eight}'-one percent in 1929. The count)' had saved approximately three hundred thousand dollars in "life capital" by a general reduction in communicable disease rates. Active cases of tuberculosis identified in the count)' dropped by half. "The percentage of incipient cases reported, and the increase in the numbers under sanatorium or home care, compares favorably with the results achieved in the Framingham project, wliich specialized in this disease," wrote

John A. IsingsbrnT.''^^'

Still, aU three control counties showed tuberculosis deaths dropping at even higher rates than Cattaraugus, even though they had not been part of the demonstration. The

"psychological" effects of the demonstration also proved unremarkable when health questionnaires measuring the success in changing count)' public opinion by "selling" or "not selling" health were compared. Yet, the experts remained exuberant. "It probably excels all other purely rural counties in tuberculosis control and laborator)' ser\'ice, and in public health seivice," claimed C.-E. A. Winslow in 1931.

In the final analysis, the failures and successes of the demonstration meant less to the significance of the demonstration than its generalizabilit)', that is, that the plans and principles

''^Winslow, hlealth on the Fami and in ti)e Village, 243. ^""Ibid., 4, 75,136, 207-9, 226, 235, 241, 262-6; Kingsburj-, "Two Years of Public Health Demonstration," 3. '"Edgar Sydenstricker, "Tlie Decline in the Tuberculosis Death Rate in Cattaraugus County," Milbank Memorial Fnnd Ouarterfy hnUetin 6 (April 1928): 41-50; Winslow, Health on the Farm and in the Village, 4, 75,136, 207-9, 226, 235, 241,262-6. " 292 worked out in Cattaraugus Count)' be both fitted and flexible enough to meet the needs of other rural counties. As William H. Welch put it, "A demonstration such as this, wliich has as one of its main objects to show how public and private health endeavors can with effective results be coordinated to a common end, is well worth while even if notliing more comes of it." Suffolk,

Cortland, and Westchester counties soon emulated Cattaraugus Count)' in establishing similar health programs in their own communities. Cattaraugus Count)' demonstrated that this

"standard" general health program might be aggressively undertaken in any "average" count)' of

New York, or in the countx)' generall)' for that matter.

Syracuse stretched the definition of t)'picalit)' in Milbank demonstrations, having an already advanced cit)' health establishment, as well as positive collaborative links with local physicians in private and institutional practice. Twelve preexisting bureaus in a cit)' health department organized in 1920 already ser\'ed tliis communit)' of 182,000, those for administration, cluld hygiene, communicable diseases, health education, health supen'ision, laboratories, milk and meat inspection, plumbing, psychiatr)', school inspection, tuberculosis, venereal diseases. A thirteenth, for industrial hygiene, was in the planning stages. Other preexisting health and welfare amenities included ten modern hospitals, an Academy of Medicine, and a superior medical school.'''''

The State Charities Aid Association, beginning in March 1923, used Milbank money to establish in conjunction with cit)' health commissioner Thomas P. Farmer and the New York

Association for Improving the Condition of the Poor, projects for the control of communicable diseases, tuberculosis case finding, industrial hygiene, social hygiene and venereal disease control,

''^Winslow, Health on the Farm and in the Village, 7, 25; idem, "The Living Hand: Elizabeth Milbank Anderson," 40; William Henr\' Welch, "The Significance of the Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 1 (lanuan- 1924); 8-10. '''"The Syracuse Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 2 (July 1924): 2; "Five Years of Health Demonstration in Syracuse; A Summarj'," Milbank Memorial Fund Quarterly Bulletin 6 (October 1928): 85-6. 293 and heahh educadon/'"" The Syracuse demonstrators inaugurated special sur\'cys of the cit\' in the closing months of 1923. Walter H. Brown, director of an American Child Health Associadon

"demonstradon" in Mansfield, Ohio, looked at cliild health in Syracuse. Walter M. Brunet of the

American Social Hygiene Association studied the venereal disease situadon in the cit)'. Wade

Wright of Harvard's Department of Industrial Hygiene sur^'eyed health conditions in local factories.'^''"

The Department of Public Instruction and the Mental Hygiene Committee of the

Onondaga Health Association sponsored a mental hygiene micro-"demonstration" in Syracuse's

Seymour School during the 1925-6 school year. These experts agreed the eight hundred Seymour smdents represented a tj'pical Syracuse student body closely, having proper proportions "of the various nationalities and classes making up the population" generally. Demonstrators consigned ninet}' students found to be "abnormal mentally" to special classes.^'""

School health workers examined the children of Syracuse for health defects, administered

Schick tests and diphtheria immunizations, and inaugurated a health education program with a regular lecture program for children and their parents. Demonstrators superintended over fifteen thousand physical examinations in 1924 alone, identifying over five thousand children with health defects. School health inspectors also discovered hundreds of cases of goiter. Fifteen percent of elementary school students, twent)' percent of high school students, and thirt)'-eight percent of all pupils in the Girl's Continuation School had persistent goiter problems. Demonsu'ators issued

124,000 chocolate-covered iodine tablets to Syracuse students to treat and prevent the disease.^'"^

"""""Progress of the Demonstration Units," MUbank Memorial Fund Oiiarlerly Btitlelin 1 (March 1923): 3-8; "Recent Progress in tlic Demonstrations," MUbank Memorial Fund Ouarterly QnUetin 1 Quh' 1923): 1, 4-5. ^"'"Recent Progress in the Demonstrations," MUbank Memorial Fund Quarterly Bulletin 1 Qanuarj' 1924): 46. 602„Tj^e Urban Health Demonstration in the Cit)' of Syracuse, New York," MUbank Memorial Fund Ouarlerly Bulletin 3 Qanuarj' 1926): 16. """^Joseph C. Palmer, "Health Work Among Public School Children in Syracuse," MUbank Memorial FundQtiarterjy Bulletin 3 (]uly 1925): 1-4; "The Syracuse Health Demonstration," MUbank Memorial FundQuarterly Bulletin 2 (April 294

Syracuse demonstrators in their health education efforts placed advertisements in cit)' newspapers and placards in street cars. The cit}- health department's Bureau of Health Education issued a bimonthly (later, monthly) sixteen page magazine with a circulation of tiiree thousand and entitled Better Health, positioning it as an organ for coordinating the like-minded; put on a children's health parade complete with a "Health Queen" and sL\ attendants, "Fresh Air,"

"Sunshine," "Exercise," "Wholesome Food," "Cleanliness," and "Happiness;" and adopted tlic slogan "Syracuse Wishes You Well." The Onondaga Count)' Tuberculosis and Public Health

Association scheduled up to two dozen public health lectures each month, and collected and distributed health films and slide shows. An Advisor)' Committee on Nutrition obsen'ed and improved family "food habits." Syracuse schools organized fort)- health clubs for students to join.^'"^

Syracuse demonstrators experimented with generalized versus specialized nursing schemes. They found generalized nursing much more efficient and useful. "Formerly, the time of a given nurse or group of nurses [in Syracuse] was devoted exclusively to one special field such as child welfare, school hygiene, or tuberculosis," explained George C. Ruhland, deputy commissioner of health and director of the S)'racuse demonstration. "This meant that in

following up cases the nurse would have to travel long distances back and forth across the Cit)'. '

Not only did this involve a loss of time, but often two or more nurses would be visiting the same

home." The new plan adopted by Syracuse health experts involved assigning one nurse to a

smaller area, and assigning to her aU home visits regardless of type.^'"^

1924): 15-6. 604

Syracuse also became a testing ground for administrative methods in communit)' health.

One of the minor, though important, administrative experiments conducted at Syracuse involved

the testing of fort)'-six different t)'pes of cit\- health record forms. Demonstrators assessed and

judged the forms as to shape, size, color of ink, and even the weight of the paper stock they were

printed upon. One sample purple card with blue ink was denounced as "illegible."

Demonstrators also attacked the problem of arrangement of form pages in files and loose-leaf

folders. They setded upon three "general purpose" standard record form sizes: 3" x 5", 5" x 8",

and SVi" x 11". Lighter paper colors were advised as superior to darker colors, and 16 to 20 lb. stock appeared strong enough for most purposes. Syracuse experts also setded an Caslon, Bold

Face, 8 pt., as an admirable font for printing on ideal record forms."^^'"^^

Laypeople and other experts in and outside the professions of health also engaged

extensively in Syracuse's health campaign. The American Red Cross, Americanization League,

Boy Scouts, Campfire Girls, Catholic Youth's Camp, Child Health Committee, Communit)'

Chest, Girl Scouts, Home Bureau, Jewish Communal Home, Junior League, Onondaga Orphan's

Home, Syracuse Department of Public Instruction, Visiting Nurse Association, Young Men's

Christian Organization, Young Women's Christian Organization, Young Men's Hebrew

Association, Young Women's Hebrew Association as well as several black organizations all

contributed their talents to the Syracuse health campaign.

Health efforts coordinated with Milbank dollars paid dividends. Syracuse won top

honors among Class 11 cities in the 1929 Inter-Chamber Health Conservation Contest sponsored

bv the American Public Health Association and the United States Chamber of Commerce for

superior water supply, sewage disposal, food sanitation, disease prevention programs, vital

'"^George C. Ruhland and I.F. Thompson, "Record Forms in the Syracuse Health Demonstration," American Journal of Public Heahb 16 (June 1926): 567-70. 296 statistics, medical conferences, and voluntar)- and public support. The cit)' went on to receive a perfect score (1,000 out of 1,000 points possible) on the APHA's Appraisal Fo/v;//'"' Syracuse, at}'pically t)'pical at best of urban health problems in modern America, sen-ed as a "cit],' set on a hill," an ideal to which other communities might strive.

Milbank demonstrators canned a metropolitan demonstration, spanning the decade from

1924 to 1934, serving a population of about 214,000 residents out of two preexisting tuberculosis surveillance districts, Bellevue and York\'^ille. Belle\'Tje-Yorkville, composed of "quite an interesting distribution of income ranges," stretched from 14th to 63rd Street and from the East

River to Fourth Avenue. Demonstrators found the age distribution, birth rate, and immigrant population percentage (then about thirt)'-five percent) "practically identical" to other parts of

Manhattan.''""'

A great challenge to demonstration work in New York Cit)' was the prior existence of so many preexisting health and welfare organizations. The metropolis supported over one hundred hospitals and five count}' medical societies, and almost one thousand other health and health-related agencies. Fift\'-six health and welfare organizations worked directly inside the bounds of the Belle\'ue-York\'ille District alone. They included seventeen hospitals, t\vcnr\--three dispensaries, twelve day nurseries, nineteen social sen-ice centers, eight milk stations, and nine maternit)' centers. Cornell Universit)' Medical College and the Henry Street Setdement called

Bellevue-Yorkville home. "Here," stated C.-E. A. Winslow, "the work was so to blend the activities of the demonstration with those of these agencies that they would fuse into one intricate and complex pattern for the benefit of the district as a whole."'^^"''

^"^"News Digest," MUbank Memorial Fund Quarterly Bulletin 8 Quly 1930): 93-4. ''"^Bailey B. Burritt, "Annual Meeting Minutes," MUbank Memorial Fund Quarterly Bulletin 1 Qanuarj' 1924): 22-4; "The Metropolitan Health Demonstration," MUbank Memorial Fund Quarterly Bulletin 2 (October 1924): 4, 7-8. "^"'ira N'aughan Hiscock, "The Development of Neighborhood Health Services in the United States," MUbank Memorial Fund Quarterly 13 Qanuan-1935): 37-8; "The Metropolitan Health Demonstration," MUbank MemorialFund 297

Putting together these extant specialized pieces into a generalized whole was no easy

matter. Physical proximit)' led off efforts to coordinate all the health and welfare agencies in the demonstration area. Demonstrators moved into the old public bath building erected using funds

provided in 1904 by Elizabeth Milbank Anderson, where the Technical Board reassigned Leverett

D. Bristol, then director of the Cattaraugus Demonstration, to the post of executive officer.

Extensively remodeled, this demonstration headquarters distributed space to official and

voluntar}' agencies working in Belle-voae-Yorkville. The rechristened "Bellevue-York\'ille Health

Building" also housed an auditorium and assembly room, a museum of hygiene, nurse training facilities, and rooms for health clubs. The Healdi Building also contained clinics for child health,

preventive cardiac care, sypliilis, well-babies and office space for a safet}' campaign.''"' The

Bellevue-Yorks'^ille officials also experimented with generalized and specialized nursing schemes in hopes of encouraging an associational "neighborhood growth of feeling.'"^^"

Local health centers dotting Bcllevue-Yorkville acted as a counteivailing force,

distributing and decentralizing the fruits of intensive coordinadon and cooperadon. The organizadonal plan for the BeUe\aie-Yorkville Demonstradon highlighted the importance of district healdi organizadon organized around health centers (called, more inclusively,

"neighborhood centers" in New York Cit)') in the community health work of large urban cities.

Each center provided aU manner of health and welfare sendees, including public health nursing,

venereal disease control, x-rays and laborator)' analyses, infant and child clinics, school hygiene.

Quarterly Bulletin 2 (October 1924): 2; Winslow, "The Living Hand: Elizabeth Milbank Anderson," 49. '''""The Metropolitan Health Demonstration in the Belle\iie-Yorkville District of the Citj- of New York," Milbank Memorial Fwui Quarterly Bulletin 3 (April 1925): 21; MUhank Memorial Fund Quarterly Bulletin 5 (.^pril 1926): 21; Charles-Edward Amor)' Winslow and Savel Zimand, Health Under the "El": The Stoty of the Bellevue-Yorkville Health Demonstration in Mid-Town New York (New York: Harper & Brothers Publishers, 1937), ix; "Bellevue-Yorkville Health Building Dedicated in New York Cit)-," Milbank Memorial Fund Quarterly Bulletin 5 Qanuary 1927): 13-20. ' As described by Sir Arthur Newsholme in "Sir Arthur Newsholme's Comments on the New York Health Demonstrations," Milbank Memorial Fund Quarterly Bulletin 6 Quly 1928): 73. See also Milbank Memorial Fund, Milbank Memorial Fund: Thirty-Five Years in Rei/iew, 20. 298 family welfare, dental hygiene, orthopedic clinics for crippled children, nutrition classes, mental hygiene, tuberculosis control, and popular health education/''"

Two peculiarly metropolitan problems distinguished the work of BeUe\'ue-Yorkville demonstrators from that performed elsewhere. First, deaths from "sti'eet accidents" in the

"traffic-congested" neighborhoods comprising the demonstration topped 230 in 1922 alone, giving a rate seventj'-four percent higher than found in tlie rest of New York City/"'^ A second characteristically metropolitan problem involved the "dual population" of Bellevue-YorkvilJe residents and the daily deluge of nonresident workers into the "financial heart New York Cit}'," located within tlie boundaries of the demonstration/''"*

Milbank funding of community healdi continued long after the end of the three New-

York demonsu-adons in Cattaraugus Count\^ Syracuse, and Bellevue-Yorl'C\'ille. Much of the impulse behind this work became regularized and insdtudonalized in the Milbank Memorial Fund

Division of Research founded in 1928. According to trustees, the Division of Research "arose naturally out of the desire to ascertain as precisely as possible the effects of public health measures applied in the demonstradon areas." Milbank researchers, addidonalJy, hoped to construct useful strategies for future "social experimentadon" from the data obtained in the demonstrations. By 1940, the Division of Research had published over 140 articles in many different journals, including its own mouthpicce the Milbank Memorial VumlQuarterly. Researchers considered among theii: major initiatives in this corpus general public health methodology, community health administration, epidemiolog)', adult health, public health economics, nutrition,

^'"See induction comments by New York Citj' Commissioner of Health Sliirley W. Wynne in "New Health Officers for Syracuse, Cattaraugus Count)', and New York City," Milbank Memorial Fund Quarterly Bulletin 6 (October 1928): 96-98; Milbank Memorial Fund, MUbank Memorial Fund: Thirtj-Fiue Years in Review, 16; Sliirley W. Wynne, "Neighborhood Health Development in the Cit)- of New York," MUbank Memorial Fund Quarterly Rulletin 9 (April 1931): 37-45. ®""The Metropolitan Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 2 (October 1924): 5-6; "News Digest of the New York Health Demonstrations," MUbank Memorial Fund Quarterly Bulletin 4 (October 1926): 70. ^'''"The Metropolitan Health Demonstration," Milbank Memorial Fund Quarterly Bulletin 2 (October 1924): 9. 299 population studies, birth control, and the building of cooperative relationships with other professions/'''

The Commonwealth Fund began organizing for demonstrations through its Child Flealth

Program in 1922. I'he Fund, incorporated in 1919 in New York Cit)', had considerable latitude.

Mrs. Stephen V. Harkness pledged over §16 million in securities to the Fund with the sole stipulation that it "to do something for the welfare of mankind." Its fu'st general director was

Max Farrand of Yale Universit}-. Requests for funding poured in, a total of 155 appeals in the first year alone. The Commonwealth Fund gave its first donations to the United War Work

Campaign, Inc., American Committee on Armenian and Syrian Relief, the Hampton Normal and

Agricultural Institute, the National Cominittee on Mental Hygiene, the New York Committee on

After-Care of Infantile Paralysis Cases, the Charity Organization Societ}', the medical school at

Johns Hopkins, the National Research Council, the Babies' Welfare Association, the National

Information Bureau, and the Junior Employment Sen-ice. By 1922, the Commonwealth Fund was disbursing $1.2 million a year for work in foreign relief, educational and legal research, social ser\'ice, and child health and welfare.^'"^'

President Herbert Hoover announced the entn' of the Commonwealth Fund into demonstration work in an address delivered at the 1922 meeting of the American Child Hygiene

Association. "Through the munificence of the Commonwealth Fund, this great association will now be able to undertake in three cities to be selected in the United States, a complete demonstration in ever)' avenue of protection of child health," he asserted. "The funds assured

^'^Milbank Memorial Fund, Program of the Dwision of Research, 1928-1940 (New York: Milbank Memorial Fund, 1941), 3, 8, 47-55. ^"'Barn- C. Smith, et al., "The Child Health Demonstrations: Program and Policies," Commomveahb Fund ChiMl-hallb Demonstration Committee Bulletin 1 (Februan- 1927): 9-10; Ma.\ Farrand, et al., "First Annual Report of the General Director of the Commonwealth Fund, Annual R^eport oJthe Commonwealth Fund 1 (1918-9): 5-11; Otto Tremont Bannard, "Extracts from the Treasurer's Report," >!««««/ Report of the Commonwealth Fund 1 (1918-9): 13-4; idem, "Appropriations X'oted, 1921-2," Annual Report of the Commonwealth Fund 4 (1921-2): 54-5. 300 through this source amount to approximately S230,000 per annum for a term of years and it is proposed to choose a cit)' in the Far West, one in the Middle West, and one [later, two] in the

South."^''^

Framingham and Milbank acted as only two sources of inspiration to Commonwealth

Fund demonstrators. The recently launched Mansfield and Richland (Ohio) Count}- Child Health

Demonstration sponsored by a two hundred diousand dollar American Red Cross donation and administered by the National Child Health Council, composed of several professional organizations under the secretar}'ship of Courtenay Dinwiddie, acted as the other.

Mansfield-Richland demonstrators selected two Ohio counties as "fairly tj'pical" industrial and agricultural communities. The Demonstration lasted from 1922 to 1925, and entertained the services of many public health experts, including Richard A. Bolt, Livingston Farrand (national chaii' for the Red Cross), James L. Fieser, Homer Folks, Elizabeth Fox, L. Emmett Holt, Sally

Lucas Jean, Owen R. Lovejoy, Anna A. Stevens, Philip Van Ingen, and Linsly R. Williams.

Mansfield-Richland became a greenhouse nurauing and "coordinating the activities of its member organizations" toward a goal of generalized health sennce through the direct agency of child healdi work. Worried that a "wide gap" had formed between "available knowledge of how to keep a child well and the actual appEcation of this knowledge," Mansfield-Richland demonstrators conducted extensive medical examinations of children in the communit}', engaged in the modern program of generalized public health nursing, encouraged the pursuit of health and physical education in schools, stimulated good nutritional habits, opened "fresh air" summer camps, and corrected dental defects. Experts designing the Mansfield-Richland Demonstration

'''^Quoted in "Program for Child Health," Annua! Report of the Commonwealth Fund 4 (1921-2): 26-7. 301 hoped diat through children, modern health protection might be extended to ever)'body in the community: parents, teachers, and neighbors/'"*

Commonwealth Fund demonstrators also advanced general health education and prophylaxis while emphasizing a central role for child health progress. Barr\' C. Smith, chairman of the Child Health Program and general director of the Commonwealth Fund, explained the purpose of the demonstrations as opportunities to "translate into effective local action the available knowledge of measures which spell freedom and inspiration for the normal, healthful growth of children of all ages, as an integral part of a well-developed general health plan." Cliild hygiene acted only as the central spoke from which radiated concerns for a clean water supply, fresh inilk, immunizations, proper sewage treatment, and good nursing. After all,

Commonwealth organizers agreed, "The health of children in any communit)' is so inextricably bound up with the whole problem of health in that communit)' that it cannot be tteated as a separate entit}'."'^^''''

The Fund's emphasis on child hygiene stemmed from expert pediatric and hygienic advice that children occupied the first and most malleable developmental rung of the ladder of life. Health in developing children generated healthy adults. This represented a progressive idea weU-known to experts for several generations. The Fund's advisors coupled this idea, though, to a new esthetic of the "plastic" child. "Especially in childhood," wrote Smith, "it is possible to influence profoundly the child's whole conception of relative values." If those values could be

^'®Li\'ingston Farrand, et al., Child Health Demonstralion: Mansfield and Richland County, Ohio, 1922 to 1925 (New York: American Child Health Association, 1926), v-xviii, 1; Brown, "Organization of Health Demonstrations," 14; Winslow, Health on the Farm and in the Village, 38. """Smith, et al., "The Cliild Health Demonstrations: Program and Policies," 1, 4-5; "Relation of Child Health to General Communit)' Health," Annual Report of the Commonwealth Fund 5 (1923): 10-1. 302 turned to healthy habits, a whole new generation of healthy adults would inevitably follow. Child health in this way could for practical purposes be equated with general health/'""

A Child Health Demonstradon Committee governed and advised Commonwealth demonstrators. Commonwealth Fund administrators and public health experts drafted from the

American Child Hygiene Association, the Child Health Organization of America, the American

Public Health Association, and the National Organization of Public Health Nursing composed the committee. The American Child Hygiene Association claimed particular expertise in the field of preschool health, the Child Health Organizadon of America for school cliildren. These two organizations melded into the American Cliild Health Association during the first year of on-site demonstration, and initially bore part of the administrative burden in the demonstrations, but the

Commonwealth Fund discontinued the relationship in 1926 as unnecessary."'

The Commonwealth Fund packed its Cliild Health Demonstradon Committee with expertise. Richard A. Bolt, Robert E. Chaddock, Lotus D. Coffman, Ella Phillips Crandall, W. F.

Draper, Samuel McClintock Hatnill, L. Emmett Holt, Sally Lucas Jean, Theresa Kraker, Cornelia

Lvne, Barbara S. Quin, Mildred C. Scoville, Philip Van Ingen, and Emma A. Winslow all sat on the committee at one time or another. Two familiar Framingham names could also be found among them: Donald B. Armstrong and Livingston Farrand. Courtenay Dinwiddie, former first executive secretary' of the National Child Health Council in Mansfield-Richland demonstration days and present general executive of the American Child Health Association, oversaw this group

as director of the Child Health Demonstration Committee until 1929.'^^"

'•"Smith, et al., "The Child Health Demonstrations: Program and Policies," 4-5; idem, et al., "Demonstrating Child Health, 1923-1927," Commonwealth Fund Child Health Demonstration Committee Bulletin 4 Qune 1927): 3. ' "Program for Child Health," Annual V^port of the Commonwealth Fund 4 (1921 -2): 30; "Program for Child Health," Annua! Report of the Commonwealth Fundi (1925): 29. '••"Program for Child Health," Annual Report of the Commonwealth Fund 4 (1921 -2): 29; "Committees Affliated with the Commonwealth Fund," Annual Report of the Commonwealth Fund 5 (1923); 4; "Committees Affliated with the Commonwealth Fund," Annual Report of the Commonwealth Fund 6 (1924): 5; "Committees Affiliated with the Commonwealth ¥unA" Annual Report of the Commonwealth Fundi (1925): 4; "Committees Affiliated with the 303

Still, the Commonwealth Fund, like the Milbank Memorial Fund, demanded local participation and control in its demonstrations. "The Committee," the Commonwealth Fund's public releases read, "is willing to finance the beginning of any t)'pe of work wliich is sound and is definitely for the health of mothers and of children of any age, provided this is considered as a first step toward the communitj' taking over a supen'isoiy and fmancial responsibilit)' for such work within a reasonable period." The Cliild Health Committee, ideally only advisory and administrative in character, stressed the importance of building communit)'-wide support for health sen'ice. "Integration" and "inter-dependence" and "correlation" and "amalgamation" were crucial features of good communit}' health work. The Child Health Committee appealed to expert knowledge as a basis for autliorit)', but did not impose its will with impunit)'. Local lay and professional associations acted as intermediaries between the Fund and demonstration units.

Communities, ideaUy, blazed a padi toward health with the assistance of the experts. Citizens and professionals created an interdependent "partnership," not a vassalage. Local interest, indeed, was a basic test of public health progress in Commonwealth demonstration communities.'^'"'

Commonwealth Fund demonstrations, also like those sponsored by the Milbank

Memorial Fund, bore the hallmark of flexibility. The Fund, "has been unwilling to go even so far as to attempt to suggest in advance the various activities which should be taken up in the order of their priorit)' or the exact procedures which should be followed in carr)'ing them out," the Annual

Report outlined. Smitli, director of the Commonwealth Fund, eschewed the value of

Commonwealth Fund," Annual Report of the Commomvealtli Fund 8 (1926): 6; "Committees Affiliated with the Commonwealth Fund," Annual Report of the Commonwealth Fund 9 (1927): 5; "Committees Affiliated with the Commonwealth Fund," Annual Report of the Commonwealtlj Fund\^ (1928): 7; "Committees Affiliated with the Commonwealth Fund," Annual Report of the Commonwealth Fund 11 (1929): 9; Roy Lubove, "Courtenay Dinwiddie, Oct. 9,1882-Sept. 13,1943," Dictionaiy of American Biography Supplement 2> (1973): 227-8. '"^Smith, et al., "The Child Health Demonstrations: Program and Policies," 2, 6-14; "Objectives: Financial Responsibility-," Annual Report of the Commonwealth Fund 5 (1923): 14; "Child Health," Annual Report of the Commonwealth Fund 8 (1926): 24-6. 304 demonstrations for the "standardization" of health practice in favor of what he called

"proportion." Commonwealth Fund demonstrations ser\'ed as rough guides to public health practice, but had to be evaluated, rearranged, modified, and reevaluated for each new communit)'.

Standardization, Smith continued, proved too rigid in a single communit)' when applied over time. Each communit)' had different problems and those problems changed with time.

Demonstrations helped generally to "bridge the gap between knowledge and practice," but this dynamic relationship required adaptation.'^^'*

The pediati'ician, tlie nurse, the teacher, and die private ph)'sician each played a crucial role in the child health demonstrations of the Commonwealth Fund. Often as a first step, the

Fund brought to each demonstration community one or more pediatricians steeped in the wider field of child health. Those familiar with the histon' of child psvchiatn' might find a counterpart to that specialt)''s involvement in child guidance demonstrations in the contemporaneous activities of the Child Healdi Committee. The Fund also relied on the semces of public health nurses organized on a generalized basis. These nurses visited schools and homes looidng for healdi defects, giving lectures, and offering advice. Teachers sei-\'ed as auxiliaries to their educational work. Cooperation from private physicians was essential, as they were to learn from new experience with communit\' health practice and take over the work of the Commonwealth

Fund when it left. All of these constituencies, along with the health administrators and the public, coordinated the multidimensional health services—child health, maternit}% disease control, sanitation among them—needed in modern, progressive communities.'^^"''

^"''"Child Health," Annual Report of the Commonwealth Fund 8 (1926): 14-5; Smith, et al., "The Child Health Demonstrations: Program and Policies," 1 -2. ''^^Barrj' C. Smith, "Foreword," in Child Health and the Community, 1-3; Dinwiddle, Child Health and the Community, 36-7,47,65-75. 305

The Commonwealth Fund's first demonstration, in Fargo, North Dakota, began in early

1923 and ended five years later in 1928. Fargo at the time was a rural communit\- of about

27,000, the largest in the state, and a crossroads marketplace for agricultural products and farm equipment. Thirty one cities in the Upper Midwest competed for this first demonstration.

Several factors recommended Fargo over other cities. The city, for one, was certainly not hostile.

Its citizens showed "intelligent public sentiment." Local physicians appeared "cooperative."

Fargo was also a cit)' with little or no recent growth by births, deaths, or migration, variables that might obscure results. It displaj'ed "average American virtues," only occasionally spoiled by

"clannish" behavior among those of Scandinavian descent and lack of "group thinking" on the part of communit)' leaders. The cit)- originally scored 320 out of 1,000 possible points on the

Appraisal Fom developed by the American Public Health Association Committee on

Administrative Practice.^'"'^'

A part-time health officer, a sanitar)' inspector, a universit}' laboratory assistant, a school nurse, a Red Cross nurse, tlie Glad Tidings Mission, and the Salvation Army took responsibilit}' for all of Fargo's health work before the Commonwealth Fund arrived. That changed immediately. The Child Health Demonstration Committee divided the health work applied to

Fargo into four departments. The Committee appointed William J. French, who had recendy worked for the Red Cross in Paris on child health programs, to direct the Executive Department and keep records of the daily activities of the Fargo Demonstration. The Medical Department, directed by Lester J. Evans, a pediatrician, superintended a well-baby clinic, preschool clinic,

^"''"Program for Child Health," A/imia/ Report of the Commonwealth Fund 4 (1921-2): 30; Smith, et al., "Demonstrating Cliild Health, 1923-1927," 9; Robert E. Chaddock, "Vital Statistics and the Measurement of Health Progress in Fargo, N.T)." American Journal of Public Health 19 (januan-1929); 37; Smith, et al., "The Child Health Demonstrations: Program and Policies," 1; "The Fargo Demonstration," Annual Report of the Commonwealth Fund 5 (1923): 14-5; "Health," Annual Report of the Commonwealth Fund 9 (1927): 20; Barn' C. Smith, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," Commonwealth Fund Child Health Demonstration Committee bulletin 1 (May 1928): 5-8; Dinwiddie, Child Health and the Community, 17. 306 school health examination program, and child health consultation sen-ice. Health education activities were coordinated by Maud A. Brown. Edith B. Pierson led the Nursing Department.

The Commonwealth Fund also hired a dental hygienist for its work in Fargo. As the demonstration proceeded, Fargo organized its own department of health under B. K. I'Cilbourne.

His liiring represented the first fuU-time health officer an)'where in the state.'^^"'

Fargo demonstrators brought together all kinds of constituencies. Experts trucked in by

the Commonwealth Fund could not stage an effective demonstration alone. Hospital staff, clubs,

parent-teacher associations, and businessmen all needed to participate. "If the program for the child is to attain its maximum success," the Commonwealth Fund reported, "the demonstration itself and the public health authorities must cooperate to an extent which will render their work a

de facto unit in the communit)''s interest." Lay leaders organized a local public health association

to act as a pool of available volunteers for health projects initiated by the official board of health.

Part of the expense of the demonstration was paid out of the funds of the Fargo Board of

Education, a local Red Cross chapter, and the local branch of the National Tuberculosis

Association, as well as Fargo's new department of health.^'"''

Children suffered examinations and inspections by the pediatrician, dentist, nurse,

teacher, and sometimes the principal. They stood in Une for Schick tests and immunizations,

recited from popular health textbooks, and religiously kept health "bank-books." Every child

with a case of the sniffles was immediately sent home. Lectures on nutritious meals drove a local

candy store into bankruptcy, even after it passed out free school blotters. Health experts and

Annua! Report of Ihe Commonwealth Fund') (1927): 20; "Departments of the Fargo Demonstration," Anmial Report of the Commonwealth Fund 5 (1923): 15; Smith, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," 11-4; Chaddock, "N'ital Statistics and the Measurement of Health Progress in Fargo, N.D.," 37. ^"^"Program for Child Health," Annual Report of the Commonwealth Fund 6 (1924): 14-5; "Health," Annual Report of the Commonwealth Fund 9 (1927): 20, 29; "The Program for Child Health," Annual Report of the Commonwealth Fund 10 (1928): 30. 307 volunteers caught unwar)' children from outside Fargo attending an Achievement Club Institute, a Boy Scout round-up, and the State Fair, scrutinizing them all for health defects/'"'

The local health department and board of education paid for public health nursing evenly. It was organized on a generalized basis, each nurse receiving her own territor)- including one or more schools as a base from which to operate. In Fargo, eighteen nurses made 15,136 field nursing visits between 1923 and 1927. They enlisted teachers to assist them in the health education of Fargo's children, freeing them to deal widi the worst cases. Teachers usually interacted wirii children more hours of the da}' than even parents. They also bore responsibility for educating and adjusting the minds of youngsters. "The direction of the child's mental life depends on the course of development and growth of the brain cells and theii" processes," explained Maud Brown. "This growth requires the same fundamental essentials of food, rest, and activit)' as does the growth of other cells—muscle, bone, gland, which form altogether an intricate interacting whole, each influenced by the life of ever)' other.'"^'^"

Collaborative activit)' by health experts and local citizens brought material gain. The

Demonstration inspired Rotarians to erect playground equipment in two cit)' parks and organize

a junior baseball league. The Fargo Board of Education introduced healthy "open ait"

classrooms. Markets stocked ten times as much spinach and other green vegetables than before.

(The Norwegians, in particular, considered them "cow feed," and preferred pickles). The

Commercial Club offered elementarj' schools trophies for best health habits, attendance, and

school sanitation.''"

^"'Smith, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," 22-6, 29, 32-5; idem, et al., "Serving the Child in Fargo: Part Three of the Final Report of the Fargo Demonstration," Commonwealth Fund Child Health Demonstration Committee Bulletin 9 (November 1928): 42-60. '''"Barr)- C. Smith, et al., Five Years in Far^o: Report of the Commonwealth Fund Child Health Demonstration in Fargo, North Dakota (New York: Tlie Commonwealth Fund, 1929), 12,20,187-94; Maud Anna Brown, "The Class-Room Teacher's Part in Health Education," Cl)ildHealth Bulletin 1 (November 1925): 88-93. "'Smidi, et al., "Demonstrating Child Health, 1923-1927," 7; idem, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," 7-8, 20, 36-7; idem, et al.. Five Years in Fargo: Report of the 308

The healthy home was also a central objective of the demonstration. Parents checked the health progress of their children with forms provided by the schools. Public health nurses conducted home visits to check on the children and the sanitar)' state of their living arrangements. Advancement in this department can be found in one student's composition.

"How I am now mamma says is from oatmeal and milk," wrote one ten year old. "Ever since the

Health Records came out I have tried to keep them up. . . . Mamma didn't care for it at first, but now she likes it. Our home is much cleaner. We had it clean before, but Oh! there is so much difference now,'"^^^"

Parents learned the lessons of health from their own children. The publications director for the Child Health Committee related the following, perhaps apocryphal, stor)':

"Say, Miss Jones, we're educating Ma." It was a tow-headed boy in a Fargo schoolroom who burst out to this effect after wiggling his hand violendy in the aii'. "Yes, Olaf?" How are you educating your mother?" "We're educating her to let us have our windows open at night. She always leaves 'em shut tight, but after she's put us to bed we get up and open one of them, 'n' then in the morning before she comes in we put it down." "That's a good way to sleep. But I don't see how your mother is going to be 'educated' if she doesn't know anything about it." Miss Jones was interested in new methods. "Oh, after we've slept through it a few nights and don't have any colds or anything we'll tell her and then she'll know it's all right."

Another child taught the virtues of adequate sleep reportedly prayed after a late part)', "Oh, God, please make it possible for me to get to bed at eight o'clock hereafter." Others complained about home ventilation and lack of fresh vegetables to their parents.^'^'^

By July, 1927, shordy before the end of the demonstration, Fargo began picking up the entire tab for its demonstradon work. Permanent health ser\'-ice in Fargo included a full-time health officer and his part-time medical assistant, a full-time public health dentist, a full-time

Commonwealth Fmid Child Health Demonstration in Fargo, North Dakota, 28, 33, 44. ''^"Quoted in "YitJiXih," Annual Report of the Commonwealth Fund 9 (1927): 27; Smith, et al., "Serving tiie Child in Fargo: Part Three of the Final Report of the Fargo Demonstration," 38-43. '^"^Quoted in Smith, et al., "Five Years in Fargo; Part One of the Final Report of the Fargo Health Demonstration," 21; idem, et al., Five Years in Fargo: Report of the Commonwealth Fund Child Health Demonstration in Fargo, North Dakota, 29-30. 309 sanitan' inspector, six full-time public health nurses, a full-time supen'isor of school health education, a public health laborator)', and two statistical clerks/'"

The Commonwealth Fund launched the second and third demonstrations in Clarke

Count)-, Georgia, and Rutherford Count\-, Tennessee, one year after Fargo in 1924/'" It chose

Clarke and Rutherford from more than fortj' applicants. The Commonwealth Fund designed the

Clarke and Rutherford demonstrations as companion pieces, as programs for urban and rural communit)' health respectivel}'/'-^'^' Clarke Count}', in northeastern Georgia, held about twent)'

thousand residents at the time of the demonstration. Organizers liked it because it seemed

"progressive," had "an unusual interest in health and social activities," and formed a microcosm of southern societ)' in its many distinctive groups: middle- and upper-class educated whites, poor white mill hands, and rural and urban blacks. Athens, the largest cit)' with sixteen thousand

people, at the time was a center for the manufacture of textiles, cotton oil, and agricultural

implements. Women made up half of its industrial work force of sixteen hundred, many of

whom had children. The citj' also boasted numerous institutions of higher education. The

Universit^' of Georgia, tlie Georgia State College of Agriculture, the State Normal School, Lucy

Cobb Junior College, and the l

there. The Fund thought these schools might help spread the word and help institutionalize the

demonstration after they were gone.^'"

The Commonwealtli Fund found Athens' record in health matters, however, less

impressive. Few people there had ever been immunized against diphtheria and tj'phoid, adversely

*"''^51111111, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," 38-9, 42-3. ''^Smith, et al, "The Child Health Demonstrations: Program and Policies," 1. "^Ibid. ®'^"Athens and Rutherford Count)'," Amma! Report of the Commonwealth Fund 5 (1923): 19-20; Barr\' C. Smith, et al., A Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke Coun^> and Athens, Georgia, 1924-1928 (New York: ITie Commonwealth Fund, 1930), 2; idem, ct al., "Cooperation for Child Health in Athens, Georgia," Commonwealth Fund Child Health Demonstration Committee Bulletin 3 (March 1927): 1-2. 310 affecting the infant mortality rate. Athens had a board of health, as did the count)' generally, but

few maternal and child health programs. Not many of the local midwives were "competent" or

"efficient" in the eyes of demonstrators. Eight}'-five percent of inspected school children had identifiable health problems. Schools sensed lunches without milk. Tuberculosis ravaged the communit\-.'^^^"

Contributions to the work of the Clarke Count)- Demonstration came from many sources. The United States Public Health Sen'ice, the Clarke County And-Tuberculosis Societ)',

Athens Board of Education, Clarke Count)' Medical Society, the Eighth District Dental Societ)', and personnel from the local tuberculosis sanatorium all contributed their talents. The chancellor of the Universit)' of Georgia, the president of the State CoUege of Agriculture and Mechanic Arts, the president of the State Normal School, and secretaries of die local Parent-Teacher Association,

Tuberculosis Association, as well as 23 physicians pledged their support. Between 1923 and 1926

the demonstrators increased the number of communit}- health experts and trained adjuncts from seven to t\vent)'-three. "Before the demonstration the health department was like a motor-car with one cylinder," explained a Child Health Demonstration Committee report. "The health

officer was at the wheel and he knew where he wanted to go, but he had to jerk along from job

to job because he lacked the staff to apply a steady flow of power." A count)' health

commissioner, three sanitar)' inspectors, six public health nurses, three clerks, two vital statistics

clerks, and one bacteriologist, statistician, demonstration director, director of school healtii

education, physical educator, oral hygienist, served the county by the late 1920s.'''^'^

^^^Smith, et al., A Chapter of Child Health: Report of tiie Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-192S, 4-6; "Program for Cliild Health," Annual Report of the Commonwealth Fundi (1925): 21-3. ^^'"Program for Child Health," Annual Report of the Commonwealth Fund 6 (1924): 16; "The Program for Child Health," Annual Report of the Commonwealth Fmid\0 (1928): 30; Smith, et al.,y4 Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928, 6,18; idem, et al., "Cooperation for Cliild Health in Athens, Georgia," 3-4,12. 311

Athens experts and citizens worked together to develop many new projects relating to health. A free clinic opened at the General Hospital for the poor, later supplemented with ten free beds each for white and black children. Milk, food, and water supplies underwent inspection. "Block mothers" rounded up neighborhood children about to enter school for medical exams. Schools established separate playgrounds for white and black children. The nutritious value of school lunches improved, commercial clubs and Sunday schools paid for the distribution of milk at morning recess, the physical educator took silliouettographs of posture and recorded height and weight gains on grade reports.'^'"'

Dental hygiene efforts paid particularly splendid dividends. The teachers in one elementar)' school created a "revolving fund" out of receipts from a special Brunswick stew and

barbecue dinner, from which loans for dental costs might be drawn. AH of the white school children in Athens eventually saw an oral hygienist who referred candidates to local dentists.

When a noted Oxford professor visited one school classroom during the demonstration, he asked

what made Athens special. Two students responded with astonishing synchronicity: "One

hundred percent dental corrections."*^""

Efforts to inti'oduce dancing as a regular playground activit)' achieved more mixed results.

Physical educator Willie Dean Andrews, paid by the Commonwealth Fund to organize structured

games for wliite and black children, noted that folk dancing taught "real social values" as an

"activity for all" (while simultaneously exercising large muscle groups) when compared against

other "solo" activities. Black children loved these dances, he found, and few needed to learn the

'''"^"Program for Child Health," Annual ^port of the Commonwealth Fund 6 (1924); 22; "Health," Annual Report of the Commonwealth F«W9 (1927): 17, 21, 28-9; Smith, et al., "Cooperation for Child Health in Athens, Georgia," 3, 8-13. ''•"Tlie fund later paid for tonsillectomies and glasses. "Program for Child Health," Annual Report of the Commonwealth Fund 6 (1924): 22; "Health," Annual Report of the Commonwealth Fund') (1927): 17, 21, 28-9; Smith, et al., "Coopetation for Cliild Health in Alliens, Georgia," 3, 8-13; idem, et al., "Demonstrating Child Health, 1923-1927," 6; Geddes Smith, "How Athens Secured Funds for Remedying Defects," Child Health bulletin 3 (April 1927): 83-5; Smith, et al., A Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928, 38-40,42-3. 312 basic rhymes and rhythms of "Steal Miss Liza," "Walking on the Green Grass," and "Sissy in the

Barn." Folk dancing among white children, however, produced "dismal results." They could learn the dances and the melodies, but pardcipated woodenly, without the "jollit)'" cvinced by the

black children. White children quit dancing when not led by the teacher or the educator, while

black children broke into dance at recess spontaneously, creatively var)'ing the choreography and

word order.^"*"

Hard times undid many of the advances of the Clarke Count)' Demonstration. Low-

cotton prices and subsequent bank failures led to a round of cost-cutting measures, AH of the

"special teaching" programs, including those for health education were removed from the

curriculum in 1929. Schools canceled furtlier dental hygienic work, and the local health officer

resigned in disgust.

The Commonwealth Fund started the Rutherford Count}', Tennessee, Demonstration in

1924. Rutherford Count}' was at the time overwhelmingly rural in character. Only sk hundred

residents worked in the seven factories of its largest cit}-, Murfreesboro, among an overall count}'

population of 33,000. Fully eight}'-five percent of them farmed, the chief crops being cotton and

corn. A few worked in red cedar lumbering, turning these sweet-smelling trees into pencils,

buckets, and chests. The count}' had no preexisting local healtii boards, and most health matters

of urgency fell on the shoulders of a single local Red Cross nurse. Typhoid, tuberculosis,

diphtheria, and scarlet fever appeared endemic, and almost every rural well was contaminated.

One-third of the population suffered illiteracy. The adage of some locals was that "children

Dean Brown, "Negro Folk Games," The Plajgmind 11 Qune 1927): 132-4; Smith, et al., A Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928, 58. ^""^Dinwiddie, Child Health and the Community, 20; "Tlie Cliild Health Program," Annual Report of the Commonwealth FundW (1929): 30. 313 outgrow their ills if left alone," and some treated goiter by using a popular home remedy; t)-ing live toads around the neck.'''*''

Given the underwhelming state of health sen'ice in Rutherford Count)' and the unfamiliarit)' of its people to modern hygienic methods, the Child Health Demonstration

Committee exercised its authorit)' over demonstration work here more than elsewhere. "This is the only demonstration in which there has been complete centralization of the work of the health department and of the demonsu'ation activities under one director," it was explained in the

Annual Ki'porl of the Commonwealth Fund. The list of needed improvements was long. The committee hired a pediatrician to organize an expert consultant ser\'ice for local physicians. It immunized and inoculated with impunity. It corrected defects in children. It built safer privies

(replacing jaunts into the woods) and sanitary drinking fountains for schools. It introduced parents and children to the benefits of green vegetables. The Fund also created a fellowship program to lure local physicians into the program.

One of the most popular health programs put in place in Rutherford Count}' involved the

"blue ribbon" campaign, an idea borrowed (though "adjusted to local needs") from the Mansfield

Child Health Demonstration. The awarding of blue ribbons required that white children measure up to several requirements. Children had to take immunization shots against smallpox, diphtheria, and t}-phoid fever. They had to maintain good health habits and behavior at school.

Cliildren also had to be free from any medical "defects." One thousand children in the count)'

^''''"Athens and Rutherford Count}'," Annual Report of the Commoimeolth Fund 5 (1923); 19-20; Harrj' Stoll Mustard, Crosi'-Sections oj Rural Health Progress: Report of the Commonwealth Fund Child Health Demonstration in Rutherford County, Tennessee, 1924-1928 (New York: The Commonwealth Fund, 1930), xi, 4, 6, 8; Bart)' C. Smith, et al., "Cliild Health and Count}' Health; Rutherford Count)', Tennessee," Commonu'ealthFund Child Health Demonstration Committee Bulletin 6 (September 1927); 5-6, 20-1; "ITie Program for Cliild Health," Annual Report of the Commonwealth Fund 10 (1928); 34-6; Smith, et al., "Demonstrating Child Health, 1923-1927," 20. ''"'^"Program for Cliild HesAdi," Annua! Report of the Commonwealth Fund 6 (1924); 22-3; "Program for Child Health," Annual Report of the Commonwealth Fund 1 (1925); 24-5; "The Program for Child Health," Annual Report of the Commomveahh FWIO (1928); 34-6; "The Child Health Annual Report of the Commomveallh FtmdW (1929); 31,33. 314 eventually met these requirements. Schools for black children staged a similar, diough "simpler,"

health contest/""^

Many agencies assisted in the Rutherford Count)- Demonstradon. The local American

Red Cross chapter, Rutherford Hospital, the Tennessee Department of Educadon, and

Tennessee State Medical Associadon, and the Middle Tennessee State Normal School in

Murfreesboro all volunteered thek time and effort to various phases of the work. The Tennessee

State Department of Health gave its valuable resources to the demonstration, receiving in return

useful information on die creation of count)- health units and ideas for reforming its own

administration and activities by integrating state educational resources. Harr)' S. Mustard

coordinated these bodies as director of the demonstration. Mustard had on his staff during the

demonstration a pediatrician, a nursing supervisor, six staff nurses (one black), a school health

educator, and a vital statistics clerk.^"*

The Commonwealth Fund supported the majorit)- of health work undertaken early in the

demonstration. The Fund paid for the first hospital in the count)', Rutherford Hospital, entirely

out of its own coffers. It also paid for five annual scholarships for physician education. The

hospital housed venereal disease and pediatric clinics. The Commonwealth Fund also established

a modern tuberculosis clinic, complete with x-ray machine and diagnostic laborator)' equipment.

A three (later ten) cent count)' tax levy earmarked specifically for the development of county

health administration paid for a slowly increasing share of the demonstration work. The

Murfreesboro Charit)' Circle, founded late in the demonstration, and the Count)' Department of

^''^Courtenav Dinwiddie, "Contributions of Demonstrations to Rural Programs," Nalion's Hea/l/j 9 ([ul)' 15, 1927); 12; Smith, et al., "Child Health and Count)- Health: Rutherford Count)-, Tennessee," 13-4; Mustard, Cross-Sections of Rural Health Progress, 14. '''^Mustard, Cross-Sections of'Rural Health Progress, "Athens and Rutherford Count)-," Annual Report of the Commomvealtlj Fund 5 (1923); 21; "Program for Child Health," Annual Report of the Commonwealth Fund 6 (1924): 16-7; "The Program for Cliild Health," Annual Report of the Commonwealth Fund 10 (1928); 29; Smith, et al., "Demonstrating Child Health, 1923-1927," 39; idem, et al., "Child Health and Count)' Health: Rutherford Count)-, Tennessee," 8. 315

Health took up and correlated health and social activities as Commonwealth organizers witlidrew.

Black schools received financial assistance for health projects from the Jeannes Fund, a private charit)- for black educadon in the Soutli/'"""

Public health nursing was key to bringing health expertise to rural residents of the sprawling, six hundred square mile count)'. The demonstration hired six nurses to cover tiiis ground. Their work did not always go smoothly despite the generally optimistic portraits painted by trustees of the Commonwealth Fund. The record of one recalcitrant father in the backwater hamlet of Burk's Hollow is illustrative:

The nurse visited that home one day about dinner time. At the table she talked with the head of the family about immunization. He wasn't sure that it worked. But, she pointed out, it certainly worked with hogs! [ByJ coincidence, her host was the functionar)' authorized to perform this ser\'ice for his neighbors' swine. Not long afterward the children presented themselves for immunization and the school score was perfect.'"''^

To supplement them and bear part of the enormous burden of health work, George Peabody

College in Nashville began using Rutherford Count}' to train its nursing students."^^^"

Still, these nurses could not hope to cover all ground in the count)'. Local lay support proved crucial. Demonstrators organized fifteen local health committees of laypeople in the count)', and they provided many kinds of support. Murfreesboro's Business and Professional

Women's Club sold "tuberculosis seals" to buy tents for a temporaiy sanatorium. Sixteen women planned and cooked hot lunches for school children twice weekly, weighed and measured the children regularly, filled a "loan closet" with first aid and maternit)' supplies, kept neighbors apprised of upcoming clinics, and informed demonstrators of cases needing special attention.

^''^Smith, et al., "Child Health and Count)' Health: Rutherford Count)', Tennessee," 19-20; "Health," AnnualKeport of the Commonwealth Fund ^ (1927): 21; "Tlie Child Health Program," Annual Kiport of the Commonwealth Fund 10 (1928): 29, 31; Mustard, Cross-Sections ofRtiral Health Pro^nss, xii, 20-2. ^""'Quoted in "Tlie Program for Cliild Healtli," Annual Riport of the Commonwealth Fund\Q (1928): 36. ^"'"Program for Child Health," Annual ?^porl of the Commonwealth Fundi (1925): 18. 316

Parent-teacher associations worked to improve the sanitar)* arrangements of schoolhouses and homes. Schools acted as natural "distributing centers" for this volunteer assistance/'"

Marion Count}', Oregon, got its demonstration in early 1925. The site of the last of the five-year regional demonstrations conducted by the Commonwealth Fund, Marion Counts- circumscribed a rich chunk of farmland and forests in and around the Willamette Valley. Not surprisingly, the economy depended on fruit farms and lumber mills. The count)' contained about 55,000 residents clustered in two cities, seven towns, and more than a dozen smaller villages. The Fund's supen'isor of health education described the count)' as a place "where the great open spaces of the movies are still found in abundance." The largest cit)' in the count)',

Salem with a population of 26,260, doubled as demonstration headquarters and state capital.*^^'

Marion Count)' originally had twent)'-two other competitors for its demonstration.

