Chapter 2

The honest use of the mortuary statistics of a large town is no easy matter, and I must therefore ask that I may be supposed to have taken every possible precaution in order not to exaggerate the reality of a great evil. Certain diseases, such as apoplexy, palsy, epilepsy, St. Vitus's dance, and lockjaw or tetanus, we all agree to consider as nervous maladies; convulsions, and the vast number of cases known in the death-lists as dropsy of the brain, effusion on the brain, etc., are to be looked upon with more doubt. The former, as every doctor knows, are, in a vast proportion of instances, due to direct disease of the nerve-centres; or, if not to this, then to such a condition of irritability of these parts as makes them too ready to originate spasms in response to causes which disturb the extremities of the nerves, such as teething and the like. This tendency seems to be fostered by the air and habits of great towns, and by all the agencies which in these places depress the health of a community. The other class of diseases, as dropsy of the brain or effusion, probably includes a number of maladies, due some of them to scrofula, and to the predisposing causes of that disease; others, to the kind of influences which seem to favor convulsive disorders. Less surely than the former class can these be looked upon as true nervous diseases; so that in speaking of them I am careful to make separate mention of their increase, while thinking it right on the whole to include in the general summary of this growth of nerve disorders this partially doubtful class.

Taking the years 1852 to 1868, inclusive, it will be found that the population of Chicago has increased 5.1 times and the deaths from all causes 3.7 times; while the nerve deaths, including the doubtful class labelled in the reports as dropsy of the brain and convulsions, have risen to 20.4 times what they were in 1852. Thus in 1852, '53, and '55, leaving out the cholera year '54, the deaths from nerve disorders were respectively to the whole population as 1 in 1149, 1 in 953, and 1 in 941; whilst in 1866, '67, and '68, they were 1 in 505, 1 in 415.7, and 1 in 287.8. Still omitting 1854, the average proportion of neural deaths to the total mortality was, in the five years beginning with 1852, 1 in 26.1. In the five latter years studied--that is, from 1864 to 1868, inclusive--the proportion was 1 nerve death to every 9.9 of all deaths.

I have alluded above to a class of deaths included in my tables, but containing, no doubt, instances of mortality due to other causes than disease of the nerve-organs. Thus many which are stated to have been owing to convulsions ought to be placed to the credit of tubercular disease of the brain or to heart maladies; but even in the practice of medicine the distinction as to cause cannot always be made; and as a large proportion of this loss of life is really owing to brain affections, I have thought best to include the whole class in my statement.

A glance at the individual diseases which are indubitably nervous is more instructive and less perplexing. For example, taking the extreme years, the recent increase in apoplexy is remarkable, even when we remember that it is a malady of middle and later life, and that Chicago, a new city, is therefore entitled to a yearly increasing quantity of this form of death. In 1868 the number was 8.6 times greater than in 1852. Convulsions as a death cause had in 1868 risen to 22 times as many as in the year 1852. Epilepsy, one of the most marked of all nervous maladies, is more free from the difficulties which belong to the last-mentioned class. In 1852 and '53 there were but two deaths from this disease; in the next four years there were none. From 1858 to '64, inclusive, there were in all 6 epileptic deaths: then we have in the following years, 5, 3, 11; and in 1868 the number had increased to 17. Passing over palsy, which, like apoplexy, increases in 1868,--8.6 times as compared with 1852; and 26 times as compared with the four years following 1852,--we come to lockjaw, an unmistakable nerve malady. Six years out of the first eleven give us no death from this painful disease; the others, up to 1864, offer each one only, and the last-mentioned year has but two. Then the number rises to 3 each year, to 5 in 1867, and to 12 in 1868. At first sight, this record of mortality from lockjaw would seem to be conclusive, yet it is perhaps, of all the maladies mentioned, the most deceptive as a means of determining the growth of neural diseases. To make this clear to the general reader, he need only be told that tetanus is nearly always caused by mechanical injuries, and that the natural increase of these in a place like Chicago may account for a large part of the increase. Yet, taking the record as a whole, and viewing it only with a calm desire to get at the truth, it is not possible to avoid seeing that the growth of nerve maladies has been inordinate.

The industry and energy which have built this great city on a morass, and made it a vast centre of insatiate commerce, are now at work to undermine the nervous systems of its restless and eager people,[1] with what result I have here tried to point out, chiefly because it is an illustration in the most concentrated form of causes which are at work elsewhere throughout the land.

[Footnote 1: I asked two citizens of this uneasy town--on the same day--what was their business. Both replied tranquilly that they were speculators!]

The facts I have given establish the disproportionate increase in one great city of those diseases which are largely produced by the strain on the nervous system resulting from the toils and competitions of a community growing rapidly and stimulated to its utmost capacity. Probably the same rule would be found to apply to other large towns, but I have not had time to study the statistics of any of them fully; and, for reasons already given, Chicago may be taken as a typical illustration.

It were interesting to-day to question the later statistics of this great business-centre; to see if the answers would weaken or reinforce the conclusions drawn in 1871. I have seen it anew of late with its population of 700,000 souls. It is a place to-day to excite wonder, and pity, and fear. All the tides of its life move with bustling swiftness. Nowhere else are the streets more full, and nowhere else are the faces so expressive of preoccupation, of anxiety, of excitement. It is making money fast and accumulating a physiological debt of which that bitter creditor, the future, will one day demand payment.

If I have made myself understood, we are now prepared to apply some of our knowledge to the solution of certain awkward questions which force themselves daily upon the attention of every thoughtful and observant physician, and have thus opened a way to the discussion of the causes which, as I believe, are deeply affecting the mental and physical health of working Americans. Some of these are due to the climatic conditions under which all work must be done in this country, some are out-growths of our modes of labor, and some go back to social habitudes and defective methods of early educational training.

In studying this subject, it will not answer to look only at the causes of sickness and weakness which affect the male sex. If the mothers of a people are sickly and weak, the sad inheritance falls upon their offspring, and this is why I must deal first, however briefly, with the health of our girls, because it is here, as the doctor well knows, that the trouble begins. Ask any physician of your acquaintance to sum up thoughtfully the young girls he knows, and to tell you how many in each score are fit to be healthy wives and mothers, or in fact to be wives and mothers at all. I have been asked this question myself very often, and I have heard it asked of others. The answers I am not going to give, chiefly because I should not be believed--a disagreeable position, in which I shall not deliberately place myself. Perhaps I ought to add that the replies I have heard given by others were appalling.

Next, I ask you to note carefully the expression and figures of the young girls whom you may chance to meet in your walks, or whom you may observe at a concert or in the ball-room. You will see many very charming faces, the like of which the world cannot match--figures somewhat too spare of flesh, and, especially south of Rhode Island, a marvellous littleness of hand and foot. But look further, and especially among New England young girls: you will be struck with a certain hardness of line in form and feature which should not be seen between thirteen and eighteen, at least; and if you have an eye which rejoices in the tints of health, you will too often miss them on the cheeks we are now so daringly criticising. I do not want to do more than is needed of this ungracious talk: suffice it to say that multitudes of our young girls are merely pretty to look at, or not that; that their destiny is the shawl and the sofa, neuralgia, weak backs, and the varied forms of hysteria,--that domestic demon which has produced untold discomfort in many a household, and, I am almost ready to say, as much unhappiness as the husband's dram. My phrase may seem outrageously strong, but only the doctor knows what one of these self-made invalids can do to make a household wretched. Mrs. Gradgrind is, in fiction, the only successful portrait of this type of misery, of the woman who wears out and destroys generations of nursing relatives, and who, as Wendell Holmes has said, is like a vampire, sucking slowly the blood of every healthy, helpful creature within reach of her demands.