Commonwealth Fund organizers liked Marion Count)' as the location of this last demonstration because of its dissimilarit)' to the other sites. Marion Count)' for them represented a growing communit\' with inadequate, though extant, health facilities. The count)' also, unlike the other demonstradon sites, produced healthier babies than almost an)'where else in the countr)'. The infant mortalit)' rate for Marion County at the beginning of demonstration work stood at about

fift)' deaths per thousand live births, compared with over sevent)' per thousand in the United

States Registration Area generally.^'^'^

Annual RBport of the Commonwealth Fund') (1927): 30; Smith, et al., "Child Health and Count}- Health: Rutherford Count}', Tennessee," 19; idem, et al., "Demonstrating Child Health, 1923-1927," 27; Mustard, Cross-Sections of Riiral Health Progress, 10,18-20. '''"Brown, "Organization of Health Demonstrations," 17; Smith, et al., "llie Child Health Demonstrations: Program and Policies," 1; idem, et al., "Child Health in Marion Count}-, Oregon," Commomvea/th Fund Child Health Demonstration Committee Bulletin 2 (Februarj-1927): 1; "Program for Child Health," Annual Report of the Commomveahh Fundi (1925): 26; Anne Simpson, "'Do-Do-Do-Then Do Some More': Ways of Teaching Healtli in One Room Rural Schools in Oregon," Child Health Bulletin 4 (March 1928): 44; Estella Ford Warner and Geddes Smith, Children of the Covered Wagon: Bjport of the Commonwealth Fund Child Health Demonstration in Marion County, Oregon, 1925-1929 (New York: Commonwealth Fund, 1930), 25. ^"Warner and Smith, Children of the Covered Wagon, 3-5,12. 317

The Commonwealth Fund tapped Walter H. Brown, former director of the Mansfield

National Child Health Council-Red Cross demonstration, as on-site director of the Marion

Count)- Demonstration. Funding came primarily from the Commonwealth Fund and the Oregon

State Board of Health, but partial and growing funding for the demonstration came from count)' taxes, Salem Count)''s schools, the Oregon State Board of Health, and the Marion Count)' Public

Health Association/'"

The Salem Health Department at the outset had a part-time cit)' health officer, a part-time count)' health officer, a part-time school physician, and a part-tiine school nurse. Participating agencies in the Marion Count)- Demonstration, extending from this original state, coordinated several health operations into a manageable whole under the guidance of a count)' health ser\'^ice administered by a full-time count)' health officer. The job of the count)' health officer was to maintain and improve health by judiciously administering the regular affairs of the office, politely ensuring the cooperation of private organizations in the area, and direcdy sponsoring temporar)- or intermittent health programs where gaps or deficits existed. The regular affairs of count)' health officer enumerated and inaugurated by demonstration organizers included a medical sen-ice for the regular examination of infants and young children, a preventive dental sen'ice, a healtli education ser\''ice, and a statistical ser\acc.'^^^'

The relative newness of the count)' led Commonwealth demonstrators to concentrate much effort on the simple, though essential, task of creating a sanitar)' infrastructure. Experts tested milk for tuberculosis and t)'phoid bacilli. They sampled local drinking water supplies, whether rivers, lakes, or wells. They directed the construction of adequate privies, lining their

pits with concrete and hanging flypaper. Experts also organized the construction and renovation

^^''"Program for Cliild Healtli," Animal Report of the Conmonwaltb Fund 6 (1924): 24; Brown, "Organization of Health Demonstrations," 17-8; "The Cliild Health Program," Annual Keport of the Commonwealth Fund 10 (1928): 32. ''^^Brown, "Organization of Health Demonstrations," 18-9. 318 of public buildings, especially schools, to create healthy levels of heating, lighting, and ventilation.

The demonstrators also stressed the health effects of "sun baths," or artificial treatment with the

Alpine lamp, for children. Overcast conditions in the region both summer and winter made this last task especially important in the minds of the demonstrators. Portland, Oregon, they agreed,

received fewer of the sun's beneficial ultraviolet rays that built strong bones than am-where else in

the nation. One in sLx children in Marion Count}' suffered mild rickets.^'^^'

Enrolling the children of this Oregon count)' in demonstration programs proved at least

as difficult as in Tennessee. Where Rutherford Count)- sprawled, Marion Count)' positively

tumbled across a wild Pacific landscape. Snowstorms cut off communication with some parts of

the county for most of the winter. The count)''s area stood at almost 1,200 square miles,

comparable in size if not populadon to Rhode Island. The task was complicated by the transient

character of setdements furthest from the administrative center in Salem. The shifting

communities of temporar)' lumberjacks and their families, and recreational "tourist camps"

complicated the job of adequate health supen'ision and education.^"^

Marion Count)' demonstrators met this geographic challenge by creating twelve

permanent health centers. Many of these centers, located in Silverton, Aurora, Mt. Angel,

Hubbard, Mill Cit)', Salem, Stayton, Woodburn, Jefferson, Scotts Mills, Ger\'ais, and Turner,

started as makesliift loan closets, caOing trees, and motor pools for count)' public health nurses

and local physicians. Some health centers occupied school rooms, but others found what space

they could in warehouse store rooms, office buildings, and churches. Luckily, however, Marion

^'^Warner and Smith, Children of the Covered Wagon, 29-35, 58-9; Dinwiddie, "Contributions of Demonstrations to Rural Programs," 11; Smith, et al., "Cliild Health in Marion Count)', Oregon," 7-12. ^^'Simpson, '"Do-Do-Do-Then Do Some Mote'; Ways of Teacliing Health in One Room Rural Schools in Oregon," 44; Warner and Smith, Children of the Covered Wa^o//, 25, 33-4. 319

County residents proved exceptionally "committee-minded" in assisting the work of the health centers/'^"

The prolific comings and goings of migrants in tliis "community on the make"

exacerbated the communicablc disease situation in Marion County. Smallpox was rife in the

population, averaging sixty cases a year, and 181 in the first year of the demonstration.

Compulsory vaccination before entry into school was not yet law in the county. Diphtheria

immunization was also rare, as were skin and sputum tests for tuberculosis. Demonstrators and

the county' health department remedied the situation b)' vaccinating two thousand youngsters a

year, administering toxin-antitoxin shots to preschoolers, and rooting out the tuberculous for

quarantine and treatment.'^^^'^

Demonstrators used the public schools as natural sites for staging health programs.

Teachers incorporated health education into evety' practicable aspect of their lessons. They

brought in fathers and mothers to trim naUs, brush teeth, comb hair, and wash hands with their

children. Teachers taught the evils of coffee and vii'tues of carrots. One ambitious teacher,

perhaps at tlie inspiration of popular Red Cross "Healthtown" literature, divided her classroom

into railroad "stations" with names like East Toothbrush, Bathmbville, Hankie Junction, and

Little Cleanface. Wrote one teacher,

I have had no difficulty in cartying out the health program. My litde band of "chickens" drink milk, eat hot mush even' morning, eat vegetables and fruit, take their baths, and clean their teeth at least evety morning. They seem to get plenty of exercise, have home chores morning and night, walk three-fourths of a mile to and from school, play games and swing up and down at the ends of the branches.'^^'^"

''^^Smith, et al, "Child Health in Marion CountA', Oregon," 16-8; Dinwiddie, "Contributions of Demonstrations to Rural Programs," 12. ^^'Oinwiddie, Child Health and the Community, 24-5; Warner and Smith, Children of the Covered Wa^on, 39-47. ^'"Quoted in Simpson, "'Do-Do-Do-Then Do Some More'; Ways of Teacliing Health in One Room Rural Schools in Oregon," 44-8. 320

The demonstration thought up other projects for special effect in impressing tlie public. At one point during the demonstration, 2,200 cMdren on a health, behavior, and academic "honor roU" marched in a parade down the main street of Salem.^'^''

Other members of tlie local communit)' were enlisted to participate directl)- in die activities of the demonstration. The local Parent-Teacher Association, American Legion, Loyal

Legion of Loggers and Lumbermen, the Woman's Club, Chamber of Commerce, and Mizpah

Club all contributed their time and talents. A school teacher became the head count)' health instructor. School superintendents became school health administrators. Fourteen local health councils, a county healtii advisor}' council, and a medical advisor)- committee sprouted up to encourage and coordinate the healtii efforts of communit)' leaders. Four local women planned and carried out an "expedition" to an isolated lumbering setdement where they outlined to squatters the utilit)- of health centers with missionar)' zeal.*^^^'"

The end of the Marion Count}' Demonstration in 1930 marked the end of nearly a decade of Commonwealth Fund-sponsored child healdi demonstrations. Each of the demonstrations made significant progress based on yearly scoring by Watson Frank Walker, field director of the

American Public Health Association. By die end of the demonstration, Fargo's Appraisal I'ortn score had risen to 827 on a 1,000 point scale. Athens' score shot up from 331 to 814.

Rutherford's health improved from 97 to 689 points. Marion County saw its score rise from 202

points to 703.

^^'Warner and Smith, Children of the Covered IFa^o/i, 86. ^^"Brown, "Organization of Health Demonstrations," 19-20; "Program for Child Health," Annual Keport of the Commonwealth Fundi (1925): 26; "Health," IXeport of the Commonwealth Fund^ 29-30. 663,.The Child Health Vtogtzm" Annual "Report of the Commonwealth Fund 10 (1928): 37-9; Watson Frank Walker, ".\ SiuTey of Public Health Work in Fargo, N.D." Commonwealth Fund Child Health Demonstration Committee Bulletin 5 (june 1927): 7-9; idem, "Public Health Work in Fargo: An Appraisal," Commonwealth Fund Child Health Demonstration Bulletin 8 (Ma)' 1928): 3-4. 321

The Commonwealth Fund also claimed that to a certain extent the records of maternal and infant mortalit)', the schedules of communicable disease rates, the regular examinations of school children showed tlic efficacy of demonstration work. The statistical details of the demonstrations, however, are omitted here for several related reasons, all recognized to some degree by demonstrators themselves.

Commonwealth Fund researchers and administrators found quantification of the accomplishments of the demonstrations more difficult and more prone to erroneous interpretation than initially thought. The Fund at fu'St assigned an autonomous Research Unit under George T. Palmer the task of collecting, comparing, analyzing, and synthesizing information generated by all of the dcmonsti-ations. This proved both impractical and less useful than statistics collection by a number of individual demonstrators looking at the demonstration problem from a variet)' of angles. The character of the statistical evidence produced at the site of each demonsu-ation proved unique, warranting local collection and study of data, and the collection of "somewhat different" kinds of data. Demonstrators also found approved professional measurements devices and taxonomic categories "in flux." Moreover, the demonstrations lasted for a ver\' short time on the human scale, only five years, and it was usually difficult to establish a reliable baseline regardless of the effort expended in researching community' medical histories.'^'^'''

These facts should not by any means diminish the claims for positive results lodged by die Commonwealth Fund's demonstrators. Few would argue that the large numbers of dental, optometric, and immunological corrections worked against health advancement in the demonstration communities, regardless of some overambitious, though mosdy innocuous,

^^''"Program for Child Health," Annual Report of the Commonwealth Fund 1 (1925): 28-9; Smith, et al., Five ^ 'ears in Fargo: Report oJ the Commonwealth Fund Child Health Demonstration in Fargo, North Dakota, 170; idem, et al., Chapter of Child Health: Report of the Commouwea/th Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928, 15. 322 activities like the indiscriminate ripping out of thousands of "diseased" tonsils. The point of the demonstrations lay not in the details, but in their overall effect in creating a positive climate for change. The proof was in the pudding, as it were, and not in the individual raisins.

One of the major accomplishments claimed by the Commonwealth Fund in all the demonstrations, and perhaps the greatest, involved improving "public opinion" regarding comprehensive health programs. "The public mind has been opened to a new range of ideas,"

the Annual "Report noted. "The sendee of doctors, nurses, and teachers has given the new ideas practical form, and the skillful promotion of communit}' organization has made the resulting health progress a matter for local pride and the object of local effort."*^^^'^

Physicians approved of tliis new communit}' oudook, especially when it reaped more

fee-paying patients. "The attempt in any demonstration should be to give to die community

confidence in its mcdical profession," the editors of the Journal of the American Medical

Association explained, "and to show to the medical profession the technique and the importance

of the practice of preventive medicine by the general practitioner." Mothers brought iii

apparently "well infants" for checkups, looked more closely at theii" children for any signs of

regress in health, and reported themselves more freely for pre- and postnatal exams. Fewer

citizens sought out irregular practitioners too. Some doctors in private practice supplemented

their clinic income with fees for preventive sendces.'^'^'''

The Commonwealth Fund handled the issue of potential health center competition

against private clinics with some delicacy. The Commonwealth Fund Child Health

Demonstration Committee needed the expertise of physicians as an indispensable part of holistic

communit}' health work. Fargo established a fairly restrictive trend, loosened somewhat in the

665"pjegjth " Annual KBport of the Commonwealth Fund 9 (1927); 19, 31. 666„.j^g Health 'DtmonsUTiUovi" Journal oj the American Medical Association 90 (Match 3,1928): 696; "Health," Annual Report of the Commonwealth Fund 9 (1927): 31-2. 323 other three locations. The health center in Fargo weighed, measured, conducted physical examinations, and took medical histories, but referred all corrective work to private physicians.

The center was "educational and not charitable" according to an abstract of the agreement made between local Fargo physicians on a special advisory committee hand-picked from members of the local medical societ}' and the demonstrators.'^^"

Athens, Rutherford, and Marion demonstrators and local physicians made the same pledge, restricting advice to matters of personal hygiene, nutrition, and physical exercise. Athens closed its health center in the most prosperous district of the cit)' a year before the end of

Commonwealth Fund sponsorship, hoping to move these families entirely to fee senace.

Rutherford Count}''s health center refused to diagnose potential illnesses, instead restricting their written comments to marks for "normal" or "defect" in the proper spaces during physical exams.

Murfreesboro demonstrators saw individual children in theii- health center a maximum of three times without special permission from a family ph}'sician. Marion Count}' demonstrators required that most children get physician referrals for free health service throughout the demonstration. Still, problems in determining abilit)' to pay in families and recalcitrance among those who could remained a source of tension nearly ever)'where.'''^^''

Health experts, if the number of articles published in the professional literature are an adequate indicator, also watched the activities of the Commonwealth demonstrations closely.

The American Public Health Association published at least twelve thousand copies of

'^'Smith, et al., "Semng the Child in Fargo: Part Three of the Final Report of the Fargo Demonstration," 104; idem, et al., F/ve Years in Fargo: Report of the Commonwealth Fund Child Health Demonstration in Farg), North Dakota, 185; "The Cliild Health Program," Annual Report of the Commonwealth Fund 11 (1929): 34-5; G.A. Carpenter, et al., "The Local Medical Societj- and Public Hazlih," journal of the American Medical Association 90 Qanuar)' 21,1928): 191,194. '^^Smith, et al., A Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928, 75-6; Mustard, Cross-Sections of Rjiral Health Progress, 35; Dinwiddie, Child Health and the Community, 39. 324 demonstration progress reports for interested parties. Some of the communities found themselves overwhelmed by tlie press of interested visitors wanting to see demonstration work firsthand/"''''

^''"Health," Annua! Report of the Commonwealth Fund') (1927): 17; Smith, et al., "Five Years in Fargo: Part One of the Final Report of the Fargo Health Demonstration," 15-6. 325

CHAPTER X. FAMILY HEALTH AND FAMILL\L EPIDEMIOLOGY

Below the communit}', but no less important, stood the American family. The family, in its biological and social relations, was considered a "natural" group for study. Indeed, health professionals often referred to the family as the most "fundamental unit" in their work. It was not that individuals did not exist, but that their needs reflected the needs of groups in collective association. Health and disease were social processes, processes diat could be understood in tlieir full complexit)' only when considered in terms of association or relation, not as independent entities tliemselves. "The communit}' is only a network or mass of families," explained two svphilis experts, "all interrelated by mutual work or play, by necessit)', or by desire." As Henr}' B.

Richardson, associate professor of clinical medicine at the Cornell Universit}' Medical College put it, the professions were in modern America "now ready for the concept of the individual as a member of a family in its communit)' setting."*^'"

Ira S. Wile, pediatrician at Mt. Sinai Hospital in New York, also described the family not in terms of its individual parts, or members, but rather as equal parts "biologic" and "sociologic."

As a biologic unit, the family resulted from the union of instinct and urge. Biolog)' left a footprint upon the status of all diat issued forth from that union, but not necessarily an indelible one. The footprint, as it were, could be smudged or preser\'ed by the action of the "sociologic," social changes in the family. The introduction of the automobile and electricity by human agency left in its wake a legacy of carnage in the form of increased accident rates and what previously

Bigelow, "Biological Foundations of the Family " Jouriia/of Socia/16 (March 1930): 129-33; Harr)- C. Solomon and Maida Herman Solomon, Syphilis of the Innocent: A Study of the Soda/Effects of Syphilis on the Family ami the Communi^' (Washington, D.C.: United States Interdepartmental Social Hygiene Board, 1922), 187; Henr)- B. Richardson, Patients Have Families (New York: The Commonwealth Fund, 1945), x\Tii. 326 would have been considered an unnatural cause of mortalit)'. Familial and social values could of their own volition alter even the fertilit)' of specific individuals and the human species generally.

Noted Wile, "The family has been impressed by a dynamic machine mold, and it has not taken a fLxed static form, as it has changed mechanically, socially, even physically.""'

The healthful home stood as the centerpiece, the great accomplishment, of the healdiy family. An examination of the social, economic, educational, political, and environmental surroundings of the family revealed much of interest to hygienic experts. The household stood at the apex of American civilizadon and determined the relative health of that civilization. The supreme importance of the healthful home as a most fundamental unit of societ)' was not so apparent to many laypeople. Wile lamented the fact that so many citizens considered healthy homes dependent solely on "individual desire and effort." Maintaining healthy homes, he noted, required the cooperation of outside agency in the form of communit)' forces that stood "beyond the control of individuals."'^'^-

Wile, who wrote extensively on the urban housing problem, also professed his disappointment that Americans erected housing solely on economic grounds in accordancc with the law of supply and demand, with little thought of public or family health. Finances, he stated, should not be allowed to "jeopardize communal welfare." Homes built without regard to basic sociological principles, without an understanding of common interactions of the family, contributed heavily to the construction of unhealthy surroundings. Wile himself blamed

"machiner\'" which "has been devastating the home because it has taken away most of its

creative values and also many of its cohesive values." Congestion, lack of privacy, noise,

^"ira Solomon Wile, is Happening to the Family?" Hospital Social Service 19 (1929): 525~33; idem, "Sociological Aspects of Housing," American Journal of Public Health 10 (April 1920); 327-31. ^'"Paul B. Popenoe, "The Family in Societ)'," Public Health Nursing 28 (1936): 567-72; Ira Solomon Wile, "The Healthful Home," American journal of Public Health 12 (April 1922): 295-8. 327 darkness, scarcity- of toiJet facilities, and overall unattractiveness—all apparendy unimportant considerations to the unblinking artificial, mechanical eye—all contributed to the physical and mental disorientation, disintegration, and deterioration of families and communities/"^

The new conception of farnily as the fundamental unit of American health progress demanded fundamental changes in the professions of health. Reverberations were felt all the way down to what seemed only the continuing and mundane task of collecting vital statistics. The sea change was enormous and heretofore largely overlooked in historical accounts. Registrars, said

Edwin W. Kopf, assistant statistician at the Metropolitan Life Insurance Company, had heretofore neglected their dut)' to produce information useful beyond the narrow confines of registration. Vital statistics collected in the past were useless to those interested in "social forces in equilibrium" or of the "social kinetics" produced in families. Registrars needed to collect "not only the aggregations of mere individuals as shown on the books of the demographer, but also the data on the most elementaiy forms of human association." Only by collecting such material on family relationships in the communit)' could the health effects of mass social events like wars, namral disasters, and economic catasttophes be truly understood.^'^"*

Taking family liistories ratlier than individual health histories revealed a more comprehensive health picture, directing the efforts of public health professionals more surely than fragmentar)' individual records. Nurses thus now recorded their work in "Family Folders."

These folders, usually measuring 5" x 8" and made of durable manila, contained all the necessary

"Sociological Aspects of Housing," 327-31; idem, "XXIiat is Happening to the Family?" 525-33. ^^•'Edwin W. Kopf, "Family Statistics from Registration Sources," American Journal of Public Health 8 (1918): 910-2. Compare this with the relatively modest goals of registration in J. Taj-lor Madison, "Personal Registration of Family Memoranda; A Plea for the Making and Preser\'ing of Homely Annals," Science 36 (October 11, 1912): 480: "Methods for laying the foundation of practical certitude are being applied to most lines of endeavor and economic progress. The one conspicuous exception is the study of human efficiency. Here methods ate so lacking in system, so disproportionate, as to disappoint reasonable expectations. Especially defective are the means employed for presen'ing significant facts bearing on the life histor)-, physical, psychologic, domestic, and other factors of personal advancement in human beings. Wliolly inadequate are the registrations of birth, marriage, death, and especially the accompanying circumstances." 328 forms for uacldng the social and health progress of a single family/'' Family folders assembled bv public health nurses often contained intimate details of family life because, as several commentators put it, interrogations in the home loosened the tongues of otherwise resen*ed individuals. But this was exactly the point. The public health of the individual was completely tied together with the thoughts, feelings, racial or ethnic customs, and emotional context of the family in toto. Nurses, having collected all the pertinent information about households, then turned over particular tasks to particular groups in the communit)' best attuned to carrj' out her wishes or, in the case of the other professions of health, engineer their own solutions/'"'

Famil}' record keeping was of particular advantage to the overworked public health nurse.

The family folder seems to have been created first to meet her needs, though it was quickly adapted and accepted in the professions of health generaDy. One of the earliest family recording systems was created in the Middle Western Office of the National Organization for Public Health

Nursing under the auspices of Katherine M. Ohnsted. For the nurse "the family predominates over the individual," she wrote in 1920. "It is the Jones family by the river that is drinking polluted water, or it is the old Brown farm where the children are aU underfed." Now, she continued, cases should be, "referred to [by] the nurse not by individual names and addresses, but by family names and locations.

Thus, the inauguration of a whole new set of recording forms, which Olnisted named the

"Family Unit Record System" made sense. "The aim of the . . . record system," she explained,

^''"Record Forms for Public Health Nursing," American Journal of Public Health 23 (1933): 473-5. ''"'Marguerite A. Wales, The Public Health Nurse in Action (New York: Tlie Macmillan Company, 1941), 423; Theda L. Waterman, Nursing for Community Health (Philadelphia: F.A. Davis Company, 1944), 49; Amelia Howe Grant, Nursing: A Cammimity Health Service (Pliiladelphia: W.B. Saunders Company, 1942), 47-8; Marian G. Randall, "Family Composition Used in the .Analysis of Home \''isits by Public Health Nurses," Milbank Memorial Fund Quarterly 15 (luncl 937): 275-91. ''^'George H. Ramsey and Marjorie T. Bellows, "Family Records in the Health Department," American journal oj Public Health yi (June 1942): 586; Katherine M. Olmsted, "Record Forms for Rural and Small Town Nurses," Public Health Nurse 12 (1920): 33-5. 329

"is to have as much information about family environment and disease as is necessar)', without gathering a great deal of material of little value either statistically or practically." The family folder contained or had stamped upon it the generalities of each particular family. The names of husband, wife, children, and any others occupying the household were listed. Social and religious contacts were inscribed on a cover sheet. Also included was special information as to particular

handicaps. Half a sheet was given over to a description of the environment of the family, including the conditions of the house, any outbuildings, the pri%-)', water supply, garbage disposal, sewerage disposal, and local dairy supplier. A record was also made of the economic state of the

family including insurance provisions, home ownership, and occupations of family members.*^'"

This family folder contained the cards of individual members of the family, and was

designed as a continuous record of illnesses, afflictions, and general health. The individual

records within each family folder could var)' substantially, but generally contained patient

histories for use by the public health officer or physicians on house calls or at clinic visits, and

records of nursing visits to family members. Moreover, the monthh' report form combined aU

of the activities of the nurse—general nursing service, school ser\dce, clinic and health station

sen-ice, social sentice, and expenses—^into one useful and generalized document.^'™

Family-oriented record keeping dovetailed nicely with the larger aim of keeping coherent

community health records. Family records transformed what before seemed a "heterogeneous

mass" of records guiding "inefficient ser\'ice" into an integrated system for collecting and

compiling health department records at all levels. Still better, the switch to family record-keeping

reduced the sheer number of primary records needed in die first place. Chief Statistician

Marjorie T. Bellows and her commissioner George H. Ramsey, for instance, found that under a

'"'"Olmsted, "Record Forms for Rural and Small Town Nurses," 35-9. ''''^Olmsted, "Record Forms for Rural and Small Town Nurses," 35-9; Marjorie T. Bellows and George H. Ramsey, "Integration of Health Department Records," journal of PubJk Health 2') (|unc 1939); 637. 330 new plan for family reorganization of the more than half a million medical and nursing record forms collected by their Westchester (New York) Count)- Department of Healtli all but 175,000 were unnecessan- "duplicates" or "spccial summarj* forms." Field records no longer needed to be copied from individual folder to folder, and were now usefully at hand whenever needed/'""

The concept of family as communit}' in microcosm reached deeper than public health administration and record keeping. Public health professionals used family relationships to more fuUv comprehend the nature of specific diseases and thereby to refashion epidemiological principles. Professional epidemiologists and infecdous disease experts stressed the totalit)' of communicable and chronic disease control over the identification of stricken individuals. Many, if not all, diseases moved in farniUes and could not be prevented or isolated simply by treadng infecdons as they became known. "Resort to medical control alone is like bailing out the kitchen when the water pipe has burst," exclaimed one nurse, "instead of shutting off the water and fixing the pipe." Besides, infected individuals often deliberately eluded discover)'. Prevention depended instead upon educating the whole family, treating the whole family, and eliminating the immoral social and personal influences that encouraged the disease.^'"'

Wade Hampton Frost, an epidemiologist with the United States Public Health Service and professor of epidemiologv at the Johns Hopkins L'niversit)- School of Hygiene and Public

Health, with his students and coUeagues found "familial association and aggregation" in many diseases, including pulmonary tubercvdosis, rheumatic fever, cancer, common colds, as well as in a wide range of other illnesses. "One of the most characteristic features in the epidemiology of

the common acute communicable diseases is the grouping of cases in time and space," he noted,

'®°Bello\vs and Ramsey, "Integration of Health Department Records," 636, 638, 640; idem, "Family Records in ihc Health Department," 585-8. ^^'Naomi Deutsch, "Generalized Public Health Nursing Services in Cities," American Journal of Public Heahb 25 (1935): 475-8; N.A. Nelson, "The Nurse in Control of Gonorrhea and Sypliilis," Public Health Nursing 25 (1933); 199-204. 331

"and this is especially apt to be noted in the group which constitutes a household, people in close contact with each other, sharing a common environment, mosdy of close kinship, and usually under the eye of at least one medical or lay obsen'er whose obsen'ation encompasses the whole group.

Frost considered his familial epidemiological principles of great value in the control and

prevention of tuberculosis, a particularly stubborn infectious disease. "Fift)' years ago," he

remarked, "in the light of Koch's discover)' and of the whole germ theor,' of disease as it then stood, one of the great students of public health could say, quite reasonably; 'There is no

theoretical reason why a purely contagious disease like tuberculosis may not be exterminated. If contagion can be prevented at aU it can be prevented completely.'" The record since then,

however, had clouded much and doubt began to creep into the minds of many public health

professionals. Understanding of the household or familial aggregation of tuberculosis, however,

could be used to keep transmission of the bacteria below the threshold level necessar)' for its

continued propagation and succession in the communit)'. "If, in successive periods," Frost wrote,

"the number of infectious hosts is continuously reduced, and this declining ratio is continued long enough, extermination must be the result."''"^

Frost collaborated with many researchers in several field saidies of familial tuberculosis.

All of die studies bore an essential commonalitj'. They were designed, explained Frost, to

"ascertain the mortalit)- and specific morbidit}' in familial contacts of persons suffering from

pulmonar)- tuberculosis, for comparison with the experience of suitable control populations."

Calculations of morbidit^• and mortalit}' correlated with family contacts revealed the "excess risk"

^®"\Vade Hampton Frost, "Epidemiologj-," in Vapers of Wade Hampton Frost, AI.D.:A Contribution to Epidemiological Method (Sew York: The Commonwealth Fund, 1941): 495; idem, "The Familial Aggregation of Infectious Diseases," American journal of Public Hcah!) 28 (lanuar)' 1938): 7. ^^"^Wade Hampton Frost, "The Outlook for the Eradication of Tuberculosis," American Ksview of Tuberculosis 32 (December 1935): 644-5. 332 found in certain tuberculous households, and their excess "secondary attack rate," the average number of family members suicken (other than the primary or "index" case) in some specified period of time/'"'' Frost took no credit for these ideas, explaining that Providence sanitarian

Charles Value Chapin had first outlined the idea of a secondary' attack rate as early as 1903, but had overlooked some of the obvious Lmplicadons for epidemiological understanding of infecdous diseases stemming from it/'"^

Frost contrasted his science against clinical diagnosis, where the fundamental unit is the individual patient and individual lesions. "For epidemiological description," he wrote, "the unit is an aggregadon of individuals making up a population, and descripuon of the mass-phenomena of a disease consists of a statement of its t}'pes and frequency of occurrence in the population as a whole and in its different component groups." Diseases, in other words, were "mass- phenomena."^'"'''

Frost and his cadre of invesugators considered the traditional definidon of epidemiology obsolete. Epidemiology as the "science or doctrine of epidemics," Frost asserted, had ardficiaUy circumscribed the field. "It is now recognized that an epidemic is only a temporar}' phase in the occurrence of any disease, and that its phenomena cannot be considered scienufically except in reladon to the antecedent and subsequent histor)' of the disease." The epidemic manifestadon of disease, in other words, could be viewed as an extreme example of its otherwise endemic

'"^'^Fiost, "lilt Familial .Aggregation of Infectious Diseases," 8,12. Ross L, Gauld of the Department of Epidemiolog}' and Biostatistics in the School of Hygiene and Public Health of Johns Hopkins Universit)' perpetuated this belief as late as 1942, writing that "the systematic study of the acute communicable diseases, using the family or household as a unit, has been due largely to the work of the late Charles Chapin and his development of the so-called "secondar)- attack rate" to measure the risk of persons exposed to a disease in another member of the same household." See Ross Laurier Gauld, et al., "Index Person: Relation to Incidence Rates in Family Studies," American Journal of Pnb/ic Health 32 Qune 1942): 577. ''''prost, "Epidemiolog)'," 495; idem, "Risk of Persons in Familial Contact with Pulmonary' Tuberculosis," American Journal of Public Health 23 (May 1933): 426-7. Epidemiologists defined the index case as either the first case of communicable disease in a family, or as the first documented by a public health worker. ^'"'Frost, "Epidemiology-," 494, 496. 333 character. This was especially apparent in comparisons of epidemics one to another. Each differed substantially in their course due to many factors, including transmission rate, pathogenicit\', host susceptibiUt)', distribution, and antigenic properties. Epidemiology became a dynamic natural science, where disease in the population fluctuated on a scale balanced by infection and immunit}'.'^"'

Diseases, Frost argued, could also be misunderstood by traditional epidemiologists who conflated the definition of "disease" and "infection." Diseases need not manifest themselves to the professional by his carefully cultivated arts of discrimination. Rather, microbes and parasites might be "subclinical" (hidden) or He dormant within an apparently healthy body. "Carriers" of disease spread disease without appearing infected themselves. They belied the ever-present

"concealed resen'oir" for disease, but ever)- human could be scratched for one dangerous invader or another. Eveiy individual, in other words, incubated the potential for disease in another. The multiple faces of disease, then, would be studied together.''""

Moreover, the older science of epidemiology neglected its roots and its associations as it canned out a professional niche. Epidemiologists, noted Frost, needed to consider broader fields of inquir)' like natural pliilosophy, natural science, and biology. They should borrow heavily from bacteriology, protozoology, and immunolog)'. "In fact," wrote Frost, "epidemiology must cither be considered broadly as including these sciences or, if more narrowly defined as distinct from them, it may be conceived as an extension from the opposite side into a field where most of the ground is in common." Even where extreme specialization might be necessar)', all sciences, including epidemiolog}', ultimately represented "converging lines of research."'^'"'^

493, 519-29. 512, 520. 497-9. 334

The modus operandi of diseases recognized by this recast "coUectivc science" of epidemiology affected various communit)' groups differendally. Suscepdbilit)' and resistance depended, in large measure, on the "characteristics and customs" of human populadons. Measles afflicted children because they lacked immunit)'; adults had akeady had the disease or been exposed. Yellow fever epidemics often spared their worst effect in children and blacks. Typhoid fever ravaged diose who ate fecal-contaminated food and drink. Race, sex, age, geographic locale, and economic status were all considered legitimate, natural groupings for epidemiological consideration.'^^''"'

The new epidemiology also emphasized the limitadons of the laboratory. While extraordinarily useful as a tool for research, wrote Frost, "the transmission of an infectious disease under controlled experimental condidons suffices to prove that all the factors essential to natural transmission are comprised within the more or less narrowly limited conditions of the experiment, but it does not prove the converse proposition, that these are the only conditions under which infection may occur." Descriptive observation in the field represented a check on

the experimentalist. Only there could epidemiological associations be made dircctiy.®'

In practice. Frost's field workers, usually but not exclusively medical social workers and

public health nurses, prepared "family schedules" to keep track of relevant information during

clinical investigations and inten-iews. Family schedules included, most crucially, information on

membership in family groups, relationships between members, and linkages with deceased or

former members. Genealogical records were only one of many ways to define a namral family

unit for public health research. A family or household "is used in a rather loose sense to denote

persons associated more or less permanendy in the same home, taking their meals together, and

^'°Ibid., 495-6, 510-17,531. Ibid., 498, 505, 540-2. 335 sleeping under the same roof," remarked Miriam Brailey of the Harriet Lane Tuberculosis Clinic of the Johns Hopkins Hospital. "Relationship by blood is usual but not essential for inclusion in the family roster." Ross L. Gauld of the Department of Epidemiology and Biostatistics in the

School of Hygiene and Public Health of Johns Hopkins Universit}' agreed. "The term 'family' is used to refer to the group of individuals who dwell together under one roof," he explained.

"That is to say, a family is composed of a group of people, usually of close kinship, who are living in intimate contact with each otlier and who share a common environment. It is, as a rule, a readily delineated group, and is a unit which can without great difficult)' be kept under obser\'auon."'^'''"

Without relating or comparing data derived from physical exams, roentgenograms, and tuberculin tests with information derived from family histories, excess risk and attack rates among tuberculous families might have been suspected, but not conclusively demonstrated.

Explained Tennessee Department of Public Health statisdcian Ruth Rice Puffer, "although the causative agent of tuberculosis has been known since 1882, the reason for the selection of certain individuals for attack has not been determined. . . . We now know the great risk for those in the household exposed to open cases.

Bv far the most wide-ranging application of Wade Hampton Frost's concepdon of the familial association and aggregation of infectious diseases was made in sun^eys and regional demonstration projects in what came to be commonly referred to as the "Tuberculosis Studies in

Tennessee." The Tuberculosis Studies in Tennessee, begun in 1927 in cooperation with the

International Health Division of the Rockefeller Foundation, were designed to discover and

''"Frost, "Risk of Persons in Familial Contact with Pulmonar)' Tuberculosis," 426-7; Miriam Brailey, "A Study of Tuberculosis Infection and Mortalit)- in the Cliildren of Tuberculous Households," American Journal of Hygiene 31 (]anuar)-1940); 1-2; Gauld, et ai., "Index Person; Relation to Incidence Rates in Family Studies," 578. ''•^Ruth Rice Puffer, Familial Susceptibility to Tuberculosis: ]ls Importance as a Public Health Problem (Cambridge; Harvard Universit)' Press, 1944), v-vi, 1, 7-21, 81. 336 conttol this particularly rampant disease in the population. The tuberculosis death rate in

Tennessee at that time was astonishingly high, about 144 per hundred thousand people, consdtuting a "definite challenge" to the health resources of the state. The studies themselves were divided among three counties in the "three grand divisions" (east, cental, and west) of the state, chosen so as to "obtain representative agricultural and industrial, urban and rural groups characteristic of each area." The agricultural Gibson Count)' was chosen in western Tennessee; industrial ICingsport (Sullivan Count)') was selected in eastern Tennessee; middle Tennessee was represented by Williamson Count)'/'"''*

Field surveyors accomplished their "tuberculosis finding" by reckoning with the familial basis of its nature and spread. "In whatever way the entiy into the family has been obtained, the attitude has been that tuberculosis is a familial disease and one case should lead to a search for others by a complete examination, including roentgenologic smdy of every member of the family," explained E. L. Bishop, the State Commissioner of Public Health of the Tennessee

Department of Public Health, and H. C. Stewart, Director of Field Studies of Tuberculosis,

Tennessee Department of Public Health. "This has led to the finding of the t)'pe of case in which the best results can be expected, namely, die early or minimal case." Indeed, household exposure to aiberculosis was found throughout the state to be the main route for the disease, and

the most "logical means of approach in the control of tuberculosis in Tennessee in the light of

information now at hand," concluded Bishop and Stewart, "would seem to center around the

breaking of the chain of long-continued contact between patients with fibroid and other types of

tuberculosis with dieir household associates.

^^''E.L. Bishop and Howard C. Stewart, "Tuberculosis in journal of the American Medkat Association 99 ([uly 30,1932): 356-9; Howard C. Stewart, at al., "Tuberculosis Studies in Tennessee; Clinic Study with Reference to Epideniiologv' within the Family," American journal of Public Health 26 (1936); 689. '''^Bishop and Stewart, "Tuberculosis in Tennessee," 357, 359. 337

Experts designed and equipped mobile diagnostic units to find afflicted cases in communides and families and place each case under appropriate medical and nursing care.

Family folders of information were established and maintained. Clinic and roentgenologic

examinations were carefully made for symptoms of mberculosis, and data on the economic,

environmental, and occupauonal cii'cumstances of families were obtained. During the first four

years of the Tennessee mberculosis surveys, 1,794 clinics were held, 28,131 individual

examinations made, and 5,243 positive cases found.^''^'^'

In the 1930-1931 lungsport (Sullivan Count)') Tuberculosis Sun^ey sponsored by the

Tennessee State Department of Health, James Anderson Crabtree, director of the Division of

Preventable Diseases, discovered disturbing excess morbidity and mortalit}' in the black

population. One hundred thirt)'-two black families were scrutinized in the sun^ey, revealing

households suffering tuberculosis morbidit}' and mortalit}' rates double the statewide rate.

Crabtree blamed the excessive rates on the household environments created by certain black

families in that communit)'. "Households that have contained cases of tuberculosis, and more

especiallv fatal or existing acdve cases," he noted, "arc more crowded, families are larger, and the

rental value of residences is lower than those with no tuberculosis; milk consumption per capita is

considerably lower, and evidence of filth and untidiness in the home is three times more frequent

in the former class of households than in the latter.'"^^'^'

Experts launched the Williamson County Study in the waning months of 1931. Ruth

Rice Puffer studied the household associates, "the most important of the classes at risk," of

tuberculous patients in the Williamson Count}' Tuberculosis Study. Here, one hundred and fift}'

357, 359. ^"james Anderson Crabtree, "Tuberculosis Studies in Tennessee: Tuberculosis in the Negro as Related to Certain Conditions of Environment,"/owraa/ of the jAmerimn Medical yissaciation 101 (September 2, 1933): 756-70; idem, "Tuberculosis Studies in Tennessee: A Communit)' Study of the Prevalence of Tuberculosis in the Negro," American Review of Tuberculosis Supplement 28 (December 1933): 1-31. 338 households were placed under scrutiny for signs of familial tuberculosis. The efforts of the researchers did not go unrewarded. Under continuous obser\'^adon, Puffer found that 55.7 percent of all household associates of white prirnar)' cases had latent priman' tuberculosis, 7.9 percent latent apical tuberculosis, and 7.4 percent manifest tuberculosis. In black families with an identified tuberculosis sufferer, 45.7 percent household associates had latent primar)' tuberculosis,

4.7 percent latent apical tuberculosis, and 5.6 percent manifest tuberculosis. Again, as in

Kingsport, a tuberculosis rate was found double that of the state considered whole.'^^'^"

Howard C. Stewart, epidemiologist with the Tennessee State Department of Health, hoped that the study of tuberculosis in Williamson Count)' might ser\'e as an appropriate example of what other communities throughout the United States might accomplish. Mobile diagnostic clinics needed for successful emulation of the Williamson Count)- demonstration included x-ray machines, tuberculin tests, microscopic sputum examination, and a highly ti'ained field staff.

Stewart kept detailed records, and realized that repeated examinations of the families were necessar)' to discover latent and incipient cases of tuberculosis for treatment.*^^'^'^

Frost's new epidemiolog)' was also applied in investigations conducted by the Johns

Hopkins Universit)' in the Harriet Lane Home, a clinic for children, and in the Eastern Healtii

District, an area comprising several cit)' blocks of Baltimore and home to sixt)' thousand people.

Miriam Brailey, member of die Department of Epidemiology of Johns Hopkins, director of the

Baltimore Bureau of Tuberculosis, and epidemiologist in the Harriet Lane Home's Tuberculosis

Rice Puffer, et al., "Use of the Index Case in the Study of Tuberculosis in Williamson Count)-," American Jimrnal of Public Health 32 Qune 1942); 601, 603; idem, et al., "Tuberculosis Studies in Tennessee: Subsequent Course of Cases Obsen-ed in Williamson Count)-," American Journal ofHygiene 28 (November 1938): 490-507; Stewart, et al., "Tuberculosis Studies in Tennessee: A Clinic Study with Reference to Epidemiology within the Family," 689, 696; Howard C. Stewart, et al., "Tuberculosis Studies in Tennessee: Infection, Morbidit)-, and Mortalit)' in the Families of the Tuberculous," AmericanJournal of Hygiene 26 (November 1937): 549; idem, et al., "Prevalence and Incidence of Tuberculosis Among Household Associates According to Age and Sex of Index Case," American Journal oj Public Health 33 (April 1943): 379-85. ""'''Stewart, et al., "Tuberculosis Studies in Tennessee: Infection, Morbidit)-, and Mortalit)- in the Families of the Tuberculous," 527-8. 339

Clinic, revealed the familial aggregation of tuberculosis disease among Baltimore residents. She discovered a sevent}'-seven percent positive tuberculin reaction rate in children aged one to fourteen where a sputum-positive adult was present, and a corresponding increase in the rate of tuberculosis mortalit)'.^""

Epidemiologists in the Cardiac Clinic of the Harriet Lane Home also found evidence of

Frost's familial aggregation of disease. Rheumatic fever had for almost a half centurj' been popularly referred to as a "house disease," that is, seeming to have a high rate of infection within the home. Bur in the Harriet Lane Home a triumvirate of related rheumatic diseases—chorea, rheumatic fever, and rheumatic carditis—were all found to exhibit familial tendencies closely approximating tliose for tuberculosis. Ross L. Gauld and Frances E. M. Read studied the familial face of rheumatic disease at the Harriet Lane Home. "The children of 95 families, in each of which one child entered the cEnic because of some rheumatic manifestation, were studied with respect to the relationship of the occurrence of the disease among them to familial association with an acute episode of tlie disease in another member of the family," tliey reported. "The analysis showed that the risk of contracting the disease among the siblings of the index cases was increased, following association with an acute episode in another member of the family, to more than twice that which prevailed prior to this association."'"'

'""ini ^'aughan Hiscock, "Tlie Development of Neighborhood Health Ser\'ices in the United States," Milhaiik Memorial FiiiulQuarterly 13 (januar)' 1935): 48-51; Frost, "Risk of Persons in Familial Contact with Pulmonary' Tuberculosis," 429-3; Miriam Brailey, "Prognosis in VCliite and Colored Tuberculous Children According to Initial Chest X-ray Findings," American Journal of Public Health 33 (April 1943); 343, 352; idem, "A Study of Tuberculosis Infection and Mortalitj- in the Cliildren of Tuberculous Households," 29; idem, "Mortalit)- in the Children of Tuberculous Households," MUbank Memorial Fund Quarterly 18 (July 1940); 222, 238. ^^'lohn R. Paul, "Mefliods of Determining the Prevalence of Rheumatic Fever in Cities and Small Communties," MUbank Memorial Fund Quarter!)' 13 Qanuar)' 1935): 53; Ross Laurier Gauld and Frances E.M. Read, "Studies of RJieumatic Disease: Familial Association and Aggregation in Rlieumatic Journal of Clinical Investigation 19 (March 1940): 393, 397; Ross Laurier Gauld, et al., "Further Obser\'ations on the Occurrence of Rlieumatic Manifestations in the Families of Rheumatic Vauents" journal of Clinical Inuestigation 18 (March 1939): 213, 216-7; Frances E.M. Read, et al., "The Frequency of Rlieumatic Manifestations Among the Siblings, Parents, Uncles, Aunts, and Grandparents of Rlieumatic and Control Patients," Journal of Hygiene 21 (May 1938): 719. Similar investigations of rheumatic diseases were conducted by the Department of Pediatrics of the Washington Universir\' School of Medicine in St. Louis and the Department of Pediatrics of the Cornell Universitj- Medical 340

The factors of heredity' and environment were both found significant to this result, but the researchers found it remained unclear to what extent each variable contributed to the mix.

Still, the possibilit)' of household exposure became key to epidemiological investigadons. "Prior to the realization of the infectious origin of this disease, the strong familial concentration was regarded as a consequence of an hereditar}' diathesis," wrote Read in 1938. "In more recent years, since the infectious nature of the disease has been accepted and its chronic course and recurrences recognized, more credence has been given to the assumption that the liigh familial incidence of rheumatic manifestations is an expression of continuous exposure to persistent foci of infection rather than to an inherited susceptibility.'"""

The Johns Hopkins School of Hygiene and Public Health and the Baltimore Health

Department created what they identified as the "Laboratory of the Eastern Health District" for

field studies of new public health procedures, and as a place where new personnel might be

routinely trained. The district initially comprised two wards of the city of Baltimore, but was

subsequentiy enlarged to include more than two more. The population in the two original wards

was about 43,000 whites and 12,363 blacks, comprising a total of 15,000 families. A report of the

number of families, now so important to proper epidemiological investigations, stood at 10,979

white families and 2,800 colored faniilies. Researchers in die Eastern Health District predicated

their work upon the then-novel belief "that the community life and environment influence the

College in New York Cin-. Edith In'ine-Jones of the St. Louis Children's Hospital and W ashington Universit)' concluded that "the undoubted familial occurrence of rheumatism would seem to be due less to a specific and contagious agent than to certain familial characteristics which favor: (a) the onset of many infections, and (b) the appearance of the syndrome known as rheumatism." May G. Wilson of the New \'ork Nurserj- and Child's Hospital and Cornell Universit}' directly patterned her investigations of rheumatic diseases after the methods used bv McPhedran and Opie in their studies of familial tuberculosis. Sec Edith Irvine-Jones, "Acute Rlieumatism as a Familial Disease," journal of Diseases of Chi/dren A5 Qune 1933): 1184-95; May G. Wilson, RJjeumatic Fever Studies of the Epidemiology', Maiiifesfations, Diagnosis, and Tnatment of the Disease Dnrin^ the First Three Decades (New York: The Commonwealth Fund, 1940), v, 21; and May G. Wilson and Morton D. Schweitzer, "Rlieumatic Fever as a Familial Disease: Enwronment, Communicabilit)', and Heredit)' in Their Relation to the Obser\'ed Familial Incidence of the Dhezse," Journal of Clinical Invesli^atioii 16 Quly 1937): 555-70. ™"Read, et al, "The Frequency of RJieumatic Manifestations Among the Siblings, Parents, Uncles, Aunts, and Grandparents of Rlieumatic and Control Patients," 719. 341 disease picture" and that "the smallest unit of group life, the family, has not been studied extensively from this point of view."'"-^

jean Downes and Sel\\7n D. Collins, both of the Division of Public Health Methods of the National Institute of Health and the Milbank Memorial Fund, conducted in this district epidemiological studies of acute and chronic "sicknesses" among the residents. So also did Wade

Hampton Frost and his collaborators. These diseases included mental afflictions, common colds, pneumonia, dental caries, tuberculosis, sypliilis, rheumatic fever, and diphtheria. Researchers canvassed neighborhoods for "household informants," one to each family and usually a mother or wife, who became responsible for recording aU of the illnesses occurring in the family over the course of a year. In regular general surveys, researchers described each individual in terms of age, race, sex, relationship within family unit, occupation, and homeowner status. By this method, for example, the rate of illness found in the district for the year ended June 22,1939, was determined

to be 1,268 per 1,000 population. Downes, Collins, and Frost, also correlated sickness rates

against the general surx'^ey variables.'"''

Tuberculosis sun^eys conducted at die outpatient clinic of the Henn' Phipps Instimtc of

the Universit}' of Pennsylvania'"' also found excess morbidity' and mortalit)' when statistics were

grouped into families. Institute workers assigned each family attending the clinic its own serial

'°"^Hiscock, "The Development of Neighborhood Health Services in the United States," 50; Jean Downes, "Illness in the Chronic Disease Family," journal of Piib/k Health 2>2 ()une 1942): 589-600; ^^A. \'olkenburgh and Wade Hampton Frost, "Acute Minor Respirator}' Diseases Prevailing in a Group of Families Residing in Baltimore, Mar\-land, 1928-1930: Prevalence, Distribution, and Clinical Description of Observed Cases," American Journal of Hygiene 17 ()anuar\- 1933); 122-53; idem, er al., "Diphtheria in Baltimore; A Comparative Study of Morbidit)-, Carrier Prevalence, and Antitoxic Immunit)' in 1921-24 and \932i-36" Amrica/i journal of Hygiene 24 (November 1936): 569-86; Lowell R. Reed, et al., "Family Studies in the Eastern Health District: General Characteristics of the Population," American journal of Hygiene 37 Qanuarj-1943): 37-9. For a rather generalized xnew of the whole work of the Eastern Health District, which still exists as a unit of study today, see Elizabeth Fee, "Partners in Communit)- Health; The Baltimore City Health Department, the Johns Hopkins School of Hygiene and Public Health, and the Eastern Health District, 1932-1992," MaQ'land Medical journal 42 (August 1993): 735-44. '"•'lean Downes and Sel\v3'n D. Collins, "A Saidy of Illness Among Families in the Eastern Health District of Baltimore," MUbank Memorial Fund Quarterly 18 (Januan' 1940): 5-6, 8-9,12. ^°^Nor to be confused with the Henn,- Phipps Psycliiatric Clinic at Johns Hopkins Universit)'. 342 number and file folder, into which diey dropped "family sheet" forms, medical histories, and examination records. Beyond x-ray films, tuberculin tests, and diagnoses, the family folder contained pertinent "sociological information" on the state of cleanliness of family members and home, occupation and employment, nadvit}-, and other habits that might mark pardcular families as prone to tuberculosis infection and ti-ansrrussion. "Family graphs" were also prepared for each folder, updated with arcane symbols tracking the sources and course of tuberculosis infection in family membersJ'"^'

The results of this reorganizadon revealed significant informadon. For instance, it became obvious through family record keeping that almost eight)' percent of children with at least one other family member with open tuberculosis diagnosed by sputum sample had acquired the disease themselves by age five. Concluded Henr)- Phipps Institute physicians F. Maurice

McPhedran and Eugene L. Opie, "The spread of tuberculosis occurs in large part by long drawn-out family or household epidemics in which the disease is slowly transmitted from one generation to the next." Opie applauded the breakthrough of familial recording applied to tuberculosis disease because it opened up a whole new and more useful picture of disease

transmission from index cases to their families and down through the generations. "It provides a

measure of the relative danger to which members of the family are subjected," he explained, "and

can be used to determine how much medical and nursing care the family needs."'"'

'"^Eugene L. Opie and F. Maurice McPhedran, "Tlie Organization of an Out-Patient Tuberculosis Clinic for Epidemiological Investigation," Journal of Hygiene 12 (November 1935): 539, 547-55; F. Maurice McPhedran and Eugene L. Opie, "The Spread of Tuberculosis in Families," American Journal qfHygiene 22 (November 1935): 565-6, 594. '"'Opie and McPhedran, "The Organization of an Out-Patient Tuberculosis Clinic for Epidemiological Investigadon," 539, 547-55; McPhedran and Opie, "The Spread of Tuberculosis in Families," 565-6, 594; Eugene L. Opie, et al., "The Fate of Persons in Contact with Tuberculosis; The E.\ogenous Infection of Children and Adults," American Journal of Hygiene 22 (November 1935): 644; Eugene L. Opie, "Present Concepts of Tuberculosis Infection and 'D'K.&'S.SC" American Review ofTubercuksis'il (1935): 617-28. 343

Phipps Institute researchers also discovered previously understudied cases of "open tuberculosis of the consort," also known as "marital tuberculosis," in their faniilial studies. In all, approximately one-half of all the spouses of husbands and wives with open tuberculosis came down witli the disease themselves after marriage. Idendfication of the many cases of marital tuberculosis reverberated throughout tlie field because it indicated that many more cases of tuberculosis were acquired during adulthood. It was a widely held belief among students of tuberculosis at the time that most cases of apical lesions in adults stemmed from latent childhood infections. It also indicated that much could be done to evaluate prospective brides and grooms in order to prevent tubercular unions. This, of course, led to much sorrow.'""