If any reader doubts my statement as to the physical failure of our city-bred women to fulfil all the natural functions of mothers, let him contrast the power of the recently imported Irish or Germans to nurse their babies a full term or longer, with that of the native women even of our mechanic classes. It is difficult to get at full statistics as to those a higher social degree, but I suspect that not over one-half are competent to nurse their children a full year without themselves suffering gravely. I ought to add that our women, unlike ladies abroad, are usually anxious to nurse their own children, and merely cannot. The numerous artificial infant foods now for sale singularly prove the truth of this latter statement. Many physicians, with whom I have talked of this matter, believe that I do not overstate the evil; others think that two-thirds may be found reliable as nurses; while the rural doctors, who have replied to my queries, state that only from one-tenth to three-tenths of farmers' wives are unequal to this natural demand. There is indeed little doubt that the mass of our women possess that peculiar nervous organization which is associated with great excitability, and, unfortunately, with less physical vigor than is to be found, for example, in the sturdy English dames at whom Hawthorne sneered so bitterly. And what are the causes to which these peculiarities are to be laid? There are many who will say that late hours, styles of dress, prolonged dancing, etc., are to blame; while really, with rare exceptions, the newer fashions have been more healthy than those they superseded, people are better clad and better warmed than ever, and, save in rare cases, late hours and overexertion in the dance are utterly incapable of alone explaining the mischief. I am far more inclined to believe that climatic peculiarities have formed the groundwork of the evil, and enabled every injurious agency to produce an effect which would not in some other countries be so severe. I am quite persuaded, indeed, that the development of a nervous temperament is one of the many race-changes which are also giving us facial, vocal, and other peculiarities derived from none of our ancestral stocks. If, as I believe, this change of temperament in a people coming largely from the phlegmatic races is to be seen most remarkably in the more nervous sex, it will not surprise us that it should be fostered by many causes which are fully within our own control. Given such a tendency, disease will find in it a ready prey, want of exercise will fatally increase it, and all the follies of fashion will aid in the work of ruin.

While a part of the mischief lies with climatic conditions which are utterly mysterious, the obstacles to physical exercise, arising from extremes of temperature, constitute at least one obvious cause of ill health among women in our country. The great heat of summer, and the slush and ice of winter, interfere with women who wish to take exercise, but whose arrangements to go out-of-doors involve wonderful changes of dress and an amount of preparation appalling to the masculine creature.

The time taken for the more serious instruction of girls extends to the age of nineteen, and rarely over this. During some of these years they are undergoing such organic development as renders them remarkably sensitive. At seventeen I presume that healthy girls are as well able to study, _with proper precautions_, as men; but before this time overuse, or even a very steady use, of the brain is in many dangerous to health and to every probability of future womanly usefulness.

In most of our schools the hours are too many, for both girls and boys. From nine until two is, with us, the common school-time in private seminaries. The usual recess is twenty minutes or half an hour, and it is not as a rule filled by enforced exercise. In certain schools--would it were common!--ten minutes' recess is given after every hour; and in the Blind Asylum of Philadelphia this time is taken up by light gymnastics, which are obligatory. To these hours we must add the time spent in study out of school. This, for some reason, nearly always exceeds the time stated by teachers to be necessary; and most girls of our common schools and normal schools between the ages of thirteen and seventeen thus expend two or three hours. Does any physician believe that it is good for a growing girl to be so occupied seven or eight hours a day? or that it is right for her to use her brains as long a time as the mechanic employs his muscles? But this is only a part of the evil. The multiplicity of studies, the number of teachers,--each eager to get the most he can out of his pupil, the severer drill of our day, and the greater intensity of application demanded, produce effects on the growing brain which, in a vast number of cases, can be only disastrous.

My remarks apply of course chiefly to public school life. I am glad to say that of late in all of our best school States more thought is now being given to this subject, but we have much to do before an evil which is partly a school difficulty and partly a home difficulty shall have been fully provided against.

Careful reading of our Pennsylvania reports and of those of Massachusetts convinces me that while in the country schools overwork is rare, in those of the cities it is more common, and that the system of pushing,--of competitive examinations,--of ranking, etc., is in a measure responsible for that worry which adds a dangerous element to work.