Epidemiological studies by Jean Downes and other investigators during the Milbank

Memorial Fund demonstration project in Cattaraugus County, New York, also uncovered many so-called "tuberculous families." Downes tackled the tuberculosis problem in Cattaraugus

Count)' using portable x-ray macliines and mass tuberculin testing. Downes found Cattaraugus

Count}' an ideal location for familial tuberculosis-finding because it offered an "unusual opportunit}' for obser\'ing the spread of tuberculosis under fairly simple conditions." Milbank

Fund workers followed up initial rounds of mass testing with the distribution of "contact books" to public health nurses. These contact books, prepared by tabulators at the count}' health department, listed the names of all household contacts of persons who had ever had an active case of tuberculosis in Cattaraugus Count}'. Nurses kept track of over 1,200 household contacts over the course of the Demonstration. Individuals, those sharing the tuberculous "pedigree" plus other friends and close associates in the "natural family," in contact with the identified

'"^Eugene 1,. Opie and F. Maurice McPhedran, "The Contagion of Tuberculosis," American Review ofTuberm/osis 14 (October 1926): 347-419; John F. Patetson, "Tuberculosis in Married Couples," American Journal of Hygiene 32 (November 1940): 67-78; Eugene L, Opie and F. Maurice McPhedran, "E.xogenous Tuberculous Infection of Adults," Archives of Interna! Medicine 50 (1932): 1774. 344 tuberculous families stood a rate of infection nine times that of the general population and suffered a "considerable excess" in mortalit}'. Downes claimed a definite drop in mortalit}- rates by familial case-fmding activities.'"'''

Epidemiologists, vital statisticians, and health officers used the ideas of familial aggregation and association, of secondar)' attack rates, and of excess familial risk of morbidit)- and mortalit)' to more fuUy understand the transmissibilit)- of many other diseases besides mberculosis. Measles, for example, according to common and professional wisdom traveled and spread among groups, often afflicting several children in a famil}' or a whole communit}' at the same time. F. L. Kelly and Eleanor Reite of the Universit)' of Calfornia-Berkeley Department of

Hygiene in 1934 calculated that over half of all susceptible family contacts with a primar)- case of measles contracted the disease. Whooping cough, mumps, certain cancers, polio, diphtheria, leprosy, and chicken pox also spread through family contacts, far exceeding their natural rates of infection. But the most troubling of the familial diseases "discovered" in the late 1910s and

1920s, other than tubercular and rheumatic diseases, were syphilis, t)'phoid fever, scarlet fever, and pneumonia.'"'

""jean Downes, "A Study of the Risk of Attack Among Contacts in Tuberculous Families in a Rural .-^rca," American journal of Hj^iene 22 (November 1935); 731-5, 738-9, 742; idem, "How Tuberculosis Spreads in a Rural Communit)'," American jonnial of Public Health 26 Qanuat)' 1936): 30-8; idem, "The Risk of Mortalit)' Among Offspring of Tuberculous Parents in a Rural .-Vrea in the Nineteenth Cmnit)'" American Journal of Hygiene 2(i (November 1937): 557-8, 562-3, 568; Charles-Edward Amor\' Winslow, Health on the Farm and in the Village (New York: The Macmillan Company, 1931), 129; Jean Downes and Edgar Sydenstricker, "Some Results of Tuberculosis .-\dministration in Cattaraugus Count)', New York," American Rfview of Tuberculosis 23 (Februan-1931): 183, 203. Downes conducted a similar study of the nutrition of tuberculous families in the Harlem are of New York Cit)' beKveen 1939 and 1947 under Milbank Memorial Fund sponsorsltip. See J ean Downes, An Experiment in the Control ofTuhercnksis AmongNegroes Milbank Memorial Fund, 1950). ""F.L. Kelly and Eleanor Reite, "Secondar}' Cases of Certain Communicable Diseases Among Non-Immune Family Contacts," American Journal of Public Health 24 (December 1934): 1240-3; James Anderson Crabtree, "Observations on the Familial Incidence of Cancer," American Journal of Public Health 31 Qanuat)' 1941): 49-56; J.A. Doull, "Factors Influencing Selective Distribution in Diphtheria," Journal of Preventive Medicine 4 (September 1930): 371; W. Lloyd .\vcock and Paul Eaton, "The Epidemiolog)' of Infantile Paralysis: The Relation Between Multiple Cases in the Same Family," American Journal of Hygiene 5 (November 1, 1925): 724-32; Cuthbert Dukes, "Multiple Intestinal Tumours: A Familial Disease," Eugenics Revieii'25 (1933-4): 241-3. 345

Not surprisingly given their public and private representation as the epitome of social

malady, epidemiologists quickly revamped their understanding of the venereal diseases, casting

them as ideal "family diseases," diseases seemingly impossible to catch without social contact.

"There has come the realization that in many instances syphilis is a disease which invades the

family," wrote neuropathologist Harr}' Solomon and social worker Maida Solomon of the Boston

Psychopathic Hospital "The family being but a unit of the communit}', it follows that the

communal structure is also involved." Public health control efforts in this area focused especially

upon the freshly delimited etiolog)' and diagnosis of "familial syphilis," and public health

professionals described openly and in troubling detail whole "syphilitic families." The disease

was familial in two important respects. First, syphilis tended to strike adult males, the

breadwinners of families. This fact meant all sorts of unpleasant effects were focused directly on

the family, including both impoverishment and social stigma. "Syphilis in the family causes more

unhappiness than any other single disease," announced one public health nurse. Second, syphilis

easily spread from husband to wife, wife to husband, and even mother to child in ulero. Clearly,

syphilis was essentially a problem of the whole family.'"

A. L. Gray, epidemiologist with the Mississippi State Board of Health, and W. H.

Cleveland, a Tupelo health officer, described the unhappy effects of syphilis spread through close

family contact in 1935. The "R. Family," he related, became peculiar propagators of the disease

after the seventeen year-old daughter became infected after repeated sexual encounters with a

known Wassermann positive clinic patient. A few months later syphilis spread to her two

year-old brother after giving him food she had partially chewed for his benefit. The disease

^"Charles C. Dennie, "Familial Sypliilis," Journal of the Kansas Medical Society 20 (1920): 134-5; Thomas Parran, Shadow on the Land: Syphilis (New York: Reynal & Hitchcock, 1937), vii, 31, 267, 276, 291; Solomon and Solomon, Syphilis of the Innocent, iii; Gladys L. Grain, "Familial Sj'philis," Pub/ic Health Nnrsing 24 (1932): 557-60; idem, "The Public Health Nurse and the Community Social Hygiene Program," Public Health Nursing 25 (1933): 103-6; idem, "Public Health Nursing and the Medical Aspects of Social Hygiene," Public Hea/th Nursing 24 (1932); 377-80; Deutsch, "Generalized Public Health Nursing Ser^aces in Cities," 475-8. 346 invaded the mother of the family by regular breast feeding of the infant. The mother, in turn, infected the father through sexual intercourse. Meanwhile, the daughter had infected another brother and a sister, possibly from the chewing of "second-hand gum." In another of Gray's cases, the "D. Family" fell prey to the disease through a single razor which several men used "in rapid succession" while on the road picking cotton. One of die men returned home witli an eruption on his face, an eruption initially misdiagnosed as measles. By the time the mistake had become known, the man had passed syphilis to his wife who, in turn, passed the infection along to tlieir child by masticated foodJ'-

Harr)' and Maida Solomon also recounted touching narratives of the familial spread of syphilis in their widely cited book Syphilis of the Innocent: A Study oj the Soda! Effects oj Syphilis on the

Family and the Community (1922):

Case 49. The Bradford family is indeed an unusual one in that there were two children both of whom had juvenile paresis. The family consisted of the father and mother and two girls 16 and 14 years, respectively, at the time of their first appearance at our clinic. The older girl had been quite well until the age of 12 when she suffered a shock which left her paralyzed. Esther, the younger, had been perfectiy healthy in her childhood and was considered a bright and active student until she reached the fourth grade in school. Then, at the age of 10, she began to show cvidencc of deterioration. She complained of headaches, trouble with her stomach, and drowsiness. Next difficult}' with speech, gait, and coordination appeared. She deteriorated ver)' rapidly and when seen at age 14 was greatly demented. The whole picture including the laboratorj' tests of the blood and spinal fluid led to the diagnosis of juvenile paresis [paralysis], with a prognosis of death in a period of months or not more than a few years. The older sister also had a positive blood and spinal fluid. The Wassermann reaction on the mother was positive and that of the father was negative. It may be mentioned that neither child was correcdy diagnosed until the ages of 16 and 14 respectively."^

Gray and W.H. Cleveland, "Sources and Modes of Infection in Two Family Outbreaks," American Journal of PubUi-Health 25 Qanuaiy 1935): 49-53. ^'^Solomon and Solomon, SyfihiHs of the Innocent, 73-4. 347

Another case related by the Harr)- and Maida Solomon describes the Mazzocca family, a fairdly plagued not only by syphilis but by many other diseases:

Case 80. Mazzocca family. Father, alcoholic, dead; Mother, poor health, Wassermann positive; Boy, dead, 11 months, diphtheria; Boy, dead, 18 months, scarlet fever; Boy, dead, 22 years, tuberculosis; Boy, dead, 20 years, pneumonia; Patient, 18, juvenile paresis; Girl, 16, syphilitic bone disease, interstitial keratitis; Stillbirth at 18 months; Girl, dead at 14 months, meningitis; Miscarriage, 3 months.''^

l^'phoid fever also flourished in susceptible families. Studies by George H. Ramsey of the Division of Communicable Diseases in the New York State Department of Health found t)'phoid infection in unvaccinated famil)' members with one active case to have a 90-day morbidity' rate 1,900 times that of the general population.^'' So-called human "carriers" of disease, those who harbored and spread disease while showing no symptoms themselves, often cropped up in families of infection. Anna Dean Dulaney, assistant professor of bactcriolog)' and preventive medicine at the Universit)' of Missouri, found a dair)' farm operating in Columbia being run by a "family of t)'phoid carriers." Dulaney traced twentN'-two cases of t\'phoid in a

1925 epidemic to the dair\^ The "S. Family," as Dulaney dubbed them, turned out to have a long historj' infecting those outside the family with t)'phoid. In fact, this was the second family dair)' to be closed by the authorities. The S. Family had been forced out of the same business eight year before on the other side of town. Only recendy, the family had infected a new member through marriage, ten months before customers began coming down with t}'phoid. Father was found to be a carrier of at least twent}'-sLx years, and Mother for sixteen years.^"^'

Dulaney blamed the reinittent epidemics of t\'phoid touched off by this family on poor licensing requirements for milk producers and the family's improvident sanitarj' rituals. The S.

^'"•IBID., 129-30. "^George H. Ramsej', "Typhoid Fever Among Household Contacts with Special Reference to Vaccmation," American Jounia/ of Vly^ene 21 (May 1935): 669. "^Anna Dean Dulaney, "A Family of Typhoid Carriers," American journal of Public Health 15 (1925): 885-6. 348

Family had made no attempt to separate themselves from the production of milk for sale. They used "wide open mouthed containers" for collecting milk, and capped the bottles by hand. The outdoor latrine stood much too close to tlie milk house and the cistern for milk bottle washing, and the hose used for washing snaked around the back of the latrine. Dulaney concluded that the sanitan' situation at the daiiy all but begged an outbreak.'"'

Even where the disease under study had low secondary' attack rates as in the case of endemic scarlet fever, where the figure was about seven percent, the family relationship proved a significant factor. G. E. Foley, researcher in tlie Department of Preventive Medicine and

Epidemiology' of the Harvard Medical School and School of Public Health, noted that "endemic scarlet fever [in a given community] is composed of numerous outbreaks occurring in basic units of population such as the family, the whole of which gives die varied t)'pe-pattern characteristic of the disease in its endemic form." Follow-up with the Dick test in families where a primary case had been identified reduced secondar)' transmission by one-third.""

The nature of pneumonia infecdon also yielded to a familial understanding of its spread.

Ironically, epidemiological activities centered on the family unit in pneumonia stemmed from a

rather innocuous question: "How does it happen that one particular person in a group develops

pneumonia, whereas the other members of his own family, of his own school class, of his own

working group, or his immediate friends, remain well.^" Experts generally agreed in the early

twentieth centur)' that pneumonia was a bacterial disease, communicated person-to-person by the

pneumococcus bacillus. Surprisingly, though, the random contact aspect of its spread did not

'"ibid. ^'^W. Lloyd Aycock and Paul Eaton, "A Comparison Between Multiple Cases of Measles, Scarlet Fever, and Infantile Paralvsis," American Journal ofHygiene 5 (November 1,1925): 733-41; G.E. Foley, et al., "Serological Types of Hemolytic Streptococci Isolated from Multiple Cases of Scarlet Fever in the Same Households," ylwenra// Journal of Public Health 34 (October 1944): 1083-6; Kelly and Reite, "Secondar)' Cases of Certain Communicable Diseases Among Non-Immune Family Contacts," 1240; J.E. Gordon, "Reaction of Familial Contacts to Scarlet Fever Infection," American Journal of Public Healtbli 1935): 531, 543. 349 preclude in the minds of many experts the as yet unconfirmed possibilit)- of its more general dissemination witliin family groups. That is to say, experts became interested in familial pneumonia epidemiolog)' even when prior experience suggested no ntationship between familial contacts and pneumonia infecdon."'*'

Milton J. Rosenau, Lloyd D. Felton, James P. Powell, and Reginald M. Atwater in the

Hani-ard Department of Preventive Medicine and Hygiene and Department of Epidemiolog)' investigated this angle as early as 1926. They studied pneumococcus infection not only in family units, but also in natural groups like liigh school pupils, medical students, laborator}' workers, and

hospital nurses. And while they determined that nearly everyone is a carrier of a fixed and identifiable kinds of pneumococcus (described as Type 1, II, III, or 1\^ at some time during a

typical year, the source of these infections comes from "local contact" with "mutual

associations."'""

Rosenau himself illustrated the spread of pneumonia by mutual associations in families in

useful graphical form, In Figure 2 below, Rosenau attempted to determine the course of

pneumococcus infection in one family by drawing circles containing the names of natural

associates around the initial patient K-313, infected with Type I pneumococcus infection. The

number of lines drawn between each individual determines the strength of the their relationship

and extent of daily contact.'"'

'"wilson George Smillie, "Tlie Relationship of Immediate Family Contact to the Transmission of Type-Specific Vr\e.\xmococa" American journal of Hygiene yi (November 1940): 79-88. '•"Milton ]. llosenaxi, et al., ".\n Epidemiologic Study of Pneumonia and Its Mode of Spread," American journal of Hygiene 6 (May 1,1926): 463-83; James P. Powell, et al., "The Epidemiology' of Pneumonia: A Study of Pneumococcus Carriers Among Four Groups of Persons Over a Period of Months," American journal of Hygiene 6 duly 1, 1926): 570-592. '"'Rosenau, et al., "An Epidemiologic Study of Pneumoma and Its Mode of Spread," 464. 350

I 31 'O

!HHT AuKii f i' /Co OO O

Kits A&e 27 ^ OjiurltUU brme Ov hi-z^ 041'^UU

/<£P>/£VJ-6 16

Figure 2. Family Contacts of Case K-313

Contact bcRvecn Sister 302 and Brother-in-Law 207, for example, is very strong, while contact between Night Nurse 303 and Day Nurse 127 is slight. In Figure 3, Rosenau outlined the spread of pneumonia w^ithin a natural family group and its eventual "escape" to another family group represented by Husband 329, unknown to the index case J-117.'^

"-Ibid., 468. 351

I to I j 321 /-tcoooo j flfiCHO ^ ^ 5o^-5 r jr

f 0»u4;(rm- Z\ FltfCNO j-too,oool 45 O.

nfte/^O 9 3Z C*u J-HT An 26 9 iOncr/l U'U ^ixKCkrl-l-tt t'ioo oee

J to \Fific/fD ^ Frtc/fD 9 iS 24

r/itiC/tO htco i'too ooo

Figure 3. Family Contacts of Case J-117

Wade Hampton Frost hoped diat an epidemiological understanding of the familial origins of communicable diseases would be immediately useful. He hoped that epidemiology might direcdy address important practical problems in the community. The health officer might assess the relative risk of infection in specific situations and take immediate action. Various methods 352

were employed where a particular individual threatened the health of other members of the famil}" unit. Removal of the sick from their homes was a common method used against a family threat. Tuberculosis sanitariums were only the most aggressive example of this. George Ramsey found a one-third reduction in secondar}' cases of tj'phoid fever simply by removing the primar)' case to the hospital.'"'

The focus of public health, then, was not upon individuals, but upon their ultimate and most natural group in the communit}': the family. Attending nurses were condnually enjoined to consider the wellness of the family first. Public healdi nurses, in particular, were enjoined to think collectively about sickness and health in family members. Families were on practical and ideal grounds the fundamental units provided public health nursing assistance. New public health nurses were trained, if not already predisposed by their personalities, to "see the individual in need of help in the light of his family background," as nurses Grace L. Anderson and Mabelle

S. Welsh described it.™

Family-oriented nursing contributed direcdy to the more inclusive aim of generalized nursing service described in an earlier chapter. Generalized service was tailor-made for evaluating and assisting families. "The family is the center of interest to a public health nurse,

and family health is the end she hopes to attain," remarked one public health nursing textbook

author. Specialized service had not, in their minds, met the needs of families because it did not

focus on family, but only upon its constituent parts. The maladjusted family spread disease and

'"^Frost, "The Familial Aggregation of Infectious Diseases," 8-9; Barbara Bates, Bargainingfor Life: A Social Hislotj of Tuberculosis, 1S76-193S (Philadelphia: Universit}^ of Pennsylvania Press, 1992), 1-3; Ramsey, "Typhoid Fever Among Household Contacts, with Special Reference to Vaccination," 678. '"""Grace L. Anderson and Mabelle S. Welsh, "Family Health Needs and Nurses' Services," Public Health Nursing 33 (March 1941): 141. 353

disorder among its members. Assisting the individual, then, did not guarantee that the problem had been eliminated.'"'

In complex modern societ)', nearly ever)' family always stood in need of assistance. Few families could provide members all the necessary functions they had in times past. Public health nurses bolstered the family by providing continuity at times when family relationships disintegrated. Protecting the family had the prophylactic effect of protecting the community.

"Through the improvement of living conditions of this small unit," noted one nurse, "societ)' as a whole is benefited."™ Family bonds did not appear to disintegrate during the Depression. "If anything, economic pressure has brought its members closer together," claimed public health nurse Violet H. Hodgson. "Never in the histor)' of public health nursing has the family called so loudly to be treated as a unit of ser\''ice."'"'

Reaching out to patients or individuals at risk depended on the rapport established between the family and nurse. Counseling and educating the individual inevitably failed without the approval of their families. Concentration on the family as die fundamental unit in public health nursing practice had several benefits beyond securing family members as agents of patient surveillance. The home, moreover, was an ideal place to glean pertinent health information.

Home visits allowed pubUc health nurses to sample real situations and use theii" abilit)' to "think and feel witli the family."™

'•^Clara B. Rue, The Public Health Nurse in the Community (Philadelphia: W.B. Saunders Company, 1944), 78; Mar)- Beard, The Nurse in Public Health (New York: Harper & Brothers, 1929), 2-3,11 -2; National Organization for Public Health Nursing, Surv^' of Public Health Nursing: Administration and Practice (New York: Tlie Commonwealth Fund, 1934), 75-7. '"^National Organization for PubUc Health Nursing, Manual of Public Health Nursing (New Y'ork: The Macmillan Company, 1939), 91-2; Grant, Nursing: A Community Health Service, 74. '"'^•'iolet H. Hodgson, "Whom Do We Ser\'e and How?" Public Health Nursing 25 (1933): 299-301. '"^Grace Ross, "Another ^'ote for Generalized Nursing," Public Health Nursing 27 (1935): 584-7; Wales, The Public Health Nurse in Action, xiii. 354

Nurses found it difficult, if not impossible, to ignore wider problems that contributed to sickness or the potential for sickness in the first place. Nurses did not separate families from

their immediate environments. Families were members of the communit}', and that communit}' could harm healthy families or be harmed by unhealthy ones. The mission of the public health

nurse was to "bring about harmony between the family and its physical, social, and emotional environment by adjusting the family to that environment or by modifying the environment itself." Producing healthy families, thus, required great choreographic skill on the part of the

nurse correlating the needs of the communit)' with those of all families.^"''

While there was much agreement among nurses as to the ideal of nursing the sick family,

they were less unified about its success in practice. Helen Bean, associate public health nursing

analyst for the National Institute of Health, and Georgie S. Brockett, of the United States Public

Health Sen^ice, sur%'eyed the profession and found "litde or no evidence" of public health nurses

rendering a "complete family scr\'ice." Instead, they concluded, nurses confined themselves too

much to sick individuals, neglecting the value of more "diversified" activities. Bean and Brockett

lamented the complete lack of appropriate action taken against tuberculous families in particular,

even though it was well-understood in the other public health professions that dissemination of

the bacillus could only be halted by stricdy observing other family members for signs of disease.

The records Bean and Brockett compiled from scrutinizing family folders showed, most

damningly, that only eleven of 3,074 families contacted saw every member ser\'ed. And, three of

those eleven had only one family member to begin with.^'"

'"'Katharine Faville, "Responsibility' of the Public Health Nurse for Social Phases of Her Work," American jounta/ of Public Health 20 (1930): 165-70; Charles Edward-Amon- Winslow, "National Health Challenges: How the Public Health Nurse is Meeting Them," Public Health Nursing 27 (1935): 120-4. '^"Helen Bean and Georgie S. Brockett, "Tlie Family as a Unit for Nursing Service," Public Health Rtports 52 PecemberSl, 1937): 1926,1928-30. 355

The familial understanding of many diseases soon entered as common assumptions in the professions of health, so common that it became acceptable fare for college textbooks. "More than two thousand years ago, Hippocrates obsen^ed that 'a consumptive is born of a consumptive,'" recalled University of Colorado bacteriologist R. C. Whitman in his Hjgiene: A

College Textbook JorNon-MedicalStudents (1930). "The striking tendency of the disease to cling to

families still remains the central fact of its epidemiology. Cases occur, of course, in persons whose families have not suffered previously, but the familial t}'pe will receive chief attention, because of its vasdy greater importance." So strong was the familial understanding of disease

that epidemiologists could become stumped when a study of family reladonships failed to uncover the familial nature of disease spread. "The frequency with which multiple cases [of

tuberculosis] have occurred within a given household," wrote two researchers in 1942, "has

tended to obscure the importance of contacts outside the immediate household." The possibility' of "extra-familial" contact was just that, exceptions to the familial rule in the spread of many

diseases.

C. W. Twinam, superintendent of the Lakeville State Sanatorium in Massachusetts, and

Alton S. Pope, director of the Division of Tuberculosis in the Massachusetts Department of

Public Health, discovered the vicissitudes of such familial thinking in an outbreak of pulmonary

mberculosis in a small town of four thousand. Each case, aU among high school girls, located by

the researchers came from a different family. No domestic link could be determined between

them. "It was during one of the visits to family 'C that a casual remark was made relative to a

certain church which opened a new approach to the problem because it was known that family

'A' attended the same church," noted Twinam and Pope in their paper. "Visits were made to

'R.C. Whitman, Hj^ieiie; A College Tex/book for Non-Medica/ Students (New York: John Wiley & Sons, Inc., 1930), 249; C.W. Twinam and Alton S. Pope, "Pulmonar)' Tuberculosis Resulting from Extra-Familial Contacts," American journal of Public Health hi (November 1942): 1215-8. 356

families 'B' and 'D' and it was discovered that both of them also attended this church." Follow up inquiries revealed the source of the infection in the former minister's wife, already in a tuberculosis sanitarium when finally tracked down. "Thus a common source of infection was found for these four girls in their fellow church member," declared Twinam and Pope. "Failure to find a source of infection within a household should not preclude further attempts at finding the source case."''" Other "natural" communities like churches, schools, and factories, in other words, should not be excluded from the pun^iew of communit}' health investigators.

'^^Twinam and Pope, "Pulmonan' Tuberculosis Resulting from E.vtra-Familial Contacts," 1215-8. 357

CHAPTER XI. THE PLACE OF THE INDH'IDUAL IN COMMUNITY HEALTH

Tantalizingly, especially to our fnt de siec/e eyes, the most fundamental units of the modern communit)' health meme, which preferred to aggregate and coordinate all things in groups, were still individuals. Groups, after all, could not and still do not exist without them. Communit)' health professionals wrote at great length about how to condition and improve the individual organism toward personal health. The singular "I" and "you" are words abundant in their collective lexicon. But even at this level of reduction the impress of communit)' thinking is clearly visible.

Late nineteenth-centur)' public health experts on the whole saw the properly functioning human body in terms of a system of efficiendy functioning specialized parts comprising a most

perfect machine. "The personal welfare of each individual," wrote New York Cit)' physiologist and surgeon Frank Overton, "depends largely on the efficiency of his bodily machinery." Organs

function solely as divided, specialized authorities in botli human anatomy and physiolog)' with the

centralized brain and nen^ous system as absolute arbiter of control, evoking dramatically the

economic "division of labor" that made human civilization possible.^'^^

Public health authorities, then, combed the population for individual persons and

individual parts in a person's body that threatened to muck up the properly functioning system of

civilization. Educational institutions seemed a good place to make such evaluations, for there

human culture was reborn with each new generation. "As a new automobile is searched

solicitously for missing or defective parts, to be solicitously and immediately made good before

'^^Frank Overton, Genera/Hygiene (New York; American Book Company, 1913), 5,18. 358 the machine is sent out to run against competitors on the highway," noted Western University-

professor Hibbert Winslow Hill, "so tlie new small citizen should have at least his sight, his hearing, and liis breathing tested before he begins the inevitable compulsor)'-education race against all comers on the public liighway of the public schools."

The older science of public health also interpreted the inculcation of individual human

bodily perfection as a primary goal of health ser\ace. Having a healthy human physiology meant

carrj'ing not one iota of disease. Possibly no human being could seriously achieve perfect health, health educators lectured, but it was worth aspiring to. Eugene Lyman Fisk, director of hygiene

at the Life Extension Institute, Inc., for instance measured the progress of human vitalit)' in terms

of what he called "functional normality," by which he did not mean relative or equilibrious

health, but rather an optimal or ideal standard. By constructing an ideal standard for health, Fisk

argued, he might ascertain how far below the ideal American health stood.

Successful application of the principles of consen-ation and efficiency bore fruits in terms

of individual human longevit)', prolongevit)', and vitalit\% and protection against degeneration.

Hill himself described true health as "the highest physical efficiency prolonged for the greatest

period of time." Vital statistics collected by life insurance companies suggested that many

Americans were in fact becoming healthier. Louis I. Dublin, statistician with the Metropolitan

Life Insurance Company in New York, proclaimed that the average life span of children under

five had increased by ten years between 1881 and 1911, and that with more proper maintenance,

human life might be extended further.

'^''Hibbert Winslow Hill, T/je New PHb/tc Health (New York; The Macmillan Company, 1916), 36-7. "^Eugene Lyman Fisk, "Some Results of Periodic Health Examinations," Popular Science Monthly 86 (April 1915); 325. ^'^Hill, The New Public Health, 35-6; Louis Israel Dublin, "The Trend of American Vitalit)'," Popular Science Monthly 86 (April 1915); 313. 359

It was commonly assumed that different races and classes of men and women had advanced with the help of hygiene to different levels of health, but the progress of hygiene also cultivated the narrowing of the gaps between the health of different races and classes in the minds of late nineteenth century public health workers. A rising tide, in other words, carried all boats. Still, racial and ethnic differences among immigrants adversely affected native American vitalit)'. The commonplace expression "What is meat for one is another's poison," conveyed to the individual seeking health the warning that the specialized aspect inherent in each human body and each race demanded specialized attention to the realization of hygienic ideals. Ideals for human physiological health, in other words, depended upon racial or ethnic affiliation. "The exposure to cold which would be disastrous for the Negro or even the white man," explained

Hibbert Winslow Hill, "is likely to suit the Inuit exacdy." '

Louis I. Dublin blamed immigrants from eastern and southern Europe, in part, for dampening gains in life span reported on his life tables, and for contributing a disproportionate share of the "degenerative diseases" plaguing the countr\\ Dublin, utilizing evidence he synthesized from state registration area statistics, claimed that between 1900 and 1910 the cancer mortality rate had increased thirtj^ percent; diabetes, sLxt)' percent; cerebral hemorrhage and apoplexy, eighteen percent; organic heart disease, fort)' percent; cirrhosis of the liver, fourteen

percent; kidney disease, eighteen percent; and arterial diseases a whopping four hundred percent.

Charles B. Davenport, director of eugenics research at Cold Spring Harbor, N.Y., laid the blame

for poor health with native American minority groups, citing figures for black mortalit)' almost

double the rate among whites, and an Indian tuberculosis death rate three times as high.^-^"

'"HiU, The New Public Health, 55. The New Public Health, 58; Dublin, "The Trend of American \''italit\-," 315; Charles B. Davenport, "The Racial Element in National Vitalit}'," Popular Science Monthly 86 (April 1915): 331-2. 360

Professionals found especially disturbing evidence of American health malaise in the decade before the Great War. Eugene Lyman Fisk at the Life Extension Institute conducted physical examinations of large groups of people in 1914 and 1915 and found disturbing degeneracy among even the healthiest classes of Americans. Fisk determined that nearly one hundred percent of all life insurance policyholders had imperfect health, and that ninet)'-three percent were not even aware of their own impairment. Twent}'-five percent had dangerously high or low blood pressure, thirty-five percent showed seriously abnormal urine composition, thirteen pcrcent had arteriosclerosis, twent\'-two percent had decayed teeth and gum disease, sixteen percent had uncorrected vision defects, nineteen percent were underweight; and fourteen percent were chronically constipated."'^

Overwhelming evidence by the 1910s of gross defects among American individuals set the stage for an impending crisis in war preparation. When the Surgeon General's Office released its figures summarizing the physical health of two million drafted men experts learned that over a half a million had been rejected outright, a staggering rate of 486 "defective men" per thousand. I f any single fact weighed most heavily on the shoulders of public health authorities in the fu'st decade of the new centun% it was this one. By the time the War Department released the enormous tome Defects Found in Drafted Men (1920) for publication, a new way of approaching health principles and practices through communit)' health had already been adopted by a new generation of public health leaders.^'"'

Communit)' health adherents reinterpreted the healthy human body as a harmonious concordance of aU its many parts. The human body, explained one professor of hygiene,

'^^Fisk, "Some Results of Periodic Health Examinations," 326-8. ^''"Albert G. Love and Charles B. Davenport, Defects Found in Drafted Men: Statistical Information Compited from the Draft Records Stnwing the Pl)ysicat Condition of tiie Men Registered and Examined in Pursuance of the Requirements of the Setective-Service Act (Washington, D.C.; Government Printing Office, 1920), 27-8. 361 consisted not as an artificial analogue to hierarchical civilization, but rather as many "interrelated and interdependent systems—circulatoiy, digestive, ner\'^ous, and so on.""" Modern physiologists did not deny that the human body could be machine-like. Instead, they denied that the body should be regarded as a special-purpose device. "If it is a machine, it is a ver)- complicated one—it is like no other machine we know—it is at once a heat engine and a chemical engine and an electrical engine, and besides manufactures such things as antitoxins and thought and gametes," explained Universit)' of Kansas professor of medicine Logan Clendening. "Besides it reproduces its own parts when they break down, which is like no other machine. It is a

Humpt^'-Dumpt)- machine because no one can reassemble it: when that spark which is indefinable leaves it, aU the parts may be there, but it won't run.""*'

Modern physiologists transformed the human body into a different kind of machine altogether, a general-purpose one. Defective parts could not be replaced by simply tearing them out and replacing them. The part in the human mechanism became more than its own identity simply bv virtue of being a constituent of the whole. The part made its contribution to the working machine, but the working machine also contributed its usefulness to the part. Without the rest of the human machine, after all, the part was useless. And, without the part, the human machine worked imperfectly or not at all.

Sickness and disease stemmed from a lack of proper coordination and cooperation among the parts. Maintaining the body's dynamic internal and external equilibrium, what the

Hansard Medical School physiologist Walter Bradford Cannon called "homeostasis," became the aspiration of the hygienic-minded physiologist. "We are many members in one body, for there is a close interrelation between all parts of the body," noted DePauw professor of physiolog)' and

Lloyd Ackerman, Health and Hygiene: A Comprehensive Study of Disease Prevention and Health Promotion (Lancaster, Penn.: The Jacques Cattell Press, 1943), 111-3. '''"Logan Clendening, The Human Body, 3rd ed. (New York: Alfred A. Knopf, 1937), 4-5. 362 hygiene Cleveland Pendleton Hiclonan. "The proper harmonious cooperation and working of all these parts should be our major aim in promoting our health." Disease, then, became understood as a deviation from a normal state of dynatnic (or self-regulative) equilibrium and the old notion of "perfect health," was dispensed with, replaced by a new goal of achieving "normal health." The central questions of hygienic physiolog)', then, involved teasing out the complex mechanisms by which the human body protected, adjusted, and repaired itself.'''^

Hickman himself noted that modern maladjustment in health, so apparent in Defects Found in Drafted Men, stemmed from the "artificial environment" Americans had so assiduously constructed in the New World. Americans, Hickman claimed, could only blame themselves for many of the maladies circumscribing good public health by ignoring their animal inclinations in their pursuit for civilization and culture. He perceived the body in its naturally healthy state as a product of prolonged struggle against the natural world, a struggle that had rendered the body closely adapted to natural rhythms of life.'''''

The ascent to modern industrial life, however, had interrupted the progress of this adaptation, ruining human health in the process. Civilization left humanit}' with the burden of

maladaptation in a bewildering new social and physical environment. "Witliin a ver}' short period

of time," Hiclonan wrote, humans have "tried to adapt to this new environment a physical body

fitted through untold thousands of years for an entirely different environment." Civilization

traumatized humanit)' by maladjusting it in many ways. The artificiality and over-specialization of

'''^Walter Bradford Cannon, Wisdom of the Body (New York: W.W. Norton & Company, Inc., 1932), 24, 305; Cleveland Pendleton Hickman, PljysioloîcalHjîeiie (HexvYotk: Prentice-Hall, Inc., 1937), 420; Charles \'aluc Chapin, "Changes in Type of Contagious Disease, with Special Reference to Smallpox and Scarlet Fever," joiiniat of Preventive Medicine 1 (September 1926): 1. On the particular contributjons of Walter B. Cannon to physiolog)' see Chandler Brooks, et al., eds.. The Life and Contributions of Walter Bradford Cannon, 1871-1945: His hifliience on the Development of Physiolog' in tin Twentieth Century (Albany, N.Y.: State University' of New York Downstate Medical Center, 1975); lago Galdston, ed., Bônd the Gem Theory: The Rotes of Deprivation and Stress in Heatth and Disease (New York: New York Academy of Medicine, 1954); and Allan Young, "W'alter Cannon and the the Psychophysiology of Fear," in Greater Than the Parts: Hotism in Biomedicine, eds. Christopher Lawrence and George Weisz, 234-56. '''"'Hickman, Physiological Hygiene, 1-2. 363

the human-built world traumatized human anatomy in unnatural ways. Heretofore unheard industrial and commercial noises dulled and pained the ears. The "closc conccnttation to details" in shifting paperwork degraded human eyesight. Changes in the diet, compounded by the artificialit)' of the "culinary arts," threatened the gastrointestinal tract and die teeth by making unavailable food that was "simple, coarse, and admirably adapted to the nutridve requirements of

[man's] primitive nature," offering instead "soft and sweet foods" that lacked "essential nutridve elements."'"''

Hickman also explained that the complexit)' of modern life demanded a more complex human neivous system. But too rapid complexification of societ)' had upset the delicate balance of human mental capacities and facilities, driving Americans to "nervous derangements," like insanit}', feelings of inferiorit)', chronic woriy and sorrow. Complex modern life also enen-ated overcompensation in the use of artificial stimulants and depressants like alcohol, tobacco, coffce, tea, opiates, "dope," and painkillers. "The employment of such agencies," Hickman claimed,

"has contributed enormously to the artificiality of [man's] environment and the intensification of his maladjustment."""^'

The purpose of what Hickman called the science of "physiological hygiene" was to reconcile die human body with civilization in a way that restored health to the populace. He did

not advocate a return to tlie primeval wilderness naturally compatible with human health.

Civilization, he wrote, had after all resulted from a marriage of two of humanit)''s greatest assets,

"inventive genius" and "resourcefulness." Instead, the continued progress of humanity could be

assured by securing a sanitary environment, lessening reliance upon intrusive artificial

medications, supporting eugenic measures to protect the adjusted from the unadjusted,

'""^Ibid., 2,4-6. '"^Ibid., 3-4. 364 appropriate clothing and shoes, comfortable and movable seats, and training for equilibrious locomotion. The purpose of physiological hygiene, in sum, involved promoting the adjustment of the human body to the new human environment, and the adjustment of the new human environment to the human body.'''^

Public health principles changed dramatically in even their most traditional and narrow aspects. Indeed, tvventieth-centur)' patliolog)' shattered the artificial distinction between that which was health and that which was disease, as well as the ver)' foundations of specificit)'.

Preventive hygiene since the discover)' of specificit}' in the late nineteenth centur)- had invol\'ed a cat-and-mouse game between microscopic invaders and the human body. The ideal human body was free from these invaders, but the normal human body of the modern age was tiiought to be

naturally riddled with aU manner of disease. Benign human pathological processes, once to be

avoided at all cost, were now embraced as helpful to the advance of the individual and the

species. "Disease processes arc not 'unnatural,' wrote Logan Clendening. "They are the perfcctiy

logical result of the activit)- of external forces, of the processes of growth and the progress of

time.'"^«

Diseases, moreover, were themselves no longer considered simply fixed, specific entities.

They instead evinced great plasticit}' and could var)' gready over time in virulence or their

infective capacit}'. As Stanford, Columbia, and Han'ard bacteriologist Hans Zinsser noted in his

classic "biography" of t}'phus fever Rats, Lice, and His/o^, "it is entirely logical to suppose that

infectious diseases are constantiy changing, new ones are in the process of developing, and old

ones being modified or disappearing." Scarlet fever, smallpox, and plague all seemed to be losing

their war against the human body in the early twentieth centur}', and influenza, infantile paralysis,

'"ibid., 1,7-8, 325-38,420-7,439-40. '''^Clendening, The Human Body, 3rd ed., 3. 365

and cancer alternately seemed to be gaining in strength. The once terrible smaUpox more and more assumed the milder characteristics of chickenpox.

• • •

In many ways the overall organization of my dissertation is its own conclusion. My dissertation tends to focus on elite administrative and organizational problems of professionals taken together. My field of vision for this very reason is deliberately narrowed by emphasis upon the published professional discourse in the abundant primar)- literature. While popular health periodicals like Hygeia and extant caches of poster material from popular health campaigns are useful in illuminating the liistor}' of the professions, their import and significance do not become clear until we know what central assumptions totaling an intellectual framework lay behind them.

This is especially true at a time in American histor)' when pivfessiomis, not laypeople, coordinated the experts and the masses.

My dissertation also focuses less on the distinctive abilities of individual experts, even when those individuals distinguished themselves in ways recognized by their colleagues. Instead it attempts to capture ideas offered by individuals that "sttuck a chord"—perhaps by noting their repetition in speech and writing and centrality to debate—without losing sight of the collective experience of professional life in health. Put another way, this dissertation did not dwell upon—or even mention—Donald B. Armstrong's constitutional shyness, interests in music, or even his graduate smdent career at MIT under the great William T. Sedgwick. In a longer dissertation, some of this might have been useful, even relevant. Still, it is his ideas and actions

'•'''Chapiii, "Changes in Type of Contagious Disease, with Special Reference to Smallpox and Scarlet Fever," 1-29; Hans Zinsser, ?j3ts, Life, and History (Boston: Litde, Brown, and Co., 1935), 43; Charles N'alue Chapin and Joseph Smitli, "Permanency of the Mild Type Journal of Preventive Medicine 6 (luly 1932): 273-320; CoreUus P. Rlioads, "Perspectives in Cancer Research," reprinted in Great Adventures in Medicine, ed. Samuel Rapport and Helen Wright (New York: The Dial Press, 1952), 752-3; Philip L. Frana, "Smallpox: Local Epidemics and the Iowa State Board of Health, Annals of Iowa 54 (Spring 1995): 87-118. 366

that matter more in a histor)' of this sort, in an intellectual histor)' of the modern re-professionalization of public health.

My dissertation also identifies and uses intellectual discontinuities in order to defme what came next. Though it may appear at first glance to present a homogeneous view of a particular group of people in the past, my dissertation actually relies on the abilit)' to identif)- what was unique and novel zhout communit)' healdi professionalism between 1915 and 1940. How else to render it separable than to note its apparent differences from that which came before and (if possible) what came after?

What did come after? Today, as in the early twentieth-century, we accept at face value that individuals comprise groups. But what distances communit}' health thinking from ours today is its insistence that the individual is continuous with, and not divorced from or discrete within, wider society.

As one relatively obscure but rhetorically gifted industrial hygienist put it in 1936, "this view seeks to interpret the organism cosmicaUy, and thus subject to the many interacting forces derived from the world in which it lives. In this sense the organism and its internal and external environment are considered as a whole." This widely held assumption in community' health

rendered meaningless analysis without synthesis, difference witiiout similitude, mechanism

without dynamism, system without network, specialization without generalization, organ without

organism, and individuation without association.^^"

''®Henn' H. Kessler, "Social Significance of Industrial Medicine," American Journal ofPubtic Health 26 (Febtuar)- 1936): l'58-9. 367

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Coleman, M. "He Couldn't Forget the Kids: Judson Health Center, New York." Collier's 74 (November 29, 1924); 30.

Davis, Graham L. "Preparing High School Students for Communit}' Service." American journal oj Public Health 34 Qune 1944): 652-5.

Davis, Michael M., Jr. Clinics, Hospitals, and Health Centers. New York; Harper & Brothers, 1927.

Davis, Nlichael M., [r. "Goal-Posts and Yarksticks in Health Center Work." .American journal of Public Health 17 (May 1927); 433-40.

Davis, Michael M., Jr. Immigrant Health and the Community. New York: Harper and Brothers, 1921. 369

Davis, Michael M., Jr. and Anna Mann Richardson. "Health Centers for New York." Surv^' 57 (March 15,1927): 786-9.

DeVilbiss, Lydia Allen. "Symposium on the Health Center: Baby Health Centers." American Joiirnal of Public Health 11 (March 1921): 231-3.

Dexter, R.C. "Group Organization and the Community\" In Social Adjustment, 378-404. New York: Knopf, 1927.

Dinwiddie, Courtenay. "A Communit}' Self-Organized for Preventive Health Work." Modem Medicine 1 (1919): 26-31.

Dinwiddie, Courtenay and B.L. Mead. Communitj Responsibility, with Statistics oj Health Services in the Unit District. Studies in Social Work. New York: The New York Cit)- School of Social Work, 1921.

Emerson, Haven. "Proof in the Public Health Pudding; East Harlem, New York Cit}^" Swvey 59 (November 15,1927): 210-1.

Emerson, Haven. "The Robust Citj'." Survey Graphic (November 1925): 121-4.

Emerson, Haven. Selected Papers. Battle Creek, Nlich.: W.K. Kellogg Foundation, 1949.

Emerson, Haven. "Toward Neighborhood Health." Surv^' 59 (March 15,1928): 776.

Emerson, Haven. "Wanted: A Communirj- Diagnosis." Public Health Nmse 11 (December 1919): 937-41.

Emerson, Haven and Martha Luginbuhl. "1200 Local Public Health Departments for the United States." American Journal of Public Health "bS (September 1945): 898-904.

Emerson, Haven, et al. Local Health Units for the Nation. New York: The Commonwealth Fund, 1945.

Fairbanks, Robert B. Making Better Citi;^ns: Housing Reform and the Community Development Strategy' in Cincinnati, 1S90-1960. Urbana: Universit)- of Illinois Press, 1988.

Ferrell, John A. "Economics of Public Health," journal of the American Medical Association 89 (July 9, 1927): 77-82.

Ferrell, John A. and Pauline A. Mead. "Historj' of County Health Organizations in the United States, 1908-1933." Public Health Bulletin 222 (March 1936): iii-vi, 1-469.

Fisher, Robert and Peter Romanofsky., eds. Community Organi:^ation for Urban Social Change. Westport, Conn.: Greenwood Press, 1981.

Foard, Fred T. "The County Health Unit of Yesterday and Today." Public Health Reports 46 (April 24, 1931): 970-7.

Follett, M.P. The New State; Group Organisation the Solution of Popular Government. New York: Longmans, 1918. 370

Freeman, Allen W. "Rural Health Organization in the United States; Past, Present, and Future." Southern Medical journal 21 (June 1934); 517-21.

Fronczak, F.E. "Health Centers: A New Agency of the Health Department." American City 17 (October 1917): 334-5.

Gately, G. Lynde. "Organizing a Large Community for Health Educadon." American Journal of Public Health 33 (June 1943): 691-6.

Gebhart.John C. The Health of a Neighborhood: A Social Studj of the Mulbeny District. New York; New York Associadon for Improving the Condidon of the Poor, 1924.

Godfrey, Edward S., Jr. "Comparadve Value of State Districts and Count)' Districts as the Basis of Local Health Organizadon." American Journal of Public Health 26 (Tvlay 1936): 465-70.

Grant, John B. "Health Centers and Regionalization." American Journal of Public Health 43 (Januarj- 1953): 9-13.

Hill, Hibbert Winslow. The Neii' Public Health. New York: The Macmillan Company, 1916.

Hiscock, Ira V. "Community' Health Educadon." American Journal of Public Health 30 (1940): 516.

Hiscock, Ira V. "The Development of Neighborhood Health Services in the United States." Milbank Memorial FundQuarterly \ Qanuary 1935): 30-51.

Hiscock, Ira V. District Health Administration: A Study ofOrgani::;alion and Planning. Lancaster, Pa.: The Science Press Prindng Company, 1936.

Hiscock, Ira V. "The Organizadon and Budget of a Health Department in a Cit)' of 20,000 Populadon." American Journal of Public Health 14 (March 1924): 203-8.

Hiscock, Ira V. and Francis M. Munson. "Public Health Pracdce in Small Cides and Towns of Connecdcut." American Journal of Public Health 14 (November 1924): 934-40.

Hiscock, Ira V., et al. Community Health Organization: Revised Plans for Communities of 100,000 and 50,000 and a New Plan for 30,000 Population. New York; The American Public Health Associadon, 1927.

Hiscock, Ira V., et al. Community Health Organit^tion: A Manual of Administration and Procedure for Cities oj 100,00, with Suggested Modifications for larger and Smaller Units. New York: The Commonwealth Fund, 1932.

Hiscock, Ira V., et al. Community Health Organisation: A Manual of Administration and Procedure Primarily for Urban Areas. Third edidon. New York; The Commonwealth Fund, 1939.

Hiscock, Ira V., et al. Community Health Organi^tion. Fourth edidon. New York: The Commonwealth Fund, 1950. 371

Hiscock, Ira V., et al. Wajs to Communitj Health Education. New York; The Commonwealth Fund, 1939.

Horning, Benjamin G., et al. "The Community Health Education Program." Ammmn Journal of Public /-W/A 31 (1941): 310.

Hutchinson, Woods. Communitj Hjgiem. Woods Hutchinson Health Series. Boston; Houghton, 1918.

Jacobs, Esther. "Carrjing Health from the Clinic to the Community." American Journal of Public Hea/th 18 (August 1928); 1003-5.

Katz, Alfred H. and jean Spencer Felton, eds. Health and the Community: Readings in the Philosophj and Sciences of Public Health. New York; The Free Press, 1965.

Kelso, R.W. "Tests of Progress in Community Organization." Proceedings of the National Conference of Social (1927); 478-81.

Leber, O.H. "Doctors Demonstrate; East Harlem Health Center." Sttntejb') Qanuary 15,1928); 501-2.

Lee, P.R., et al. Report of a Study of the Interrelation of the Work of National Soda! Agencies in Fourteen American Communities. New York; The National Information Bureau, Inc., 1923.

Le\T, Abraham J. "The Health Center as a Community Health Service Unit." D.Ph. diss., Yale University, 1931.

Lindeman, E.C. "Aspects of Community Organization in Relation to Public Policy." Annals of the American Academy of Political and Social Science 105 Qanuar)' 1923); 83-7.

Lindeman, E.C. The Community: An Introduction to the Stucfy of Community Leadership and Organi^tion. New York; Association Press, 1921.

Lindeman, E.C. "Tlie Place of the Local Community- in Organized Society." Proceedings of the National Conference of Social Work (1922); 67-77.

Lubove, Roy. Community Planning in the 1920's: The Contribution of the Regional Planning Association oJ America. Pittsburgh; University of Pittsburgh Press, 1963.

Lubove, Roy. The Urban Community: Housing and Planning in the Progressive Era. Westport, Conn.; Greenwood Press, 1981.

Lumsden, Leslie Leon. "Extent of Rural Health Service in the United States, 1922-1926." Public Health Reports (May 7,1926); 870-81.

Lumsden, Leslie Leon. "Extent of Rural Health Ser\'ice in the United States, 1926-1930." Public Health Reports (May 9,1930); 1065-81.

Marcus, Alan I. "Disease Prevention in America; From a Local to a National Outlook, 1880-1910." Bulletin of the History of Medicine 53 (1979); 184-203.

Meyer, Ernst Christopher. "Community Medicine and Public Health." American journal oJ Public Health 10 Oune 1920); 489-97. 372

Miller, K.E. "Development of County l-Iealth Work." Public Health Reports 33 Oune 14, 1918): 968-72.

Miller, Zanc L. "The Role and Concept of Neighborhood in American Cities." In Community Organi^tion for Urban Social Change, ed. Robert Fisher and Peter Romanofsky, 3-32. Westport, Conn.: Greenwood Press, 1981.

Miller, Zane L. Suburb: Neighborhood and Commiwitj in Forest Park. Ohio, 1935-1976. Knoxville: The Universitj' of Tennessee Press, 1981.

Moore, Harry Hascall. American Medicine and the People's Health. New York: D. Appleton and Company, 1927.

Moore, Harn' Hascall. Public Health in the United States: An Outline with Statistical Data. New York: Harper & Brothers Publishers, 1923.

Mustard, Harn* Stoll. An Introduction to Public Health. New York: The Macmillan Company, 1935.

Mustard, Harry StoU. Rural Health Practice. New York: The Commonwealth Fund, 1936.

Park, Robert E. "The City as a Social Laborator)-." In Chicago: An Esperiment in Social Science Research, T.V. Smith and Leonard D. VC'liite, eds., 1-19. Chicago: The University of Chicago Press, 1929.

Park, Robert E., et a!. The City. Chicago; University of Chicago Press, 1925.

Paul, Benjamin D., ed. Health. Culture, and Community: Case Studies of Public Reactions to Health Proffam.(. New York: Russell Sage Foundation, 1955.

Peterson, E.A. "Wliatis a Health Center?" Nation's Health 3 (1921): 272-4.

Piatt, Philip S. Report on New Haven Health Center Demonstration, ]ulj 1920-June 1923. New Haven, Conn.: New Haven Health Center, 1923.

Piatt, Philip S. "Symposium on the Health Center: Is the Health Center a Health Center? Need of a Posidve Health Ideal in the Health Center." American journal of Public Health 11 (March 1921): 221-6.

Pomeroy, J.L. "Health Center Development in Los Angeles County." Journal of the American Medical .Association 93 (1929): 1546-50.

Raymond, Julia. "Discussion on Community' Chest Relationships." Public Health Nurse 20 Quly 1928): 356-7.

Rickards, Burt Ransom. "Symposium on the Health Center: What New York State Has Done in Health Centers." American Journal of Public Health 11 (March 1921): 214-7.

Roemer, Milton I. and Barbara Faulkner. "The Development of Public Health Services in a Rural County, 1838-1949." journal of the History of Medicine 6 (\X'inter 1951): 22-43, 373

Rosen, George. "The First Neighborhood Health Center Movement: Its Rise and Fall." In From Medical Police to Soda! Medicine: Essays on the Histotj of Health Care, 304-27. New York: Science History- Publications, 1974.

Ruediger, Gustav F. "Program of PubUc Health for Towns, Villages, and Rural Communities." American journal of Public \-\eatthl (March 1917): 235-47.

Ruediger, Gustav F. "Rural Health Administration Under the Cooperative or Local Health District Plan." American Journal of Public Health 8 Qune 1918): 406-11.

Russell Sage Foundation. "Community Health; A Selected Bibliography." Bulletin of the Kiissell Sage Foundation Librar)'4S (Februarj-1921): 2-4.

Russell Sage Foundation. "Community- Organization: A Selected Bibliography." Bulletin of the Russell Sage Foundation Ubraty 86 (December 1927): 2-4.

Sippy, John J. "Local Responsibilit}' in Public Health Administration." American journal of Public Health 34 (1944): 1139.

Smiley, Dean Franklin and Adrian Gordon Gould. Community Hygiene. New York: The Macmillan Company, 1929.

Smiley, Dean Franklin and Adrian Gordon Gould. Personal and Community Hygiene. New York: The Macmillan Company, 1941.

Smille, Wilson George. "Future of Count)' Health Work in the United States." Journal of the American Medical Association 89 (September 24,1927): 1034-8.

Smillie, NX'ilson George. Preventive Medicine and Public Health. New York: The Macmillan Company, 1946.

Soule, Elizabeth Sterling and Christine MacKenzie. Community Hygiene. New York: The Macmillan Company, 1940.

Southmaj'd, Henry and Geddcs Smith. Small Community Hospitals. New York; The Commonwealth Fund, 1944.

Steadman, Robert F. Public Health Organiv^ation in the Chicago Region. Chicago; The Universit)' of Chicago Press, 1930.

Steel, Ernest William and Ella Gertrude Vt^ite. Hygiene of Community, School, and Home. New York; Harper & Brothers, 1932.

Steiner, J.F. Community Organi^cition: A Study of Its Theory and Current Practice. New York: The Centur)' Co., 1925.

Steiner, J.F. "Next Steps in Community Organization." journal of Applied Sociolo^' 11 (November 1926); 103-7.

Street, Elwood. "Triangular Relationship Between the National Organization, Local Organization, and Communit)' Chest." Public Health Nurse 20 Quly 1928); 350-5. 374

Sydenstricker, Edgar. "The Changing Concept of Public Healtii." Mi/hank Memorial Fund Omirterly 13 (October 1935): 301-10.

Terris, Nfflton. "Hermann Biggs' Contribution to the Modern Concept of the Health Center." bulletin of the HistoQi of Medicine 20 (October 1946): 387-412.

Tobey, James Alner. The Common Health: Disease Prevention in the Home and Community. National Health Series. New York: Funk and Wagnalls Company, 1937.

Tobey, James Alner. "The Health Center Movement in the United States." Modem Hospital 14 (iVlarch 1920): 212-4.

Tobey, James Alner. "The Historical Development of a Health Center." American Journal of Public 11 (1921): 212.

Tobey, James Alner. "Symposium on the Health Center: The Historical Development." American Journal of Public Health 11 (March 1921): 212-3.

Turner, Clair Elsmere. "The Communit)' Program of Health Education." American Journal of Public Health 25 (June 1935): 725-9.

Turner, Clair Elsmerc. Personal and Community Health. St. Louis: The C.y. Mosby Company, 1925.

Turner, Clair Elsmere, et al. Community Organi^tion for Health Education: A Committee Report. Cambridge, Mass.: The T'echnolog)- Press, 1941.

Vaughan, Henr)' F. "Established Points in a Community- Program of Health Education: The Health Department's Program." American Journal of Public Hea/th 20 (April 1930): 351-6.

Vaughan, Henr\- F. "The Evolving Pattern of Tomorrow's Health: The Health Department of the Future." American Journal of Public Health hi} (December 1943): 1414-1418.

Walker, Watson Frank. "The New Appraisal Form for Local Health Work." American journal of Public /-W/A 29 (May 1939): 490-500.

Walker, Watson Frank. Recording of Local Health Work. New York: The Commonwealth Fund, 1935.

Vi'arren, M.D. "The Concept of Communit)- Medicine." Community Health 4 (1973): 275.

Wliitford, Grace. "School Hygiene for Rural Communities." American Journal oj Public Health 10 (NIarch 1920): 246-9.

Wilinsky, Charles F. "The Blossom Street Health Unit." Nation's Healths Qune 15, 1924): 397-8.

Wilinsky, Charles F. "Department Store of Health." Survey 57 (March 15, 1927): 790-1.

Wilinsky, Charles F. "The Health Center." American Journal of Public Health 17 (July 1927): 677-82. 375

Wilinsky, Charles F. The Health Units ofBoston, 1924-1933. Boston; Citx- ofBoston Printing Department, 1933.

Willard, W.R. "Working for Better Nutrition in a Rural Communit\'." American JournalofPublic Health 32 (1942); 996.

Winslow, Charles-Edward Amor}'. "Communit)- Defense of Nadonal Vitalit}'." Popular Science Monthly 86 (1915); 319-24.

Winslow, Charles-Edward Amor)\ "The Communitj' Health Program." Transactions of the College of Physicians of Philadelphia 53 (1931): 66.

Winslow, Charles-Edward Amor)-. The Evolution and Significance of the Modern Public Health Campaign. New Haven, Conn.; Yale Universitj' Press, 1923.

Winslow, Charles-Edward Amor)-. "The Health Center Movement." Modem Medicine 1 (1919); 327.

Winslow, Charles-Edward Amor\'. "Organizing a Communit)- for Public Health." Health News: Monthly Bulletin oj the New York State Department of Health 10 (1915); 109-11.

Winslow, Charles-Edward Amor)-. "Organizing for Better Communit)' Ser\'ice." American Jountalof Nursing 38 (July 1938); 761-7.

Winslow, Charles-Edward Amo^)^ "Our Debt to the Community Health Associadon." In The Hospital Without Walls, 1886-1936. n.p., 1936.

Winslow, Charles-Edward Amor)-. "Preventive Health in a Cooperadve Health Program." Cooperative Health 1 (1938); 5-6,14-1

Winslow, Charles-Edward Amor)\ "Public Health and Communit)- Well-Being." Social Welfare 10 (1927); 11-3.

Winslow, Charles-Edward Amor)-. "The Training ofPublic Health Personnel for the Americas." In Inter-American Conference ofPnfessors of Hjgiene, 34-42. Publicadon no. 212. Washington, D.C.; Pan American Sanitan- Bureau, 1945.

Winslow, Charles-Edward Amor)-. "The Viewpoint of the Communit)'." Public Health Nurse 19 Qune 1927); 301-6.

Winslow, Charles-Edward Amor)', et al. "Ideal Health Department for a City of 100,000." .American journal of Public Health 12 (November 1922); 891-907.

Winslow, Charles-Edward Amor)', et al. The Community Health Association and its Relations to Boston's Health Program. Boston, 1926.

Woods, A.E. "Philosophy of Communit)' Organizadon." Papers and Proceedings of the American Sociological Society (1922); 178-84.

Woods, Robert A. The Neighborhood in Nation-Building. Boston; Houghton Mifflin Company, 1923. 376

W ynne, Shirley W. "Neighborhood Health Development in the Cit)- of New York." Mi/bank Memorial Fund Quarterly "bulletin 9 (1931): 37-45.

Zinsser, Hans. "Medicine in the Communit}'." Boston Medical Surgical Journal\9\ (December 4,1924); 1057-67.

CHAPTER II. BEFORE COMMUNITY HEALTH

Abbott, Samuel Warren. "Nadonal Registcadon a Necessit}\" Reports and Papers of the American Public Health Association 19 (1894): 63-4.

Abbott, Samuel Warren. The Past and Present Condition of Public Hygiene and State Medicine in the United States. American Social Economics Monographs, no. 19. Boston: Department of Social Economy for the United States Commission to theParis Exposidon of 1900,1900.

Abbott, Samuel Warren. "What Consdtutes a Filth Disease." Reports and Papers of the American Public Health Assodation 16 (1890): 30-49.

Acheson, Roy M. "The Origins, Content, and Early Development of the Curriculum in State Medicine and Public Health, 1856-1895." Community Medicine 9 (November 1987): 372-81.

Acheson, Roy M. "Three Regius Professors, Sanitar}' Science, and State Mcdicine: The Birth of an Academic Discipline." British Medical Journal 292) (1986): 1602-6.

Allen, Nathan. "The Relations Between Sanitar)- Science and the Medical Profession." Reports and Papers of the American Public Health Assodation 12 (1886): 85-98.

American Medical Association. Addresses, Papers, and Discussions in the Section on State Medidne. Chicago; American Medical Association, 1891.

"American Public Health Association." Science 4 (1884): 440.

"American Public Health Association." Sdence 10 (1887): 258-89.

Anderson, H.B. State Medidne a Menace to Democracy. New York, 1920.

Anderson, Odin Waldemar. The Uneasy Ecjuilihrium: Private and Public Finandng of Health Services in the United States. 1875-1965. New Haven, Conn.: College & Universit)' Press, 1968.

Anderson, Odin Waldemar and George Rosen. An Examination of the Concept oj Preventive Medidne. New York: Health Information Foundation, 1960.

Bacon, C.S. "Should Medicine and Dentistry Become a Function of the State?" Journal of the American Medical Association 20 (1893): 331-5.

Baker, Henr}' B. "Recent Advances in State Medicine." Journal of the American Medical Association 11 (1888): 397-405.

Baker, Henry B. "Remarks on the Classification of Diseases." Reports and Papers of the American Public Health Assodation 14 (1888): 30-2. 377

Baker, Samuel L. "Phvsician Licensure Laws in the United States, 1865-1915." journal of the His/ofj of A'Wtvwe 39 (1984): 173-97.

Barker, T.H. On Malaria and Miasmata. 1863.

Bell, A. Nelson. "The Relation of the Mechanical Arts to Preventive Medicine, Particularly Illustrated by the Artesian Wells and Tidal Drains of Charleston, S.C." Reports and Papers oflbe American Public Health Association 16 (1890); 227-35.

Bell, A. Nelson. "The Relations of Certain Filth Diseases to Cold Weather." Reports and Papers of the American Public Health Association 6 (1880): 154-7.

Benedict, Les M. "Contagion and the Constitudon: Quarandne Agitation from 1859 to 1866." journal of the Histoty of Medicine 25 (1970): 177-93.

Bernstein, Nancy R. The First One Hundred Years: essays on the Histoiy of the American Public Health Association. Washington, D.C.: American Public Health Associadon, 1972.

Bevan, A.D. "Medicine a Function of the State." American Medical .Association bulletin 9 (1914): 2(ih-12.

Bierring, Walter L. "Prevendve Medicine: Its Changing Concepts, 1859-1959." journal of the American Medical Association 171 (1959): 2190-4.

Biggs, Hermann M. "Preventive Medicine; Its Achievements, Scope, and Possibilides." Boston Medical and Suryical journal \Q\ (1904): 668-74.

Biggs, Hermann Nlichael. "Sanitarj- Science, the Medical Profession, and the Public." Medical News 72 (1898): 48-9.

Biggs, Hermann Michael. "Sanitar)' Science, the Medical Profession, and the Public." Transactions of the New York .Academy of Medicine {\%S)1)\ 199-213.

Biggs, Hermann Michael. "Sciendfic Democracy in the United States." .American journal of Public /-W/A 11 (1921): 1088.

Billings, Frank Seaver. "State Medicine." Journal of the American Medical Association 5 (1885): 309-15.

Billings, John Shaw. "Methods of Tabulating and Publishing Records of Death." Reports and Papers of the .American Public Health Association 11 (1885): 62-3.

Billings, John Shaw. "The Rights, Dudes, and Privileges of the Community in Relation to Those of the Individual in Regard to Health." Reports and Papers of the American Public Health Association 3 (1875-6); 51.

Blake, John Ballard. "Lemuel Shattuck and the Boston Water Supply." bulletin oj the Hislo^ ojMedicine 29 (1955): 554-62.

Blake, John Ballard. "The Origins of Public Health in the United States." .American journal of Public Health (1948): 1539-50. 378

Bodily, Howard Lynn. "The First Section: Laborator\'." American journal of Public Health G3 (August 1973); 667-8.

Bowditch, Henrj' Ingcrsoll. "Address on Hygiene and Preventive Medicine." Transactions of the international Medical Congress of Philadelphia, 1876.

Bowditch, Henr)' IngersoU. Public Hygiene in America: Being the Centennial Discourse Delivered Before the International Medical Congress, Philadelphia, September 1876. Boston: Little, Brown, and Company, 1877; reprint. New York: Arno Press, 1972.

Brieger, Gert H. "Sanitar}' Reform in New York Cit)" Stephen Smith and the Passage of the Metropolitan Health Bill." Bulletin of the Histo/y of Medicine 40 (September-October 1966); 407-29.

Brundage, Anthony England. England's 'Prussian Minister": Edwin Chadtuick and the Politics of Government Growth, 1S32-1S54. Universit}' Park; Pennsylvania State Universit}' Press, 1988.

Bullough, Bonnie. Preventive Medidne in the United States, 1900-1990: Trends and Interpretations. Canton, Mass.: Science Histor)' Publications, 1992.

Burrow, James G. .AMA: Voice of American Medicine. Baltimore: The Johns Hopkins Press, 1963.

Bynum, William F., ct a!., eds. Medical journals and Medical Knowledge: Historical E-ssays. London; Routledge, 1992.

Caldwell, Charles. An Essay Upon the Nature and Sources of the Malaria or Noxious Miasma. From Which Originate the Family of Diseases Usually Known by the Denomination of Bilious Diseases; Together with the Best Means of Preventing the Fonnation of Malaria. Philadelphia: Carey & Lea, 1831.

Caldwell, Charles. Thoughts on Febrile Miasms, Intended as an An.nver to the Boylston Medical Pri^e Question, for the Year 1830, "Whether Fever is Produced by the Decomposition of.4nimalor 1 'egetable Substances, and If By Both. Their Comparative Influence?" Lexington, Ky., 1830.

Carmona y Valle, Manuel. "Can S)^hilitic Contagion Form the Vehicle for the Transmission of Tuberculosis as Well?" Reports and Papers of the American Public Health Association 19 (1893): 204-9.

Carroll, A.L. "Address on State Medicine." journal of the American Medical Association 14 (1890): 754-60.

Cassedy, James Higgins. "The Roots of American Sanitar\' Reform, 1843-7: Seven Letters from John H. Griscom to Lemuel Shattuck." journal of the Histoiy of Medicine 30 (April 1975); 136-47.

Cavins, Harold M. "The National Quarantine and Sanitaiy Conventions of 1857 to 1860 and the Beginnings of the American Public Health Association." Bulletin of the Histoiy of Medicine 13 (April 1943); 419-25.

Chadwick, Edwin. "Centralizadon; Public Charities in France," London Review 2 (1829); 536-65.

Chadwick, Edwin. The Health of Nations. London; Longmans, Green, and Co., 1887. 379

Chadwick, Edwin. "Progress of Sanitation: Prevention as Compared with that of Curative Science." Transactions of the National Association of Social Science (1881): 623-49.

Chadwick, Edwin. Report to Her Majesty V Principle Secretaiy of State for the Home Department, from the Poor Law Commissioners on an Enquity into the Sanitary Condition of the Labouring Population of Great Britain. London: Clowes, 1842.

Chadwick, Edwin. "The Requisite Attributions of a Ivlinister of Health, and the Principles of Central and Local Administrative Organization and Action According to British Experiences." Sanitarian 7 (1879): 59-67.

Chadwick, Edwin. Sanitary Progress: Progress in Preventive, as Compared with That of Curative, Science: Including Results, in the Saving of Sickness and Death. London: Spottiswoode, 1881.

Chaille, Stanford E. "State Medicine and State Medical Societies." Transactions of the American Medical Association 30 (1879): 299-320.

Chapin, Charles Value. "Arc Diphtheria and T\phoid Fever Filth Diseases?" MedicalNem 60 (March 19, 1892): 312-6.

Chapin, Charles Value. "The End of the Filth Theor)' of Disease." Popular Science Monthly 60 (January 1902): 234-9.

Chapman, W.D. "Paternalism Destroys Self-Reliance: State Medicine a Menace to the People." Illinois Medical Journal \\ (1921): 278-82.

Citizen's Association of New York. Sanitary Condition of the City: Report of the Council of Hygiene and Public Health of the Citi^n's Association of New York. Reprint, New York: Arno Press, 1970.

Claypole, E.\X'. "The Popularization of Sanitar)' Science in the Schools." Reports and Papers of the American Public Health Association 3 (1875-6): 208-15.

Clendenin, NX'illiam. "The General Causes of Disease." Reports and Papers of the American Public Health Association 1 (1873): 49-53.

Cogshall, Bela. "Is Tubercular Consumption a Contagious and Parasitic Disease?" Reports and Papers of the American Public Health Association (1882): 164-173.

Comegj's, C.G. "On the Importance of the Establishment of Legal Medical Councils of State and Medical Politics." Transactions of the American Medical Association 28 (1877): 499-503.

Conn, Granville P. "State Medicine vs. Fads." Journal of the American Medical Assodation 25 (1895): 861-4.

"Doctor Medicinae Civitatis." Journal of the American Medical Association 24 (1895): 985.

Duffy, John. "The American Medical Profession and Public Health: From Support to Ambivalence." Bulletin of the Histoiy of Medicine 53 (Spring 1979): 1-22.

Duff)', John. The Sanitarians: A Histo^' of American Public Health. Urbana: University of Illinois Press, 1990. 380

Ellis, John H. Yellow Fever and Public Health in the New South. Lexington: The Universit)' Press of Kentucky, 1992.

Emmert, J.M. "State Medicine: Past, Present, and Future." ]ourncil of the .American Medical Association 38 (1902): 1568-78.

Eyler, John M. "The Conversion of Angus Smith: The Changing Role of Chemistrj- and Biology in Sanitar)- Science, 1850-1880." bulletin of the Histoij' of Medicine 54 (1980): 216-34.

Farnsworth, P.]. "Relndon of the State to Sanitar)- Science." Transactions of the Iowa State Medical Societj 2 (1872-6): 169-81.

Fee, Elizabeth. "Public Health and the State: The United States." Clio Medica 26 (1994): 224-75.

Fee, Elizabeth and Dorothy Porter. "Public Health, Preventive Medicine, and Professionalization: England and America in the Nineteenth Centur}'." AH isto^- of Education in Public Health, ed. Andrew Wear, 15-43. New York: Oxford Universit)'Press, 1990.

Finer, Samuel Edward. The Life and Times of Sir Edwin Chadwick. London: Methuen, 1952; reprint, New York: Barnes & Noble, 1970.

Finer, Samuel Edward. "The Transmission of Benthamite Ideas, 1820-1850." In Studies in the Growth of Nineteenth-Century Govenment, ed. Gillian Sutherland, 11-32. London; Routledge and Kegan Paul, 1972.

Fishbein, Morris. A Hi.ftoty of the .American Medical .Association, 1847 to 1947. Philadelphia; W.B. Saunders Company, 1947.

Formento, Felix. "The President's Address." Reports and Papers of the American Public Health Association 18 (1892); 1-14.

Frankel, Lee Kaufer. "The Plans and Purposes of the American Public Health Association." .American journal of Public Health Ci\ (July 1971): 1443-4.

George, C. Duty of the State Towards the Medical Profession. Ann Arbor, 1885.

Gibson, John M. Soldier in White: The Life of General George Milter Sternberg. Durham, N.C.: Duke Universit)' Press, 1958.

Gordon, J.E. "Public Health and the Contexts of Its Social, Biological, and Medical Origins." Bulletin of the New York Academy of Medicine 42 (October 1966): 868-95.

Grant, W.W. "The Progress of American Medicine and Its Relation to Public Affairs." Journal of the American Medical Association (1903); 1379-83.

Griscom, J ohn. Annua! Report of the Interments in the City and County of Neii^ York for the Year 1842, with Remarks Therein, And a Brief \-lew of the Sanitar)' Condition of the City. Reprint, New York, 1943. 381

Griscom, John. A Histoij, Chronological and Chriimsliintial of the I 'i.sitalions of Yellow fever at Kew York. New York, 1858.

Griscom, John. "Improvements of the Public Health and the Establishment of a Sanitar)- Police in the Cit}' of New York." Transactions of the Medical Society of the State of New York (1857).

Griscom, John. The Sanitaij Condition of the Lahoting Population of New York with Suggestions for Us Improvement. New York: Harper & Bros., 1845.

Griscom, John. Sanitary Legislation, Past and Future: The Value ofSanitaty Kefon?! and the True Principles for Its Attainment. New York, 1861.

Griscom, John. Survival Mechanisms andPhysiok^'. New York, 1839.

Griscom, John. The Uses and Abuses of Air: Showing Its Influence in Sustaining Life, and Producing Disease. New York; Redfield, 1850.

Hamilton, J.B. "International Comit)' in State Medicine." Journal of the American Medical Association 13 (1889): 263-5.

Hamilton, J.B. "Address of the Chairman of the Section on State Medicine." Journal of the American Medical .Association 14 (1890): 780-5.

Hamlin, Christopher. "Could You Starve to Death in England in 1839? The Chadwick-Farr Controvers}' and the Loss of die 'Social' in Public Health." American Journal of Public Health 85 Qune 1995): 856.

Hamlin, Christopher. Public Health and Social Justice in the Age of Chadwick: Britain, 1800-1854. New York: Cambridge Universit)' Press, 1998.

Harrington, Mark XX'. "The Relations of the Official Weather Ser\'ice to Sanitan' Science." Reports and Papers of the American Public Health Association 18 (1892): 37-42.

Harris, EUsha. "General Health Laws and Local Ordinances, Considered with Reference to State and Local Sanitar)- Organization." Reports and Papers of the American Public Health Association 1 (1873): 472-82.

Harris, Elisha. "Report on Plans for Complete and Authentic Records of Death and the Causes of Deaths in the United States." Reports and Papers of the American Public Health Association 4 (1879): 143.

Herrick, S.S. "The Relation Between Underground Sewarage and Filth Diseases." Reports and Papers of the American Public Health Association 10 (1884): 180-3.

Hill, Hibbert Winslow. The New Public Health. New York: The Macmillan Company, 1916.

Holton, Henr}' D. "Address on State Medicine." Journal of the American Medical Association 24 (1885): 823-8. 382

Hunt, Ezra M. "Sanitar)' Nomenclature." Reports and Papers of the American Public Health Association 11 (1885); 31-7.

Jamieson, Duncan Robert, "Towards a Cleaner New York: John H. Griscom and New York's Public Health, 1830-1870." Ph.D. diss., Michigan State Universit}-, 1972.

Jones, Dorsey D. "Edwin Chadwick and the Early Public Health Movement in England." Ph.D. diss., Universit)' of Iowa, 1929.

Kedzie, R.C. "The President's Address." Reports and Papers of the American Public Health Association 8 (1882): 2-10.

Kober, George Martin. "The Progress and Tendeny of Hygiene and Sanitar)' Science in the Nineteenth Centur)'." Medical Record 59 (1901): 898-906.

Kramer, Howard D. "Agitation for Public Health Reform in the 1870s." Journal of the His/or^' of Medicine 3 (1948): 473-88.

Kramer, Howard D. "The Beginnings of the Public Health Movement in the United States." Bulletin of the History of Medicine 21 (1947): 352-76.

Kramer, Howard D. "Early Municipal and State Boards of Health." Bulletin of the Histor)' of Medicine 24 (1950): 503-29.

La Berge, Ann Elizabeth Fowler. "Edwin Chadwick and the French Connection." Bulletin of the Histor)' o/ A/fr//«w 62 (1988): 23-41.

Leavitt, Judith Walzer. "'Typhoid Mary' Strikes Back: Bacteriological Theory and Practice in Early Twentieth-Centur}' Public Health." ]sis 83 (1992): 608-13.

Lewis, Richard A. "Edwin Chadwick and the Public Health Movement, 1832-54." Ph.D. diss., L'nivcrsit}- of Birmingham, 1949.

Lewis, Richard A. Edwin Chadwick and the Public Health Movement, 1832-1854. London: l.ongmans and Green, and Co., 1952; reprint. New York: Augustus M. Kelley, Publishers, 1970.

Lindsley, C.A. "An Epidemic of Typhoid Fever." Reports and Papers of the American Public Health Association 11 (1885): 39-40.

Lindsley, J.B. "Address on State Medicine: The People and the Public Health Movement." Journal of the American Medical Association 19 (1892): 1-5.

Lindsley, J.B. "Popular Progress in State Medicine." Journal of the American Medical Association 13 (1892): ' 43-6.

Lundy, C.J. The Relation of the State and the Medical Profession. Ann Arbor, 1886.

Lvman, Henr)- M. "A Review of the Present State of Exact Knowledge Regarding the Causation of Epidemic Infectious Diseases." Reports and Papers of the American Public Health Association 4 (1879): 93-102. 383

Maclean, D. Observations upon the Miiluiil Relations of the Medkn! Profession and the S lute. Lansing, 1885.

Markham, H.C. "State Regulation of the Practice of Medicine: Its Value and Importance." ]otinml of the American Medical Association 10 (1888): 5-7.

McDaniel, J.E.D. "The Prevention of War and the Promotion of Peace in Relation to State Medicine." Journal of the American Medical Association 27 (1896): 453-6.

McGuire, H. "President's Address." Journal of the American Medical Association 20 (1893): 621-6.

"Meeting at Long Branch." Reports and Papers of the y\merican Public Health Association 2 (1874-5): 533.

"Meeting of the American Public Health Association, 1885." Science 6 (1885): 511, 531.

Mendizabal, Gregorio. "Dermatosis as Commonly Transmitted to the Pupils of Public Schools by Contagion, and Means of Prevention." Reports and Papers of the American Public Health Association 24(1898): 234-6.

Meyer, Henry C. The Story of the Saiiitaij' "E-ngmeer, hater the Engineering Record. New York: Jacques & Company, Inc., 1928.

Monjaras, J.E. "Necessity of Uniformir^' in the Meaning of the Term Still-Birth." Journal of the American Public Health Association 22 (1896): 128-9.

MontgomePi', L.H. "Chairman's Address." Journal of the American Medical Association 25 (1895): 345-50.

Moore, Harr)- H. Public Health in the United Slate.c An Outline with Statistical Data. New York: Harper, 1923.

Muench, Hugo. "Lemuel Shattuck, Still a Prophet: The Vitalit)' of Vital Statistics." American Journal oj Public Health 39 (1949): 151-5.

Noriega, Alberto. "Miasmatic Fevers in the State of Sonora." Reports and Papers of the American Public Health Association 22 (1896): 294-6.

Noriega, Tomas. "The Contagion of Venereal Diseases on Railroads." Reports and Papers oJ the .American Public Health Association 2\ (1895): 303-8.

Ohlmacher, A.P. "The Necessit)' for Medical Trusteeship and for a Central Laboratory in State Medical Institutions." journal of the American Medical Association 42 (1904): 165.

Oliver, Peter. "Notes on Science, Medicine, and Public Health in the Y'ear 1800." Bulletin of the Histo^' oJ Medicine 16 (1944): 116-30.

Parker, William Thornton. "The Overshading of Our Homes." Reports and Papers of the American Public Health Association 15 (1889): 41.

Paterson, Robert G. "Lemuel Shattuck and Public Health: A Letter to the Editor." Journal oj the Histoiy oJ Medicine 1 {\To2)-.\Kl-9. 384

Preston, C.H. "Medicine and the State." ]onrim/ of the Amencan Medka! Association 30 (1898): 413-6.

"Proceedings and Discussion at the Tenth Annual Meeting." Reports and Papers of the Ameman Public Health Association 8 (1882): 191-209.

Rauch, John Henn-, "Address in State Medicine." journal of the American Medical Association 6 (1886): ' 645-52.

Ravenel, Mazyck Porcher. "The American Public Health Association: Past, Present, and Future." In A HalfCentui^' of Public Health: jubilee Historical I'oliime of the American Public Health Association, ed. Mazyck Porcher Ravenel, 13. New York: American Public Health Associadon, 1921.

Reeves, james E. "The Eminent Domain ofSanitan* Science, and the Usefulness of State Boards of Health in Guarding the Public Welfare." Reports and Papers of the American Public Health Association'i (1883): 171-84.

"Report of Committee on Nomenclature and Forms of Stadsucs." Reports and Papers of/he .American Public Health Association 2\ (1895): 517-35.

"Report of the Committee on Vital Statistics." Reports and Papers of the American Public Health Association 7 (1881): 429-31.

"Revised List of Members." Journal of the American Public Health Association (1900): xvi-xxviii.

"Revised List of Members." Reports and Papers of the Anierican Public Health .•Issodation 15 (1890): 335-46.

Richards, Ellen H. Conservation bj Sanitation: Air and Water Supply Disposal of Waste. New York: John Wiley & Sons, 1911.

Richmond, PhyUis Allen. "American Attitudes Toward the Germ Theorj' of Disease, 1860-1880." journal of the Histoiy of Medicine 9 (1954): 428-30.

Richmond, Phyllis Allen. "Some Variant Theories in Opposition to the Germ Theor)' of Disease." journal of the Histor)' of Medicine 9 Quly 1954): 290-303.

Ringen, l

Richards, Ellen FL Sanitation in Daily Life. Boston: VCIiitcomb & Barrows, 1907.

Roberts, DeeringJ. "Address in State Medicine." jotmial of the American Medical Association 3 (1884): 1-6.

Rohe, G.H. "Address in State Medicine: Recent Advances in Preventive Medicine." journal of the American Medical Association 9 (1887): 1-11.

Rosen, George. "WilUam H. Welch and the Myth of Lemuel Shattuck." journal of the Histoiy of Medicine 6 (1951): 127-8. 385

Rosenberg, Carroll Smith and Charles E. Rosenberg. "Pietism and the Origins of the American PubLc Health Movement: A Note on John H. Griscom and Robert H. Hartley." joiinui/ of the Histoiy of Mecliane 25 (Spring 1968): 16-35.

Rosenkrantz, Barbara Gutmann. "Cart Before the Horse: Theor)', Practice, and Professional Image in American Public Health, 1870-1920." journal of the Histoiy of Medicine 29 (1974); 55-73.

Sedgwick, William Thompson. Principles of Sanitary Science and the Public Health, with Special Reference to the Causation and Prevention of Infectious Diseases. New York: The Macmillan Company, 1902.

Shattuck, Lemuel. Bills of Mortality, 1810-1849, City of Boston. Boston: Registn- Department, 1893.

Shattuck, Lemuel. "On the Vital Statistics of Boston." American journal of the Medical Sciences 1 (April 1841): 369-401.

Shattuck, Lemuel. Report of a General Plan for the Promotion of Public and Personal Health, Devised, Prepared, and Recommended /;)• the Commissioners Appointed Under a Re-whe of the Legislature of the State. Boston: Dutton & Wentworth, 1850; reprint, Cambridge: Han-ard Universit)' Press, 1948.

Shryock, Richard Harrison. "The Early American Public Health Movement." In Medicine in America: Historical Essays, ed. Richard Harrison Shryock, 126-38. Baltimore: Johns Hopkins Press, 1966.

Shr)'ock, Richard Harrison. "The Origins and Significance of the Public Health Movement in the United States." Annals of Medical Histoiy \ (1929): 645-65.

SmiUie, Wilson George. "Lemuel Shattuck; Still a Prophet." American journal of Public Health 39 (F'ebruar)' 1949): 135-44.

Smith, Stephen. "On the Limitations and Modifying Conditions of Human Longevit)', the Basis of Sanitan' Work." Reports and Papers of the American Public Health Association 1 (1873): 7, 12.

Smith, Stephen. "Remarks." Reports and Papers of the American Public Health Association 22 (1896): 20-4.

Snow, Edwin Miller. "Does Smallpox Become Epidemic, or Spread Only by Its Own Contagion?" Reports and Papers of the American Public Plealth Association 2 (1874-5): ?

Staples, Franklin. "Concerning the Present Condition of State Medicine in the United States." journal of the American Medical Association 28 (1897): 685-7.

Stevens, Thaddeus M. "The True Value of Chemical Analysis in Determining the Hygienic Purit)' of Potable Water." Reports and Papers of the American Public Health Association 10 (1884): 96-9.

Taft, William Howard. The Public Health. Washington, D.C.: Government Printing Office, 1911.

Tannenbaum, Rebecca J. "Earnestness, Temperance, Industr)': The Definidon and Uses of Professional Character Among Nineteenth-Century American Physicians." journal of the Hislo^ of Medicine 49 (1994): 251-82.

Terris, Milton. "Evolution of Public Health and Preventive Medicine in the United States." American journal of Public Health (>b (Februarj' 1975): 162. 386

Tesh, Sylvia N. "Miasma and 'Social Factors' in Disease Causalit)-: Lessons from the Nineteenth Centur}'." ]oiintal of Health Politics, Policy, and Law 20 (Winter 1995): 1001-24,

Tomes, Nancy. "The Private Side of Public Health: Sanitarj- Science, Domestic Hygiene, and the Germ Theor)-, 1870-1990." Bulletin of the Histo^' of Medicine 64 (Winter 1990): 509-39.

Tucker, W.G. State Control in Medianc. Albany, N.Y., 1895.

Valdiserri, R.O. "Temples of the Future: An Historical Overview of the Laborator)''s Role in Public Health Practice." Annual Preview of Public Health 14 (1993): 635-48. van der Poel, Oakley. "General Principles Affecting the Organization and Practice of Quarantine." Reports and Papers of the .4merican Public Health Association 1 (1873): 402-26.

Vaughan, Henr)- F., et al. "Report of Committee on Reorganization." American ]oiirnal of Public Health 12 (December 1922): 987-91. von Pettenkofer, Max. "What We Can Do Against Cholera." Reports and Papers of tijc American Public Health Association \ (1873): 335.

Waller, EKvyn. "Report on Disinfection and Disinfectants." Reports and Papers of the American Public Health Association 1 (1873): 459-71.

Ward, Benjamin, ed. The Health of Nations; A Review of the Works of Edwin Chacbvick, 2 vols. London: Longmans, Green & Co., 1887; reprint, London: Dawsons of Pall Mali, 1965.

Warner, ]ohn Harley. "The Fall and Rise of Professional Myster\-: Epistemology, Authorit)', and the Emergence of Laboratorj- Medicine in Nineteenth-Centurj- America." In The Laboratoi^' Revolution in Medicine, ed. Andrew Cunningham and Perr}' Williams, 110-41. Cambridge: Cambridge University- Press, 1992.

Washburn, Emor)^ "Expert Testimony and the Public Semce of Experts." Reports and Papers of the American Public Health Association 3 (1875-6): 38.

Watson, Roger. Edwin Chadwick, PoorLuiw, and Public Health. London: Longman, 1969.

Welch, William Henry. "Considerations Concerning Some External Sources of Infection in their Bearing on Preventive Medicine." journal of the American Medical Association 13 (1889): 73-83.

Wight, Orlando W. "The Management of Contagious and Infectious Diseases in Milwaukee." Reports and Papers of the American Public Health Association 6 (1880): 86-92.

Wilbur, Cressy L. "The Outlook for a General System of Registration of Vital Statistics in the United States." Journal of the American Public Health Association 2\ (1895): 231-41.

Wilbur, Cressy L., et al. "Report of the Committee on the Nomenclature of Diseases and Forms of Statisucs." Journal of the American Public Health Association 22> (1897): 337. 387

Wilde, George W. "Sanitar)- Sciencc in the Camp." Ameiiaiii Mecliuil Times 3 (july 24, 1861): 51.

Williams, Huntington. "The Influence of Edwin Chadiwick on American Public Health." Medica! Of/icer 95 (1956): 273-9.

Wilson, W.R. The Kight Kelalion of the General Public to State Preventive Medicine. Raleigh, N.C., 1883.

Winslow, C.E. "The Physician and the State." journal of the American Medical Association 23 (1894): 295.

W'inslow, Charles-Edward Amor}'. "Lemuel Shattuck, Still a Prophet: The Message of Lemuel Shattuck for 1948." American Journal of Public Health 39 (1949): 156-62.

Woknan, Abel. "Lemuel Shattuck, Still a Prophet: Sanitadon of Yesterday, But W'liat of Tomorrow?" American Journal of Public Health 1>9 (1949): 145-50.

Woodhull, Alfred A. "May Not Yellow Fever Originate in the United States? An Edological Study of the Epidemic at Savannah in 1876." Reports and Papers of the American Public Health Association 5 (1879): 89-107,

Wright, O.W. "Laws Requiring Medical Men to Report Deaths and Cases of Infecdous Disease to the Public Authorides." Reports and Papers of the American Public Health Association 8 (1882): 17-22.

Wright, Peter and Andrew Treacher,eds. The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh: Edinburgh Universitj- Press, 1982.

Wvman, Walter. Government Aids to Public Health. Chicago: American Medical Associadon, 1890.

Young, Andrew. "The Reladon of the Plumbers and the Physicians." Reports and Papers of the American Public Healthybsociation 17 (1891): 48-52.

CHAPTER III. TWO VIGNETTES: SANITARY SCIENCE AND COMMUNITY HEALTH

Emerson, Haven, et al. "Charles-Edward Amor)- Winslow, Februarj' 4th, 1877-Januar)' 8th, 1957: A Memorial." American Journal of Public Health Al (Februar}' 1957): 151-67.

Hiscock, Ira V. "Charles-Edward Amory Winslow, February- 4th, 1877-January 8th, 1957." Journal of Bacteriolog)' 73 (March 1957): 295-6.

Sedgwick, William Thompson. "American Achievements and American Failures in Public Health Work." American Journal of Public Healths (1915): 1103.

Sedgwick, William Thompson. "American Achievements and American Failures in Public Health Work." Science 42 (September 17,1915): 361-5.

Sedgwick, William Thompson. "Cold Storage and Public Health." American Journal of Public Health 1 (1912): 825.

Sedgwick, WiUiam Thompson. "Early School of Public Health at Lyons, France." American Journal oj Public Health 10 (1920): 352. 388

Sedgwick, William Thompson. "Editorial." American journal of Public Hea/lh 11 (1921): 361.

Sedgwick, William Thompson. "The Genesis of a New Science: Bacteriologv." journal ofBac/eriolo^' 1 (Januar}' 1916): 1-4.

Sedgwick, William Thompson. "Instruction in Hygiene for Architects and Engineers." Reports and Papers of the American Public Health Association 27 (1901): 92-3.

Sedgwick, William Thompson. "On the Influence of Variations in the Composition of Nutrient Gelatin Upon the Development of Water Bacteria." Reports and Papers of the American Public Health Association 20 (1894): 450-8.

Sedgwick, William Thompson. "On the Proper Correlation of Physicians, Engineers, and Other Specialists, in Public Health Work." American journal of Public Health 1 (1911): 28.

Sedgwick, William Thompson. "On the Proper Correladon of Physicians, Engineers, and Other Specialists, in Public Health Work." journal of Infectious Diseases 36 (1911): 19-22.

Sedgwick, William Thompson. "The Origin and Disseminadon of T)'phoid Fever." Reports and Papers of the American Public Health Association 19 (1893): 235-41.

Sedgwick, William Thompson. "The Origin, Scope, and Significance of Bacteriolog)'." Science 13 (1901): 121-8.

Sc'dgwick, William Thompson. "Photograph." American journal of Public Health 11 (1921): 363.

Sedgwick, William Thompson. Principles of Sanitary Science and the Public Health, with Special Reference to the Causation and Prevention of Infectious Diseases. New York: Macmillan Co., 1902.

Sedgwick, William Thompson. "Rats and Insects as Public Enemies." American journal of Public Health 8 (1918): 34.

Sedgwick, William Thompson. "The Readjustment of Educadon and Research in Hygiene and Sanitadon." journal of Infectious Disea.m'i\ pt. 1 (1905): 115-20.

Sedgwick, William Thompson. "Reappearance of the Ghost of Malthus." American journal oj Public Hftf///&3 (1913): 1032.

Sedgwick, William Thompson. "The Reladon of Illuminadng Gas to Public Health." American journal of Public Health

Sedgwick, William Thompson. "Reladons of Public Health Science to Other Sciences." Science 21 Qune 16,1905): 905-14.

Sedgwick, William Thompson. "Tj^phoid Fever: A Disease of Defecdve Civilizadon." In Typhoid Fever Its Causation, Transmission, and Prevention, by George Chandler VC-liipple, xxiii-xxxvi. New York: lohn Wiley & Sons, 1908. 389

Scdgwick, William Thompson. "A Welcome to Women in Public Health Work." American jouriml of Public Health^ {m^y. 164.

Scdgwick, William Thompson. "Wliat Massachusetts Has Done and May Yet Do for the Public Health." American journal ojPublic Health 5 (1915): 637.

Sedgwick, William Thompson. "Women's New Fields of Work." American ]ounial of Public Health 9 (1919): 371-2.

Sedgwick, William Thompson and T. Hough. "What Training in I'hysiolog)- May We Reasonably Expect in Public Schools?" Science 18 (1903): 333-60.

Sedgwick, William Thompson and J. Scott MacNutt. "On the MUls-Reinicke Phenomenon and Hazen's Theorem Concerning the Decrease in Mortalitj- from Diseases other than Tj'phoid Fever Following the Purification of Public Water Supplies." journal of Infectious Diseases 7 (August 1910): 489-564.

Sedgwick, William Thompson and William Ripley Nichols. "A Study of the Relative Poisonous Effects of Coal Gas and Water Gas." Annual Report of the Massachusetts Board of Health, Ltinaiy, and 6 (1885): 275-313.

Sedgwick, William Thompson and F. Schneider. "Relation of Illuminating Gas to Public Health." American Journal of Public Health 1 (1911): 385.

Sedgwick, William Thompson and Edmund B. Wilson. Introduction to General Biology. New York; Henr)' Holt and Company, 1886,

Sedgwick, William Thompson and Charles-Edward Amor\' Winslow. "On the Relative Importance of Public Water Supplies and Other Factors in the Causation of Typhoid Fever." Reports and Papers of the American Public Health Association 28 (1902): 288-95.

Sedgwick, William Thompson, et al. "Report of Committee on the Teaching of Hygiene and Grandng of Diploma of Doctor of Public Health." Reporis and Papers of the American Public Health Association 11 (1901): 87-91.

Sedgwick, William Thompson, et al. "Report of Committee on the Teaching of Hygiene and Granting of Diploma of Doctor of Public Health." Reports and Papers of the American Public Health Association 2% (1902): 170-1.

Winslow, Charles-Edward Amor)'. "The Bacteriological Analysis of Water and Its Interpretation." Journal of the New England Water Works Association 15 (1901): 459-82.

Winslow, Charles-Edward Amor}'. "A Bibliography, 1896-1945." Yale journal of Biokg^' and Medicine 19 (1947): 779-800.

Winslow, Charles-Edward Amor}'. "The Changing Challenges of Public Health." American journal of Public Health'h^ (March 1945): 191.

Winslow, Charles-Edward Amory. "Charles-Edward Amor}'Winslow, Feb. 4, 1877-Jan. 8,1957." Dictionary of American Biography Supplement 6 (1980): 701. 390

Winslow, Charles-Edward Amor)-. "The Charles-Edward Amorj- Winslow Papers." Contemporan* Medical Care and Health Policy Collection. Manuscripts and Archives. Yale University' Libran'. New Haven, Connecdcut.

Winslow, Charles-Edward Amor)-. "Cit)' Health Administration." Survey 55 (November 1, 1925): 166.

Winslow, Charles-Edward Amor}'. A City Set on a Hill: The Sigmficance of the Health Demonstration at Syracuse, New York. Garden Cit}', N.Y.: Doubleday, Doran & Company, Inc., 1934.

Winslow, Charles-Edward Amon*. "Communit}- Defense of National Vitalit)-." Popular Science 86 (April 1915); 319-24.

Winslow, Charles-Edward Anion'. The Conquest of Epidemic Disease: A Chapter in the History of Ideas. Princeton, N.J.: Princeton Universit}' Press, 1943; reprint, New York; Hafner, 1967.

Winslow, Charles-Edward Amor}'. The Cost of Sickness and the Price of Health. Geneva; World Health Organizadon, 1951.

Winslow, Charles-Edward Amor}'. "Cultural Objectives of Health Education." School and Sodety 40 Quly 7, 1934): 1-5.

Winslow, Charles-Edward Amory, Dean Winteniit^^and the Yale School of Medicine. New Haven, Conn.; Yale University Press, 1935.

Winslow, Charles-Edward Amor}-. "The Deeper Significance of Scientific Education." Technolo^ Review 1 {msy.m-l.

Winslow, Charles-Edward Amor}-. "Dr. William Thompson Sedgwick, 1855-1921." Interne\\ (1945); 177-8,192.

Winslow, Charles-Edward Amor)'. "Educational Opportunities of the Health Department." American Journal of Public Health 1 (1911); 77.

Winslow, Charles-Edward Amor}-. "Effect of Atmospheric Conditions Upon Fatigue and Efficiency." American Journal of Public Health! (1917): 827-34.

Winslow, Charles-Edward Amor}'. Elements of Applied Microscopy: A Text-Book for Beginners. New York: John Wiley & Sons, 1905.

Winslow, Charles-Edward Amor}-. "The Epidemiology of Noah Webster." Transactions of the Connecticut Academy of Arts and Sciences 32 (Januar)' 1934): 21-109.

Winslow, Charles-Edward Amor}'. "European Health Conditions." American journal of Public Health 12 (1922); 94.

Winslow, Charles-Edward Amor}-. The Evolution and Significance of the Modem Public Health Campaign. New Haven, Conn.: Yale University Press, 1923, Reprint, New Haven, Conn.: Yale Universit}' Press, 1984. 391

Winslow, Charles-Edward Amon,'. "The Evolving Patterns of Tomorrow's Health: The Post-War Cit)-." American Journal of Public Health 33 (December 1943):1408-13.

Winslow, Charles-Edward Amor)'. "Fifteen Years of the Committee on Administradve Pracdce: The Evoludon of the Program." American journal of Public Health 25 (1935): 1303.

Winslow, Charles-Edward Amon*. "The First Fort}' Years of the Societ}- of American Bacteriologists." 91 (1940): 125-9. '

Winslow, Charles-Edward Amor}'. Fresh Air and Ventilation. New York: E.P. Button & Company, Inc., 1926.

Winslow, Charles-Edward Amor}'. "The Future: Problems and Trends." In The University and Public Health Statesmanship, 21-32. Philadelphia: Universit}' of Pennsylvania Press, 1941.

Winslow, Charles-Edward Amory. "A Half-Centun* of the Massachusetts Public Health Association." American journal of Public Health 30 (April 1940): 325-35.

Winslow, Charles-Edward Amor}'. Handbook oj Health in War and Peace. New York: The Centur}' Co., 1917.

Winslow, Charles-Edward Amon'. "Health Educadon in a Democracy." Science 91 (February 26,1943): 189-92.

Winslow, Charles-Edward Amor}'. "Health-Educauon Problems of the Elementar}' Schools." In The Changing Elementaty School, ed. Leo ]. Brueckner, 273-81. New York: Inor Publishing Company, 1939.

VX'inslow, Charles-Edward Amor}'. Health in the Twentieth Centuty. New York: Arno, 1977.

Winslow, Charles-Edward Amor}'. "Health in War and Peace." Proceedings of the National Conference oJ Social 44 (1917): 169-73.

Winslow, Charles-Edward Amor}'. "Health Legislation in Colonial Connecticut." Bulletin of the Society on Medical History of Chicago 3 (December 1924): 317-35.

Winslow, Charles-Edward Amor}'. Health on the Farm and in the Village: A Revien> and Evaluation oj the Cattaraugus County Health Demonstration with Special Reference to Its Les.(ons for Other Rural Areas. New York: The Macmillan Company, 1931.

Winslow, Charles-Edward Amory. "The Health Survey as a Social Instrument." Proceedings of the National Conference of Social Work 57 (1930): 163-71.

Winslow, Charles-Edward Amor}'. Health Survey of New Haven. New Haven, Conn., 1928.

Winslow, Charles-Edward Amor}'. Health Through the Ages. New York: Metropolitan Life Insurance Company, 1933. 392

Winslow, Charles-Edward Amor)'. "Housing and Health." Public Heal/lj Nursing (July 1940): 434-9.

Winslow, Charles-Edward Amor)-. "Housing and Public Health." Atnmcan journal of Public Health 35 (1945): 18.

Winslow, Charles-Edward Amor}\ "Housing as a Public Health Problem." American journal of Public HW/A 27 (1937): 56.

Winslow, Charles-Edward Amor\-. "Industrial Tuberculosis." Boston Medical & Surgical journal \')2 (fanuar)'29, 1925): 215-7.

Winslow, Charles-Edward Amor\-. "Industry in Medicinc." American Journal of Public Health 23 (1933): 450.

Winslow, Charles-Edward Amor}-. "An Insect-Borne Disease: Infant Paralysis." American Museums journal \7> (1914): 229-35.

Winslow, Charles-Edward Amor)'. "The Laboratorj' in the Ser\'ice of the State." .American journal of Public Health 6 (March 1916): 222-233.

Winslow, Charles-Edward Amor)-. "League of Nations News." American journal of Public Health 19 (1929): 342.

Winslow, Charles-Edward Amor)-. "Lemuel Shattuck, Sdll a Prophet: The Message of Lemuel Shattuck for 1948." American journal of Public Health 39 (1949): 156-62.

Winslow, Charles-Edward Amor)'. The Life of Hermann M. Big^s. Physician and Statesman of the Public Health. Philadelphia: Lea & Febiger, 1929.

Winslow, Charles-Edward Amor)-. "The Living Hand: Elizabeth KOlbank Anderson." In MUbank Memorial Fund: .-I Meeting Com?»emorating the Tiventy-Fifth Anniversaty, 11-62. New ^'ork: Milbank Memorial Fund, 1930.

Winslow, Charles-Edward Amory. "Making the School Safe for the Child." Elemeiitaiy School Journal IS (May 1928): 649-58.

Winslow, Charles-Edward Amory. Man and Epidemics. Princeton, N.J.: Princeton University Press, 1952.

Winslow, Charles-Edward Amory. Man and the Microbe: Hoiv Com?nnmcabk Diseases are Controlled. New York: Funk & Wagnalls Company, 1924.

Winslow, Charles-Edward Amon-. "A Method for Determining the Number of Dust Pardcles in Air." Journal of Infectious Diseases 34 (1908): 248-9.

Winslow, Charles-Edward Amor)'. "New Profession of Public Health Nursing and its Educadonal Needs." Proceedings of the Pan American Scientific Congress 5 (1917): 330-6.

Winslow, Charles-Edward Amor)-. "Nursing in Relation to the Three Plans for Municipal Health Departments." American journal of Public Health 17 (1927); 246. 393

Winslow, Charles-Edward Amor)-. "Opportunities and Responsibilities of the Health Officer in Connection with Federal Housing Acts." American journal of Public Health 2?> (November 1938); 1269-76.

Winslow, Charles-Edward Amon-. "Organizing a State Campaign of Public Health Education." American journal of Public Health 6 (1916): 805.

Winslow, Charles-Edward Amon'. "An Outbreak of Tonsilitis or Septic Sore Throat in Eastern Massachusetts and its Relation to an Infected Milk Supply." Journal of infectious Diseases 10 (1912); 73-112.

Winslow, Charles-Edward Amor)-. The Past, Present, and Future of the Yale Universitj School of Medicine. New Haven, Conn.; Yale Universit}' Press, 1922.

Winslow, Charles-Edward Amory. "A Physician of Two Centuries Ago; Richard Mead and His Contributions to Epidemiology." Bulletin of the Institutes of the Histor)' of Medicine 3 (1935); 509-44.

Winslow, Charles-Edward Amory. "The Place of Public Health in a University." Science 62 (1925); 335-9.

Winslow, Charles-Edward Amor)'. "Poverty' and Disease." American Journal of Public Health 38 (1948); 173-84.

Winslow, Charles-Edward Amor)'. "President of the American Public Health Association." American journal of Public Health 15 (1925); 996.

Winslow, Charles-Edward Amor\'. "Preventing Sickness and Prolonging Life." In Modern Science and People's Health, ed. Benjamin Charles Gruenberg, 183-212. New York; W.W. Norton & Compnay, Inc., 1926.

Winslow, Charles-Edward Amory. "Preventive Medicine and Health Promotion; Ideals or Realities." Yak journal of Biolo^ and Medicine 14 (1942); 443-52.

Winslow, Charles-Edward Amor)'. "Program and Preliminar)' Results of the Committee on the Grading of Nursing Schools." American journal of Public Health 18 (1928); 448.

W'inslow, Charles-Edward Amorv. "A Program of Medical Care for the United States." Science 77 (1933); 102-7.

Winslow, Charles-Edward Amor\'. "Public Health Aspects of Medical Care." American journal of Public Hm/z/J 29 (1939); 16.

Winslow, Charles-Edward Amor\'. "Public Health at the Crossroads." American journal of Public Health 16 (1926); 1075-85.

Winslow, Charles-Edward Amory. "Public Health Education in the United States." Journal oj the Royal Sanitary Institute 35 (1914); 263-71.

Winslow, Charles-Edward Amor)'. "Public Health in the Past and in the Future." journal of Home Economics 8 (October 1916); 513-20. 394

Winslow, Charles-Edward Amor)'. "Rccent Advances in Our Knowledge of die Problems of Air Conditioning." American Journal of Public Health 21 (1937): 767.

Winslow, Charles-Edward Amor)-. "The Recommendations of the Committee on the Costs of Mcdical Care." Neiv England journal of Medicine 201 (1932); 1138-42.

Winslow, Charles-Edward Amor\-. "The Recruiting of Sanitarians for the Future Semce of the State." American journal oj Public Health 13 (1923): 355-60.

Winslow, Charles-Edward Amor}'. "Retires from Yale." American journal of Public Health 35 (1945): 314.

Winslow, Charles-Edward Amory. "Role of the Public Health Nurse in the Modern Public Health Campaign." Connecticut Health Bulletin 33 (1919): 5-10.

Winslow, Charles-Edward Amor\'. "Role of the Public Health Nurse in the Modern Public Health Campaign." Monthly bulletin of the New York City Department of Health^ (1919): 188-93.

Winslow, Charles-Edward Amor)'. "The Sanitar)' Dangers of Certain Occupadons." journal of the Massachusetts Association of Boards of Health 14 (1904): 92-100.

Winslow, Charles-Edward Amon'. The School Health Program. New York: The McGraw-Hill Book Company, Inc., 1938.

Winslow, Charles-Edward Amor)'. "School Ventiladon in New York Cit}'." American journal of Public H

Winslow, Charles-Edward Amor)'. "Sedgwick Medalist, 1942." American journal of Public Health 32 (1942): 1416. '

Winslow, Charles-Edward Amor)'. "Some Factors in the Spread of Typhoid Fever." American journal oj Public Hygiene 18 (1908): 131-6.

Winslow, Charles-Edward Amor)'. "Some Relations of Medicine to Industn'." Neii> York State Medical ]ournal21 (1927): 1246-50.

Winslow, Charles-Edward Amon'. "Standard Methods and New Procedure for the Isoladon of Colon Bacilli from Water." American journal of Public Health 24- (1934): 456.

Winslow, Charles-Edward Amor)'. "A Stadsdcal Study of the Fatalit)' of Typhoid Fever at Different Seasons." journal of the American Statistical Association^ (September 1902): 103-25.

Winslow, Charles-Edward Amory. "There Were Giants in Those Days." American journal of Public Health 43 Oune 1953): 15-9.

Winslow, Charles-Edward Amor)'. "Tuberculosis in Dust)' Trades." Sumej 54 (June 15, 1925): 353-5.

Winslow, Charles-Edward Amor)'. "The Untiiled Fields of Public Health." Modern Medicine 2 (March 1920): 183. 395

Winslow, Charles-Edward Amor)-. "The Untilled Fields of Public Health." Science 5\ (|anuar}'9, 1920);23-33.

VN'inslow, Charles-Edward Amor\'. Ventilcttion: Report of the New York Slate Commission on Ventilation. New York: E.P. Dutton & Company, 1923.

Winslow, Charles-Edward Amor)'. "William Thompson Sedgwick, 1855-1921." journal of hacteriolo^' 6 (1921): 225-62.

Winslow, Charles-Edward Amon*. "\'ale Valedictorj' Address, June 16,1945." Yak journal ofBiolo^- and Medicine 18 (1945): 1-5.

Winslow, Charles-Edward Amorj' and Margaret R. Burkliardt. "Public Health Nursing." Public Health Nurse 14 (October 1922): 514-20.

Winslow, Charles-Edward Amor)' and M.L. Duran-Reynals. "Jacme D'Agramont and the First of the Plague Tractates." Bulletin of the History of Medicine 22 (1948): 747-65.

Winslow, Charles-Edward Amon' and I.S. Falk. "A Contribution to the Dynamics of Toxicit)' and the Theor)'of Disinfection." journal of Bacteriolo^- \\ (1926): 1-25.

Winslow, Charles-Edward Amor)' and Franklin Fearing. "Steps in Planning a Health Education and Publicit)' Program." American journal of Public Health 19 (1929): 647.

Winslow, Charles-Edward Amor)' and Josephine Goldmark. Niirsing and Nursing Education in the United States. New York: The Macmillan Company, 1923.

Winslow, Charles-Edward Amor)- and C.E. Gray. "Tuberculosis MortaUt)' in Relation to the Pasteurization of Municipal Milk Supplies." American Kevieiu of Tuberculosis 10 (1924-5): 186.

Winslow, Charles-Edward Amor)' and David Greenberg. "Effcct of Putrefactive Odors upon Growth and upon Resistance to Disease." American journal of Public Health 8 (1918): 759.

Winslow, Charles-Edward Amor)- and L. Greenburg. "Industrial Tuberculosis and the Control of the Factor)' Dust Problem." journal of Industrial Hygiene 2 (1921): 333-43.

Winslow, Charles-Edward Amor)' and L. Greenburg. "A Study of the Dust Hazard in the Wet and Dr)' Grinding Shops of an Ax Factor)'." Public Health Reports 35 (1920): 2393-2401.

Winslow, Charles-Edward Amor)' and C.C. Grove. "Note on Certain Correlation Factors of the 1918 Influenza Epidemic." American journal of Hygiene 2 (1922): 240-5.

Winslow, Charles-Edward Amor)' and P. Hansen. "Some Statistics of Garbage Disposal for the Larger American Cities in 1902." Reports and Papers of the American Public Health Association 29 (1903): 141-65.

Winslow, Charles-Edward Amon' and L.P. Herrington. Temperature and Human Life. Princeton, N.J.: Princeton Universit)' Press, 1949. 396

Winslow, Charles-Edward Amory and I.W. Hubbard. "Epidemiology' and Symptomolog)' of an Outbreak of Septic Sore Throat in Westchester Count)', New York." Jotmtal oflnfeclious Diseases 18 (1916): 106-17.

Winslow, Charles-Edward Amor\' and I.J. Kligler. "A Quantitative Study of the Bacteria in Cit}- Dust with Special Reference to Intestinal and Buccal Forms." American journal of Ptiblic Health 2 (1912): 663.

Winslow, Charles-Edward Amor)' and Z.W. Koh. "The Mortality of the Chinese in the United States, Hawaii, and the Philippines." American Journal of Hjgiene A (1924): 330-55.

Winslow, Charles-Edward Amor)- and Z.W. Koh. "The Mortality of the Chinese in the United States, Hawaii, and the Philippines." China Medical journal !>% (November 1924): 877-99.

Winslow, Charles-Edward Amory and Anna M.R. Lauder. "New Profession of Public Health Nursing and Its Educational Needs." Modem Hospital6 (June 1916): 438-41.

Winslow, Charles-Edward Amor)' and George Truman Palmer. "A Comparative Study of Fecal Streptococci from the Horse, the Cow, and Man." journal oflnfeclious Diseases 35 pt. 1 (1909): 375-6.

Winslow, Charles-Edward Amory and Earle B. Phelps. "Experiments on the Purification of Boston Sewage." journal of Infectious Diseases 3\ pt. 1 (1905): 16-28.

Winslow, Charles-Edward Amory and E.A. Robinson. "An Investigation of the Extent of the Bacterial Pollution of the Atmosphere by Mouth-Spray." journal of Infectious Diseases 35 pt. 1 (1909): 227-30.

Winslow, Charles-Edward Amor)' and A.F. Rogers. "A Revision of the Coccaceae." Science 21 (1905): 669.

Winslow, Charles-Edward Amor)' and A.F. Rogers. A Statistical Study of Generic Characters of the Coccacae. Chicago: Universit)' of Chicago Press, 1906.

Winslow, Charles-Edward Amor)- and A.F. Rogers. "Statistics of the 1918 Epidemic of Influenza in Connecticut with a Consideration of the Factors Wliich Influenced the Prevalence of this Disease in Various Communities." journal of Infectious Diseases 26 (1920): 195-216.

Winslow, Charles-Edward Amor)' and William T. Sedgwick. "I. Experiments on the Effect of Freezing and Other Low Temperatures Upon the Viabilit)' of the Bacillus of Typhoid Fever, with Considerations Regarding Ice as a Vehicle of Infectious Disease. II. Statistical Studies on the Seasonal Prevalence of Typhoid Fever in Various Countries, and Its Relation to Seasonal Temperature." Memoirs of the American Academy of Arts and Sciences 12 (1902): 469-577.

Winslow, Charles-Edward Amor)' and H.J. Shaughnessy. "The Alkaline Isopotential Point of the Bacterial Cell." journal of General Physiok^ 6 (1924): 697-701.

Winslow, Charles-Edward Amor)' and Allan A. Twichell. "Healthful Housing." American journal of Public Health (March 1938): 354-72. 397

Winslow, Charles-Edward Amor)' and Pauline Brooks Williamson. The Laws of Health and How to Teach Them. New York: Charles E. Merrill Company, 1925.

Winslow, Charles-Edward Amor)' and Anne Rogers Winslow. The Systematic Relationships oj the Coccaceo": With a Discussion of the Principles of Bacterial Classification. New York: John Wiley & Sons, 1908.

Winslow, Charles-Edward Amon' and Savel Zimand. Health Under the "El": The Stoiy of the Bellevue-Yorkville Health Demonstration in Mid-Town New York. New York: Marper & Bros., 1957.

Winslow, Charles-Edward Amor)', et al. Basic Principles of Healthful Housing: Preiiminatj Report. New York; American Public Health Association, Committee on the Hygiene of Housing, 1938.

Winslow, Charles-Edward Amory, et al. Basic Principles of Healthful Homing. 2nded. New York; American Public Health Association, Committee on the Hygiene of Housing, 1939.

Winslow, Charles-Edward Amor)', et al. "Committee Report on Basic Principles of Healthful Housing." American journal of Public Health 28 (1938); 351.

Winslow, Charles-Edward Amory, et al. "The Dust Hazard in the Abrasive Industr)'." Public Health Reports ZA (1919); 1171-87.

Winslow, Charles-Edward Amor)', et al. "The Families and Genera of the Bacteria; Preliminar)' Report of the Committee of the Societ}' of American Bacteriologists on Characterization and Classification of Bacterial T)'pes." Journal of Bacteria 2 (1917); 505-66.

Winslow, Charles-Edward Amor)', et al. "Final Report of the Committee on Standard Methods for the Examination of Air." American journal of Public Health 1 (1917): 54.

Winslow, Charles-Edward Amor)', et al. "Hazards from Tetraethyl Lead Gasoline; The Use of Tetrathyl Lead Gasoline and its Relation to Public Health," Public Health Bulletin 163 (1926); 1-123.

Winslow, Charles-Edward Amor)'., et al. "Health-Education Problems of the Elementary Schools." In The Changing Elementary School, ed. Leo J. Brueckner, 273-81. New York; Inor Publishing Company, 1939.

Winslow, Charles-Edward Amory, et al. The Histor)^ of American Epidemiology. St. Louis: C.V. Mosby, 1952.

Winslow, Charles-Edward Amor)', et al. "Hygiene of Housing." American Journal of Public Health Yearbook (1938-9): 27.

Winslow, Charles-Edward Amor)', et al. "Hygiene of Housing." American journal of Public Health Yearbook (1940-1): 61.

Winslow, Charles-Edward Amor)% et al. "Ideal Health Department for a City of 100,000." American Journal of Public Health 12 (1922): 891.

Winslow, Charles-Edward Amory, et al. "The Improvement of Local Housing Regulation Under the Law." American journal of Public Health 32 (1942): 1263. 398

Winslow, Charles-Edward Amor)', et al. "Infantile Paralysis: A Round-Table Discussion." American Journal of Public Heahhl (1917): 117-43.

Winslow, Charles-Edward Amor)', et al. "New Method for Measuring the Qualit)' of Urban Housing." American Journal of Public Health 33 (1943): 729.

Winslow, Charles-Edward Amory, et al. "An Outbreak of Food Poisoning Traced to the Consumption of Egg Salad." American Journal of Hygiene 3 (1923): 238-46.

Winslow, Charles-Edward Amor)', et al. "Report of the Committee of Sixteen: Standardization of Public Health Training." American Journal of Public Health 11 (1921): 371-5.

Winslow, Charles-Edward Amor)', et al. "Report on Administrative Practice." American Journal of Public 18 (1928): 180, 348.

Winslow, Charles-Edward Amor)', et al. "Report on Administrative Practice." American Journal of Public Hw//A 19 (1929): 317.

Winslow, Charles-Edward Amor)-, et al. "Report on Municipal Health Department Practice." American Journal of Public Health 15 (1925): 39.

Winslow, Charles-Edward Amor)', et al. Report on the Sewage Disposal Pnbkm of New Haven. New Haven: n.p., 1918.

Winslow, Charles-Edward Amor)', et al. "Some Results of the First Year's Work of the New York State Commission on Ventilation." American Journal of Public Health 5 (1915): 85.

Winslow, Charles-Edward Amor)', et al. "Standardization of Public Health Training." American Journal of Public Health

Winslow, Charles-Edward Amor)', et al. Ventilation: Report of the Neiv York State Commission on Ventilation. New York: E.P. Dutton & Company, 1923.

Winslow, Charles-Edward Amor)', trans. Magcla: A Play in Four Acts, by Hermann Sudermann. Boston: Lamson, Wolffe & Co., 1896.

CHAPTER IV. PUBLIC HEALTH NURSING

Abrams, Sarah Elise. "'Dreams and Awakenings': The Rockefeller Foundation and Public Health Nursing Education, 1913-1930." Ph.D. diss., Universit)' of California-San Francisco, 1992.

Adamson, Elizabeth I. "Function of the Public Health Nurse." Public Health Nursing 26 (1934): 542-6.

"Adjustments in Public Health Nursing." Public Health Nursing 24 (1932): 663-6.

Anderson, Elin L. "Communit)' Nursing: The Challenge of Nursing Education." Public Health Nursing 38 (1946): 637-40, 643.' 399

Anderson, Gaylord W. "The Role of die Public Heakh Nurse in Communicable Disease Control." Public Health Ntirsinglld (1934); 66-75.

Anderson, Grace L. and Mabelle S. Welsh. "Family Health Needs and Nurses' Sen'ice." Public Health Nursing 33 (1941): 137-41.

Armstrong, Donald Budd and Alma C. Haupt. "A Fort)'-Year Demonstration of Public Health Nursing by the Metropolitan Life Insurance Company." Public Health Nursing 43 (1951): 41-4.

Arnstein, Margaret G. "Relationship of the Public Health Nurse to the Part-time Local Health Officer in Communicable Disease Work." American journal of Public Health 26 (1936): 512-6.

Arnstein, Margaret G. "Research in the Nursing Field." American Journal of PUIJHC Health 40 (1950): 988-92.

Ash, W.S. "The Industrial Nurse and Safet)'." Public Health Nursing 25 (1933): 325-8.

"Ask Nurses to Study New Structure Plans (editorial)." Public Health Nursing 41 (1949): 171-3.

Babb, LaVona. "Industry's Challenge to the Nurse." American journal of Public Health 29 (1939): 1025-8.

"Bad Times Bring Good Health." Ulerary Digest 114 (December 24, 1932): 4.

Barnett, H.N. and L.E. Ledbetter. "Generalized Public Health Nursing in Texas." Public Health Mming 24 (1932): 131-3.

Bartlett, Louise L. "The Volunteer Assumes Important Tasks." h/blic Health Nursing 29 (1937): 183-4.

Barton, Nina. "Experiences of an FIR.A. Nurse." Public Health Nursing 26 (1934): 665-7.

Bauer, W.W. "Death-Rate in the Depression." American Mercuiy 29 (May 1933): 19-25.

Bauer, W.W. "Educating the Public in Health." Public Health Nursing 25 (1933): 69-75.

Bauer, W.W. "How the Official Health Organization Can Aid the Nurse in Industr)'." Public Health Nursing 22 (1930): 382-4.

Beard, Mar)'. The Nurse in Public Health. New York: Harper & Brothers Publishers, 1929.

Bearg, Philip A. and Eleanor L. Wood. "Community' Planning for Parent Education." Public Health Nursing 39 (1947): 256-7, 261.

Bender, Cynthia. Nurses in PHS Celebrate Proud Hislotj. RockviUe, Md.: Public Health Service, 1989.

Beuchat, Kathrj'n W. "The Role of the Public Health Nursing Consultant in the Hospital Consultation Program." American Journal of Public Health (1951): 72-5.

Bigelow, Helen A. "Maternity Care in Rural Areas by Public Health Nurses." American Journal of Public Health 27 (1937): 975-80. 400

Bischoff, Lillian M. "How an Emergency Program Ser\'ed a Community Need." Public Health Nwj7/7J28 (1936): 668-72.

Bishop, E.L. "TVA's New Deal in Health." American journal of Public Health 24 (October 1934): 1023-7.

Bixler, Elizabeth S. and Evelyn L. Coolidge. "Mental Hygiene Aspects of the Industrial Nurse's Job." Public Health Nursing 23 (1931): 67-9.

Blackwell, Gordon W. "The Social Scientist Looks at the Health Council Movement." Public Health Nursing A2 (1950): 316-21.

Blaisdell, Leah M. "Preparation of the Nurse of the Future." American journal of Public Health 29 (1939): 467-72.

Blakey, Lois. "Relation of Psychiatric Social Work to Public Health Nursing." Public Health Nursing 22 (1930): 26-30.

Bloom field, J.J. "Teamwork for Industrial Health." American journal of Public Health 36 (1946): 261-8.

"The Board Faces Facts and the Future." Public Health Nursing 25 (1933): 172-8.

Bolton, Frances Payne. "Hail and Farewell: NOPHN." Public Health Nursing AA (1952): 367-9.

Bond, Helen E. "Publicit}- Program for Count)- Public Health Nursing Ser\'ices." Public Health 22 (1930)? 424-6.

Borowski, Anthony J. "Positions and Rates of Pay in Public Health Agencies." American journal of Public Health 28 (1938): 1197-1202.

Bosley, Jose. "Selling Ser\'ice." Public Health Nursing 24 (1932): 449-51.

Boudreau, Frank G. "Family Health: Goal of Public Health." Public Health Nursing 30 (1938): 346-53.

Boudreau Frank G. and H.D. Kruse. "Malnutrition: A Challenge and an Opportunit)\" American journal of Public Health 29 (Nlay 1939): 427-33.

Brainard, Annie Maria. The E.volution of Public Health Nursing. Philadelphia; W.B. Saunders Company, 1922.

Brainard, Annie Maria. Organit^ation of Public Health Nursing. New York: The Macmillan Company, 1919.

Brickman, Jane Pacht. "Public Health, Midwives, and Nurses, 1880-1930." In Nursing History, ed. E.C. Lagemann, New York: Teachers' College Press, 1983.

Brinsmade, J osephine S. "^Iien You Present Your Budget to the Community Chest." Public Health Nursing 28 (1936): 322-3.

Brooks, Ethel G. "Union Health Departments." Public Health Nursing 42 (1950): 335-7. 401

Brown, Esther Lucille. "Studies in Interpersonal Relationships in the Therapeutic Setting." Public Health Nursing 43 (1951): 360-3.

Brown, Mae A. "Let's Coordinate." Public Health Nursing 30 (1938): 472-3.

Brown, Phoebe. "The Industrial Nurse's Part in the Prevention of Sickness." Public Health Nursing 30 (1938): 85-8.

Brunner, Edmund S. "A Sociologist Looks at Nursing." Public Health Nursing 33 (1941): 399-403.

Bryan, Alice I. "Improving Our Interviews." Public Health Nursin_^ 32 {1940): 360-2.

Brj'an, Edith. The Art of Public Health Nursing. Philadelphia: Saunders, 1935.

Buck, Carl E. "The Citizen's Role in Public Health." Public Health Nursing 34 (1942): 129-33.

Buell, Bradley. "Social Planning for Family Health." Public Health Nursing 30 (1938): 405-11.

Buhler-Wilkerson, Karen Ann. "False Dawn: The Rise and Decline of Public Health Nursing in Arnerica, 1900-1930." In Nursing Histor)\ ed. E.C. Lagemann, 89-106. New York: Teachers' College Press, 1983.

Buhler-Wilkerson, Karen Ann. False Dawn: The R/se and Decline of Public Health Nursing, 1900-1930. New York: Garland, 1989.

Buhler-Wilkerson, Karen Ann. "Lillian Wald: Public Health Pioneer." Nursing Research 40 (Sept.-Oct. 1991): 316-7.

Buker, Helene B. "Nursing Care of the Sick as a Part of Complete Nursing Service in Rural Areas." American journal of Public Health hi (1941): 1057-60.

Burke, Mar\'A. "Extra-Familial Contact Tracing." PwMr 35 (1943): 15-20.

Byington, Margaret F. "Team Work Between the Nurse and the Social Worker." Public Health Nursing 24 (1932): 13-6.

Campbell, Theresa M. "A Joint Program of Social Work and Public Health Nursing." Public Health Nursing 24 (1932): 546-9.

Cantor, Nathaniel. "Understanding the Patient." Public Health Nursing 38 (1946): 265-8.

"Can You Stand Alone?" Public Health Nursing 23 (1931): 461-3.

Carc\-, Harn" M. "Communit\' Partners." Public Health Nursing 29 (1937): 560-6.

"Cars for Nurses (editorial)." American journal of Public Health 42 (1952): 1308-9.

Carter, Dorothy J. "The Public Health Nurse and Orthopedic Nursing Care." American journal of Public Health 28 (1938): 458-63. 402

Caton, Eva. "The Industrial Nurse in Her Communit)'." Public Health Nursing 35 (1943): 463-4.

Central Hanover Bank and Trust Company. The Public Health Nurse. New York: New York Department of Philanthropic Information, 1937.

"A Chat widi the First Director of the N.O.P.H.N." Public Health Nursing 29 (1937): 208-11.

Chayer, Mary Ella. School Nursing: A Contribution to Health Education. New York: Putnam, 1931.

Chayer, Mar)' Ella. "Shall We Teach Them All to Fly?" Public Health Nursing (1949): 368-72.

Chayer, Mar)'Ella. "Supervision: A Teamwork Job." Public Health Nursing?)! (1945): 315-6.

Ciocco, Antonio and Martha D. Ring. "An Evaluation of Study Methods: A Summar)'." American Journal of Public Health A\ (1951): 7-17.

Clancy, Marguerite. "A Community Plan of Public Health Nursing Sen'ice for a Small Cit\'." Public Health Nursing 22 (1930): 418-20.

Clark, Dean A. "Broadening the Base of Communit)' Pardcipadon in Public Health." Public Health Nursing 35 (1943): 606-10.

Cochran, Helen F. "Drought Relief in Campbell Count)', Virginia." Public Health Nursing 23 (1931): 442-4.

Cohen, Hedwig, et al. "Comment of NOPHN Field Staff on Seatde and Richmond Reports." American Journal of Public Health l)?) (1948): 1673-4.

Committee for Guides on Communit)' Pardcipation. "Guides for Community Pardcipation in Public Health Nursing: Introducdon and Guide I." Public Health Nursing 40 (1948): 35-41.

Committee for Guides on Communit)' Pardcipadon. "Guides for Communit)' Pardcipadon in Public Health Nursing: Guide II." Public Health Nursing 40 (1948): 84-9.

Committee for Guides on Communit)' Pardcipadon. "Guides for Communit)' Pardcipadon in Public Health Nursing: Guides III and IV." Public Health Nursing AQ (1948): 144-50.

Committee for Guides on Communit)' Pardcipadon. "Guides for Communit)' Pardcipadon in Public Health Nursing: Guide V." Public Health Nursing 40 (1948): 205-9.

Committee for Guides on Communit)' Pardcipadon. "Guides for Community Pardcipadon in Public Health Nursing: Guide VI." Public Health Nursing 40 (1948): 269-75.

Committee for Guides on Communit)' Participation. "Wliat About Lay Participation?" Public Health Nursing 40 (1948): 2-4.

"Communit)' Nursing Service for All (editorial)." Public Health Nursing 32 (1940): 283-4.

"Communit)- Planning for Nursing Ser\'-ice." Public Health Nursing 38 (1946): 353-7. 403

Comstock, Laura. "Selling Proper Nutrition to Industrial Workers." Public Health Nursing 22 (1930): 406-9.

Connolly, Mar)' P. "Health Education Through Personal Contact." Public Health Nursing 30 (1938); 573-5.

Connor, Mary- C. "Preparation of the Public Health Nurse to Meet Psychosomatic Problems in Today's Health Program." American journal of Public Health 35 (1945); 133-9.

Conway, Joseph M. "Management Looks at Industrial Nursing." Public Health Nursing 32 (1940); 340-3.

Cook, Beatrice. "Publicit)' Pays; And How!" Public Health Nursing 38 (1946); 243-5.

Cooper, Cathlena A. "The 'TERA Nurses' in Syracuse, N.Y." Public Health Nursing 25 (1933); 444-50.

"Cooperadon, Coordinadon, Amalgamadon (editorial)." Public Health Nursing 37 (1945); 287.

"Count of Public Health Nurses." Public Health Nursing35 (1943); 154-5.

Coyle, David Cushman. "The Changing Order of Today." Public Health Nursing 26 (1934); 365-71.

Crain, Gladys L. "Facts About Gonorrhea." Public Health Nursing 25 (1933); 43-6.

Crain, Gladys L. "Familial Sj'philis." Public Health Nursing 24 (1932); 557-60.

Crain, Gladys L. "The Public Health Nurse and the Communit)' Social Hygiene Program." Public Health Nursing 25 (1933); 103-6.

Crain, Gladys L. "The Public Health Nurse and the Educadonal Phases of a Social Hygiene Program." Public Health Nursing 25 (1933); 163-6.

Crain, Gladys L. "Public Health Nursing and the Medical Aspects of Social Hygiene." Public Health 24 (1932); 377-80.

Crain, Gladys L. "The Public Health Nurse in the Control of Syphilis and Gonorrhea." Public Health Nursing 29 (1937); 5-9, 95-8,160-4, 237-41, 303-5, 376-381,435-7, 475-9.

Crain, Gladys L. "The Role of the Nurse in the Control of Syphilis and Gonorrhea." American Journal of Public Health 28 (1938); 181-6.

Crain, Gladys L. "Sj^hilis." Public Health Nursing 24 (1932); 443-5.

Cray tor, Josephine Kelly. "Teaching in the Pediatric Clinic." Public Health Nursing 33 (1941); 666-70.

Cree, Margaret A. "Present-Day Views on School Nursing." American Journal of Public Health 42 (1952); 818-24.

Dahlin, Bemice and Helen Hotchner. "The New Family Record." Public Health Nursing 44 (1952); 142-5. 404

Davis, Evelyn K. "The Volunteer: Asset or Liabilit}'." Public Health Ktming 26 (1934); 598-603.

Davis, Evelyn K. "The Volunteer Office and the Public Health Nursing Agency." Public Health Nursing 37 (1945): 307-9.

Davis, Evelyn K. "Volunteers Increase Nurse Power." Public Health Nursing 33 (1941): 162-7.

Davis, Graham L. "The Hospital as a Community Health Center." Public Health Nursing 40 (1948): 311-4.

Davis, Ivlichael M. "The Cidzen's Responsibilit)^ for Community Health." Public Health Nursing 22 (1930): 367-8. de Benneville, Alice I

Dehli, Kari. "'Health Scouts' for the State? School and Public Health Nurses in Early Twentieth- Century Toronto." Historical Studies in Education 2 (1990): 247-64.

DeOenbaugh, Mrs. Frederick S. "The Structure of Organized Nursing from a Non-Professional Point of View." Public Health Nursing 39 (1947): 380-1, 392.

Deming, Dorothy. "Milestones of the Past Fifteen Years in Public Health Nursing." American journal of Public Health 29 (1939): 128-34.

Deming, Dorothy. "The Public Health Nurse's Bookshelf" American journal oj'Public Health 41 (1951): 375-82.

Deming, Dorothy. "Setting Up New Minimum Qualifications for Public Health Nurses." American journal of Public Health ?)\ (1941): 158-61.

Deming, Dorothy. "Tomorrow's Opportunities in Tuberculosis Nursing." American \oHrnal of Public • H«rt///) 34 (1944): 957-61.

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"Looking Ahead with NOPHN (editorial)." Public Health Nursing A\ (1949): 461-3.

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Nicholson, Jane D. "The State Public Health Nursing Unit and Its Relation to Special Services." American Journal of Public Health 29 (1939): 55-60.

"The NLN." Public Health Nursing 44 (1952): 365-6.

Norquist, Frances. "Nursing in a Department Store." Public Health Nursing 24 (1932): 437-8.

"Not just anv Nurse, Please! (Editorial)." Public Health Nursing 29 (1937): 139-40.

"The Nurse in Industrj' (editorial)." American Journal of Public Health 35 (1945): 510-1.

"The Nurses Count Costs (editorial)." American Journal of Public Health AQ (1950): 1143.

"Nurses Plan for the Postwar Period." Public Health Nursing 36 (1944): 274-6.

"Nurses Unite for Ser\'^ice (editorial)." American Journal of Public Health A2 (1952): 993-4.

"Nursing Activities in the Control of Syphilis and Gonorrhea." Public Health Nursing 23 (1931): 479-81. 418

"Nursing Oudook (editorial)." T^ublic Health Nursing 44 (1952): 482-3.

Nyswander, Dorothy B. "Citizen Pardcipadon in Public Health Nursing." Public Health Nursing 42 (1950): 484-95.

Nyswander, Dorothy B. and Hayhew Derrj'berr}'. "The Physician's and the Nurse's Part in Health Education." American Journal of Public Health!') (1939): 1109-13.

"The Objectives of Public Health Nursing." Public Health Nursing!!) (1931): 439-41.

"One Organization (editorial)." Public Health Nursing AG (1948): 534.

Orr, D.W. andJ.W. Orr. "When We Choose Health Insurance." Surv^'21 (March 1938): 135-8.

Oxholm, Mar)- H. "These Lay Committees Work!" Public Health Nursing 32 (1940): 369-71.

Palmquist, Emil E. and Marguerite Prindiville. "It Works in Seatde." American journal of Public Health 38 (1948): 1663-8.

Parran, Thomas. "National and International Horizons in Health." Public Health Nursing 38 (1946): 583-7.

Parran, Thomas. "Public Health Nursing Marches On." Public Health Nursing 29 (1937): 617-22.

Parran, Thomas. "Spearhead of Public Health." Public Health Nursing (1949): 631-5.

Pearce, Donna. "Coordination of Health and Social Sen'ice." Public Health Nursing 24 (1932): 371-6.

Perozzi. Lucile A. "Public Health Nursing in Relation to Child Health Scr\'ices." American Journal of Public Health 40 (1950): 395-9.

Perrott, G. St. J. "Health and the Depression." Science Monthly 39 (November 1934): 461-3.

Perrott, G. St. ]. "Medical Care During the Depression." Milbank Memorial Fund Quarterly 12 (April 1934):" 99-114.

Perrott, G. St. J. and SeKv)'n D. Collins. "Sickness Among the 'Depression Poor.'" American Journal of Public Health 24 (1924): 101.

Perrott, G. St. J. and D.F. Holland. "Health as an Element in Social Securit)'." Annals of the American Academy of Arts and Sciences 202 (March 1939): 116-36.

Peskin, Samuel. "A Challenge to Health Councils." Public Health NursingAA (1952): 29-32.

Peterson, Olivia. "The Use of Lay Boards by Official Health Agencies." American Journal of Public Hm///; 27 (1937): 499-504.

Peterson, Paul Q. "Cooperation of Departments of Education and Health in the Administration of School Health Programs." Public Health Nursing 44 (1952): 173-7. 419

Peterson, Rosalie I. "Public Health Nursing in the Cancer Control Program of the U.S. Public Health Service." American Journal of Public Health 38 (1948): 206-10.

Petry, Lucile. "Communit}' Needs for Nursing Care." Public Health Nursing 40 (1948): 389-2.

Petr)', Lucile. "The Public Health Significance of the U.S. Cadet Nurse Corps." American ]ournal of Public Hm///; 33 (1943): 1353-5.

Phaneuf, Maria. "Challenge of the Family Folder." Public Health Nursing Ah (1951): 132-4.

Phillips, Elisabeth C. "Auxiliar}- Workers." Public Health Nursing 36 (1944): 516-9.

Phillips, Elisabeth C. "The Role of the Practical Nurse in Public Health Nursing Services." American Journal of Public Health 42 (1952): 717-22.

Pieraccini, Bertha, et al. "Meeting Maternit)' Nursing Needs in Wartime." American Journal of Public HeaZ/A 35 (1945): 1196-204.

Pitts Mosley, Marie Oleatha. "A Historj' of Black Leaders in Nursing: The Influence of Four Black Communit)' Health Nurses on the Establishment, Growth, and Practice of Public Health Nursing in New York Cit)', 1900-1930." Ph.D. diss., Columbia Universit}', 1992.

Popenoe, Paul. "The Family in Societ)'." Public Health Nursing 28 (1936): 567-72.

Porter, Winifred H. "The Specialized Public Health Nursing Consultant in State Health Departments." American Journal of Public Health AX (1951): 13-19.

Powers, Alfred. "Wlien the Public Health Nurse Handles Her Own Publicity'." Public Health Nursing 22 (1930): 196-7.

Pratt, Frances R. "Programs for Public Health Nurses in Birth Control Work." American Journal of Public 30 (1940): 1096-8.

Pray, Kenneth L.M. "The Communit)''s Role in Health Promotion." Public Health Nursing 32 (1940): 428-33.

Price, George Moses. Hygiene and Sanitation: A Text-book for Nursing. Philadelphia: Lea & Febinger, 1913.

"Pride in Achievement (Editorial)." Public Health Nursing 26 (1934): 121-2.

"Professor Winslow Retires from Yale." American Jouma/ of Public Health 35 (1945): 314.

"The Public Health Nurse and Relief Giving." Public Health Nursing 25 (1933): 588-92.

"The Public Health Nurse and the Social Worker." American Journal of Public Health 38 (1948): 1148-50.

"Public Health Nursing." American Journal of Public Health 23 (1933): 168-71, 281-4, 379-81, 519-22, 637-8,747-50, 873-4,1000-1,1202^, 1326-8. 420

Public Health Nursing Section. "Duties of Nurses in Industr)\" American Joiimal of Public Health 2)7) (1943): 865-81.

Public Health Nursing Section. "Recommended Qualifications for Public Health Nursing Personnel, 1940-1945." American journal of Public Health 32 (1942): 748-52.

"Public Health with the Civilian Conservation Corps Work Camps." American ]oumal of Public Health 24 (May 1934): 560-1.

"Qui Bono." Public Health Nursing 23 (1931): 1-3.

Randall, Marion G. Personnel Policies in Public Health Nursing. New York: Macmillan Company, 1937.

Randall, Marian G. "The Public Health Nurse in a Rural Health Department." American journal of Public 21 (1931): 737-50.

Ravenel, Mazyck Porcher. "Drought and Health." American Journal of Public Health 2\ (November 1931): 1198-1202.

"Record Forms for Public Health Nursing." American journal of Public Health 23 (1933): 473-5.

Reid, Mabel. "What Does Public Health Nursing Cost." .'imerican journal of Public Health 39 (1949): 1106-9.

Reider, Norman. "Human Needs and Nursing." Public Health Nursing 42 (1950): 388-93.

"The Resun'-ey of Graduate Nurses." American journal of Public Health 43 (1943): 25.

Reverby, Susan. "'Something Besides Waiting': The Politics of Private Dutj- Nursing Reform in the Depression." In Nursing Histo/y, ed. E.C. Lagemann, 133-56. New York: Teachers' College Press, 1983.

Richmond, Clara. "Nursing in Group Medical Practice." American journal of Public Health 41 (1951): 1268-74.

Roberts, Dorothy I. "Our Volunteers Speak for Themselves." Public Health Nursing 33 (1941): 276-8.

Roberts, Dorothy I. "The Volunteer in a Private Agency." Public Health Nursing 27 (1935): 524-7.

Roberts, Kingsley. "Group Health Movement in this Countr\'." Public Health Nursing 33 (1941): 150-3.

Roche, Josephine. "Economic Health and Public Health Objectives." American Journal of Public Health 25 (November 5,1935): 1181-5.

Roche, Josephine. "National Health Challenges Today." Public Health Nursingll (1935): 117-9.

Rogers, Jack. "Public Health Nurses in Mississippi: Good Work in Hard Times." Gulf Coast Historical 2 (1986): 25-38. 421

Rogers, Katharine Gamble. "The Volunteer of the Junior League and Public Health Nursing." Public Health Nursing 21) (1931); 144-6.

Rood, Elma. "Communitj' Health Education in Communicable Disease Control." Public Health Nursing!?, (1936): 519-24.

Rooney, Mar)' Alyce. "Wartime Public Health Nursing Responsibilities." Public Health N/irsi/i_g ' 35 (1943); 345-50.

Rose, Norman J., et al. "A Report of an Area Epidemic of Sj^philis." Public Health Nursing 44 (1952): 620-9.

Ross, Grace. "Another Vote for Generalized Nursing." Public Health Nursingll (1935); 584-7.

Ross, Grace. "The Future Commands Our Attention." Public Health Nursing 34 (1942): 293-5.

Ross, Grace. "Is the Health Officer Fulfilling His Responsibility in Reladon to the Nursing Program?" American Journal of Public Health 29 (1939): 305-10.

Ross, Mabel. "The Nurse and Family Counseling." Public Health Nursing 4\ (1949): 485-8.

Rue, Clara B. The Public Health Nurse in the Community. Philadelphia: W.B. Saunders Company, 1944.

Rugen, Mabel E. Michigan's Communit)' Health Service Project." Public Health Nursing 37 (1945); 448-53.

Ruhland, George C. "Public Health Nursing Program of the Future." American Journal oj Public Health 29 (1939): 1015-8.

Russell, Albert E. "Syphilis in Industr)\" Public Health Nursing 33 (1941): 364-9.

Rutstein, David D., et al. "The Rlieumadc Fever Community Program." American Journal of Public Health 38 (1948); 1082-91.

St. Clair, Lulu. A Study of the Community Nursing Seivice in Salt hake City and Salt hake County, Utah. Salt Lake City, Utah; Joint Committee on Nursing Service, 1936.

St. J. Perrott, George. "Rationing Health Services in Wartime." Public Health Nursing 34 (1942): 392-5.

Sallee, Lila. "Utilizing the Services of Volunteers in a County." Public Health Nursing 24 (1932); 697-9.

Saw'er, William A. "The Nurse's Place in Industrial Health." Public Health Nursing 23 (1931): 222-6.

Scheele, Leonard A. "Public Health in a Changing World." Public Health Nursing 40 (1948): 385-8.

Schilling Ethel P. "Selling Management on an Industrial Health Program." Public Health Nursing 28 (1936): 254-5.

Schwab, Ernesdne. "Relationship of Public and Private Agencies." Public Health Nursing 28 (1936); 675-7. 422

"Sedgwick Memorial Medal for 1942 Awarded to Dr. C.-E. A. W'inslow." American joiinial of Public Hm//A 32 (1942): 1416-7.

Setter, Virginia. "Volunteer of the Month." Public Health Nursing 36 (1944): 245-7.

"Shall Public Health Nurses Have a Code (Editorial)." Pnb/ic Health Nursing 25 (1933): 633-4.

Sheahan, Marion W. "The Public Health Nurse's Contribution in the Annual Planning of a Public Health Program." American Journal of Public Health Y! (1947): 1586-8.

Sheahan, Marion W. "Public Health Nursing in the War." Public Health Nursing 34 (1942): 371-9.

Sherrill, Lloyd. "Getting Along with People." Public Health Nursing 30 (1938): 385-9.

Sieder, Violet M. "Future ofVolunteer Programs." Public Health N/mi/ig 36 (1944); 415-8.

Sigerist, Henrj- E. "Realities of Socialized Medicine." Atlantic Monthly 163 (June 1939): 794-804.

"The Significance of F.E.R.A. Programs to Public Health Nursing." Public Health Nursing 26 (1934): 515-7.

Smith, Agnes. "Posters and Their Making." Public Health Nursing 22 (1930): 477-9.

Smith, Charlotte P. "Communit}- Action Against Venereal Disease." Public Health Nursing 36 (1944): 368-70.

Smith, M. Josephine. "Co-ordination of Nursing Resources in a Communit)'." Public Health Nursing 22 (1930): 369-71.

Smith, S.L. "Wliite Nurses, Black fvlidwives, and Public Health in Mississippi, 1920-1950," Nursing Histoij Rei'ieii' 2 (1994): 29-49.

"Social Securit)- and Public Health." American journal of Public Health 25 (April 1935): 485-6.

Soule, G. "The Government Fights for Health." New Republic95 (August 3, 1938): 350-2.

Stafford, J. "The VX'agner Health Bill." Science 89 (May 26, 1939): supplement 10.

"Standing Orders for Nurse-Teachers." American Journal of Public Health 24 (1934): 1062-4.

"State ERA. Activities in Public Health Nursing." Public Health Nursing 27 (1935): 95-102, 209-17, 263-71,338-41,385-9.

Stephens, Philip. "The Industrial Nurse." Public Health Nursing 28 (1936): 608-10.

Stevens, Helen V. "Super\'ision of School Nursing by a V.N.A." Public Health Nursing 34 (1942): 501-5.

Stevens, Helen V. and Sybil H. Pease. "The Public Health Nurse and Her Relation to Authoritative Agencies." Public Health Nursing36 (1944): 570-4. 423

Stevenson, Jessie L. "Public Health Nursing in the 1943 Polio Epidemic." Public Health Nursing 36 (1944): 336-9.

Stewart, Dorothy D. "Do You Doubt Value of Lay Committees?" Public Heahb Nming 34 (1942): 268-9.

Stokes, Agnes Nicholson. "The Biennial Convention: Through the Eyes of a Lavman." Public Health 26 (1934): 276-7.

Stokes, Agnes Nicholson. "Stretching the Dollar." Public Health Nursing 25 (1933): 538-41.

Stuart, Men-n Elisabeth. ""Let Not the People Perish for Lack of Kjiowledge': Public Health Nursing and the Ontario Rural Child Welfare Project, 1916-1930." Ph.D. diss., Universit)' of Pennsylvania, 1987.

"Student War Nursing Reserve (editorial)." American Journal of Public Health 33 (1943): 994-5.

Sydenstriker, Edgar. "Health in the New Deal." Annals of the American Academy of Arts and Sciences 176 (November 1934): 131-7.

Sydenstriker, Edgar. "Sickness and the New Poor: Income and Health for 7500 Families, 1929-1933." Surv^'22) (April 1934): 160-2.

Talcott, Agnes G. "Contribution of Public Health Nursing to Maternit^', Infancy, and Preschool Age Group." American journal of Public Health 24 (1934): 525-6.

Tattershall, Louise M. "Census of Public Health Nursing in the United States, 1931." Public Health NursinglA (1932): 205-7.

Tattershall, Louise M. "Changes in the Public Health Nursing Field During 1932." Public Health Nursing 25 (1933): 216-8.

Tattershall, Louise M. "Nurses in Commerce and Industrj-." Public Health Nursing 22 (1930): 147-8, 194-5, 572-5, 633-7.

Tattershall, Louise M. "Salaries of Public Health Nurses." Public Health Nursing 22 (1930): 254-5.

Tattershall, Louise M. "Salaries of Public Health Nurses." Public Health Nursing 24 (1932): 253-62.

Tattershall, Louise M. "Salaries of Public Health Nurses." Public Health Nursing 25 (1933): 289-98.

Tavlor, jane and Anne Falther. "A Specialized Consultant Helps Improve a General Nursing Service." Public Health Nursing 35 (1943): 587-9.

Taylor, Mary G. "A Generalized Citj' Health Ser\'ice." Public Health Nursing 23 (1931): 428-31.

Terman, Lewis M. and John C. Almack. The Hygiene of the School Child. Boston: Houghton Mifflin, 1929.

"This is Tomorrow! (editorial)." Public Health Nursing 43 (1951): 525. 424

Thomas, Maurice J. "Unifying Health Sen'ices Through Public Education." Public Health Nursing 40 (1948): 168-73.

Thompson, Ella M. "Should Qualified Practical Nurses Be NLN Members?" Public Health Nursing 44 (1952): 280-3.

Tinkham, Catherine W. and Eleanor F. Voorhies. 1893-1993: One Hundred Years of Public Health Nursing in Massachusetts. Boston: Massachusetts Public Health Association, 1993.

Tisdale, E.S. "The 1930-1931 Drought and its Effect upon Public Water Supply." American Journal of Public Health 2\ (November 1931): 1203-18.

Tobey, James Alner. "The Menace to National Health." Current Histoiy 37 (December 1932): 323-6.

Tracy, Catherine O'Connell. "Cooperation Between Metropolitan Life Insurance Agents and Public Health Nurses." Public Health Nursingll (1935): 147-9.

Trawick, Mrs. Arch. "The Use of Laymen in Official Public Health Nursing Programs: State." American Journal of Public Health 2A (1934): 722-6.

Trawick, Kate H. "La)- Participation in Public Health Work." Public Health Nursing 26 (1934): 604-7.

Tucker, Katharine. "Preparation of the Public Health Nurse." Public Health Nursing5\ (1939): 606-13.

Tucker, Katharine, "Public Health Nursing in National Defense." Public Health Nursing 33 (1941): 697-704.

Tucker, Katharine. "Public Health Nursing in National Defense." American Journal of Public Health 31 (1941): 1293-1300.

T ucker, Katharine. Survej of Public Health Nursing: Administration and Practice. N ew York: The Commonwealth Fund, 1934.

Tuttle, Mildred L. "Public Health Nursing Field Experience." American Journal of Public Health 36 (1946): 141-6.

Underwood, Felix J. "A Critical View ofNurses and Nursing Programs." American Journal of Public 29 (1939): 318-20.

The United States Department of Labor. Children's Bureau. A Handbook on Records and Statistics in the Field of Public Health Nursing. Washington, D.C.: Government Prindng Office, 1932.

"Useful Employment as a Health Measure." Science 87 (March 25, 1938): supplement 10.

Van Riper, Hart E. "The School Nurse and the Child with Polio." Public Health Nursing 40 (1948): 183-5.

Vaughan, Elsbeth H. "The Economic Emergency." Public Health Nursing 24 (1932): 340-2. 425

Vaughan, Henn- F. "The Coordination and Integradon of the Public Health Program." American Journa/ qfPublic Health 38 (1948): 331-4.

Vaughan, Henr}' F. "Getdng Public Health Needs Across to Appropriating Bodies by a Municipal Health Department." American Journal of Public Health 22 Quly 1932): 700-4.

Vaughan, Henry F. "How the Nurse Can Help the Health Officer to Get His Message Across." American journal of Public Health 20 (1930): 930-4.

Vaughan, Henry F. "Together We Can Do It." Public Health Xnrsing'5'i {\S)4\)\ 101-3.

Viney, Hester. "Community Organizadon for Health." Public Health Nursing 22 (1930): 314-6.

Wagner, Robert F., Jr. "The Nadonal Health Bill." American Labor Legislation Review 29 (1939): 13-44.

Wagner, Robert F., Jr. "Progress Toward Healtli Insurance." American Labor Legal Review 30 (March 1940): 17-19.

Wales, Marguerite A. "New Methods of Cooperadon." Public Health Nursing 23 (1931): 19-22.

Wales, Marguerite A. The Public Health Nurse in Action. New York: The Macmillan Company, 1941.

Wales, Marguerite A. "V(1iy Not Save Hospital Beds?" American Journal of Public Health 24 (1934): 379-4.

Wallace, Ruby V. "Prescripdon for Lay Pardcipadon." Public Health Nursing 38 (1946): 424-6.

Walsh, Patricia and EUa E. McNeil. "Field Training Program in Public Health Nursing Supen-ision." American Journal of Public Health 41 (1951): 846-51.

Warner, Estella Ford. "Health Situadons in the Family." Public Health Nursing 28 (1936): 573-5.

XN'aterman, Theda L. "Changing Views with Changing Seats." Public Health Nursing Tl (1935): 383-5.

Waterman, Theda L. Nursingfor Community Health. Philadelphia; F.A. Davis Company, 1944.

Watkins, Margaret H. "Lay Members' Responsibilies in Public Health Nursing." Public Health Nursing 27 (1935): 136-8.

Weaver, Abbie R. "Nurses Employed and Communides Sen'ed by Georgia ERA." Public Health Nursing 27 {1935): \9-2\.

Weisner, Dorothy E. and Margaret M. Murphy. "Publicit}' and Public Health Nursing." Public Health Nursing 36 (1944): 243-4.

Weisner, Dorothy E. and Margaret M. Murphy. "Reladonships of Health Agencies." Public Health Nursing 36 (1944): 39-43.

Wensley, Edith. "Communitj- and Public Health Nursing." Public Health Nursing 43 (Februar)' 1951): ' 109-10. 426

Wensley, Edith. "Communit}'and Public Health Nursing." Public Health Nursing A2) (March 1951): 161.

Wensley, Edith. "Communit}' and Public Health Nursing." Public Health Nursing 43 (May 1951): 305.

Wensley, Edith. "Whv People Wlio Are Not Nurses Arc Needed in NLN." Public Health Nursing 44 (1952): 576-9.'

"We Vote on Structure (editorial)." Public Health Nursing 42 (1950): 315, 366.

"What a Lot We Know! (editorial)." American Journal of Public Health 41 (1951): 447.

"NXTiat Kind of Organization (editorial)." Public Health Nursing 37 (1945): 493-5.

"W'Tiat Next for Our National Structure? (editorial)." Public Health Nursing 39 (1947): 541-3.

"Wliat the Health Department Nurses are Doing." American Journal of Public Health 36 (1946): 660-2.

"Whence the Term 'Public Health Nursing'?" Public Health Nursing 29 (1937): 712-4.

Wiesner, Dorothy E. and Lily Mar\- David. "The Economic Status of Public Health Nurses, 1946-1947." American Journal ofPuhlic Health ?>8 (1948): 1097-1102.

Wilcox, Barbara. "Where Will You Work: Cit)- or Country?" Public Health Nursing 40 (1948): 409-11.

Wilkins, Evelyn. An Introduction to Social Science for Health Visitors. Arnold, 1932.

Williams, Huntington. "The Health Department Nurse and Private Medical Practice." Public Health Nursing 27 (1935): 303-6.

Williams, Huntington. "\^alue of Community Health Centers in Preventive and Curative Medicine." American Journal of Public Health 36 (1946): 623-8.

Williams, Katherine Roulston. "Major Trends in Public Health Nursing 1902 to 1925: The Transition from Specialized to Generalized Practice." Ph.D. diss., Columbia University, 1981.

Wilson, .\lberta B. "Using Emergency Personnel." Public Health Niirsing 36 (1944): 137-41.

Wilson, Charles C. "Health Counseling in Schools." Public Health Nursing 37 (1945): 436-42.

Wilson, Dorothy. "Public Health Nurses and the Brown Report." Public Health Nursing 40 (1948): 496-8.

Wilson, Russell H. and Lila Anderson. "A Wartime Public Health Nursing Program." Public Health Nursing 36 (1944): 160-3.

Wilson, Sue. "Teamwork in a Rural Communit)'." Public Health Nursing 32 (1940): 183-6.

Windesheim, Gustave. "The Industrial Nurse's Responsibilit}' to the Community." Public Health Nursing 24 (1932): 621-2. 427

Winslow, Anne R. "The Private Agency in Today's Health Program." Pub/k Health Nursing 29 (1937): 204-7.

Winslow, Anne R. and Charles-Edward Amor)-. "District Health Unit and Voluntar)- Nursing Agency." P/ib/ic Health Nursing 4\ (1949): 315-9.

Winslow, Charles-Edward Amor)-. "Can Health Be Bought?" Si/rv^' 23 (December 1934): 610-3.

Winslow, Charles-Edward Amory. "The Challenge of Today." Public Health Nursing 26 (1934): 283-91.

Winslow, Charles-Edward Amor)-, "Changing Challenges of Public Health." American Journal of Public Health 35 (1945): 191-8.

Winslow, Charles-Edward Amor)'. "The Evolving Pattern of Tomorrow's Health." American Journal of Public Health 33 (1943): 1408-13.

Winslow, Charles-Edward Amor)-. "Florence Nightingale and Public Health Nursing." Public Health Nursing 38 (1946): 330-2.

Winslow, Charles-Edward Amor)'. "The Larger Problem of Community Nursing." Public Health Nurse 20 (1928): 324-8.

Winslow, Charles-Edward Amor)'. "Nauonal Health Challenges: How the Public Health Nurse is MeedngThem." Public Health Nursing 27 (1935): 120-4.

Winslow, Charles-Edward Amor)-. "The New Leadership." Public Health Nursing 23 (1931): 108-13.

Winslow, Charles-Edward Amory. "Nursing and the Communit)-." Public Health Nursing 30 (1938): 230-7.

Winslow, Charles-Edward Amor)-. "The Public Health Nursing Super\'isor." Public Health Nursing 24 (1932): 551-6.

Winslow, Charles-Edward Amor)'. "The Voluntar)' Nursing Agency." Public Health Nursing 38 (1946): 608-14.

'With the ERA Nurses." Public Health Nursing 27 (1935): 436-9.

Woodward, Ellen S. "Nursing and Public Health Projects Under WPA." Public Health Nursing 29 (1937): 169-72.

Zahorsky, John and Elizabeth Noyes. The Infant and Child in Health and Disease with Special Reference to Nursing Care. 2nd ed. St. Louis: The C.V. Mosby Company, 1939.

Zehring, Mary- E. "The Industrial Nurse's Introducdon to Her Job." Public Health Nursing 23 (1931): 63-7.

Zetzsche, Louise. "Maternity Service; A Communit)' Program." Public Health Nursing 32 (1940): 374-8. 428

CHAPTER V. CHILD HYGIENE

Adams, Paul L. "Health of the State; British and American Public Health Policies in the Depression and World War II." D.S.W. diss., Universit)' of California, 1979.

Altmeyer, Arthur J. The Formative Years of Social Security. Madison: University' of Wisconsin Press, 1968.

"The American Child Health Association." American Journal of Public Health 25 (1935); 1142-3.

"The American Child Health Association Copyright to the American Public Health Association." .American Journal of Public Health 2(s (1936): 184-5.

"Bad Times Bring Good Health." Literary Digest 114 (December 24,1932): 4.

Bauer, W.W. "Death-Rate in the Depression." American Mercury 29 (May 1933); 19-25.

Bauer, W.W. "Health Aims and Professional Services: Infancy, Preschool, and School Ages." American Journal of Public Health 22 (Januar)' 1932); 59-64.

Bigelow, Helen A. "Maternit)' Care in Rural Areas by Public Health Nurses." American Journal of Public Health 27 (1937); 975-80.

Bishop, E.L. "Public Health at the Cross-Roads." American Journal of Public Health 25 (1935); 1175-80.

Bishop, E.L. "TVA's New Deal in Health." American Journal of Public Health 24 (October 1934): 1023-7.

Bolt, Richard Arthur. "Child Health and Child Welfare in England." American Journal of Public Health 23 (1933); 1198-1200.

Bolt, Richard Arthur. "Child Health Today." American Journal of Public Health 22 (1932); 1005-8.

Bolt, Richard Arthur. "The Child Hygiene Section," American Journal of Public Health 23 (1933): 1324.

Bolt, Richard Arthur. "The Child Hygiene Section." American Journal of Public Health 24 (1924); 77-527.

Bolt, Richard Arthur. "Child Welfare in Germany." American Journal of Public Health 24 (1934); 77-9.

Bolt, Richard Arthur. "A Community Wide Program for the Reduction of Dental Caries in Children." Child Health \\ Quly-August 1944); 1-5.

Bolt, Richard Arthur. "The Community Fund and Child Care." Child Health bulletin 3 (November 1936); 1-5.

Bolt, Richard Arthur. "Effects of Unemployment on Children and Young People in Belgium." American Journal of Public Health 22> (1933); 1091-2.

Bolt, Richard Arthur. "The Effects of Unemployment on Children and Young People in Germany." American Journal of Public Health 23 (1933); 744-7.

Bolt, Richard Arthur. "Health of the Preschool Child." American Journal of Public Health 21 (1931); 1162. 429

Bolt, Richard Arthur. "The Infant, Before, During, and After Birth." American Journal of Public Health 21 (1931): 843-50.

Bolt, Richard Arthur. "Maternal and Child Welfare Work in Russia." American Journal of Public Health 24 (1934); 525-6.

Bolt, Richard Arthur. "Maternal Deaths; A Brief Report of a Study Made in 15 States." American Journal of Public Health 24 (1934): 527-9.

Bolt, Richard Arthur. "Physical Preparadon for School Admission." American Journal of Public Health 25 (1935): 1215-20.

Bolt, Richard Arthur. "What Can We Learn for School Admission." American Journal of Public Health 24 (1934): 951-6.

Boudreau, F.G. and H.D. Kruse. "Malnutrition: A Challenge and an Opportunity." American Journal oj' Public Health 29 (May 1939): 427-33.

Bousfield, M.O. "Reaching the Negro Community." American Journal of Public Health 24 (March 1934); 209-15.

Bradbur}', D.E. Four Decades of Action for Children: A Short History' of the Children's Bureau. 1956.

Brown, Walter H. "The Communit}- Health Program as it Applies to the Child from Six Years to Adolescence." American Journal of Public Health 2\ (August 1931): 857-61.

"Child Health Day; May Day." American Journal of Public Health 26 (1936): 479.

"Child Health in Mining Camps and Village." American Jonmat of Public Health 22) (1933); 517-9.

"Child Hygiene and Parental Education." American Journal of Public Health 23 (1933); 278-81.

"Child Hygiene: Childhood and the Depression." American Journal of Public Health 22 (1932): 972-4.

"Child Hygiene; Health of the School Child." American Journal of Public Health 21 (1931); 1278-9,

"Child Hygiene: The United States' Children's Bureau." American Journal of Public Health 23 (1933): 166-8.

"Child Hygiene Work of a Count)' Department of Health." American Journal of Public Health 22 (1932); 426.

"Child Labor and Child Health." American Journal of Public Health 23 (1933); 72.

"Childhood and the Depression." American Journal of Public Health 22 (1932): 872.

Childs, L.W. "The Tuberculin Skin Test from the Physician's Standpoint." American Journal of Public Health 23 (1933); 997-9. 430

Collins, Selwyn D. "The Health of Youth." Anmh of the American Academj of Arts and Sciences 194 (November 1937): Sl-99.

Cravens, Hamilton. Before Head Start: The Iowa Station and America !r Children. Chapel Hill: Universit}^ of North Carolina Press, 1993.

"The Depression and Health." American journal of Public Health 2?> (March 1933): 247-8.

"The Depression and Health: An Editorial." American Journal of Public Health 23 (September 1933): 943-4.

"The Depression and Health Appropriations." American journal of Public Health 23 (1933): 1298.

"The Depression and Public Health." American Journal of Public Health 22 (1932): 395.

"The Depression and Public Health Expenditures." American Journal of Public Health 24 (July 1934): 755.

Dickens, D. "Health in Relation to Prosperit)^ in the South." Journal of Home Economics 30 Qune 1938): 370-5.

"Do Not Let Up in Health Work or Funds for Health Work." American Journal of Public Health 22 (September 1932): 940-2.

"Don't Drop Your Guard." Collier's Maga^ne 92 (December 2,1933): 50.

Dublin, Louis I. "Health Against the Odds." Woman's Health Chronicle 61 (April 1934): 20.

Dublin, Louis L "Health of the People in a Year of Depression." American Journal of Public Health 22 (November 1932): 1123-35.

Dyer, I. "Tlie Count)' Health Unit with Proper Functioning Maternal and Child Health Program." American Journal of Public Health 31 (May 1941): 471-6.

"Economy: Budget Cuts Threaten Health Programs." SurvejlS (June 1939): 188.

"Effect of the Depression on Health." School and Society 38 (October 21, 1933): 528-9.

"Effect of the Economic Depression upon Health." Monthly Labor Revieii'58 (januar)' 1934): 82-7.

Eliot, Martha M. "The Need of the Child Hygienist." American Journal of Public Health 26 (1936): 493.

Eliot, Martha M. "Progress in Maternal and Child Welfare Under the Social Securit)' Act." American Journal of Public Health 2(> (1936): 1155.

Falk, LS. Security Against Sickness. Garden City, N.Y.: Doubleday, Doran, 1936.

"Federal Emergencj' Relief and Public Health." American Journal of Public Health 24 (June 1934): 642-3.

"Federal Money is Not Manna from Heaven." American Journal of Public Health 28 (September 1938): 1047. ' 431

Ferrell, John A. "Training in Administrative Procedures of Personnel for Child Health Work." American Journal of Public Health 22 (1932); 705.

"Findings of the Nadonal Health Inventory." Survey 74 (Februarj- 1938): 54.

"First Aid for Health Serv'ices." Sumy 69 (Februar)' 1933); 75.

"A Five Month Survey of Child Health in New Jersey." School and Society4\ Qanuar}- 12, 1935); 60.

Franzen, Raymond. "Public Health Aspects of Dental Decay in Children." American journal of Public Health 20 (1930); 908.

French, XX'.J. "The Place of Maternal and Child Health Ser\'ices in a Generalized Program in a Health Unit." American Journal of Public Health 1)1 (iVlay 1941); 465-70.

"Further Cuts in Health Budgets Hazardous to Safet)'." Hjgeia 12 (April 1934); 379.

Geiger, J.C. and Paul S. Barrett. "A Nutritional Surx-^ey of Forty-Five Hundred Children on Relief (San Francisco, Calif.)." American Journal of Public Health 25 (1935); 183.

"General Health and the Depression." Science 81 Qanuarj- 18,1935); supplement 6.

Gesell, Arnold. The Pre-School Child From the Standpoint of Public Hygiene and Education. Boston; Houghton Mifflin Company, 1923.

"The Government Health Plan." Commonweal 2^ (November 11,1938); 60.

"Grants-in-Aid for Public Health W'ork." Science 86 (September 3, 1937); 217.

Green, H.W. "Business as an Ally in Public Health." National Conference in Social Work (1928); 617-24.

Hall, J. "Premarital and Prenatal Tests for Syphilis." American Journal of Public Health 29 (December 1939); 1331-7.

"Health in the Depression." Survey 61 (Februar)' 15, 1933); 541.

"Health Ser\'ices with Forced Economy." American C//)'49 (December 1934); 70.

Hirschfield, Daniel. The Lost Reform: The Struck for Comptilsotj Health Insurance in the United States from 1932 to 1943. Cambridge: Harvard Universit)' Press, 1970.

Hiscock, I.V. "Public Health Facilides in the School Health Education Program." Hjgeia 19 (June 1941); 510-1.

Holt, Luther Emmett., et al. Health for School Children: Keport of the Advisory Committee on Health Education of the National Child Health Council School Health Studies, no. 1. Washington, D.C.: Department of the Interior, Bureau of Education, 1923.

"How Will the Drought Affect Health?" Uteraty Digest 118 (August 18,1934); 15. 432

"Illness and Idleness." The Nation 137 (October 25, 1933): 471.

"Integration of Federal, State, and Local Agencies." American ]ournal of Public Health 24 (June 1934): 636-7.

"Infant Mortalit)' in Our Cities." American Journal of Public Health 19 (1929); 1351.

I"Cnox,J.H.M. "Reduction of Maternal and Infant Mortalit}' in Rural Areas." American Journal of Public Health 2S Qanuar^^ 1935); 68-75.

Landis, C. "The Depression and Mental Disease." Science Monthly A\ (December 1935); 550-3.

Lenroot, Katharine F. "National Aspects of the Social Security Program as They Pertain to the Children's Bureau." American Journal of Public Health 25 (1935): 1327.

Leuchtenberg, William. Franklin D. Roosepelt and/he New Deal. 1932-1940. New York; Harper & Row, 1963.

Le^y, Julius. "Maternal and Infant Mortalit}'." American Journal of Public Health 19 (1929); 225.

Lininger, Fred F. "Relation of the Use of Milk to the Physical and Scholastic Progress of Undernourished Children." American Journal of Public Health 23 (1933): 555.

McNamara, John j. "Lowell Fights Undernourishment Among its School Children." American Journal of Public Health 19 (1929); 605.

Meanes, L.L. "Baby and the Family Health Center." Hygeia 12 (August 1934): 734-7.

Meckel, Richard A. Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929. Baltimore: Johns Hopkins Universit)- Press, 1990.

"Mental Hygiene and the Depression." American Journal of Public Health 22 (1932); 393.

Miller, Iva M. "Child Health in Mining Camp and Village (Harlan Count)^ Ky.)." American Journal of Public Health 23 (1933); 517.

Munro, W.B. "Some Economic Repercussions of Medical Progress." Science Monthly 51 (August 1940): 172-8.

Myers, P. "Mountain Mothers of Kentucky." Hygeial (April 1929); 353-6.

Orr, D.W. and J.W. Orr. "NXIien We Choose Health Insurance." Surv^' Tl (March 1938); 135-8.

Palmer, George Truman, et al. A Health Survey of 86 Cities the Research Division of the American Child Health Association. New York: American Child Health Association, 1925.

Parran, T., Jr. "Health of the Nation's Children." ParentsMagassjne 16 (January 1941): 34-5.

Parran, T., Jr. "Relationship of Maternal and Child Health to the General Health Program." American Journal of Public Health 28 (March 1938): 256-62. 433

Perrott, G. St. J. "Health and the Depression." Science Monthly V) (November 1934): 461-3.

Perrott, G. St. J. "Medical Care During the Depression." MUbank Memorial FundQtmrlerfy 12 (April 1934): 99-114.

Perrott, G. St. J. and SeKvyn D. Collins. "Sickness Among the 'Depression Poor.'" American journal of Public Health 24 (1924); 101.

Perrott, G. St. J. and D.F. Holland. "Health as an Element in Social Securit)'." Annals of the American Academy of Arts and Sciences 202 (March 1939); 116-36.

Phair, j.T. "Child Health and the Elementarj' School." American Joiiriial of Public Health 26 (1936): 455.

Piatt, Philip S. and George Truman Palmer. "A Communit)' Child Health Sur\'ey." American Jomial of Public Health 15 (Februarj^ 1925): 102-6.

Postol, T. "Public Health and Working Children in Twendeth-Centun- America; An Historical Overx'iew." Journal of Public Health Poliij 14 (Autumn 1993): 348-54.

"Public Health with the Civilian Conser\'ation Corps Work Camps." American Journal of Public Health 24 (May 1934): 560-1.

Ravenel, Mazyck Porcher. "Drought and Health." American Journal of Public Health 21 (November 1931): 1198-1202.

Richards, Esther L. "Are the 'Nenxs' and Badness of Childhood of Any Importance to the Field of Public Health?" American Journal of Public Health 27> (1933); 198.

Roberts,L.J. "Status of Nutrition Work with Children." Annals of the .American Academy of Arts and Sciences 2\2 (November 1940): 111-20.

Roche, ]. "Economic Health and Public Health Objectives." American Journal of Public Health 25 (November 5,1935): 1181-5.

Rogers, ]ames Frederick. "Child Hygiene." American Journal of Public Health 22 (1932): 1147.

Rood, Elma. "Participation of Lay People in the Promotion of a Rural Child Health Program." American Journal of Public Health 22 (1932): 1027.

Sargent, C.A. "A Plan to Obtain More Accurate Records of Infant Hygiene Field Work." American Journal of Public Health 23 (1933): 677.

Schumacher, Henr\- C. "The Depression and Its Effect on the Mental Health of the Child." American Journal of Public Health 24 (1924): 367.

Schwartz, A.B. "Nutrition and Child Health." American Journal of Public Health 25 (1925): 1194.

Shaftel, Norman. "A History of the Purification of Milk in New York, Or 'How Now, Brown Cow."' Neiv York State Journal of Medicine 58 (1958): 915-21. 434

Sherman, H.C. "The Problem of Sweets for Children." American journal of Public Health 19 (1929): 1205.

Sigerist, Henrj' E. "Realities of Socialized Medicine." Atlantic Monthly 163 Qune 1939): 794-804.

"Social Securitv" and Public Health." American Journal of Public Health 25 (April 1935): 485-6.

Soule, G. "The Government Fights for Health." New Repiiblic9S (August 3, 1938): 350-2.

Stuart, Meryn Elisabeth. ""Let Not the People Perish for Lack of I'Cnowledge': Public Health Nursing and the Ontario Rural Child Welfare Project, 1916-1930." Ph.D. diss., University of Pennsylvania, 1987.

Sydenstriker, Edgar. "Health in the New Deal." Annals of the American Academy of Arts and Sciences 176 (November 1934): 131-7.

Sydenstriker, Edgar. "Sickness and the New Poor: Income and Health for 7500 Families, 1929-1933." Survey 23 (April 1934): 160-2.

Tisdale, E.S. "The 1930-1931 Drought and its Effect upon Public Water Supply." American Journal of Public Health 2\ (November 1931): 1203-18.

Tobey, James Alner. "The Menace to National Health." Current Histoiy 37 (December 1932): 323-6.

Tonney, Fred O. "\'itamin D in Child Health." American Journal of Public Health 26 (1936): 665.

"Two Important Pronouncements by the American Youth Commission Relating to a Nationwide Public-Health Program and the Problem of Unemployment Among Youth." Elementaiy School Journal40 Qanuarj- 1940): 321-5.

"Useful Employment as a Health Measure." Science 87 (Ivlarch 25,1938): supplement 10.

Wagner, Robert F., Jr. "The National Health Bill." American Laborljc^slation Review 29 (1939): 13-44.

Wagner, Robert F., Jr. "Progress Toward Health Insurance." American Liubor Legal Rmwy 30 (March 1940): 17-19.

Wasserman, Manfred J. "The Emergence of Modern Child Health Care: Pediatrics, Public Health, and the Federal Government." Ph.D. diss., Catholic Universit)' of America, 1982.

Wasserman, Manfred J. "Henr)' L. Coit and the Certified Milk Movement in the Development of Modern Pediatrics." Bulletin of the Histoiy of Medicine 46 (1972): 359-90.

Webster, Charles. "Health, Welfare, and Unemployment During the Depression." Past and Present 109 (1985): 104-30.

"^%at Shall We Do to Increase the Health and Physical Fitness of our Youth?" National Education AssociationjQumat29 (December 1940, supplement): 158. 435

Wile, Ira Solomon. "Mental Health of the Preschool Child." American Journal of Publk Heatlb 23 (1933): 191.

Wilinsky, Charles F. "The Communit)' Health Program as it Applies to the Child of from One to Six Years." American Journal of Public Health 2\ (1931): 851.

Winslow, Charles-Edward Amor)'. "Can Health be Bought?" Survey 23 (December 1934): 610-3.

Wynne, Shirley W. "Free Clinics for the Preschool Child." American Journal of Public Health 20 (1930): 263.

CHAPTER VI. INDUSTRIAL HYGIENE

Allan, James R. "Industrial Hygiene Codes." American Journal of Public Health 29 Quly 1939): 748-52.

Anderson, V.V. The Contribution of Mental Hygiene to Industry. New York; The American Foundation for Mental Hygiene, Inc., 1930.

Armstrong, Donald Budd. "The Framingham Health Demonstradon and Industrial Medicine." Journal of Industrial Hygiene 3 (October 1921): 183-6.

Armstrong, Donald Budd. "The Prevention of Tuberculosis in Industry." Modern Medicine 1 (May 1919): 51-3.

Babb, LaVona. "Industr)''s Challenge to the Nurse." American Journal of Public Health 29 (September 1939): 1025-8.

Barkan, Ilyse D. "Industr)' Invites Regulation: The Passage of the Pure Food and Drug Act of 1906." American Journal of Public Health 75 (Januar)' 1985): 18-26.

Barnard, Margaret W. "X-Ray Mass-Procedure Applicable for the Discover)' of Early Tuberculosis in Industrial Groups." American Journal of Public Health 2A (Januar)' 1934): 8-16.

Bean, W.S. "The Role of the Federal Government in Promoting Industrial Hygiene." American Journal of Public Health 15 Quly 1925): 625-9.

Beard, Mar)'. "Public Health Nursing and Industrial Hygiene." Journal of Industrial Hygiene 1 (August 19i9): 194-9.

BelJ, Louis. "Industrial Lighting Codes." Journal of Industrial Hygiene 2 (August 1920): 133-9.

Bellingham, Ellen F., et al, comps. "Bibliography of Industrial Hygiene, 1900-1943: A Selected List." Public Health Bulletin 289 (1945): i-xi, 1-95.

Bergquist, Charles W. "The Tuberculosis Worker and His Placement in Industry." American Journal of Public Health 19 (March 1929): 265-73.

Black, John T., et al. "Report of the Committee in Industrial Hygiene, State and Provincial Health Authorities." American Journal of Public Health 12 (October 1922): 839-40. 436

Bloomfield, J.J. "Development of Industrial Hygiene in the United States." American Journal of Public Health 28 (December 1938): 1388-97.

Bloomfield, J J. "Engineering Control of Occupational Diseases." American journal of Public Health 25 (November 1935): 1196-204.

Bloomfield, J J. "Industrial Health Records: The Industrial Hygiene Survey." American journal of Public Health 35 (June 1945): 559-67.

Bloomfield, J J. "Industrial Hygiene: Retrospect and Prospect." American journal of Public Health 29 (November 1939): 1215-24.

Bloomfield, J J. and W. Scott Johnson. "Potential Problems of Industrial Hygiene in a Tj^ical Industrial Area." American journal of Public Health lb (April 1935): 415-24.

Brannan, John W. "Occupational Therapy." American journal of Public Health 12 (May 1922): 367-76.

Brinton, H.P. "Nonindustrial Injuries Among Male and Female Employees." Public Health Reports 54 (1939): 6.

Bristol, Leverett D. "An Appraisal Form for Industrial Health Ser\'ice." American journal of Public Health 22 (December 1932): 1263-71.

Bristol, Leverett D. Industrial Health Service. Philadelphia: Lea and Febiger, 1933.

Bristol, Leverett D. "Industrial Hygiene: XXliat Ever}' Health Officer Should Know." American journal of Public Health 28 (September 1938): 1080-2.

Bristol, Leverett D. "Practical Application of an Industrial Health Appraisal Form." American journal of Public Health 26 (April 1936): 390-5.

Brown, Hanxy Dee. "A Plan for Establishing Health Departments in Smaller Industries." Proceedings of the National Conference of Social Work 59 (1932): 145-55.

Burlingame, C.C. "The Art, Not the Science, of Industrial Medicine." journal of Industrial Hy§ene 2 (February 1921): 368-73.

Calver, Homer N. "Resources of Industry for Health Education." American journal of Public Health 34 (May 1944): 489-93.

Campbell, Charles MacFie. "Mental Factors in Industrial Hygiene." journal of Industrial Hygiene 5 (August 1923): 130-7.

Chenoweth, Laurence B. and Willard Machle. Industrial Hygiene; A Handbook of Hygiene and Toxicology for Engineers and Plant Managers. New York: F.S. Crofts & Co., 1938.

Clark, W. Ir\nng,Jr. "Industrial Medicine in 1922." journal of Industrial Hygiene A (March 1923): 474-9.

Clark, W. Irving, Jr. "Sub-Standard Workmen." journal of Industrial Hygiene 2 (October 1920): 228-31. 437

Clark, W. Irving, jr., and Philip Drinker. Industrial Medicine. National Medical Monographs. New York: Nadonal Medical Book Company, Inc., 1935.

Clarke, Walter. "Dealing with Syphilis and Gonorrhea as Industrial Problems." Journal of Industrial Hygiene 15 (January 1933): 79-88.

Clewell, C.E. "Industrial Lighting." American journal of Public Health 9 (March 1919): 196-9.

Cobb, Percy W. "Lighting in the Industries." Jomval of Industrial Hygiene 7 (May 1925): 185-98.

Cobb, Stanley. "Applications of Psychiatry to Industrial Hygiene." journal of Industrial Hygiene 1 (November 1919): 343-7.

Coleman, Bernard S. "Extension of Industrial Hygiene by Tuberculosis Associations in the United States." American journal of Public Health 19 (Februar)-1929): 157-65.

Coleman, Bernard S. "The Tuberculosis League, the Sanatorium, and Industr)'." journal of Industrial Hygiene 11 (September 1929): 217-27.

Coliis, E.L. and Major Greenwood. The Health of the Industrial iWorker. Philadelphia: Blakiston, 1921.

Connolly, Joel I. "The Air We Breathe and the Sounds We Hear." American Journal of Public Health 24 '(March 1934): 260-5.

Connolly, Joel I. "Engineering Services in Industry' Other Than Control of Occupational Diseases." American Journal of Public Health 31 Januarj-1941): 21-6.

Cook, Warren A. "The Industrial Hygiene Laborator\'," Journal of Industrial Hygiene and Toxicology 18 (November 1936): 623-36.

Cowgill, George R. "Nutrition: A Factor Important for Industrial Hygiene." American Journal oj Public Health 34 (June 1944): 630-6.

Craig, Frank A. "Tuberculosis as it Affects the Industrial Worker." journal of Industrial Hygiene 4 (August 1922): 170-6.

Dallavalle, J.M. and R.R.Jones. "Basic Principles of Industrial Sanitation." American Journal of Public Health 30 (April 1940): 369-84.

Dershimer, F.W. "Further Studies in Mental Hyiene in Industr)': Malingering." Jostmal of Industrial Hygiene 5 (December 1923): 293-8.

Dershimer, F.W. "Practical Mental Hygiene in Industr)-." Journal of Industrial Hygiene 5 (May 1923): 1-2.

Dershimer, F.W. "The Prevention of Traumatic Neuroses." Journal of Industrial Hygiene 16 (January 1934): 40-51. 438

Diehl, L.J. and F.R. Eastwood. Industrial Kema/ion: Its Development and Present Status. Lafayette, Ind.: Purdue Universit)-, 1940.

Dill, D.B., et al. "Industrial Fatigue." Journal of Industrial Hygiene 18 (1936); 417.

Dill, D.B., et al. "Industrial Fatigue and the Physiolog)- of Man at Work." Industrial Medicine 8 (1939): 315.

Dodson, John. "The Industrial Physician and Preventive Medicine." Journal of Industrial Hygiene 6 (September 1924): 193-8.

Dowling, Oscar M. "Medical and Nursing Service in Industrial Plants." American Journal of Public Health 15 (Februar)' 1925): 141-2.

Doyle, Henr)' N. The Federal Industrial Hygiene Agency: A Histotj of the Division of Occupational Health, United States Public hIeaJlh Service. Cincinnati; American Conference of Governmental Industrial Hygienists, 1975.

Draper, W.F. "State Support of Industrial Hygiene Ser\'ices: An Urgent Necessity'." American Journal of Public Health 34 (March 1944): 224-30.

Drinker, Philip. "Humidity Control in Residence." American Journal of Public Health 15 (August 1925): 689-95.

Drinker, PhiHp. "Laboratories of Ventilation and Illumination, Harvard School of Public Health, Boston." Journal of Industrial Hygiene b Qune 1924): 57-66.

Dublin, Louis Israel. "Incidence of Tuberculosis in the Industrial Populations." American Journal of Public Health 22 (Ivlarch 1932): 281-91.

Dublin, Louis Israel. "The Mortalit)' Trend in the Industrial Population." .American Journal of Public Health 19 (May 1929): 475-81.

Dublin, Louis Israel and Alfred J. Lotka. Tiventy-Five Years of Health Progress: A Study of Mortality Experience .Among the Industrial Poliiyholders of the Metropolitan Ufe Insurance Company, 1911-1935. New York: Metropolitan Life Insurance Company, 1937.

Dyktor, Herbert G. "Industrial Hygiene and Labor." American Journal of Public Health 35 (May 1945); 480-4.

Dyktor, Herbert G. "Integration of Industrial Hygiene with Industrial Medicine." Industrial Medicine 9 (April 1940); 193-6.

Dyktor, Herbert G. "A Pracdcal Housekeeping Program for Industry." American Journal of Public 33 (May 1943); 557-60.

Easom, H.F. and M.F. Trice. "Development of an Industrial Hygiene Program in a State Health Department." American Journal of Public Health 22i (May 1938); 610-5. 439

Edmunds, Page. "The Role of Syphilis in Industrial Disablement: Analysis of 291 Physical Sur\'eys." journal of Industrial Hygiene A Qanuarj' 1923): 380

Elkind, Henr}- B. "Behavior Studies in Industr}'." Journal of Industrial Hygienel Qanuar)^ 1925): 17-24.

Elkind, Henn,' B. "Industrial Psychiatr}'." journal of Industrial Hygiene 6 (October 1924): 251-8.

Elkind, Henrj' B. "Industrial Psychiatr)'." Mental Hjgienc 13 (April 1929): 378-92.

Elkind, Henrj' B., ed. Preventive Management: Mental Hjgiene in Industty. New York: B.C Forbes Publishing Company, 1931.

Emmons, Arthur B. Health Control in Mercantile Life: A Problem in Conserving Human Energ}'. New York: Harper & Brothers Publishers, 1926.

Emmons, Arthur B. "Health in Mercantile Establishments: Common Sanitar)- Defects in Stores." journal of Industrial Hjgiene 2) (May 1921): 29-36.

Evans, \N'.A. "Health Education in Industr)'." journal of Industrial Hjgiene 1 (December 1919): 397-401.

Everett, Ray H. "The Cost of Venereal Disease to Industr)^" ]on)'nal of Industrial Hjgiene 2 (September 1920): 178-81.

Everts, Glenn S. "Industrial Hygiene for die Smaller Plant." American Journal of Public Health 30 (January 1940): 17-21.

Fillmore, Anna M. "Nursing Records in Industrj'." American journal of Public Health 35 (March 1945): 221-7.

Fisher, H.E. "Employee Examinations." Industrial Medicine 6 (1937): 503.

Fisher, Judson C. "Malingering: Involving the Problem of Getdng the Sick or Injured Empoyee Back to Work." journal of Industrial Hjgiene 1 (December 1919): 408-14.

Fisk, Eugene Lyman. "Fatigue in Industry'." American journal of Public Health 12 (March 1922): 212-7.

Fisk, Eugene Lyman. "Industrial Fadgue." American journal of Public Health 18 (December 1928): 1465-9.

Ford, C.E. "Annual Address of the President of the American Association of Industrial Physicians and Surgeons." journal of Industrial Hjgiene S (December 1923): 279-87.

Ford, C.E. "The Co-ordination of Industrial and Community' Health Activities." journal of Industrial Hygiene 1 (December 1919): 402-7.

Ford, C.E. "Health Education in Industrj'." American journal of Public Health \\ Qune 1921): 489-97.

Ford, C.E. "The Physician in Industry and His Relation to Health Agencies." Proceedings oj the National Conference of Social Work 49 (1922): 190-4. 440

Ford, C.E. "Some Considerations for the Physician in Industry'." ]oimial of Industrial Hygiene 4 (May 1922): 1-8.

Franlcel, Lee Kaufer. "Industrial Nursing as a Means of Fighting Tuberculosis." Transactions of the Annua! Meetin^^ of the National Tuberculosis Association 17 (1921): 525-31.

Frankel, Lee Kaufer and Ale.xander Fleisher. The Human Factor in Industiy. New York: The Macmillan Company, 1920.

Franklin, M. Burnett. "The Successful Industrial Medical Department: Essential Cooperation of Executives and Employees Gained by Proper Methods." Journal of Industrial Hygiene 2 (May 1920): 22-4

Gafafer, William M. "The Course of Disabling Morbidit)- Among Industrial Workers, 1921-38." Public Health Reports 55 (May 31,1940): 962-74.

Gafafer, William M. "Disabling Sickness Among Industrial Workers." American journal of Public Healthl\ (May 1941): 443-51.

Gafafer, William M. "Time Lost by Industrial Workers from Disabling Sickness and Accidents During the Early Davs of Disabilit}'." American Journal of Public Health 29 (April 1939): 359-70.

Gilbreth, Frank B. and Lillian A. Gilbreth. "Unnecessary Fatigue; A Multi-Billion Enemy to America." Journal of Industrial Hygiene 'i (March 1920): 542-5.

Gillespie, Richard. "Industrial Fatigue and the Discipline of Physiology." In Physioh^' in the American Context, 1850-1940, ed. Gerald L. Geison, 237-62. Bethesda, Md.: American Physiological Societ}', 1987.

Graff, Wesley M. "The Compensation Aspect of Industrial Hygiene." American journal of Public Health 27 Ouly 1937): 667-70.

Graham-Rogers, C.T. "Compensation and Industrial Hygiene." American Journal of Public Health 17 Qune 1927): 560-2.

Graham-Rogers, C.T. "Relation of Health Departments to Industrial Hygiene." American Journal of Public Health 16 (Februar)' 1926): 117-20.

Graves, L.M., et al. "Integrating Industrial Hygiene with Local Health Ser\'ice." American Journal of Public Health 30 (May 1940): 493-8.

Hackett, James Dominick. Health Maintenance in Industry. Chicago: A.W. Shaw Company, 1925.

Hamilton, Alice. E\floring the Dangerous Trades; The Autobiography of Alice Hamilton. Boston; Little, Brown, and Company, 1943; reprint, Boston: Northeastern Universit)', 1985.

Hamilton, Alice. "Industrial Hygiene." American Journal of Public Health 23 (April 1933): 332-4.

Hamilton, Alice. Industrial Poisons in the United States. New York: Macmillan, 1941. 441

Hamilton, Alice. htdNStria! Toxico/o^'. New York; Harper, 1934.

Hamilton, Alice. "The Present Status of Industrial Toxicolog)- in the United States." In De Lamar Ijedtms, 1925-1926,19-42. Baldmore: The Vl'illiams & Wilkins Company, 1927.

Harrington, Thomas F. "Industrial Health." American Journal of V'ubHc Heatthl (March 1917); 322-30.

Harris, L.I. "Relation of Industrial Hygiene to General Practice." Nw York Medical Journal(1918): 928.

Hartman, W. Louis. "The Economic Viewpoint upon Syphilis in Industn'." Journal of Industrial Hyiiene 5 (Januar)'1924); 341-6.

Harvey, Verne K. "An Industrial Health Program for Federal Employees." American Journal of Public HeaM 35 (March 1945); 239-42.

Hayhurst, Emery R. ".\djustments in Health Administration for Industrial Diseases on Account of the War." American Journal of Public Health^ (March 1919); 169-71,

Hayhurst, Emer^' R. "Ideals in the Organization of an Industrial Medical Sen'ice." American Journal of Public Health 10 (September 1920): 715.

Hayhurst, Emer)- R. "The Industrial Hygiene Section, 1914-1934." American Journal of Public Health 24 (October 1934); 1039-44.

Hayhurst, Emerj- R. "Light and Health." American Journal of Public Health 16 (April 1926); 381-3.

Hayhurst, Emer)' R. "Medical Argument Against Night Work, Especially for Women Employees." American Journal of Public Health 9 (May 1919); 367-8.

Havhurst, Emen- R. "Medical Inspection of Industries." American Journal of Public Health 14 (May 1924); 379-82."

Havhurst, Emer)' R. "Need for a General System of Sanitar)- Supervision of Industries in Times of War." American Journal of Public Health 8 (April 1918); 301-3.

Hayhurst, Emer)' R. "Points in the Detection of Industrial Fatigue and Measures for its Possible Complete Elimination." Journal of Industrial Hygiene! (November 1920); 256-8.

Hayhurst, Emer)- R. "The Role of the State in Industrial Hygiene." American Journal of Public Health 15 (August 1925); 681-6.

Hayhurst, Emer)' R. "Swan Song in Public Health Work." American Journal oj Public Health 19 1929); 627-30,

Hayhurst, Emer)' R. "\'^alues in the Maintenance of tiie Health of the Worker." American Jour^ml of Public Health 15 (Februar)' 1925); 116-21.

Henderson, L.J. and Elton Mayo. "The Effect of Social Environment." Journal of Industrial Hjgiene and Toxicology' 18 (September 1936); 401-16. 442

Hersey, Rex B. "The Subjective Side of Fatigue in Industr)'." JournaloflndtislrialHjgiene 13 (June 1931): 185-203.

Hobbs, C.W. Essentials of Workmen's Compensation Insurance. Philadelphia: Spectator Co., 1939.

Hodgson, Violet H. "The Industrial Nurse in Gear with the Machinen- for Human Adjustment." American Journal of P/Mic Health 20 (December 1930): 1323-7.

Hodgson, Violet H. "Industrj': A Field of Opportunit)' for Public Health Nursing." Transactions of the National Tuberculosis Association 27 (1931): 303-12.

Hodgson, Violet H. "The Nurse in Industr}'." Public Health Nurse 2\ (1929): 597-601.

Hodgson, Violet H. Public Health Nursing in Industry. New York: Macmillan, 1933,

Hoffman, Frederick L. The Menace of Dusts, Gases, and Fumes in Modem Industry. Newark, N.J.; Prudential Press, 1919.

Hoffman, Frederick L. Occupational Diseases and Their Compensation, with Special Reference to Anthrax and Miners' Lung Diseases. Newark, N.J.: Prudential Insurance Company, 1920.

Hoover, Herbert C. "The Waste of Human Effort in Industry." Proceedings of the National Conference of Soda/Work A9 {1922)-. GA-1.

Hubbard, Ruth W. "Industrial Nursing." American Journal of Public Health 30 (October 1940): 1224-5.

Hubbard, Ruth W. "Use of Existing Visiting Nurse Sen'ices for Industrial Work in Small Plants." American Journal of Public Health'i\ ()anuan' 1941): 21-2)3.

Hyslop, Frances L. and William McKinle\' Gafafer. Bibliograpfy of Occupational Health: Occupational Health and Related Publications from the Public Health Service, 1909-1953. Pub. no. 300. Washington, D.C.: Public Health Service, 1954.

Illuminating Engineering Society. Lighting Principles and Practice: A Bibliography of Papers Dealing with Lighting Application. New York: The Illuminating Engineering Societ)-, 1942.

Jarrett, Mar)' C. "Mental Hygiene of Industry." Mental Hjgiene 4 (October 1920): 867-84.

Johnson, Orlen J. "Public Health and Medical Relationships in Industrial Health." American Journal of Public Health 32 (October 1942): 1157-63.

Johnson, W. Scott. "An Administrative Approach to Industrial Hygiene." American Journal of Public Health 30 Quly 1940): 806-10.

Kennedy, Dudley R. and Richard M. Neustadt. "The Proper Executive Function of the Industrial Physician." Journal of Industrial Hjgiene 1 Qanuarj' 1920): 428-34.

Kennedy, F. "Fatigue and Noise in Industry'." New York State Journal of Medicine 36 (1927): 1936. 443

Kerr, J.W. "Relation of Public Health Ser\-ice to Problems of Industrial Hj-giene." American jonrmt! of Pub/k Health 7 (September 1917): 776-82.

Kersten, Evelyn Smith. "Industrial Nursing from 1895 to 1942: Development of a Specialt)'." Ph.D. diss., Columbia University- Teacher's College, 1985.

Kessler, Henr}- H. "Rehabilitation of the Disabled." American journal of Stn^etj "hi (Februarj' 1936): 316-28.

Kessler, Henry H. "Social Significance of Industrial Medicine." American Journal of Public Health 26 (February 1936); 158-64.

Kessler, Henry H. and Bernard S. Coleman. "Medico-Legal Aspects of Occupauonal Disease." American Journal of Public Health 18 (March 1928): 269-78.

Kessler, Henrj' H., et al. "Nomenclature in Occupational Disease as Affecting Standard Practices in Workman's Compensadon." American Journal of Public Health 2\ (januar)-1931): 78-83.

I'Cibbey, C.H. "Pneumonia and Tuberculosis Among Industrial Workers and their Dependents." American Journal of Public Health 27 Qune 1937): 555-9.

Kibbey, C.H. "Relauve Pneumonia Fatalit\- Among Surface Workers and Miners." American Journal of Public Health 22 (April 1932): 360-6.

Kiefer, Guy L. "Preventive Medicine in Industr)-." American Journal of Public Health 14 (December 1924): 1050-2.

Knapp, Robert P. "How Far Should Industrj' Go in Caring for Cases of Illness Not Due to Employment?" Journal of Industrial Hj^iene 10 Qanuar)' 1928): 1-6.

Kober, George Marun. "Histon* of Industrial Hygiene and its Effects on Public Health." In A Half Century of Public Health: Jubilee Historical Volume of the American Public \-\ealth Association, ed. Mazyck Porcher Ravenel, 361-411. New York: American Public Health Association, 1921.

Kober, George Mardn and William C. Hanson, eds. Diseases of Occupation and Vocational Pljgiene. Philadelphia: P. Blakiston's Son & Co., 1916.

Kober, George Mardn and Emery 11. Hayhurst, eds. Industrial Health. Philadelphia: P. Blakiston's Son & Co., 1924,

Kronenberg, Milton H. "Undergraduate Training of Industrial Hygiene Personnel." American Journal of Public Health 33 (1943): 545-9.

Laird, Donald A. "Influence of Noise on Producdon and Fatigue as Related to Pitch Sensation, Level, and Steadiness of Noise." Journal of Applied Psjchologf 17 (1933): 320.

Laird, Donald A. "The Measurement of the Effects of Noise on Working Efficiency," Journal of Industrial Hygiene^ (October 1927); 431-4, 444

Landes, Jacob H. "Plan of the Fort Greene Industrial Health Committee." American Joiiniii/ of Public Health 35 Qune 1945): 602-6.

Lanza, A.J. "Obser\'ations on Industrial Hygiene." American journal of Public Hecilth2\ (May 1931): 529-34.

Lanza, A.J. and Jacob A. Goldberg, eds. Industrial Hygiene. New York; Oxford Universit)- Press, 1939.

Lauffer, Charles A. "Industrial Health Hazards." Journal of Industrial Hygiene 1 (December 1919): 373-9.

Leathers, Walter S., et al. "Desirable Qualifications of Nurses Appointed to Public Health Nursing Positions in Industr)'." American journal of Public Health 29 (July 1939): 789-90.

Lee, Roger I. "Investigative Opportunities in the Physical Examination of Large Groups of Individuals." journal of Industrial Hygiene 3 (February 1922): 304-8.

Legge, Robert T. "Relation of Industrial Medicine to Public Health." American journal of PublicHealth 11 (January 1921): 62-4.

Lemon, C.H. "Social Medicine in the Industries." Wisconsin Medical journal 16 (1917-8): 453-9.

Lincoln, Miriam. "Industrial Aspects of Heart Disease: A Study of Eight)' Industrial Workers from the Cardiac Clinic of the Massachusetts General Hospital, Boston, Mass." journal of Industrial Hygiene 6 (May 1924): 1-13.

Link, Henrj- C. "A Practical Study in Industrial Fatigue." Journal of Industrial Hygiene 1 (September 1919): 233-7.

Lockhart, Leonard P. "Modern Problems in Industrial Medicine." journal of Industrial Hygiene 14 (March 1932): 81-3.

Lovekin, Osgood S. "The Quantitative Measurement of Human Efficiency Under Factor)- Conditions." journal of Industrial Hygiene 12 (March 1930): 99-120.

Lovekin, Osgood S. "The Quantitative Measurement of Human Efficiency Under Factor)' Conditions." journal of Industrial Hygiene 12 (April 1930): 153-67.

Luckiesh, Matthew. AriiftdalLight: Its Influence Upon Civilisation. The Century Books of Useful Science Series. New York: The Century Co., 1920.

Luckiesh, Matthew. Ught and Work: A Discussion of Quality and Quantity of Light in Relation to Effective Vision and Efficient Work. New York: D. Van Nostrand Company, 1924.

Luckiesh, Matthew and F.K. Moss. The Science of Seeing. New York: Van Nostrand, 1937.

Mayers, May R. "Fatigue in the Washing Departments of the New York Steam Laundries." journal of Industrial Hygiene 6 (November 1924): 270-80.

Mayo, Elton. "The Basis of Industrial Psycholog)'." Bulletin of the Taylor Society 9 (December 1924): 249-59. 445

McBirney, Robert S. "The Medical Consultant in Industry and His Value to the State." American Journal of Public Health 16 (December 1926): 1182-5.

McCartey, Charles F. "Medical Cooperation with the Fort Greene Industrial Health Committee." American Journal of Public Health 35 (September 1945): 947-50.

McConnell, William J. "The Industrial Physician and the Qualifications Essential to His Success." Journal of Industrial Hygiene'i (August 1921): 130-4.

McCord, Carey P. "Industrial Health Promotion in Small Plants." American Journal of Public Health 15 (April 1925): 299-302.

McCullough, John W.S. "Relation of Public Health Workers to Industrial Hygiene." American Journal of Public Health 15 (November 1925): 984-5.

McDavitt, T.V. "Industrial Medical Records: Some Legal Considerations." American Journal ofPublic Health 35 Qune 1945): 568-71.

Mock, Harr)' E. Industrial Medicine and Surgery. Philadelphia: W'.B. Saunders Company, 1921.

Mock, Harr)- E. "Industrial Medicine and Surgery, the New Specialt)'." Journal of the American Medical Association 68 (1917): 1.

Mock, Harrj- E. "Industrial Medicine and Surger\': A Resume of its Development and Scope." Journal of Industrial Hygiene 1 (May 1919): 1-7.

Mock, Harr}' E. "Industrial Medicine and Surger)" A Resume of its Development, Scope, and Benefits." Journal of Industrial Hygiene 1 (September 1919): 251-4.

Monger, John Emerson, ct al. "Industrial Hygiene." American Journal of Public Health 13 (August 1923): 642-3.

Moore, Joseph Earle. "Sj'philis and Unemployment." Journal of Industrial Hygiene and Toxicology 19 (May 1937): 189-92.

Mudd, Richard D. "Discussion of Sickness and Accidents in Industrial Workers." American Journal of Public Health 29 (AprU 1939): 370-4.

Mudd, Richard D. "Discussion: Sickness Among Industrial Workers." American Journal of Public Health 31 (May 1941): 451-6.

Murphv, T.F. "Need for Better Occupation Returns on Death Certificates." American Journal of Public Health 19 (November 1929): 1210-4.

Myers, Harr)'. "The Relation of Indusuial Medicine to the General Practice." Journal of Industrial Hjgiene 5 (December 1923): 288-92.

National Industrial Conference Board, Inc. Medical Care of Industrial Workers. New York: National Industrial Conference Board, Inc., 1926. 446

National Industrial Conference Board, Inc. Medical Supervision and Service in Industry. New York; National Industrial Conference Board, Inc., 1932.

National Research Council. Committee on Work in Industr)'. Fatigue of Workers: Its Re/ation to Industrial Production. New York: Reinhold, 1941.

Nau, Carl A. "Industrial Hygiene Program in a State Health Department." American Journal of Public Health 29 (Februar)' 1939): 151-7.

Nelson, O.T. "Discussion: Industrial Hygiene Codes." American journal of Public Health 29 Quly 1939): 751-2.

Newman, Bernard J. "A Program for Organizing and Coordinating Industrial Clinics." American journal of Public Health 10 (August 1920): 637-47.

Newman, Bernard J. "Work Environment as a Factor in the General Health of Workers." American Journal of Public Health 2\ (December 1931): 1354-9.

Newquist, Melvin N. Medical Service in Industry and Workmen's Compensation Larvs. Chicago: American College of Surgeons, 1938.

Oliver, Edward A. "Syphilis, and Inestimable Factor in Industrial Inefficiency." Journal of Industrial Hygiene 1 (September 1919): 246-50.

Oliver, Thomas. "Industrial Hygiene." American Journal oj'Public Health 14 Qanuar)- 1924): 6-8.

O'Neil, Daniel. "Where Industrial Service Becomes Communit}- Sen'ice." Nation's Health 6 Qanuarj' 1924): 1-3, 58, 60.

Page, Robert C. "The Importance of Preemployment and Periodical Medical Examination." Industrial 7 (June 1938): 362-4.

Parker, Carleton H. The Casual Laborer and Other Essays. New York: Harcourt, Brace & Co., 1921.

Parmenter, D.C. "A Future Development in Industrial Hygiene." American Journal of Public Health 15 (December 1925): 1050-2.

Pedley, Frank G. "The Trend of Occupational Mortality in the United States." Journal of Industrial Hygiene 9 (November 1927): 475-82.

Persons, H.S. "Industrial Psychology." Bulletin of the Taylor Society 9 (August 1927): 163-71.

Peterson, Carl M. "Postgraduate Education of Physicians for Industrial Health Service." American Journal of Public Health 33 (May 1943): 541-4.

Pharris, Crit. "Medical Ser\'ices in Small Industrial Plants." American journal of Public Health 32 (August 1942): 860-4.

Pinto, S.S. and M. Bowditch. "Industrial Hygiene." New England Journal of Medicine 225 (1941): 949-52. 447

Prendergast, John ), "Industrial Medical Department Organization." American Jonmai of Public Heullh 29 Gunc 1939): 641-4.

Price, George Moses. Modem Fcicloiy. New York: John Wiley & Sons, 1914.

Price, George Moses. "Practical Standards for Factor)- Sanitation." American Journal of Public HeaJ/b 8 (April 1918): 288-90.

Price, George Moses. "Scientific Management in Industr}' and Wliat it Includes." American joitmai of Public Health 6 (1916): 836.

Puffer, Ruth Rice. "Industrial and Occupational Environment and Health." In backgrounds of Social Medicine, 119-37. New York: Milbank Memorial Fund, 1949.

Rabinbach, Anson, The Human Motor. Eiter^', Fatigue, and the Origins of Modernity. New York, 1990.

Rector, Frank Leslie. "Industrial Hvgiene bv Employers' Organizations." .-h/ierican Journal of Public 15 (May 1925): 423-6.

Rector, Frank Leslie. "Medical Provisions of Workmen's Compensation Laws." Journal of Industrial Hygiene (> (September 1924): 174-80.

Rector, Frank Leslie. "Occupational Disease and Workmen's Compensation Laws." .American Journal of Public Health 14 (September 1924): 763-5.

Rector, Frank Leslie. "Present Status of the Mineral VC'ater Industr)'." American Journal of Public Health 1 (August 1917): 868.

Rector, Frank Leslie. "XX'liat O'Clock is it in Industrial Hygiene?" American Journal of Public Health 19 (December 1929): 1327-33.

Reile)', A.D. "The Insurance Company in Industrial Hygiene." .American Journal of Public Health 10 (Februar)' 1920): 160-4.

Richardson, Baxter Kev. "Health Opportunities in Industr)-." Industrial Medicine 8 (December 1939): 523-5.

Robson, R.B. "Health Maintenance in Small Industry-." American journal of Public Health 31 (Februar)' 1941): 162-6.

Roclcwood, M.L. "Industrial Hygiene and Local Health Departments." .American Journal of Public Health 16 (April 1926): 343-5.

Roethlisberger, F.J. and W.J. Dickson. Management and the Worker. An Account of a Research Program Conducted by the Western Electric Company, Hawthorne Works, Chicago. Cambridge: Han'ard Universit)- Press, 1939.

Rosenau, Milton J. Preventive Medicine and Hjgiene. 6th ed. New York: Appleton Centur)', 1935. 448

Russell, A.E. "Control of Syphilis in Industrj'." Journal of Social Hj^iene 24 (1938): 10.

Russell Sage Foundation. "Industrial Hygiene: A Selected Bibliography." Bulletin of the Russell Sage Foundation Ubrary 36 (August 1919): 2-4.

Sabine, Paul E. "The Problem of Industrial Noise." American journal of Public Health 34 (March 1944); 265-70.

Sappington, C.O. "The Control of Occupational Diseases by Laboratorj' Methods." Journal of Industrial Hygiene 17 (January 1935): 21-6.

Sappington, C.O. "Discussion of Occupational Disease Control." American Journal of Public Health 29 Ouly 1939): 737-8.

Sappington, C.O. Essentials of Industrial Health. Philadelphia: J.B. Lippincott Company, 1943.

Sappington, C.O. "Industrial Morbidit}' Data and the Physician." American Journal of Public Health 17 (July 1927): 711-3.

Sappineton, C.O. "Integrated Control of Occupational Diseases." American Journal of Public Health 26 (August 1936): 781-5.

Sappington, C.O. "Preventive Medicine in Industrj': Experience of a Western Mail Order House." Journal of Industrial Hygiene') (January' 1927): 12-7.

Sappington, C.O. "Relation Between Health Supervision in Schools and Industries." American Journal of Public Health 16 Qune 1926): 594-6.

Sappington, C.O. and N.D. Marbakcr. "The Industrial Physician and the General Practitioner." Journal of the American Medical Association 95 (December 27, 1930): 1955-7.

Saj'ers, R.R. "Findings from Major Studies of Fatigue." Proceedings of the Industrial Hygiene Foundation of America 6 (1941): 66.

Savers, R.R. "President's Address: Health Promotion in Industr)-." IndustrialMedicinel (July 1938): 410-5.

Savers, R.R. "S},'philis Control in Industry-." American Journal of Public Health 28 (Februar)-1938): 155-61.

Bayers, R.R. and J.J. Bloomfield. "Industrial Hygiene Activities in the United States." American Journal of Public Health 26 (November 1936): 1087-96.

Scheffel, Carl. "The Mental Hygiene of Industrial Workers." Journal of Industrial Hygiene 2 (September 1920): 182-8.

Schereschewsky, J.W. "Need and Method of Coordinating Federal, State, and Local Health Agencies in Promoting Industrial Hygiene." American Journal of Public Health 9 (December 1919): 937-42.

Schereschewsky, J.W. "Plan for Education in Industrial Hygiene and Avoidance of Occupational Complaints." American Journal of Public Health 6 (1916): 1031. 449

Schevitz, Jules. "Industrial Health Education: A Means and an End." Amerkan journal of Public Health 10 (October 1920): 780-2.

Schram, C.F.N. "Why Should the Physician Go Out into the Plant?" journal of Industrial Hygiene 5 Qanuary 1924): 325-8.

Schulze, Wilmer H. "Industrial Hygiene Applied to the Clothing Manufacturing Industn-." American journal of Public Health 28 (April 1938): 476-8.

Selby, Clarence D. "Approaching the Health Problems of Adult Life Through Industrj'." American Journal of Public Health 30 (April 1940): 336-40.

Selby, Clarence D. "Functions and Plan of Organization of Division of Industrial Hygiene." American journal of Public Healths ()uly 1919); 521-5.

Selb)^ Clarcnce D. "Health Maintenance in Industi}-." American Journal of Public Health 28 (November 1938): 1328-31.

Selby, Clarence D. "The Promotion of Industrial Health." American journal of Public Health 15 (March 1925): 209-12.

Selby, Clarence D. "Proposed Bureau of Industrial Safet\', Sanitation, and Hygiene, to be Maintained on the Mutual Plan." American Journal of Public Health 6 (1916): 1187.

Selbv, Clarence D. "The Relation of Industn' to the Health Department." Ohio Public Health Journal 8 (1917): 66.

Selby, Clarence D. "Renaissance of Industrial Hygiene." American Journal of Public Health 30 (December 1940): 1422-6.

Selby, Clarence D. "Scope of the Physical Examination in Industr\'." Journal of Industrial l-iygiene 1 (December 1919): 380-4.

Sellers, Christopher C. "Factory as Environment: Industrial Hygiene, Professional Collaboration, and the Modern Sciences of Pollution." Environmental Histo^' Review 18 (1994): 55-83.

Sellers, Christopher C. Hazards of the Job: From Industrial Disease to Rnvironmental Health Science. Chapel Hill: The Universit)' of North Carolina Press, 1997.

Sellers, Christopher C. "The Public Health Service's Office of Industrial Hygiene and the Transformation of Industrial Medicine." 'Bulletin of the Histoty of Medidne 65 (1991): 42-73.

Sellers, Christopher C. "Working Disease In: Silicosis, Science, and the Social Histor)' of Medicine (An Essay Review)." journal of the History of Medicine 38 (1993): 98-109.

Shepard, G.H. "Effect of Rest Periods on Production." Personnel Journal 1 (1928): 186.

Shepard, Mrs. ]ohn S. "Placing Cardiac Patients in Regular Industries." Journal of Industrial Hysiene 5 (October 1923): 189-204. 450

Shoudy, Loyal A. "Annual Address of die President of the American Association of Industrial Physicians and Surgeons." Jouma/ of Industria/Hjgiene 6 (September 1924): 169-73.

Sigerist, Henrj' Ernest. "Historical Background of Industrial and Occupational Diseases." BnHelin of the New York Academy of Medicine 12 (1936): 597-609.

Southard, Elmer Ernest. "The Modern Specialist in Unrest: A Place for the Psychiatrist in Industrj-." Journal ofhiduslrial Hygiene 2 (May 1920): 11-9.

Spaeth, Reynold A. "The Prevention of Fatigue in Manufacturing Industries." Journal of Industrial Hyigiene 1 Qanuar)' 1920): 435-47.

Spaeth, Reynold A. "The Problem of Fatigue." Journal of Industrial Hjigiene 1 (May 1919): 22-53.

Stearns, A. Warren. "Social Work and Industrial Hygiene." Journal of Industrial Hygiene 2 (May 1920); 20-1.

Stern, Bernhard J. Medicine in Industry. New York: The Commonwealth Fund, 1946.

Strong, Anne H. "Problems in the Training of Industrial Nurses." Journal of Industrial Hygiene 1 (October 1919): 297-300.

Sydenstricker, Edgar and D.K. Brundage. "Industrial Establishment Disability Records as a Source of Morbidit)'Statistics." Quarterly Publication of the American Statistical Association 17 (March 1921): 594-8.

Tead, Ordway. "Human Nature and Management." In Preventive Management: Mental Hygiene in Industty, ed. Henr)' B. Elkind, 21-49. New York: B.C. Forbes Publishing Company, 1931.

Thompson, W. Oilman. "Industrial Hygiene in Wartime." American Journal of Public Health 8 (Januar)- 1918): 27-33.

Thomson, Alec N. "Syphilis and Industr)\" Journal of Industrial Hygiene 3 (july 1921): 99-101.

Thomson, James E.M. "Review of the Recent Advances in Industrial Medicine and Surger)': Proposed Scheme of Application of These Principles in a City of Small Industries." Journal of Industrial Hygiene 2 (October 1920): 219-23.

Tinker, Miles A. "Hygienic Lighting Intensities." Journal of Industrial Hjgiene 17 (November 1935): 258-62.

Tobey, Harold G. "Common Colds in Relation to Industrial Hygiene." Journal of Industrial Hygiene 3 (March 1922): 333-8.

Tobey, James Alner. "Industrial Cleanliness and the Courts." American Journal of Public Health 19 (October 1929): 1119-22.

Townsend, James G. "Industrial Hygiene Activities in the Public Health Service." American Journal of Public Health (April 1943): 324-9. 451

Townsend, lames G. "The Problem of Industrial Hygiene." Nen^ Orleans Medical Surncal Journal 95 (May 1943); 505.

Truesdell, Leon E. "The Outlook for MortaUt)' Statistics by Occupation." American journal of Public Health 19 (June 1929); 620-6.

Turner, John A. "Practice of Preventive Medicine in Industrj-." American journal of Public Health 17 (November 1927); 1125-9.

Vernon, H.M. Industrial Fatigue and Eflicieniy. New York; E.P. Dutton, 1921.

Vernon, H.M. "The Influence of Fatigue on Health and Longevit}'." Journal of Industrial Hygiene 3 (July 1921); 93-8.

Viteles, Morris S. "Psychology and Psychiatrj' in Industrj'; The Point of View of the Psychologist." Men/al Hjgiene 13 (April 1929); 361-77.

Vonachen, H.A. "Sjphilis in Industn-." Industrial Medicine 1 Quly 1938); 416-9.

Wadsworth, Augustus B. "Development of the State Departments of Health in Relation to Health Insurance and Industrial Hygiene." American journal of Public Health 10 (Januar)' 1920); 53-8.

Wampler, F.J., ed. Principles and Practice of Industrial Medicine. Baltimore; Williams & Wilkins, 1943.

Waters, Theodore C. "Administration of Laws for the Prevention and Control of Occupational Diseases." American journal of Public Health 29 Quly 1939); 728-37.

NX'Tiidock, Olive M., et al. "Duties of Nurses in Industrj-." American journal of Public Health 33 (1943); 865-81.

Wliitlock, Olive M., et al. "To Suidy the Duties of Nurses in Industry." American Jomyial of Public Health Yearbook (1941-2); 170.

Winslow, Charles-Edward Amor)-. "Industrial Tuberculosis." Boston Medical Surgical journal 192 Qanuan' 29,1925); 215-7.

Winslow, Charles-Edward Amory. "Industry' in Medicine." American journal of Public Health 23 (May 1933); 450-8.

Winslow, Charles-Edward Amorj-. "Some Relations of Medicine to Industry." New York Stale Medical journalll (1927); 1246-50.

Wright, Wade. "Hospital and Industrial Hygiene." American journal of Public Health 1 (November 1917); 949-52.

Wright, Wade. "Industrial Morbidity Statistics." American journal of Public Health 15 (January 1925); 31-4.

Wyatt, Bernard Langdon. "The Economics of Health Supervision in Industry." American journal of Public Health 13 (November 1923); 914-19. 452

CHAPTER VII. MENTAL HYGIENE

Adamson, Elizabeth. "The Aims and Accomplishments of a Health Center Mental Hygiene Program." American Journal of Public Health 2Z (March 1933): 211-6.

Adamson, Elizabeth I. "The Aim and Accomplishments of a Health Center Mental Hygiene Program." Medical Woman's Journal AO (March 1933): 59-62.

Adamson, Elizabeth I. "A Communit)' Program for Prevention of Mental Disease." American Journal of Public Health 26 (1936): 480.

Adler, Herman M. "Unemployment and Personality: A Study of Psychopathic Cases." Mental Hygiene 1 Qanuary 1917): 16-24.

"The American Foundation for Mental Hygiene." Mental Hjgiene 13 (October 1929): 673-7.

Anderson, Harold H. "Character Education or Mental Hygiene: Which Shall It Be?" Mental Hygiene 18 (April 1934): 254-62.

Anderson, Harold H. "Conflicts in Personalit)' Development." Mental Hygiene 20 (October 1936): 605-13.

Anderson, Victor V. P^rhial)y in Edm-ation. New York: Harper and Brothers, 1932.

Anderson, Victor V. Psychiatiy in Industry. New York: Harper and Brothers, 1929.

Andress, J.M. "The Study of Habit in a Course in Psycholog)'." American Journal of School H}giene 1 (1917): 126-30.

Angell, James Rowland. "Mental Hygiene and Education." Mental Hygiene 19 Qanuar)' 1935): 3-6.

Angell, lames Rowland. "Mental Hygiene in Colleges and Universities." Mental Hygiene 11 (October 'l933): 543-7.

Angell, James Rowland, et al. Social Aspects of Menial Hygiene. New Haven, Conn.: Yale University Press, 1925.

Angj'al, Andras. Foundations for a Science of Personality. New York: The Commonwealth Fund, 1941.

Bagby, English. The Piychology oj Personality. New York: Henrj' Holt & Co., 1928.

Bailey, Pearce. "VC'ar and Mental Disease." American Journal of Public Health 8 (1918): 1.

Barker, Lewellys F. "The First Ten Years of the National Committee for Mental Hygiene, with Some Comments on its Future." Mental Hygiene 2 (October 1918): 557-81.

Barker, Lewellys F. "The Wider Field of Work of the National Committee for Mental Hygiene." Mental Hygiene 1 Qanuar)" 1917): 4-6. 453

Barnes, Harn' Elmer. "The Social Basis of Mental Health." Survej Qanuarj- 15, 1928): 490-1.

Bassett, Clara. Mental Hjgiene in the Community. New York: The Macmillan Company, 1934.

Bassett, Clara. The School and Mental Health. New York; The Commonwealth Fund, 1931.

Bassett, Clara, et al. "Organizing a Communit)' for Mental Hygiene: Report of Subcommittee V, the Committee on Mental Hygiene, of the Steering Committee on Social Planning, Rochester CouncO of Social Agencies." Mental Hjgiene 17 Qanuar)-1933): 424-50.

Beers, Clifford Whittingham. "An Intimate Account of the Origin and Growth of the Mental Hygiene Movement." Mental Hygiene 15 (October 1931): 673-84.

Beers, Clifford NX-Tiittingham. A Mind That Found Itself: An Autobiography. London; Longmans, Green, and Co., 1907.

Beers, Clifford Wliittingham. "Organized Work in Mental Hygiene." Mental Hygiene 1 Qanuar)' 1917); 81-7.

Beers, Clifford Whittingham. "Some Intimate Remarks." Mental Hygiene 19 Qanuarj' 1935); 16-28.

Bernreuter, Robert G. The Personality Inventoty. Stanford Universit)' Press, 1934.

Bigelow, Elizabeth B. "Experiment to Determine the Possibilities of Subnormal Girls in Factor)' Work." Mental Hygiene 5 (April 1921): 302-20.

Bills, Arthur Gilbert. The Psychology of Efficiency: A Discussion of the Hygiene of Mental W^ork. New York: Harper & Brothers Publishers, 1943.

Bingham, Anne T. "Wliat Can Be Done for the Maladjusted?" Mental Hygiene 4 (April 1920): 422-33.

Bingham, W.V. "Achievements of Industrial Psycholog)'." Mental Hygiene 14 (April 1930): 369-83.

Blanchard, Phyllis. "The Family Situation and Personality Development." Mental Hygiene 11 Qanuan- 1927): 15-22.

Bolt, Richard Arthur. "Mental Health." Child Health 10 (March-April 1943); 1-4.

Boorman, W. Ryland. Personality in its Teens. New York: Macmillan Co., 1931.

Bridges, K.M. Banham. "Some Obser\''ations on 'Contrariness' or Negativism." Mental Hygiene 9 (July 1925); 521-8.

Brill, Abraham A. "Adjustment of the Jew to the American Environment." Mental Hygiene 2 (April 1918): 219-31.

Brown, Sanger, II. "Training the High-Grade Mental Defective for Community Life." Mental Hygiene 16 Quly 1932): 440-5. 454

Buhler, K. The Mental Development of the Child. New York: Harcourt, Brace, 1930.

Burgess, Ernest W. "The Cultural Approach to the Study of Personalit)'." Mental Hjgiene 14 (April 1930): 307-25.

Burnham, John Chynoweth. "Mental Health for Normal Children." Mental Hygiene 2 (Januar)' 1918): 19-22.

Burnham, John Chynoweth. "Psychiatry, Psycholog)% and the Progressive Movement." American Quarterly 12 (Winter 1960): 457-65.

Burnham, John Chynoweth. Psychiatry, Psycholog}\ and the Progressive Movement, Indianapolis: Bobbs-Merrill, 1960.

Burnham, John Chynoweth. Psychoanalysis in American Medicine, 1894-1918: Medicine, Science, and Culture. New York; International Universities Press, 1967.

Burnham, William H. "The Development of the Wliolesome Personalit)-." In Symposium on Physical Education and Health, 191-9. New York Universit)' Press, 1930.

Burnham, NX'illiam H. "The Fundamental Principle of Hygiene." Pedagogical Seminary 25 (1918): 329-68.

Burnham, William H. Great Teachers and Mental Health. New York; D. Appleton and Co., 1926.

Burnham, William H. "The Group as a Stimulus to Mental Activit)-." Science 31 (1910): 761-7.

Burnham, William H. "A Health Examination at School Entrance." journal of the American Medical Association 68 (1917): 893-9.

Burnham, William H. "Mental Health for Normal Children." Mental Hygiene 2 Qanuar)' 1918): 19-22.

Burnham, William H. "Mental Hygiene in the School." Mental Hygiene 16 (January 1932); 26-36.

Burnham. William H. The Nomal Mind: An Introduction to Mental Hygiene and the Hygiene of School Instmction. New York; D. Appleton and Company, 1925.

Burnham, William H. "The Normal Mind." Pedagogical Seminary 29 (1922); 383-9.

Burnham, William H. "Personalit)- and Public Speaking." Journal of Expression 2 (1928); 129-37.

Burnham, William H. "The Significance of the Conditioned Reflex in Mental Hygiene." Mental Hygiene 5 (192]); 673-706.

Burnham, William H. "Success and Failure as Conditions of Mental Health." Mental Hygiene 3 Quly 1919): 387-97.

Burnham, William H. "Suggestion in School Hygiene." PedagogicalSeminaty 19 (1912): 228-49.

Burnham, William H. "A Survey of the Teaching of Mental Hygiene in the Normal Schools." Mental Hygiene b{\n\y. 19-45. 455

Burnham, William H. What Teachers Want to I

Burnham, William H. The Wholesome Personality: A Contribution to Mental Hygiene. New York; D. Appleton and Company, 1932.

Butler, George F. How the Mind Cures: A Consideration of the Relationship Between Your Outside and ^ 'our Inside Individualities and the Influence Thej Exercise Upon Each Other for ^ 'our Physical and Mental W^elfare. N e\v York; Alfred A. Knopf, 1921.

Buzzard, E. Farquhar. "Some Aspects of Mental Hygiene." Mental Hygiene 6 Quly 1922): 449-62.

Buzzard, E. Farquar. "Traumatic Neurasthenia." Mental Hygiene 8 (Februar)^ 1928); 425-37.

Campbell, Charles MacFie. "Education and Mental Hygiene." Mental Hygiene 3 Quly 1919); 398-408.

Campbell, Charles MacFie. "Mental Health of the Community' and the Work of the Psychiatric Dispensar\\" Mental Hygiene 1 (October 1917): 572-84.

Campbell, Charles MacFie. The Mental Health of the Community and the Work of the Psychiatric Dispensary. New York; National Committee for Mental Hygiene, Inc., 1917.

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Wells, Frederic Lyman. "Common Factors in Mental Health and Illness." Popular Science Monthly 83 (1914): 569-81.

Wells, Frederic Lyman. "Mental Adaptation." Mental Hygiene 1 (January 1917): 60-80.

NX'ells, Frederic Lyman. MentalAdjnsttnents. New York: Appleton, 1917.

Wells, Frederic Lyman. "Psycholog}' in Medicine." Mental Hygiene 6 (October 1922): 700-7.

\X•^^itaker, Catherine Jean. "Almshouses and Mental Institutions in Michigan, 1871-1930." Ph.D. diss., Universit)' of Michigan, 1986. 468

Wliite House Conference on Child Health and Protection. The Adolescent in the Family: A Study of Personality Development in the Home Environment. New York: D. Appleton-Centurj' Company, 1934.

Wliite, William Alanson. "The Behavioristic Attitude." 5 (Januar)'1921); 1-18.

V(^ite, William Alanson. "Childhood; The Goldern Period for Mental H)'giene." Mental Hygiene 4 (April 1920): 257-67.

White, William Alanson. "The Dynamics of the Relation of Physician and Padent." Mental Hygiene 10 Qanuar)- 1926): I-ll.

V^'liite, William Alanson. "The Frontier of the Ivlind." Mental Hygiene 19 Qanuarj' 1935): 78-94.

White, William Alanson. "The Influence of Psychiatric Thinking on General Medicine." Mental Hygiene 2Q (April 1936): 189-204.

Vdiite, William Alanson. Insanity and the Criminal Law. New York: The MacmiUan Co., 1923.

Wliite, William Alanson. An Introduction to the Study of the Mind. Washington, D.C.: Nervous and Mental Disease Publishing Co., 1924.

V^-liite, William Alanson. "Man, the Great Integrator." Science 81 (March 8, 1935); 237-43.

White, William Alanson. Mechanisms of Character Formation. New York; The MacmiUan Company, 1916.

VC-liite, WilUam Alanson. "Mental Hygiene of Adolescence." American Journal of Public Health 23 (1933): 206.

NXTiite, William Alanson. The Mental Hygiene of Childhood. Boston; Litde, Brown, and Company, 1924.

XX-liite, William Alanson. "Mind; Man's Most Distinctive Organ." Mental Hygiene 13 (July 1929); 462-72.

\Xliite, NX'illiam Alanson. "The Origin, Growth, and Significance of the Mental Hygiene Movement." Mental Hygiene 14 (July 1930); 555-64.

Wliite, WilUam Alanson. "Preventive Principles in the Field of Mental Medicine." American journal of Public Health 1 (1911): 82-3.

White, William Alanson. "Preventive Principles in the Field of Mental Medicine." journal of Infectious D/jwjw 36 (1911); 30-7.

Wliite, WilUam Alanson. The Principles of Mental Hygiene. New York; The MacmiUan Company, 1923.

Wliite, WilUam Alanson. "Unconscious Motives Determining Social Attitudes." Proceedings of the National Conference of Social Work 50 (1923); 91-4.

VC'liite, WilUam Alanson. "Underlying Concepts in Mental Hygiene." Mental Hygiene 1 Qanuary 1917): 7-15. 469

Wliite, William Alanson. "Underlying Concepts in the World Movement for Health: Mental Hygiene." Proceedings of the National Conference of Social Work 49 (1922): 43-8.

White, William Alanson and Morris Fishbein, eds. Why Men Fail New York: D. Appleton Centura- Company, Inc., 1928.

Whitehurst, Robert Eugene. "The Rise of Communitj' Mental Health: A Polidcal and Historical Analysis." Ph.D. diss., Universit)' of Michigan, 1983.

Wilbur, R.L. "Mental Health as a National Problem." Mental I-I)igiene 15 Quly 1931): 449-55.

Wile, Ira Solomon. Can We Change Personalitj? New York: Nadonal Probation Association, 1939.

Wile, Ira Solomon. The Challenge of Adolescence. New York: Greenberg, 1939.

Wile, Ira Solomon. The Challenge of Childhood: Studies in Personality and Behavior. New York: Thomas Seltzer, 1925.

Wile, Ira Solomon. "'Good' Education and 'Bad' Children." Mental Hygiene 9 (Januan-1925): 105-12.

Wile, Ira Solomon. "Laziness in School Children." Mental Hygiene 6 Qanuary 1922): 68-82.

Wile, Ira Solomon. "Mental Health of the Preschool Child." American Journal of Public Health 23 (1933): 191.

Wile, Ira Solomon. "Mental Hygiene Approach to Public Health." Mental Hygiene 17 (July 1933): 380-95.

Wile, Ira Solomon. "Mental Hygiene of Younger Children." Proceedings of the National Conference of Social H'or-fe 51 (1924): 455-9."

Wilkinson, J uha P. "The Education of the Nurse in the Principles of Mental Hygiene." Mental Hygiene! (July 1923): 538-64.

Williams, C.L. and J. Westermeyer. "Public Health Aspects of Mental Health: The Last 75 Years of the American Journal of Public Health." American Journal of Public HealthlS (July 1985): 722-6.

Williams, Frankwood Earl. "Advances in Mental Hygiene in 1923." Modern Hospital22 (Januar)-1924): 41-3.

Williams, Frankwood Earl. "Communit)' Responsibilit)' in Mental Hygiene." Mental Hygiene 7 (July 1923): 496-508.

Williams, Frankwood Earl. "Finding a Way in Mental Hygiene." Mental Hygiene 14 (April 1930): 225-57.

Williams, Frankwood Earl. "The Importance of Social Relationships in the Development of the Personalit)' and Character of the Adolescent." Mental Hygiene 14 (October 1930): 901-6.

Williams, Frankwood Earl. "Is There a Mental Hygiene?" Psychoanalytic Quarterly 1 (April 1932): 113-20. 470

Williams, Frankwood Earl. "Mental Hygiene; An Attempt at a Definition." Mental Hygiene 11 (July 1927): 482-8.

Williams, Frankwood Earl. "Mental Hygiene and Hard Times; Out from Confusion." Proceeding)- of the Kationa! Conference of Social Work 59 (1932); 338-52.

Williams, Frankwood Earl. "Relation of Alcohol and Sj'philis to Mental Hygiene." American Journal of Public Health 6 (1916): 1272.

Williams, Frankwood Earl. "Role of the Public Health Nurse in Communit)' Mental Hygiene." American journal of Public Health 17 (July 1927): 699-703.

Williams, Frankwood Earl. "The Significance of Mental Hygiene for the Teacher and the Normal Child." Proceedings of the National Conference of Social Work 48 (1921): 359-63.

Williams, Frankwood Ear). "Symposium on Health Supervision in Colleges; Mental Hygiene and the College Student." American journal of Public Health \\ (1921): 341.

Williams, Frankwood Earl. "Symposium on Health Super\'ision in Colleges; Public Health Education and Mental Hygiene." American journal of Public Health 11 (1921); 420.

Williams, Frankwood Earl, et al. Social Aspects of Mental Hygiene. New Haven; Yale Universit)' Press, 1925.

Williams, Frankwood Earl, ed. Neuropsychiatry and the ll'ar New York: Nadonal Committee for Mental Hygiene, 1918.

Winslow, Charles-Edward Amor)'. "A Communit}- Mental Hygiene Program; The Next Great Opportunity." Milbank Memorial Fund Quarterly 13 (July 1935); 211-8.

Winslow, Charles-Edward Amor\'. "The Mental Hygiene Movement and its Founder." Mental Hygiene 17 (October 1933); 533-42.

Winslow, Charles-Edward Amon'. "The Mental Hygiene Movement, 1908-1933, and Its Founder." In A Mind That Found Itself 38th printing, by Clifford VCInitdngham Beers, 307. 1966.

Winslow, Charles-Edward Amor)'. "Twent)' Years of Mental Hygiene." Mental Hygiene 12 (July 1928): 504-15.

Winternitz, Milton C. "A Physician Looks at Mental Hygiene." Mental Hygiene 16 (April 1932); 221-32.

Winters, Eunice E. "Adolf Meyer and CUfford Beers, 1907-1910." Bulletin oj the History ojMedicine 43 (September-October 1969): 414-43.

Winters, Eunice E. "Adolf Meyer's Two and a Half Years at Kankakee." Bulletin of the History of Medicine 40 (1966); 441-58.

Witmer, Helen Leland. Psychiatric Clinics for Children. New York: Commonwealth Fund, 1940.

Wright, Harold W. "Symposium on Mental Hygiene; Social Aspect of Mental Defect." American journal of Public Health 11 (1921): 431. 471

Wright, Wade. "Industrial Hygiene." Mental Hygiene 5 (July 1921): 497-8.

Yerives, Robert Mearns. "Significance of Intelligence in the Conser\'ation of Health." Proceedings of the National Conference of Social U^or^ 50 (1923); 88-91.

CHAPTER VIII. SELLING HEALTH

Abramson, Judith and D.K. Freedman. "Health Education in a Housing Project." Public Health Nursing 38 (April 1938): 178-81.

Akin, C.V. "The Present Status of Public Health Education." American journal of Public Health 30 (1940): 1436.

American Museum of Health, Inc. Proceedings of the Dedication of the Museum, June 17, 1939, in the Medicine and Public Health Building, Neiv York World's Fair, 1939. New York: American Museum of Health, Inc., 1939.

American Public Health Association. Community Organisation for Health Education. Cambridge, Mass.: Technolog}'Press, 1941.

Amundsen, Grace. "Public Health Education." American Journal of Public Health 12 (October 1922): 815-25.

Andress, James Mace. The Boys and Girls of Wake-Up Town. Boston: Ginn & Company, 1924.

Andress, James Mace. Health Education in KitralSchools. Boston: Houghton Mifflin Company, 1919.

Andress, James Mace. Health Education in RjiralSchools. Revised edition. Boston: Houghton Mifflin Company, 1925.

Andress, James Mace. "The Teaching of Hygiene in Elementary' Schools." In Educational Hjgiene, ed. I..W. Rapeer. New York: Charles Scribner's Sons, 1915.

.-\ndress, James Mace. The Teaching of Hjgiene in the Grades. Boston: Houghton Mifflin Company, 1918.

Andress, James Mace and Mabel C. Bragg. The Sunshine School. Boston: Ginn & Company, 1928.

Andress, James Mace and W.A. Evans. Health and Good Citi^nship. Boston: Ginn & Company, 1925.

Andress, James Mace and W.A. Evans. Health and Success. Boston; Ginn & Company, 1925.

Armstrong, Donald Budd. "Educational Work in Sanitary Food Values in New York City." American Journal of Public Health 5 (1915): 347.

Armstrong, Donald Budd. "The Objectives of the Conference; The Radio in Health Education." In ^dio in Health Education. 39-40. New York: Columbia Universit}' Press, 1945. 472

Armstrong, Donald Budd. "\'ital Statistics for Educational Uses." American Journal ofPub/ic Health 15 (1925): 217-9.

Averill, Lawrence Augusms. Educational Hygiene. Boston; Houghton Mifflin Compan}-, 1926.

Bache, Louise Franklin. Health Education in an American City. New York; Doubleday, 1934.

Bache, Louise Franklin. "Health Education Program in a Cit\' of 100,000." American Journal of Public Health 18 (1928): 581.

Baker, Helen Cody and Mar)' Swain Routzahn. Horn to Inteipret Social Work: A Stucly Course. New York; Russell Sage Foundation, 1937.

Bauer, W.W. and Leslie Edgley. Your Health Dramatit^ed: Selected Radio Sciipts. New York: Dutton, 1939.

Bauer, W.W. and Thomas G. Hull. Health Education of the Public: A Practical Manual of Technic. Philadelphia: W.B. Saunders Company, 1937.

Beachley, Ralph G. "Selling Public Health." American Journal of Public Health 16 (June 1926): 616-7.

Bent, Michael J. and Ellen F. Greene. Rural Negro Health: A Report on a Five-Year Esperiment in Health Education in Tennessee. Nashville, Tenn.; Rosenwald Fund, 1937.

Bigelow, Maurice A. and Jean Broadhurst. Health for Evetj Day. New York: Silver, Burdett & Co., 1927.

Blanchard, Alan. "Health Information on the Air." American Journal of Public Health 25 (October 1935): 1081-8.

Blanchard, Alan. "Technic of Radio Broadcasting in Health Education." American Journal of Public Health 27 (1937); 796.

Blanchard, V.S. "Integration of the School Health Program with Communit)- Health Education." American Journal of Public Health 2G (1936): 625.

Bolduan, Charles F. "Education Versus Compulsion." New York State Journal of Medicine 39 (August 1, 1939); 1505.

Bolt, Richard Arthur. "The Cleveland Health Museum." Child Health 1 (October- November 1940): 1-5.

Bolt, Richard Arthur. "Education for Home and Family Life." American Journal of Public Health 21 (April 1931); 438-41.

Bolt, Richard Arthur. "Health Education." American Physical Education Review 26 (March 1921); 109-15.

Bolt, Richard Arthur. "Parental Education and Child Hygiene." American Journal of Public Health 23 (March 1933); 278-81.

Bolt, Richard Arthur and Ethel Gordon. "Nursery Education." Child Health 7 (Januar)' 1940); 1-4. 473

Broadhurst, Jean. AUThmu^h the Day the Looking G/ass Philadelphia; J.B. Lippincott Company, 1926.

Broadhurst, Jean. A// Through the Day the Mother Goose ir'iV)'. Philadelphia; J.B. Lippincott Compant, 1921.

Broadhurst, Jean. Health 'Education; A Manual for Bjiral Teachers. Albany, N.Y.; The Universit}- of the State of New York, 1931.

Brown, Bertrand. "A New Deal in Health Education." American Journal of Public Health 24 (July 1934); 743-8.

Brown, Earle G. "Health Education in a Medium Urban Communit)\" American Journal of Public 33 (1943): 985.

Brown, Earle G. "Keeping the Public Interested in Accident Data." American Journal of Public Health 22 (1932); 544.

Brown, Maud Anna. Teaching Health in Fa/go. New York: The Commonwealth Fund, 1929.

Brown, Walter H. "Adult Health Educadon." American Journal of Public Health 22 (October 1932); 1061-8.

Brown, Walter H. "School Health Education." American Journal of Public Health 30 (1940); 35.

Brydon, Mar}' E. "The Virginia Plan for Health Educadon in Public Schools." American Journal of Public Health 14 (1924); 229.

Br)'son, Lyman. "The Responsibility for Program Planning: The Radio in Health Educadon." In Radio in Health Education, 82-90. New York: Columbia University Press, 1945.

Bundesen, Herman N. "Selling Health; A Vital Dut}\" American Journal of Public Health 18 (December 1928): 1451-4.

Burkard, William E. "An Analysis of Educadonal Objectives and Outcomes in the Field of Health Education." Ph.D. diss., Universit)-of Pennsylvania, 1927.

Burkhard, William E., et al. Health Habits bj Practice. Chicago; Lyons and Carnahan, 1926.

Burnham, William H. "The Home in Relation to the Other Factors in Education." Proceedings of the Child Conference for Kesearch and Welfare (1909); 165-7.

Burrows, E.G. "Newspaper Publicit)'." American Journal of Public Health 15 (April 1925); 317-22.

Calver, Homer N. "Exhibit Medium." American Journal of Public Health 29 (1939); 341.

Calver, Homer N. "New Developments in Health Education." American Journal of Public Health 34 (1944); 876.

Calver, Homer N. "Resources of Industr}' for Health Education." American Journal of Public Health 34 (1944); 489. 474

Calver, Homer N. "Tent-Speaking for Health." MUbank Memorial Fund Quarterly Bulletin 7 (October 1929): 1.

Calver, Homer N. and Bertrand Brown. "Marketing Mass Education." American Journal of Public Health 22 (January 1932): 49-58.

Calver, Homer N., et al. "Scientific Exhibits." American Journal of Public Health Yearbook (1937-8): 42-3.

Calver, Homer N., et al. "Scientific Exhibits." American Journal of Public Health Yearbook (1941-2): 54-60.

Calver, Homer N., et al. "Use of Ratings in the Evaluation of Exhibits." American Journal oj'Public Health 33 (1943): 709.

Cantril, H. and G.W. Allport. The Psjcholo^ ofBuidio. New York: Harper, 1935.

Carlton, B.L. "Publicity as a Means of Promoting Efficiency in Health Work." American City 23 (July 1920): 56-7.

Case, Claude E., et al. "Education in Health at Cornell University, 1919-1920." American Journal of Public Health 11 (April 1921): 309-26.

Champion, Merrill E., et al. "Status of Health Education." American Journal of Public Health 14 (Octobcr 1924): 868-77.

Chase, Arthur F. "Address of Welcome: The Radio in Health Education." In Radio in Health Education, 37-8. New York: Columbia Universit\- Press, 1945.

Chayer, Mar}' Ella. Bibliography in Health Education for Schools and Colleges. New York: G.P. Putnam's Sons, 1936.

Chayer, Mar}- Ella. School Nursing: A Contribution to Health Education. New York: G.P. Putnam's Sons, 1931.

Chesley, A.J. "Is Indian Susceptible to Health Education?" American Journal of Public Health 15 (Februar}' 1925): 133-6.

Child, H.L. Practical Methods for Identifying Public Opinion. New York: Social Work Publicit}' Council, 1937.

Child, H.L. A Reference Guide to the Study of Public Opinion. Princeton: Princeton University Press, 1934.

Cohen, Philip H. "Using the Established Program as a Medium: The Radio in Health Education." In Radio in Health Education, 65-7. New York: Columbia Universit}' Press, 1945.

Connolly, Mar)- P. "Interpreting the Physician and Making Him a Part of the Health Education Program." American Journal of Public Health 29 (1939): 473.

Connolly, Mary P. "Organization of Adult Groups for Health Education." American Journal of Public Health 24 (June 1934); 571-5. 475

Connolly, Man' P. "WTiat Every Health Officer Should Know; Health Education." American ]otirnalof /W/VHw/z/; 28 (1938): 1083.

Conrad, Howard L. and Joseph F. Meister. Teaching Procedures in Hea/tb Eciiicalion. Philadelphia; W'.B. Saunders, 1938.

Cronan, Dorothy S. and Clare W. Alcroft. So You're Going to Do Piihlhi/j! A Publicity Primer in Terms of Health Education. New York; The Woman's Press, 1939.

Dansdill, Theresa. Health Training in the Schools: A Handbook for Teachers and Plealth Workers. Second edition. New York; National Tuberculosis Association, 1923.

Dealey, W.L. "Discussion: Health Education and Publicit)^" American journal of Public Health 12 (April 1922): 283-4.

Delameter, H. "Education and Care of Undernourished Pre-Tuberculous Children." American Journal of Public Health 16 (1926): 378.

Deming, Dorothy. "Selling Health Through Washing Machines." Suniej 57 (Februar)' 15,1927): 632-34.

De Muth, Lucy. "Health Teaching in the Small Industry'." Public Health Nursing 28 (October 1936): 678.

Derryberry, Mayhew. "Exhibits." American Journal of Public Health 31 (1941); 257.

Dern'berry, Mayhew and A. Weissman. "Health Using Tests as Medium." Pub/ic Health Reports 55 (March 22,1940): 485-9.

Dinwiddie, Courtenay. "Discussion: Health Education and Publicity." American Journal of Public Health 12 (April 1922):'282-3.

Dowling, Oscar M. "Publicity in Health Matters a Public llight." American Journal of Public Health 8 (May 1918); 341-4.

Dublin, Louis Israel, et al. "The American Museum of Hygiene." American Journal of Public Health Yearbook (1938-9); 30-1.

Dublin, Louis Israel, et al. "The American Museum of Hygiene." American Journal of Public Health Yearbook (1939-40): 45-6.

Dublin, Louis Israel, et al. "The American Museum of Hygiene." American Journal of Public Health Yearbook (1940-1): 60.

Dublin, Louis Israel, et al. "The American Museum of Hygiene." American Journal of Public Health Yearbook (1941-2): 52-3.

Dublin, Louis Israel, et al. "The American Museum of Hygiene." American Journal of Public Health 33 (April 1943): 432.

Egolf, Willard D. "Does Radio Owe a Doctor's Bill?" In Radio in Health Education, 1?>-S2. New York: Columbia University'Press, 1945. 476

Ellis, Carlyle. "Discussion: Motion Picture Symposium." American Journal of Public Heal/li 12 (1922); 272.

Emerson, Haven. "Making Health ICnowledge the Property of the Communit}^" Proceedings qflbe National Conference of Social ]Y''ork 48 (1921): 63-8.

Evans, W.A. "What Can Be Done at the Next Convention to Advance Efficient Work in Health Education and Publicit}'?" American Journal of Public Heallh 12 (April 1922); 288-9.

Everett, Ray H. "Publicit}' and the Campaign Against Venereal Disease." American Journal of Public Health 9 (November 1919); 854-8.

Fall, Delos. "A Plea for the Teaching of Sanitarj' Science in Our Schools." Education 17 (1897); 266-72.

Fall, Delos. "The Teaching of Hygiene and Sanitary Science in the Secondary Schools." The School Review 6 (1898): 65-75.

Feldman, Harry. "Vitamines, Public Health, and Publicit)\" M.D. thesis, Universit)' of Wisconsin, 1931.

Fishbein, Morris. Medical Writing: The Technique and the Art. Chicago: American Medical Association, 1938.

Fisher, I. and Eugene Lyman Fisk. Health Education: A Manual for Bairal Teachers. Albany, N.Y.: The Universit}' of the State of New York, 1931.

Ford, C.E. "Health Education in Industr)'." American Journal of Public Health 11 (June 1921): 489-97.

Franzen, Raymond. Health Education Tests: A Description of the Tests Used in the School Health Study, with Norms for Fifth and Sixth Grade Children, and Directions for Giving the Tests. School Health Research Monographs, no. 1. New York: American Child Health Association, 1929.

Galdston, lago. "A Critique of the Objectives and Techniques in Health Education." In Radio in Health Education, 40-4. New York: Columbia Universit}' Press, 1945.

Galdston, lago. "The Cultural Background of the Health Educator." Lancet! (July 22, 1939): 233.

Galdston, lago. "Debunking Health Education." Journal of the American Medical Association 91 (October 6, 1928); 1055-6.

Galdston, lago. "Hazards of Commercial Health Advertisements." American Journal of Public Health 21 (March 1931); 242-8.

Galdston, lago. "Health Education." American Journal of Public Health 23 (April 1933); 337-8.

Galdston, lago. The Health Talk. New York: National Tuberculosis Association, 1932.

Galdston, lago. "How to Tell Wliat in Popular Health Instruction." American Journal of Public Health 20 (Februar)' 1930); 171-4. 477

Galdston, lago. "Psychologic Factors of Health Education." Ammcan journal of Public Heallh 26 (1936); 171.

Galdston, lago. "The Psychophysics of Health Education." Transactions of the National Tuberculosis Association 28 (1932); 270-8.

Galdston, lago. "What Constitutes Health Education in the High School." American Journal of Public Health 22 (May 1932); 505-13.

Gebhard, Bruno. "The Changing Ideolog)' of Health Museums and Health Fairs Since 1850." Bulletin of the Histo^' of Medicine 33 (1959); 160-7.

Gebhard, Bruno. "Health E.xhibits." American Journal of Public Health 30 (1940); 657.

Gellott, Laura. "Visiting the Rural Communit)'; A Public Health Education Program in the 1930s." Mid-America 69 (1987); 21-38.

Goldstein, Leon. "The Local Radio Station in Health Education." In Radio in Health Education, 96-103. New York; Columbia Universit}- Press, 1945.

Gonzalez-Rivera, Manuel. "Ways to Communit)' Health Education." American journal of Public Health 33 (Februan-1943); 146-8.

Graves, W. Brooke. Readings in Public Opinion. New York; Appleton, 1928.

Green, Howard Wliipple. "Objecdves of Publicit}" On What Basis Are They Selected." American Journal ofPublic Health 19 (May 1929); 516-9.

Gregg, Alan. "Basis, Purpose, and Method; The Radio in Health Educadon." In Radio in Health Education. 67-9. New York; Columbia University- Press, 1945.

Grout, Ruth E. "Appraising a School Health Educadon Program." American Journal of Public Health 30 (1940); 797.

Grout, Ruth E. "Function of the School in the Rural Health Program." American Journal of Public /-W/A 27 (1937); 583.

Grout, Rurii E., ed. Handbook of Health Education: A Guide for Teachers in Rural Schools. New York; The Odyssey Press, 1934.

Gruenberg, Benjamin Charles. "Motivation in Health Education." American Journal of Public Health 23 (Februan' 1933): 114-22.

Gruenberg, Benjamin Charles. A Museum of Heallh. New York, 1937.

Gudakunst, Don W. "The School Health Program as an Educational Activity." American Journal ofPublic Health 25 (April 1935); 463-8.

Hahn, Mar)- L. "Health Education in Illinois Teachers' Colleges." American Journal ofPublic Health 19 (May 1929); 488-494. 478

Hall, G. Stanley. EdiicalionalProblems. 2 vols. New York: D. Appleton and Company, 1911.

Hall, P.M. "Publicity and Public Health." American journal of Public Health 4 (1914): 105.

Hallock, Grace Taber. Dramatizing Child Health: A Neiv Book of Health Plays, with Chapters on the Writing, the Producing, and the Educational Value of Dramatics. New York: American Child Health Association, 1925.

Hallock, Grace Taber and Charles-Edward Anion- Winslow. The Land of Health. New York: Charles E. Merrill Company, 1922.

Harding, Mabel Traer. "Rousing Interest in Health." Survey 43 (March 13,1920): 742-3.

Hawkins, Norval Abiel. The Selling Process: A Handbook of Salesmanship Principles. 8th ed. Detroit: N.A. Hawkins, 1920.

Hedrich, A.W. "Safeguards in the Publicit)' Use of Vital Statisdcs." American Journal of Public Health 24 (April 1934): 336-41.

Heiser, Victor G., et al. "American Museum of Hygiene." American Journal of Public Health Yearbook (1934-5): 53.

Heiser, Victor G., et al. "American Museum of Hygiene." American journal of Public Health Yearbook (1936-7): 38-40.

Hewitt, Richard M. "Tabular and Textual Lantern Slides." American Medical Association Bulletin 31 (December 1936): 184.

Higby, William Ford. "Health Education of the Public." American Journal of Public Health 30 (1940): 278.

Higby, WHliam Ford. "Public Health Education Technics of Special Experiences; Newspapers." .•American Journal of Public Health 25 (May 1935): 605-8.

Hill, Frank Ernest. EducatingJbr Health: A Stuely of Programs for Adults. Studies in the Social Significance of Adult Education in the United States Series. New York; American Associauon for Adult Education, 1939.

Hill, Frank Ernest. "On Forming a Program; The Radio in Health Education." In Radio in Health Education, 37-8. New York: Columbia University Press, 1945.

Hiscock, Ira V. "Community Health Education." American Journal of Public Health 30 (1940): 516.

Hiscock, Ira V. "Organization, Content, and Conduct of an Institute on Public Health Education." American Journal of Public Health Yearbook (1939-40): 112.

Hiscock, Ira V. "Set-Up and Budget for Public Health Education." American Journal of Public Health 26 (1936): 593. 479

Hiscock, Ira V. "The Value of Health Department Reports." American JoiiriictI of Public Health 15 (November 1925): 963-6.

Hiscock, Ira V., et al. "Methods in Health Education." American Jourmil of Public Health Yearbook (1935-6): 207.

Hiscock, Ira V., et al. "Methods in Health Education." American ]ournal of Public Health Yearbook (1936-7): 147.

Hiscock, Ira V., et al. Wajs to Community Health Education. New York: The Commonwealth Fund, 1939.

Horning, Benjamin G., et al. "The Communic\- Health Education Program." American journal of Public 31 (1941): 310.

Hussey, Marguerite M. Teaching/or Health. New York: Prentice-Hall, Inc., 1939.

Hutchinson, Woods. "Publicit)' in Public Health Work." American ]oumal of Public Health 3 (August 1913): 777-9.

Jacobs, Philip P. "Health Education for Adults." In Handbook of Adult Education in the United States, Compiled Under the Auspices of the American Assodation for Adult Education. New York: American Association for Adult Education, 1936.

Jacobs, Philip P. "How Can Health Departments and Health Organizations Work Together to Have Suitable Pictures Produced?" American journal of Public Health 12 (April 1922): 211-9.

Jacobs, Philip P. "Tuberculosis in Motion Pictures." journal of the Outdoor Life 9 (December 1912): 302-5.

Jean, Sally Lucas. "Creating a Demand for Health." Proceedings of the National Conference of Social Work 47 (1920): 12-6.

Jean, Sally Lucas. "Health Education Source Material and Criterion by Wliich it Can Be Judged." American journal of Public Health 16 (November 1926): 1094-8.

jean, Sally Lucas. "Success and Failure in Health Promotion." Trained Nurse and Hospital Review 97 (September 1936): 221.

Jenkins, H.O. "Sanitar)- Education in California by Means of a Traveling Railroad Exhibit." journal of Infectious Diseases 35 pt. 1 (1909): 164-6.

Jenkins, Hester D. "Educational Work of the Brooklyn Anti-Tuberculosis Committee." American journal of Public Healthl (1917): 187.

[ones, Myron Jermain. "Popular Education in Mouth Hygiene Through Organized Publicit)', Through the Platform, Through Exhibits, Through Modon Pictures, Through the Press." American journal of Public Health 5 (1915): 405.

Keller, Thomas McNeese. "Public Health on the Railroad; William Freeman Snow and the California Sanitation Exhibit." American journal of Public Health 87 (November 1997): 1859-61. 480

Kiernan, Frank. "Health Education Demonstrations in Massachusetts High Schools." TmnsMtions of the National Tuberculosis Association 28 (1932): 254-8.

Kings bur}', John A. "Right Publicit)' and Public Health Work." Proceedings of the National Conference of Charities and Corrections (1909): 333-8.

Kingsbur)', John A. "Scope and Nature of Publicit)' as a Factor in Popular Educational Movements in Public Health." Journal of Infectious Diseases pt. 1 (1909): 167-78.

I'Geinschmidt, H.E. "The Early Days of the Public Health Education Section." American Journal of Public 34 (1944): 1058.

Kleinschmidt, H.E. Making an Amateur Health Movie. New York: National Tuberculosis Association, 1931.

Kleinschmidt, H.E. "A Publicit)- Campaign of National Scope." American Journal of Public Health 18 (November 1928): 1369-74.

Kleinschmidt, H.E. "Who Shall Make the Motion Picture, the Health Worker or the Motion-Picture Man?" American Journal of Public Health 12 (April 1922): 276-7.

Lamkin, Nina B. Health Education in Rural School and Communities. New York: A.S. Barnes and Company, 1946.

Lasswell, H.D., etal. Propaganda and Promotional Activities: An Annotated Bibliographj. Minneapolis: Universit)' of Minnesota, 1935.

Lazarsfeld, Paul F. and Patricia Kendall. "The Listener Talks Back: Report on a Test of a Public Health Program." In Radio in Health Education, 48-65. New York: Columbia Universit)' Press, 1945.

Le^', Ernest Coleman. "Advantages and Difficulties of Publicitv* in Connecdon with Municipal Public Health Work." Journal of the American Medical Association 52 (February 27, 1909): 683-6.

Le\7, Julius. "Reduction of Infant Mortality' by Economic Adjustment and by Health Education." American Journal of Public Health') (September 1919): 676-81.

Lewis, Sinclair. Arrowsmith. London: Jonathan Cape, 1925; reprint, Chicago: Harcourt, Brace, and Company, 1945.

Link, William A. "Privies, Progressivism, and Public Schools: Health Reform and Education in the Rural South, 1909-1920." Journal of Southern Histoij 54 (November 1988): 623-42.

Marcus, Lawrence. "What Can Be Done Cooperatively During This Year to Study Methods and Materials?" American Journal of Public Health 12 (April 1922): 287-8.

Marquette, Bleecker. "A Small Town Health Exposition." American Journal of Public Health 13 (May 1923): 396.

Marquette, Bleecker. "\'oluntary Agencies' Activities in a Cit)' Health Education Program." American Journal of Public Health 19 (October 1929): 1123-8. 481

Mayer, R.C. Ho;v to Do Publidtj. New York: Harper, 1937.

McClintock, Miller. "Planning for the Future; The Radio in Health Education." In Radio in Health Fulucatioii, 90-6. New York: Columbia Universit)- Press, 1945.

McKernon, Edward. "How the Health Officer May Obtain Newspaper Publicit)\" American journal of Public Health 17 (September 1927): 912-7.

McMurtrie, Douglas C. "Appropriate T\*pographical St^'le in Public Health Printing." Nation's- Health 6 (August 1924): 8.

Meyer, Ernst Christopher. "What are the Needs in Health Motion Pictures That are Not Met at Present?" American Journal of Public Health 12 (April 1922): 275-6.

Miller, R. Justin. "Labor Camp Sanitadon: A Basis for Education and Citizenship." American Journal of Public Health 11 (August 1921): 697-702.

Moree, Edward A. "Public Health Publicit^': Making a Meeting Effecuve." American Journal of Public Health

Moree, Edward A. "Public Health Publicit)-: Newspaper Adverdsing." American Journal of Public Health 6 (1916): 730,

Moree, Edward A. "Public Health Publicit)" Newspaper Publicit)-." American journal of Public Health 6 (1916): 497.

Moree, Edward A. "Public Health Publicit)" Organization for Health Publicity." American Journal of Public Health (y{\<)\G)-.2G9.

Moree, Edward A. "Public Health Publicit)': The Scope of Publicit)\" American Journal of Public Health 6 (1916): 97-108.

Moulton, Nathalie Forbes. The Brownie's Health Book. Boston: Litde, Brown and Co., 1925.

Nash, Jay B. Teachable Moments: A New Approach to Health. New York: A.S. Barnes and Company, 1938.

Neurath, Otto. "Visual Education." Surv^' Graphic IG Qanuar)' 1937): 25.

New York Academy of Medicine. Radio in Health Education. Frontiers in Public Health Education, no. 1. New York: Columbia Universit)' Press, 1945.

Osborn, Stanley. "What Standard Should Be Set for the Pictures Used By Health Agencies?" American Journal of Public Health 12 (April 1922): 272.

Overstreet, H.A. influencing Human Behavior. New York: Norton, 1925.

Palmer, George Truman and Mayhew Derryberr)'. "Appraising the Educational Content of a Health Service Program." American Journal of Public Health 27 (1937): 476. 482

Patterson, Raymond S. "Influencing Human Behavior." Public Hea/tb A'«w of the New Jersey Department of Health 14 (April 1929): 100.

Patty, Willard Walter. Teaching Health and Safety in Elemental^' Grades. New York: Prentice-Hall, Inc., 1940.

Payne, E. George. Education in Health. Lyons and Carnahan, 1921.

Payne, E. George and Louis C. Schroeder. Health and Safety in the New Curricutum: A Teacher's Training Book. New York: The American Viewpoint Societ)% Inc., 1925.

Peter, W.W. "The Psychology of Public Health Educadon." American Journal of Public Health 17 (May 1927): 485-9.

Peterson, Mrs. Frederick. Child Health Alphabet. 9th ed. New York: Macmillan Company, 1922.

Quiett, Glenn C. and Ralph D. Casey. Principles ofPublicitj. New York: Appleton, 1926.

Resnick, David. "Publicity for Your Nursing Service." Public Health Nursing 28 (August 1936): 501.

Resnick, David, et al. "Udlization of Commercial Advertising for Health Education." American journal of Public Health 35 (1945): 859.

Rickards, Burt Ransom. "Discussion; Local Publicit)' Use ofStadsdcs from Nadonal and State Sources." American journal of Public Health 24 (April 1934): 334-5.

Rickards, Burt Ransom. "Wliat Should be the Policy of the Monthly Health Bulledn?" American journal of Public Health 12 (April 1922): 286.

Ries, Joseph. "The Health Educator on the Radio." American journal of Public Health30 (1940): 641.

Roadhouse, C.L. "Educadonal Aspects of Diar)- and Milk Inspecdon." American Journal of Public Health 19 (October 1929): 1129-32.

Roberts, Bertrand E. "Nutritional Education in the Home." American Journal of Public Health 28 (1938): 944.

Roberts, James. "Diphtheria Immunization Exhibit." American Journal of Public Plealth 22 (1932): 852.

Robinson, Edward S. "Psychology and Public Policy." School and Society 37 (April 29,1933): 537.

Robinson, Edward S. "The Psychology of Public Education." American journal of Public Health 23 (Februarj-1933): 123-8.

Rogers, Charles F. "Commercial Salesmanship Applied to Public Health Work." American journal of Public Health 15 (October 1925): 891-3.

Rood, Ehna. "The Part the School Nurse Plays in the School Health Education Program." American journal of Public Health 2^ (November 1935): 1215-20. 483

Rood, Elma. "Participation of Lay People in the Promotion of a Rural Child Health Program." American Jonnta!oj Public Health 22 (October 1932): 1027-32.

Rood, Elma. "Training Teachers in Health Education." American Journal of Public Health 19 (December 1929): 1321-6.

Rood, Elma. Tuberculosis Education: A Cuide for Professional and Lay W'^orkers. Madison College, Tenn.: Rural School Press, 1936.

Rose, Marie L. "Problems to be Solved in Health Education." American journal of Public Health 12 (April 1922): 286-7.

Rose, Milton S., et al. "Exhibit Awards." American Journal of Public Health Yearbook (1941-2): 60-1.

Routzahn, Evart Grant. "Health Education and Publicity." American Journal of Public Health 13 (March 1923): 248-50.

Routzahn, Evart Grant. "In Memoriam." American Journal of Public Health 29 (1939): 676.

Routzahn, Evart Grant. "Sources of Material." American Journal of Public Health 16 (March 1926): 268-73.

Routzahn, Evart Grant. "Symposium on How to Further Progress in Health Education and Publicit)-." American Journal of Public Health 12 (April 1922): 279.

Routzahn, Evart Grant. "Symposium on Motion Pictures: Introductor)' Remarks." American Journal of Public Health 12 (April 1922): 269-70.

Routzahn, Evart Grant. "VC'lien is an Exhibit?" Transactions of the Annual Meeting of the National Tuberculosis Association 17 (1921): 485-90.

Routzahn, Evart Grant and Man- Swain Routzahn. The ABC of Exhibit Planning. New York: Russell Sage Foundation, 1928.

Routzahn, Evart Grant and Mary Swain Routzahn. "Training for Health Education and Publicit}-." American Journal of Public Health 14 (June 1924): 480-1.

Routzahn, Evart Grant, et al. "Educational Publicit)' Round Tables." American Journal of Public Health 17 (June 1927): 572-5.

Routzahn, Marj' Swain. "The Clinic on Printed Matter." American Journal of Public Health 14 (January 1924): 43-50.

Routzahn, Mary Swain. "Discussion: Health Education and Publicit}'." American Journal of Public Health 12 (April 1922): 284-5.

Routzahn, Man- Swain. Notes on Planning a Publicity Program. New York: Social Work Publicit}' Council, 1937. '

Routzahn, Mary Swain. Social Work Interpretation in Pittsburgh. Pittsburgh: Social Std of Pittsburgh and Allegheny County, 1936. 484

Routzahn, Marj' Swain. "Steps in Planning a Health Education and Publicit)' Program." Ameman ]ourital of Public Health 19 (May 1929); 513-6.

Routzahn, Mary Swain and Evart G. Routzahn. Piiblicily for Social Work. New York; Russell Sage Foundation, 1928.

Rowell, Hugh Grant and James AlnerTobey. "Need for Health Instruction in Cleanliness." American journal of Public Health 2S (November 1935): 1237-40.

Russell Sage Foundation. "Motion Pictures; A Selected Bibliography." 'Bulletin of the Russell Sage Foundation Ubraty (August 1922): 2-4.

Saltzstein, Harr)' C. "Publicity in Cancer." Journal of the American Medical Association 82 Qune 28,1924); 2140-1.

Schevitz, Jules. "Advertising as a Force in Public Health Education." American Journal of Public Health 8 (December 1918); 916-21.

Schevitz, Jules. "Industrial Health Education: A Means and an End." American Journal of Public Health 10 (October 1920); 780-2.

Sheffield, Alfred Dwight. Training for Group Experience. New York; The Inquiry% 1929.

Shelley, Hilton ]. "Local Publicit)' Use of Statistics from National and State Sources." American Journal of Public Health 24 (May 1934): 331-4.

Snow, William Freeman. "'What is Being Done to Study Methods in Health Educadon and Publicity for Adults and Children?"' American Journal of Public Health 12 (April 1922): 280-2.

Sobeloff, Isidore. Publicity in Social Work: Its Place and Function. New York; Social Work Publicit)' Council, 1935.

Stebbins, Ernest L. "The Responsibilit)' of the Radio Industry in Public Health." In R^idio in Health Education, 69-73. New \'ork: Columbia Universit)- Press, 1945.

Stillman, Charles C. Social Work Publicity. The Social Worker's Libran' Series. New York; The Century Co., 1927.

Strang, Ruth M. and Dean F. Smiley. The Kole of the Teacher in Health Education. New York; The Macmillan Company, 1941.

Sundwall, lohn. "Are We Becomine Overly Health Conscious?" lournal of Health and Physical Education 2 (October 1931): 9.

Temkin, Owsei. "Health Education Through the Ages." American Journal of Public Health 30 (September 1940); 1091-5.

Terr)', Clair Elsmere and F. Schneider, Jr. "Public Health Education and the Family Magazine." American Journal of Public Health 8 (May 1918): 345-8. 485

Tietze, Felix. "Letter on Health Exhibitions." American jouma/ of Public Health 20 (1930): 189.

Tobey, James Alner. "Pamphleteering and Public Health." American Jouma/ of Public Health 12 (Februarj- 1922): 148-9.

Tobey, James Alner. "Progress in Health Education and Publicity'." American journal of Public Health 16 (February 1926): 106.

Tobey, James Alner. "Selling Health by Window Exhibits." American City 25 (September 1921): 232-3.

Trask, John W. "Health Publicit)' an Aid to Cooperation Between Health Department and Citizens." American Journal of Public Health 8 Qune 1918): 417-20.

Turner, Clair Elsmere. "The Communin- Program of Health Education." American Journal of Public Health 25 Qune 1935): 725-9.

Turner, Clair Elsmere. "Determining the Efficacy of the Health Education Program." Hjgeia 12 (December 1934): 1130.

Turner, Clair Elsmere. "Maiden Studies in Health Education: A Preliminarj' Report." American Journal oj' Public Health 15 (May 1925): 405-14.

Turner, Clair Elsmere. "Maiden Studies on Health Education and Growth." American Journal of Public Health 18 (October 1928): 1217-30.

Turner, Clair Elsmere. "Motion Pictures as Used in Health Education." Nation's Health 4 Qanuarj' 1922): 17-9.

Turner, Clair Elsmere. Principles of Health Education. Second edition. Boston: D.C. Heath and Company, 1939.

Turner, Clair Elsmere. "'Should There Be Any Difference in the Type of Motion Picture Produced for Classroom Use and That For Popular Education?"' American journal of Public Health 12 (April 1922): 270-1.

Turner, Clair Elsmere and Georgie B. Collins. Health. Boston: D.C. Heath & Co., 1924.

Turner, Clair Elsmere, et al. Community Organi^tion for Health Education: A Committee Report. Cambridge, Mass.: The Technolog)' Press, 1941.

Turner, Clair Elsmere, et al. "Effectiveness of Radio in Health Education." American journal of Public Health 25 (May 1935): 589-94.

N'aughan, Heniy F. "Established Points in a Communin,' Program of Health Educadon: The Health Department's Program." .American Journal of Public Health 20 (April 1930): 351-6.

Warfel, Edward. "Publicity and Public Health Education." American City 22/ (August 1920): 170-2. 486

Wheatley, George M. "Progress in School Health Procedures." Medical Woman's Journal 48 (April 1941); 109-12.

Whipple, Katharine Z.W. "Health Education." In College Women and the Social Sciences, b\' Herbert Elmer Nlills, et al. New York, 1934.

Wilcox, Herbert B., ed. Radio in Heahb Education. New York; Columbia Univcrsitj- Press, 1945.

Wile, Ira Solomon. "Public Health Publicit)' and Education Through Public Schools." American Journal of PtMc Health 8 (May 1918); 336-40.

Wilinsky, Charles F. "The Department Store of Health." Surv^- 57 (March 15, 1927): 790-1.

Williams, Huntington. "Selling Health Department Members First on Health Education." American Journal of Public Health 25 Qune 1935); 715-719.

Williams, Jesse Feiring and Fannie B. Shaw. Methods and Materials of Health Education. Nelson Educational Series. New York; Thomas Nelson and Sons, 1936.

Winslow, Charles-Edward Amory. "Cultural Objecdves of Health Education." School and Society 40 Quly 7, 1934); 1-5.

Winslow, Charles-Edward Amory. "Health Education in a Democracy." Science 97 (Februar)- 26, 1943); 189-92.

Winslow, Charles-Edward Amor}^ "Health-Educadon Problems of the Elementar)' Schools." In The Changing Elementary School, ed. Leo J. Brueckner, 273-81. New York; Inor Publishing Company, 1939.

Winslow, Charles-Edward Amor)'. "Public Health Education in the United States." Journal of the Royal Sanitary Institute yb (1914); 263-71.

Winslow, Charles-Edward Amor)- and Franklin Fearing. "Steps in Planning a Health Education and Publicit)'Program." American Journal of Public Health 19 (June 1929); 647-57.

Winslow, Charles-Edward Amory., et al. "Health-Education Problems of the Elementar)' Schools." In The Changing Elementary School, ed. Leo J. Brueckner, 273-81. New York; Inor Publishing Company, 1939.

Winslow, Emma A. "Stimulating Health Education." Journal of Home Economics 19 (December 1927); 669-73.

Wood, Thomas D. and Marion Olive Lerrigo. Health Behavior: A Manual of Graded Standards of Habits, Attitudes, and Knowledge Conducive to Health of the Physical Organism, and of Personality, Home, Community, and Race. Bloomington, 111.; Public School Publishing Company, 1927.

Wood, Thomas D., et al. Health Education: A Program for Public Schools and Teacher Training Institutions. New York; Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association, 1924. 487

XX'ootten, Kathleen Wilkinson. Health Education Activities. New York: The National Tuberculosis Association, 1932.

Wootten, Kathleen Wilkinson. A Health Education Procedure for the Grades and Grade Teachers. N ew York: The National Tuberculosis Association, 1926.

Wootten, Kathleen Wilkinson. A Health Education Workbook. New York: Barnes, 1936.

Zimand, Savel. "The Campaign Calendar of the Public Health Organization." Milbank Memorial Fund Ouatlerly Bulletin 9 (October 1931): 165-78.

Zimand, Savel. "An Organized Communit)- Health Education Program." Milbank Memorial Fund Quarterly 12 (October 1934): 329.

CHAPTER IX. COMMUNITY HEALTH DEMONSTRATIONS

Andrews, Willie Dean. "Negro Folk Games." The Playground \\ (June 1927): 132-4.

Armstrong, Donald Budd. "Adequate Count}' Health Organization, Tuberculosis Control, and the Medical Profession." New England journal of Medicine 20^ (September 17,1931): 569-73.

Armstrong, Donald Budd. "Certain Minimums and Maximums in Tuberculosis Control." American journal of Hjgiene 1 (May 1921): 278-83.

Armstrong, Donald Budd. "Civilian Tuberculosis Control Following War Conditions." American journal of Public Health 8 (December 1918): 897-903.

Armstrong, Donald Budd. "Communit)' Machinery for the Discover)- of Tuberculosis." Boston Medical and Surgical journal\ ^\ (August 28, 1919): 255-60.

Armstrong, Donald Budd. "Four Years of the Framingham Demonstration." American Review of Tuberculosis (Februar)' 1921): 908-19.

Armstrong, Donald Budd. "Framingham Health and Tuberculosis Demonstradon." American Journal of Public Health 7 (1917): 318-22.

Armstrong, Donald Budd. "Framingham Health and Tubeculosis Demonstradon." Journal of the Outdoor Life 14 (September 1917): 257.

Armstrong, Donald Budd. "The Framingham Health Demonstration and Industrial Medicine." Journal of Industrial Hjgiene 3 (October 1921): 183-6.

Armstrong, Donald Budd. "Framingham Yardsticks." Transactions of the Annual Meeting of the National Tuberculosis Association 17 (1921): 505.

Armstrong, Donald Budd. "Indications from the Experience of the Framingham Tuberculosis Experiment." iioston Medical and Surgical Journal 188 (March 29,1923): 433-5. 488

Armstrong, Donald Budd. "Medical Aspects of the Framingham Communit)- Health and Tuberculosis Demonstradon." American Review of Ttiberailosis 2 Qune 1918): 195-206.

Armstrong, Donald Budd. "The Prevendon of Tuberculosis in Industr)-." Modern Medicine 1 (Mav 1919): 51.

Armstrong, Donald Budd. "Program of Clinical Activides for Towns of Approximately Twentj- Thousand Populadon." Modern Hospital\2 (March 1920): 218-20.

Armstrong, Donald Dudd. "The Tuberculosis Demonstradon Plans of the Milbank Memorial Fund." American Journal of Public Health 13 Qanuarj' 1923): 14-6.

Armstrong, Donald Budd and P. Challis Bardett. "Framingham Community Health and Tuberculosis Demonstration: Certain Medical Results." Journal of the American Medical Association 11 (August 20, 1921): 585-7.

.'\rmstrong, Donald Budd and A.K. Stone. "Health Equipment in Framingham: Then and Now." Nation's Health 5 (March 1923): 125-7.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Medical Examination Campaigns. Framingham Monographs, no. 4. Framingham, Mass.; Communit)- Health Station, 1918.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Program. Framingham Monographs, no. 1. Framingham, Mass.: Communit)' Health Station, 1918.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Schools and Factories. Framingham Monographs, no. 6. Framingham, Mass.: Communit)' Health Station, 1919.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: The Sickness Census. Framingham Monographs, no. 2. Framingham, Mass.; Communit)- Health Station, 1918.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National Association for the Study and Prevention of Tuberculosis: Tuberculosis Findings. Framingham Monographs, no. 5. Framingham, Mass.; Communit)' Health Station, 1919.

Armstrong, Donald Budd, et al. Framingham Community Health and Tuberculosis Demonstration of the National As.iociation for the Study and Prevention of Tuberculosis: Vital Statistics. Framingham Monographs, no. 3. Framingham, Mass.: Communit)- Health Station, 1918.

Bache, Louise Franklin. Health Education in an .American City: An Account of a Five-Year Program in Syracuse, Neiv York Garden Cit)', N.Y.; Doubleday, Doran & Company, Inc., 1934.

Bannard, Otto Tremont. "Appropriations Voted, 1921-1922." .4nnual Report of the Commonwealth Fund 4 (1921-2): 54-5. 489

Bannard, Otto Tremont. "Extracts from the Treasurer's Report." Annual Keport of the Commonwealth Fund 1 (1918-9): 13-4.

Barnard, Margaret Witter. "A Tuberculosis Service for Children." Milbank Memorial Fund Quarterly Bulletin 10 (October 1932): 261-73.

Bellevue-York\'ille Health Demonstration. The Bellevue-Yorkville Health Demonstration District, New YorkCily, Vital Statistics, 1922, 1923, 1924: An Analysis of the Principal Causes of Mortality and Morbidity, bj the Statistical Division of the Bellevue-Yorkville Health Demonstration in Cooperation with the Bureau of Records of (he New York City Department of Health. New York: Department of Health, 1926.

Bellcvue-Yorkville Health Demonstration. Ten Years at Bellevue-\'orkville: An F.xperiment in Health Center Administration. New York: Belle\aie-Yorkville Health Demonstration, 1934.

Benedict, Agnes E. Children at the Crossroads. New York: The Commonwealth Fund, 1930.

Brown, Edward F. "Dental Clinics as a Communit}' Investment." .American journal of Public Health 5 (May 1915): 396-404.

Brown, Maud Anna. "The Class-Room Teacher's Part in Health Education." Child Health Bulletin 1 (November 1925): 88-93.

Brown, Maud Anna. "Fargo and the Health Habits." Hjgeia 6 (May 1928): 267-9.

Brown, Maud Anna. "Fargo and the Health Habits." Hjgeia 6 (June 1928): 335-8.

Brown, Maud Anna. "Simplicit)- in Health Teaching." Hygeia 5 (October 1927): 519-23.

Brown, Maud Anna. Teaching Health in Fargo. New York; The Commonwealth Fund, 1929.

Brown, Walter H. Extent and Character of Child Health Work in Syracuse, N.Y.: Report Made Through the State Committee on Tuberculosis and Public Health of the State Charities Aid Association of New York to the Health Agencies Participating in the Syracuse Health Demonstration of the MUbank Memorial Fund. Syracuse, N.Y.: Department of Health, 1924.

Brown, VC'alter H. "Organization of Health Demonstrations." .American Journal of Public Health Supplement 17 (February 1927): 13-22.

Brunet, Walter Minson. "Cervico-Vaginitis of Gonococcal Origin in Children: Report of a Project of the Belle'V'Tje-Yorkville Health Demonstration ofNew York Cit}'." Hospital Social Service Magazine Supplement 1 (1933): ?

Brunet, Walter Minson. A Survey of the Facilities Provided Syracuse, New York, for the Prevention and Treatment of Syphilis and Gonorrhea: Report Made Through the State Committee on Tuberculosis and Public Health oj the State Charities Aid Association of New York to the Health Agencies Participating in the Syracuse Health Demonstration of the MUbank Memorial Fund. Syracuse, N.Y.: Department of Health, 1923.

Carpenter, G.A., et al. "The Local Medical Societ}- and Public Health." journal of the American Medical .Association 90 (januar)- 21, 1928): 191-4. 490

Carpenter, Thelma E. Recreation Program of the Bellevue-Yorkvilk Health Demonstration, 1927-1930. New York: Bellevue-Yorladlle Health Demonstration, 1932.

Cattaraugus Count)' Board of Health. Public Health in Cattaraugus County. Salamanca, N.Y.: Leach Publishing Co., 1922-50.

Chaddock, Robert E., et al. "Vital Statistics and Measurement of Health Progress, Fargo, N.D." American journal of Public Health 19 Qanuar}' 1929): 37-45.

Dinwiddie, Courtenay. Child Health and the Community: An Inteipretation of Cooperative Effort in Public Health. New York: The Commonwealth Fund, 1931.

Dinwiddie, Courtenay. "The Commonwealth Fund Child Health Demonstration Program." Hospital Social Service (September 1923): ?

Dinwiddie, Courtenay. "The Commonwealth Fund Child Health Demonstradons." Proceedings of the Second Annual Conference on Public Health, A.M..4. Bulletin!?) (November 1928): 206.

Dinwiddie, Courtenay. "The Contribudons of Demonstradons to Rural Health Programs." Nation's Health 9 Quly 15,1927): 9-12,70.

Downes, lean and Margaret W. Barnard. "Tuberculosis Administradon in the Bellevue-Yorkville Health Center District of New York Cit)'." Milhank Memorial VundQiiarterly 14 (July 1936): 242-57.

Downes, Jean and Clara R. Price. "A Study of Public Health Nursing Ser\'ice in Tuberculous Families in the Mulberr}' District of New York Cit)-." MUbank Memorial Fund Quarterly 17 Qanuary 1939): 29-49.

Drolet, Godias Joseph. Statistical Reports of Services, Bellevue-Yorkville Health Demonstration and Cooperating Organi^tions: A Review and Summaty for 1929 and Three-Year Period, 1927-29. New York, 1934.

Duffield, Thomas J. "School Ventilation: Its Effect on the Health of the Pupil." American journal of Public Health

Duffield, Thomas J. "School Ventilation Study in Syracuse, N.Y." American journal of Public Health 18 (1928): 326.

Evans, Lester J. "The Physician's Way of Securing the Parent's Co-operadon." Public Health Nune 18 (September 1926): 480-2.

Farrand, Livingston. "The Philosophy of Health Demonstradons." American journal of Public Health Supplement \1 (Februar)' 1927): 1-4.

Farrand, Livingston, et al. Child Health Demonstration: Mansfield and Richland County, Ohio, 1922 to 1925. New York: American Child Health Associadon, 1926.

Farrand, Livingston, et al. "Health Demonstradons in the United States." American journal of Public Health Supplement 17 (February 1927): 1-22. 491

Farrand, Max, et al. "First Annual Report of the General Director of the Commonwealth Fund, 1918-1919." Annual Keport of the Commonwealth Fundi (1918-9): 5-11.

Folks, Homer. "Financial Aspects of Health Demonstrations." American Journul of Public Health Supplement 17 (Februar)' 1927): 5-12.

Folks, Homer. "The Growth of the Idea." In Ten Years at Bellevtte-Yorki'ille: An Fsperiment in Health Center Administration, 5-7. New York: Bellevue-YorkviUe Health Demonstration, 1934.

Greenleaf, Clarence Albert. School Health Work in Cattaraugus County: A Vreliminary Remw of the School Program of the Cattaraugus County Health Demonstration. New York: Milbank Memorial Fund, 1929.

Grout, Ruth E. "Function of the School in the Rural Health Program." .American Journal of Public Health 27 (1931): 583.

Grout, Ruth E., ed. Handbook of Health Education: A Guide for Teachers in Rural Schools. New York: The Odyssey Press, 1934.

"The Health Demonstradon." Journal of the American Medical As-wciation 90 (March 3, 1928): 696.

Heyd, Charles Gordon. "The Medical Profession and the Demonstration." In Ten Years at Bellevue-YorkviUe: An FLxperiment in Health Center Administration, 15-8. New York: Bellevue-Yorla'ille Health Demonstration, 1934.

Hiscock, Ira V. District Health Administration: A Study of Organisation and Planning. Lancaster, Pa.: The Science Press Printing Company, 1936.

Isiscr, Clyde Vernon. The Milbank Memorial Fund: Its Leaders and its Work, 1905-1974. New York: The Milbank Memorial Fund, 1975.

Lapham, Maxwell E. Maternity Care in a Rjiral Community: Pike County, Mississippi, 1931-1936. New York: The Commonwealth Fund, 1938.

Laurer, Frank A. "Hearing Sur\'ey Among a Group of Pupils of Syracuse Schools." .American Journal of Public Health 18 (1928): 1353.

Lew, Harr\' H. "Vision Survey Amone a Group of Pupils of Syracuse Schools." American Journal ot Public Hm//A 18 (1928): 1273.

Lubove, Roy. "Courtenay Dinwiddie, Oct. 9,1882-Sept. 13, 1943." Dictionar)' of American Biography Supplement 3 (1973): 227-8.

Milbank, Albert G. "The Social Signficance of the Demonstration." In Ten Years at Bellevue-YorkviUe: .An Experiment in Health Center Administration, 19-26. New York: Bellevue-Yorkvillc Health Demonstration, 1934.

Milbank Memorial Fund. Catalogue of Publications. New York: NElbank Memorial Fund, 1955. 492

Nlilbank Memorial Fund. The Family as the Unit of Health: Papers Presented at a Round Table at the 194S Annual Conference of the Milbank Memorial Fund, 17-18, 194S. New York: Milbank Memorial Fund, 1949.

Milbank Memorial Fund. Milbank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversaiy. New York: Milbank Memorial Fund, 1930.

Milbank Memorial Fund. Milbank Memorial Fund: Thirty-Five Years in Review. New York: Mibank Memorial Fund, 1940.

Milbank Memorial Fund. The Organi^tion of the Syracuse and Cattaraugus County Health Demonstrations. New York: State Committee on Tuberculosis and Public Health, State Charities Aid Associauon, 1925.

Mustard, Harr)- StoU. Cross-Sections of Rural Health Progress: Report of the Commonwealth Fund Child Health Demonstration in Rjithetjord County, Tennessee, 1924-1928. New York: The Commonwealth Fund, 1930.

Mustard, Harry Stoll and J.I. Waring. "Thyroid Enlargement: Occurrence in School Children in Rutherford County, Tennessee." Journal of the American Medical Association 88 (March 5, 1927): 714-6.

Newsholme, Arthur. The New York Health Demonstrations in the City of Syracuse and in Cattaraugus County. New York: Milbank Memorial Fund, 1927.

New York Commission on Ventilation. Studies of School Ventilation: Collected Reprints of the Neii' York Commission on Ventilation Whose W^orkwa.c Financed by the Milbank Memorial Fund, 1913-1923, 1926-1929. ne\vYotk,\S)2>2.

New York State Charities Aid Association. Committee on Tuberculosis and Public Health. A Chronological Report oj Significant Events and Steps in the Organic^ation and Progress oj the Cattaraugus County and Syracuse Health Demonstrations, May 1922 to December 1930. New York: State Charities Aid Association, 1930.

New York State Charities Aid Association. Committee on Tuberculosis and Public Health. The Organit^ation of the Syracuse and Cattaraugus County Health Demonstrations, Carried on ty the Ijocal Official and Voluntary Health Agencies, with the Advice and Financial Assistance of the Milbank Memorial Fund and Under the General Oversight and Supervision of the State Charities Aid Association. New York: State Charities Aid Association, 1925.

Nyswander, Dorothy B. Solving School Health Problems: The Astoria Demonstration Study. New York: The Commonwealth Fund, 1942.

Odell, Ruby M. Improving the Dieta^' Habits of a Rural Community: Three Years of Nutrition Work in Cattaraugus County. New York: Milbank Memorial Fund, 1929.

Prescott, [osephine W. "School Nursing Consultation Sen'ice in the Bellevue-Yorkville District." Milbank Memorial FundQuatlerly 12 (Januar)' 1934): 81-4. 493

Randall, Marian G. "The Public Health Nurse in a Rural Health Department; An Introductor)- Report on the Study in Progress in Cattaraugus County." American Joiirna/ of Public Health 21 Quly 1931); 737-50.

Randall, Marian G. "Public Health Nursing Sen'ice for Infants." MUbank Memorial FundQiiailerly 13 (April 1935); 185-200.

Randall, Marian G. "The Use of Records in Making a Visit More Producdve." Public Health Nursing 26 (October 1934); 546-9.

Rice, John L. "Work Bears Fruit Throughout the City." In Ten Years at Belleviie-Yorkville: An Experiment in Health Center Administration, 8-14. New York; Belle\Tae-York\'ille Health Demonstradon, 1934.

Ross, M. "Health to the Crossroads; Cattaraugus Count)- Tries to Pracuce All We I

Ruhland, George C. "Health Demonstradons." American Journal of Public Health 19 (March 1929); 287-92.

Ruhland, George C. and I.F. Thompson. "Record Forms in the Syracuse Health Demonstradon." American Journal of Public Health 16 (1926); 567-70.

Ruhland, George C., et al. "Record Forms." American Journal of Public Health 19 (1929); 527.

Sears, Frederick W. "Rural Health Administration under the State Health District Plan." American Journal of Public Health 8 (1918); 412.

Sears, Frederick W. "Schools for Health Officers; Wliat Has Been Done at Syracuse." American Journal of Public Health 10 (1920); 155.

Sears, Frederick W. "Some Problems in Rural Hygiene." In De Lamar Lectures, 1925-1926,31-69. Baltimore; The Williams & Wilkins Company, 1927.

Sheldon, Edward W. and Albert G. Milbank. "Milbank Memorial Fund: Twcnt)'-Fifth Anniversar)'." In MUbank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversary, 5-10. New York; Milbank Memorial Fund, 1930.

Simpson, Anne. "'Do-Do-Do Then Do Some More'; Ways of Teaching Health in One-Room Rural Schools in Oregon." Child Health 'bulletin 4 (March 1928); 44-9.

Sipher, E.F. "Automatic Control of Sewage at the Syracuse Sewage Treatment Plant." American City 37 (July 1927); 6-9.

Smith, Barr)' C., et al. A Chapter of Child Health: Report of the Commonwealth Fund Child Health Demonstration in Clarke County and Athens, Georgia, 1924-1928. New York; The Commonwealth Fund, 1930.

Smith, Barrjf C., et al. "Child Health and County Health: Rutherford Count}', Tennessee." Commonwealth Fund Child Health Demonstration Committee Bulletin 6 (September 1927); 1-30. 494

Smith, Barn' C., et al. "The Child Health Demonstrations: Program and Policies." Commonmahh Fund Child Health Demonstration Committee Biilletin 1 (Februar)-1927); 1-16.

Smith, Barry C., et al. "Cooperation for Child Health in Athens, Georgia." Commonwealth Fiind Child Health Demonstration Committee Bulletin 3 (March 1927); 1-16.

Smith, Barrv' C., et al. "Demonstradng Child Health, 1923-1927." Commonmahh Fund Child Health Demonstration Committee Bulletin(June 1927): 1-44.

Smith, Barry C., et al. "Five Years in Fargo; Part One of the Final Report of the Fargo Health Demonstration.". Commonwealth Fund Child Health Demonstration Committee Bulletin 1 (May 1928); 1-51.

Smith, Barr)' C., et al. Fife Years in Far^o: Report of the Commonwealth Fund Child Health Demonstration in Fargo. North Dakota. New York; The Commonwealth Fund, 1929.

Smith, Barr)' C., et al. "Serving the Child in Fargo: Part Three of the Final Report of the Fargo Demonstration." Commomvealth Fund Child Health Demonstration Committee Bulletin 9 (November 1928); 1-127.

Smith, Geddes. "How Athens Secured Funds for Remedying Defects." Child Health Bulletin 3 (April 1927); 83-5.

Smith, Geddes. "On the Health Bandwagon." Survey 60 Quly 15,1928): 419-20, 443.

Walker, Watson Frank. "Public Health Work in Fargo; An Appraisal." Commonwealth Fund Child Health Demonstration Committee Bulletin 8 (May 1928); 1-24.

Walker, Watson Frank. "A Sur\'ey of Public J-Iealth Work in Fargo, N.D." Commonwealth Fund Child Health Demonstration Committee Bulletin 5 (June 1927); 1-32.

Walker, Watson Frank and Carolina R. Randolph. Inflnence of a Public Health Program on a Rural Community. Fifteen Years in Rutherford County, Tennessee, 1924-1938. New York; The Commonwealth Fund, 1940.

Warner, Estella Ford and Geddes Smith. Children of the Covered Wagon: Report of the Commonwealth Fund Child Health Demonstration in Marion County, Oregon, 1925-1929. New York; The Commonwealth Fund, 1930.

Welch, William Henry. "The New York Health Demonstradons." In Milbank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversary, 63-70. New York: Milbank Memorial Fund, 1930.

Wlieeler, Lilla C. "Impressions of Some of the Work of the Milbank Memorial Fund." In Milbank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversaty, 71-5. New York: Milbank Memorial Fund, 1930.

Wiehl, Dorothy G. and Katharine Berry. "Maternal Health and Super\'ision in a Rural Area." Milbank Memorial FundQuarterly 17 (April 1939): 172-204. 495

Winslow, Charles-Edward Amor\-. A City Se! on a Hi//: T/je Signijicance of the Hea/ll.i Demoiislnilion a! Syracuse, New York. Garden City, N.Y.: Doubleday, Doran & Company, Inc., 1934.

Winslow, Charles-Edward Amon,'. Hea/l/j on the Farm and in t/ie I 'i//age: A Review and Eva/nation of the Cattaraugus County Hea/th Demonstration with Specia/ Reference to Its Lessons for Otfjer Rura/Areas. New York: The Macmillan Company, 1931.

Winslow, Charles-Edward Amor)'. Hea/th in the Twentieth Century. New York; Arno Press, 1923; reprint. New York: Arno Press, 1977.

Winslow, Charles-Edward Amor}-. "The Living Hand: Elizabeth Milbank Anderson." In Miibank Memorial Fund: A Meeting Commemorating the Twenty-Fifth Anniversaiy, 11-62. New York; Milbank Memorial Fund, 1930.

Winslow, Charles-Edward Amor\- and Savel Zimand. Hea/th Under t/je 'El": The Stoty of the Bel/evue-Yorkvil/e Hea/th Demonstration in Mid-Town New York. New York; Harper & Bros., 1957.

Wright, Wade. Investigations Regarding Hea/th in Industry, Syracuse. New York: Report Made T/jrough the State Committee on Tubercu/osis and Pub/ic Hea/th of the Stale Cluirities Aid A.

Zimand, Savel. "Five Years at Bellevue-Yorkville." American Journal ofPuh/ic Hea/th 22 (1932): 403.

CHAPTER X. FAMILY HEALTH AND FAMILIAL EPIDEMIOLOGY

Ackerman, N.W. "The Family as a Social and Emotional Unit." Bu//etin of the Kansas Menta/ Hygiene Society 12 (1937): 1-3.

Anderson, Grace L. and MabeUe S. Welsh. "Family Health Needs and Nurses' Service." Pub/ic Hea/th Nursing33 (March 1941); 137-41.

Aycock, W.L. "Familial Susceptibility to Leprosy." American journal of t/je Medical Sciences 201 (1941); 450.

Aycock, W.L. "Familial Aggregation in Poliomyelitis." American journal of t/je Medical Sciences 203 (1942): 452.

Aycock, W.L. and Paul Eaton. "Epidemiolog)' of Infantile Paralysis: Relation Between Multiple Cases in the Same Family." American journal of Hygiene 5 (November 1925): 724-32.

Bean, Helen and Georgie S. Brockett. "The Family as a Unit for Nursing Service." Public Health Reports 52 (December 31,1937): 1923-31.

Bellows, Marjorie T. and George H. Ramsey. "Integration of Health Department Records." American journal of Public Health 29 (June 1939): 636-40.

Bigelow, M.A. "Biological Foundations of the Family." journal of Social Hygiene 16 (March 1930); 129-33. 496

Bingham, Arthur Wallace and Joseph J. Gallagher. "Communit)- Control of the Acute Infections." American journal of Public Health 17 (May 1927): 448-53.

Bishop, E.L. and H.C. Stewart. "Tuberculosis in Tennessee." Journal of the American Medical Association 99 Quly 30, 1932): 356-60.

Bolt, Richard Arthur. "Education for Home and Family Life." American Journal of Public Health 21 (April 1931): 438-41.

Brailey, Miriam E. "Nlortalit)- in the Children of Tuberculous Households." MUbank Memorial Fund Quarterly 18 Quly 1940): 222-38.

Brailey, Miriam E. "Prognosis in W'^iite and Colored Tuberculous Children According to Initial Chest X-ray Findings." American Journal of Public Health l)?) (April 1943): 343-52.

Brailey, Miriam E. "A Study of Tuberculosis Infection and Mortalit}' in the Children of Tuberculous Households." American Journal of Hygiene hX Qanuarj'1940): 1-43.

Buell, B. "Social Planning for Family Health." Michigan Public Health 26 (1938): 123-30.

Chapin, Charles Value. "Plural Deaths in Families as an Index of the Fatalit)' of Disease." Jounial of Infectious Diseases 34 (1908): 373-6.

Collins, Sel\v)'n D. "Causes of Illness in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928-31." Public Health Reporis48 (March 24,1933): 283-318.

Collins, SeKwn D. "Frequency of Immunizing Procedures of Various Kinds in 9,000 Families Obser\'ed for 12 Months, 1928-1931." American journal of Public Health 2'b (November 1935): 1221-5.

Collins, Selwj'n D. "A General View of the Causes of Illness and Death at Specific Ages, Based on Records for 9,000 Families in 18 States Visited Periodically for 12 Months, 1928-31." Public Health Reports 50 (February- 22,1935): 237-79.

Crabtree, James Anderson. "Obser\'ations on the Familial Incidence of Cancer." American journal of Public Health 31 Qanuar}' 1941): 49-56.

Crabtree, James Anderson. "A Study of the Prevalence and Mortality' of Tuberculosis in the Negro Population of I

Crabtree, James Anderson. "Tuberculosis Studies in Tennessee: Tuberculosis in the Negro as Related to Certain Conditions of Environment." journal of the American Medical Association \Q\ (September 2, 1933): 756-70.

Crabtree, James Anderson, et al. "Tuberculosis Studies in Tennessee: A Communit)' Study of the Prevalence of Tuberculosis in the Negro." American Review of Tuberculosis Supplement 28 (December 1933): 1-31.

Dennic, Charles C. "Familial Syphilis." journal of the Kansas Medical Society 20 (1920): 134. 497

Doull, J.A. "Factors Influencing Selective Distribution in Diphtheria." Journal of Preventive Medicine 4 (September 1930): 371-80.

Doull, J.A. "The Importance of Field Studies of Leprosy, with Especial Reference to the Risk of Household Exposure." American Jo/irna/ of Hygiene 29 Oanuan- 1939): 27-33.

Downes, Jean. An Experiment in the Control of Tuberculosis Among Negroes. New York: Milbank Memorial Fund, 1950.

Downes, Jean. "How Tuberculosis Spreads in a Rural Communit)-." American Journal ofPiiblic Health 26 (January 1936): 30-8.

Downes, Jean. "Illness in the Chronic Disease Family." American Journal of Public Health 32 (June 1942): 589-600.

Downes, Jean. "The Risk of Mortalit)' Among Offspring of Tuberculous Parents in a Rural Area in the Nineteenth Centur}\" American Journal of Hj^iene 26 (November 1937): 557-69.

Downes, Jean. "A Study of the Risk of Attack Among Contacts in Tuberculous Families in a Rural Area." American Journal of Hygiene 22 (November 1935): 731-42.

Downes, Jean and Selw)'n D. Collins. "A Study of Illness Among F-'amilies in the Eastern Health District of Baldmore." MUbank Memorial Fund Quarterly 18 Qanuar\' 1940): 5-26.

Downes, Jean and Edgar Sydenstricker. "Some Results of Tuberculosis Administradon in Cattaraugus County, New York." American Review of Tuberculosis Ih (Februar)-1931): 183-206.

Drolet, Godias J. "Community' Organizadon in the And-Tuberculosis Campaign." American Journal of Public Health 12 (April 1922): 311-6.

Drolet, Godias J. and William H. Guilfoy. "Organizadon of Local Health Area Stadsdcs in New York City." American Journal of Public Health 20 (April 1930): 380-6.

Dukes, Cuthbert. "Muldple Intesdnal Tumours: A Familial Disease." Eugenics Keview 2^ (1933-4): 241-3.

Dulanev, Anna Dean. "A Family of Tj-phoid Carriers." American Journal of Public Health 15 (1925): 885.

Eller, C.H. "Tuberculosis Infecdon and Mortalit)- of Children Exposed to Household Contact with Open Pulmonary Tuberculosis." D.P.H. thesis, Johns Hopkins Universit)', 1934.

Evans, Griffith. Essays on Chronic and Familial Syphilis. Bristol: Wright, 1934.

Faulkner, J.M. and P.D. Wliite. "Incidence of Rheumadc Fever, Chorea, and Rheumadc Heart Disease, with Especial Reference to its Occurrence in Families." Journal of the American Medical Association 83 (August 9, 1924): 425-6.

Fee, Elizabeth. "Partners in Communit}' Health: The Baltimore Cit)' Health Department, the Johns Hopkins School of Hygiene and Public Health, and the Eastern Health District, 1932-1992." Maryland Medical Journal 42 (August 1993): 735-44. 498

Foley, A.R. "A Study of Tuberculosis Infection in Gibson County, Tennessee: I. Mortality, 1919-1929; II. Prevalence of Infection." D.P.H. thesis, Johns Hopkins University, 1931.

Foley,G.E., et al. "Serological Tjqaes of Hemolytic Streptococci Isolated from Muluple Cases of Scarlet Fever in the Same Households." American Journal of Public Health 34 (October 1944): 1083-6.

Fosdick, Harry Emerson. "What is Happening to the American Family?" Journal of Social Hygiene 15 (March 1929): 139-51.

Frost, Wade Hampton. "The Familial Aggregation of Infectious Diseases." American Journal of Public Health 28 (January 1938): 7-13.

Frost, Wade Hampton. "How Much Control of Tuberculosis?" American Journal of Public Health 27 (1937): 1.

Frost, Wade Hampton. "The Oudook for the Eradication of Tuberculosis." American Revietv of Tuberculosis yi (December 1935): 644-650.

Frost, Wade Hampton. Papers of Wade Hampton Frost, M.D.: A Contribution to Epidemiological Method. New York: The Commonwealth Fund, 1941.

Frost, Wade Hampton. "Risk of Persons in Familial Contact with Pulmonarj' Tuberculosis." American Journal of Public Health 23 (Mav 1933): 426-432.

Gauld, Ross Laurier. "A Study of Reported Cases of Tuberculosis and Their Family Contacts." D.P.H. thesis, Johns Hopkins University, 1936.

Gauld, Ross Laurier and Frances E.M. Read. "Studies of Rheumadc Disease: Familial Associauon and Aggregation in Rheumatic Disease." Journal of Clinical Investigation 19 (March 1940): 393-8.

Gauld, Ross Laurier, et al. "Further Observations on the Occurrence of Rheumatic Manifestations in the Families of Rheumatic Patients." Journal of Clinical Investigation 18 (March 1939): 213-7.

Gauld, Ross Laurier, et al. "Index Person: Relation to Incidence Rates in Family Studies." American Journal of Public Health 32 (June 1942): 577-84.

Goodman, Herman. "Prostitution and Communit)' S\'philis." American Journal of Public Health 9 (]uly 1919): 515-20.

Gordon, John E., et al. "Reaction to Familial Contacts to Scarlet Fever Infection." American Journal of Public Health 25 (May 1935): 531-44.

Graham, A.H., et al. "The Fate of Persons Exposed to Tuberculosis in White and Negro Families in a Rural Area of East Alabama." American Journal of Hjgiene Monographic Series 16 (1941): 149.

Gray, A.L. and W.H. Cleveland. "Sources and Modes of Infection in Two Family Outbreaks of Syphilis." American Journal of Public Health 25 (Januan-1935): 49-53. 499

Hahn, R.G. "Tuberculosis in the Household: Its Occurrence in Marital Partners and Other Members of the Household Wlien the Primar\' Case was a Parent or Another Member of the Family." American Keview of Tuberculosis A1 (1943): 316.

Hill, Hibbert Winslow. "All the Typhoid of a Community' for Five Years from a Carrier Through Milk." American Journal of Public Health 4 (August 1914): 667-73.

Ir\'ine-Jones, Edith. "Acute Rheumatism as a Familial Disease." American Journal of Diseases of Children 45 (June 1933): 1184-95.

Kelly, F.L. and Eleanor Reite. "Secondar)' Cases of Certain Communicable Diseases Among Non-Immune Family Contacts." American journal of Public Health 24 (December 1934): 1240-3.

Kimbrough, R.C., et al. "Rural Sj'philis: A Localized Outbreak." American journal of Public Health 28 (June 1938): 756-8.

Klein, Henr)^ and Carroll E. Palmer. "Dental Caries in Brothers and Sisters of Immune and Susceptible Children." Milbank Memorial ¥undQuarterly 1% Qanuan' 1940): 67-82.

Knopf, S. Adolphus, "Modern Aspect of the Tuberculosis Problem in Rural Communities and the Dut)' of the Health Officers." American journal of Public Health A (December 1914): 1127-35.

Kopf, Edwin W. "Famih' Statistics from Registration Sources." American jonrmt of Public Health 8 (1918): 910-2.

McPhedran, F. Maurice and Eugene L. Opie. "The Spread of Tuberculosis in Families." American journal of Hygiene 22 (November 1935): 565-643.

Milbank Memorial Fund. The Family as the Unit of Health: Papers Presented at a Round Table at the 1948 .•Innual Conference of the Milbank Memorial Fund, 17-1S, 1948. New York: Milbank Memorial Fund, 1949.

Nelson, N.A. "Neighborhood Organization vs. Tuberculosis." Modern Medicine 1 (1919): 515-21.

Olmsted, Katherine M. "Record Forms for Rural and Small Town Nurses." Public Health Nurse 12 (1920): 33-51.

Opie, Eugene L. "Present Concepts of Tuberculosis Infection and Disease." American Review of Tuberculosis 32 (1935): 617-30.

Opie, Eugene L. and Maurice F. McPhedran. "The Contagion of Tuberculosis." American Review of Tuberculosis 14 (October 1926): 347-419.

Opie, Eugene L. and Maurice F. McPhedran. "The Organization of an Out-Patient Tuberculosis Clinic for Epidemiological Investigation." American journal ofHjgiene 22 (November 1935): 539-64.

Opie, Eugene L., et al. "The Fate of Persons in Contact with Tuberculosis: The Exogenous Infection of Children and Adults." American journal of Hjgiene 22 (November 1935): 644-82.

Parran, Thomas. Shadow on the hand: Syphilis. New York: Reynal & Hitchcock, 1937. 500

Paul, l.R. "Age Susceptibilit\' to Familial Infection in Rlieumatic Fever." lonrna! of Clinical Investisation 10 (AprU 1931): 53-60.

Paul, J.R. and R. Salinger. "The Spread of Rheumatic Fever Through Families." Jo/inieil of Clinical Investigation 10 (April 1931): 33-51.

Paul, J.R., et al. "The Social Incidence of Rlieumadc Heart Disease: A Stausdcal Study in New Haven School Children." American Journal of the Medical Sciences 188 (1934); 3.

Popenoe, Paul B. The Conservation of the Family. Baltimore, 1926.

Popenoe, Paul B. "The Family in Societ)'." Public Health Nursing 28 (1936): SGI-12.

Puffer, Ruth Rice. Familial Susceptibility to Tuberculosis: Its Importance as a Public Health Problem. Cambridge: Harvard Universit)' Press, 1944.

Puffer, Ruth Rice, et al. "Tuberculosis Studies in Tennessee; Morbidit)- and Mortalit)' in Colored Families During the Period of Obsen'ation." American Journal of Hygiene 35 (May 1942): 367.

Puffer, Ruth Rice, et al. "Tuberculosis Studies in Tennessee: Subsequent Course of Cases Observed in Williamson Count}'." American Journal of Hygiene (November 1938); 490-507.

Puffer, Ruth Rice, et al. "Use of the Index Case in the Smdy of Tuberculosis in Williamson Count)-." American Journal of Public Health hi (June 1942); 601-5.

Ramsey, George H. "Typhoid Fever Among Household Contacts, with Special Reference to Vaccination." American Journal of Hygiene 2\ (May 1935); 665-78.

Ramsey, George H. and Marjorie T. Bellows. "Family Records in the Health Department." American Journal of Public Health 32 (|une 1942): 585-8.

Randall, Marian G. "Family Composition Used in the Analysis of Home Visits by Public Health Nurses." Milbank Memorial Fund Quarterly 15 (June 1937): 275-91.

Read, Frances E.M., et al. "The Frequency of Rheumatic Manifestations Among the Siblings, Parents, Uncles, Aunts, and Grandparents of Rheumatic and Control Patients." American Journal of Hygiene 27 (May 1938): 719-37.

Richardson, Henrj' B. Patients Hane Families. New York: The Commonwealth Fund, 1945.

Roberts, j.A.F. and W.A.R. Thomson. "An Inquir)- into the Family Incidence of Acute Rheumatism." Annals of Eugenics 6 (1934): 3.

St. Lawrence, W. "The Family Association of Cardiac Disease, Acute Rheumatic Fever, and Chorea: A Study of 100 Families." Journal of the American Medical Association 79 (December 16,1922): 2051-5.

Solomon, Harrj' C. and Maida Herman Solomon. Syphilis of the Innocent: A Study of the Social Effects of Syphilis on the Family and the Community. Washington: United States Interdepartmental Social Hygiene Board, 1922. 501

Stewart, Howard C. "The Epidemiolog)' of Tuberculosis in Gibson Count}-, Tennessee: A Study of the Prevalence of Tuberculosis Infection and Disease in 389 Families." D.P.H. thesis, Johns Hopkins Universit)', 1931.

Stewart, Howard C., et al. "Prevalence and Incidence of Tuberculosis Among Household Associates According to Age and Sex of Index Case." American journal ofViiblk Health 33 (April 194.3): 379-85.

Stewart, Howard C., et al. "Tuberculosis Studies in Tennessee: A Clinic Study with Reference to Epidemiolog)' within the Family." American Journal of Hygiene 26 (November 1937): 527-56.

Stewart, Howard C., et al. "Tuberculosis Studies in Tennessee; A Clinic Study with Reference to Epidemiolog)'within the Family." American Journal of Public Health 2(i (1936): 689-96.

Stewart, Howard C., et al. "Tuberculosis Studies in Tennessee: Infection, Morbidit)-, and Mortalit}' in the Families of the Tuberculous." American journal of Hygiene 26 (November 1937): 527-56.

Sydenstricker, Edgar. "The Decline in the Tuberculosis Death Rate in Cattaraugus Count)-." Milhank Memorial FundQuatlerly bulletin 6 (1928): 41-50.

Sydenstricker, Edgar and Jean Downes. "The Prevalence of Tuberculosis Infection in a Rural Communit}- in New \'ork State." Milbank Memorial Fund Quarterly 'Bulletin 11 (1933); 221 -32.

Sydenstricker, Edgar and Jean Downes. "Some Results of Tuberculosis Administration in Cattaraugus Count}', New York." American Review of Tuberculosis 23 (1931): 183-206.

Sydenstricker, Edgar and Jean Downes. "Some Results of Tuberculosis Administration in Cattaraugus Count)', New York." Tubercle 12 (1931): 1-17.

S)'denstricker, Edgar and W.I. I-Cing. "The Measurement of the Relative Economic Status of Families." Publications of the American Statistical Assodation 17 (1920-1): 842-57.

Svdenstricker, Edgar and Ralph E. V^Tieeler. "Wliooping Cough in Sur\'eyed Communities." American Journal of Public Health 26 Quae 1936): 576-85.

Town, Clara Harrison. Familial Feeblemindedness: Study of One Hundred and Forty-One Families. Buffalo, N.Y.: Foster & Stewart Publishing Corporation, 1939.

Turner, Thomas B., et al. "Results of Contact Investigation in Syphilis in an Urban Communit)'." American Journal of Public Health 29 (July 1939): 768-76.

Twinam, C.W. and Alton S. Pope. "PuLmonar}- Tuberculosis Resulting from Extra-Familial Contacts." American Journal of Public Health 32 (November 1942): 1215-8.

Van Volkenburgh, V.A. and Wade Hampton Frost. "Acute Minor Respirator)' Diseases Prevailing in a Group of Families Residing in Baltimore, Mar)'land, 1928-1930: Prevalence, Distribution, and CEnical Description of Observed Cases." American Journal of Hygiene 17 Qanuary 1933): 122-53.

Waller, W.W. The Family: Dynamic Inteipretation. New York, 1938. 502

Warner, Estella Ford, "Health Situations in the Family." PHbiic Health Nursing 28 (1936); 573-5.

Watt, J. "A Study of Infection and Mortalit)' in Children Exposed to Household Contact with Pulmonar)' Tuberculosis." D.P.H. thesis, Johns Hopkins Universit}% 1936.

Webster, Herbert T. The Physician and the Family: A Discussion of Their Mutual Relationships, Comments Concerning Disease Expressions, andSa^estions Relative to TheirTreatment. Cincinnati: Lloyd Brothers Pharmacists, Inc., 1927.

Wliitman, R.C. Hj;giene:A College Textbook for Non-Medical Students. New York: John Wiley & Sons, Inc., 1930.

Wile, Ira Solomon. "The Healthful Home." American Journal of Public Health 12 (April 1922): 295-8.

Wile, Ira Solomon. "Sociological Aspects of Housing." American Journal of Public Health 10 (April 1920); 327-31.

Wile, Ira Solomon. "\X1iat is Happening to the Family?" Hospital Social Service 19 (1929): 525-33.

Wilson, May G. Rheumatic Fever. Studies of the Epidemiology, Manifestations, Diagnosis, and Treatment of the Disease During the First Three Decades. New York: The Commonwealth Fund, 1940.

Wilson, May G. and Morton D. Schweitzcr. "Rheumatic Fever as a Familial Disease: Environment, Communicabilit}', and Heredit}- in Their Relation to the Obser%'ed Familial Incidence of the Disease." Journal oj Clinical Investigation 16 Quly 1937): 555-70.

CHAPTER XI. THE PLACE OF THE INDIVIDUAL IN COMMUNITY HEALTH

Allen, C.B. and M.A. Allen. The Man Wondeiftil in the House Beautiful. New York, 1883.

-Mien, Nathan. Physical Degeneracy. New York: D. Appleton, 1870.

Allen, Nathan. Physical Development, Or the Laws Governing the Human System. Boston: Lee and Shepard, 1888.

Allen, Nathan. The Physiological Laws of Human Increase. Philadelphia: Collins, 1870.

Allen, Nathan. "Perfection of Structure in the Human Body, as a Leading Element of Hygiene." Reports and Papers of the American Public Health Association 1 (1873); 36-45.

Borell, Merriley. "Instruments and an Independent Physiolog)'; The Har\'ard Physiological Laborator)-, 1871-1906." In Physiology in the American Context, 1850-1940, ed. Gerald L. Geison, 293-321. Bethesda, Md.: American Physiological Societ)-, 1987.

Brooks, Chandler McC. "The Development of Physiology in the Last Fiftj- Years." Bulletin oj the Histo^^ ofMedicine 33 {1959): 249-62. 503

Brooks, Chandler McC. "Homeostasis and Adaptation." In The Life and Contributions of W alter Bradford Cannon, 1871-1945: His InPttence on the Development of Physiology in the Tiventietb Centuty, ed. Chandler McC. Brooks, et al., 84-6. Brooklyn: State Universit)' of New York, Downstate Medical Center, 1975.

Brooks, Chandler McC., et al. "The Breadth of Walter B. Cannon's Interests." In The Life and Contributions of Walter Bradford Cannon, 1871-1945: His Influence on the Development of Physiology in the Twentieth Centuy, ed. Chandler McC. Brooks, et al., 170-85. Brooklyn: State Universit}- of New York, Downstate Medical Center, 1975.

Brooks, Chandler McC. and Paul F. Crancfield, eds. The Historical Development of Physiological Thought: A Symposium Pleldat the State University of New York, Downstate Medical Center. New York: The Hafner Publishing Company, 1959.

Brooks, Chandler McC., et al., eds. The Life and Contributions ofWalter Bradford Cannon, 1871-1945: His Influence on the Development of Physiotog)' in the Twentieth Centuty. Brooklyn: State University of Ncw York, Downstate Medical Center, 1975.

Cannon, Bradford. "Walter B. Cannon: Personal Reminiscences." In The Life and Contributions ofWalter Bradford Cannon, 1871-1945: His influence on the Development of Physiology in the Twentieth Century, ed. Chandler McC. Brooks, et al., 151-69. Brooklyn: State Universit)- of New York, Downstate Medical Center, 1975.

Cannon, Walter Bradford. Bodily Changes in Pain, Hunger, Fear, and Rage. New York: D. Appleton and Company, 1923.

Cannon, Walter Bradford. "The Role of Emotion in Disease." .Annual of Internal Medicine 9 (1936): 1453-65.

Cannon, W alter Bradford. Traumatic Shock. New York; D. Appleton and Company, 1923.

Cannon, Walter Bradford. The Way of an Investigator A Scientist's Experiences in Medical Research. New York: W.W. Norton & Company, Inc., 1945.

Cannon, Walter Bradford. The Wi.fdom of the Body. New York: W.W. Norton & Company, Inc., 1932.

Clendening, Logan. The Human Bocly. New York: Alfred A. Ivnopf, 1927.

Davenport, Horace W. "Physiolog)', 1850-1923: The View from Michigan." Physiologist 24 (1982, supplement no. 1): 1-96.

Fisk, Eugene Lyman. "Some Results of Periodic Health Examinadons." Popular Science Monthly 86 (April 1915): 324-30.

Frank, Robert G., Jr. "American Physiologists in German Laboratories, 1865-1914." In Plysiology in the American Context, 1850-1940, ed. Gerald L. Geison, 11-46. Bethesda, Md.: American Physiological Societ}% 1987.

Fulton, John F. Selected Readings in the Histoty ofPlysiology. Springfield, 111.: C.C. Thomas, 1930. 504

Fve, W. Bruce. The Development of American PhjsioioQ-: Scientific Medicine in the Nineteenth Century. The Henn' E. Sigerist Series in the Histor)- of Medicine. Baltimore; The Johns Hopkins Univcrsit}' Press, 1987.

Fve, W. Bruce. "Growth of American Physiolog)', 1850-1900." In Physiology in the American Context, 1850-1940, ed. Gerald L. Geison, 47-65. Bethesda, Md.: American Physiological Societ)', 1987.

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