The following remarks as to the influence of home life in Massachusetts are not out of place here, and will be reinforced by what is to be said farther on by a competent authority as to Philadelphia:

"The danger of overwork, I believe, exists mainly, if not wholly, in graded schools, where large numbers are taught together, where there is greater competition than in ungraded schools, and where the work of each pupil cannot be so easily adjusted to his capacity and needs. And what are the facts in these schools? I am prepared to agree with a recent London School Board Report so far as to say that in some of our graded schools there are pupils who are overworked. The number in any school is, I believe, small who are stimulated beyond their strength, and the schools are few in which such extreme stimulation is encouraged. When, with a large class of children whose minds are naturally quick and active, the teacher resorts to the daily marking of recitations, to the giving of extra credits for extra work done, to ranking, and to holding up the danger of non-promotion before the pupils; and when, added to those extra inducements to work, there are given by committees and superintendents examinations for promotion at regular intervals, it would be very strange if there were not some pupils so weak and so susceptible as to be encouraged to work beyond their strength. There is another occasion of overwork which I have found in a few schools, and that is the spending of nearly all of the school time in recitation and putting off study to extra time at home. When, in a school of forty or more, pupils belong to the same class, and are not separated into divisions for recitation and study, there is a temptation to spend the greater part of the time in recitation which few teachers can resist; and if tasks are given, they have to be learned out of school or not at all. Pupils of grammar schools are known to feel obliged to study two or three hours daily from this cause at a time when they should be sleeping, or exercising in the open air. Frequently, however, it is not so much overwork as overworry that most affects the health of the child,--that worry which may not always be traced to any fault of system or teacher, but which, it must be admitted, is too often induced by encouraging wrong motives to study.

"In making up the verdict we must not forget that others besides the teacher may be responsible for overwork and overworry. The parents and pupils themselves are quite as often to blame as are the teachers. An unwillingness on the part of pupils to review work imperfectly done, and a desire on the part of parents to have their children get into a higher class, or to graduate, frequently cause pupils to cram for examinations and to work unduly at a time when the body is least able to bear the extra strain. Again, children are frequently required to take extra lessons in music or some other study at home, thus depriving them of needed exercise and recreation, or exhausting nervous energy which is needed for their regular school work.

"It will be observed that in this charge against parents I do not speak of those causes of ill health which really have nothing to do with overwork, but which are oftentimes forgotten when a school-boy or girl breaks down. I allude to the eating of improper and unwholesome food, to irregularity of eating and sleeping, to attendance upon parties and other places of amusement late at night, to smoking, and to the indulgence of other habits which tend to unduly excite the nervous system. For very obvious reasons these causes of disease are not brought prominently forward by the attending physician, who doubtless thinks it safer and more flattering to his patrons to say that the child has broken down from hard study, rather than from excesses which are somewhat discreditable. While parents are clearly to blame for endangering health in the ways indicated, it may be a question whether the work required to be done in school should not be regulated accordingly; whether, in designating the studies to be taken, and in assigning lessons, there should not be taken into consideration all the circumstances of the pupil's life which can be conveniently ascertained, even though those circumstances are most unfavorable to school work and are brought about mainly through the ignorance or folly of parents. Of course there is a limit to such an adjustment of work in school, but with proper caution and a good understanding with the parents there need be little danger of advantage being taken by an indolent child; nor need the school be affected when it is understood to be a sign of weakness rather than of favor to any particular pupil to lessen his work. Not unfrequently there are found other causes of ill health than those which I have mentioned; such, for instance, as poor ventilation, overheating of the school-room, draughts of cold air, and the like; not to speak of the annual public exhibition, with the possible nervous excitement attending it. All of these things are mentioned, not because they belong directly to the question of overwork, but because it is well, in considering the question, to keep in mind all possible causes of ill health, that no one cause may be unduly emphasized."[1]

[Footnote 1: Forty-ninth Annual Report of the Massachusetts Board of Education, p. 204 (John T. Prince).]

In private schools the same kind of thing goes on, with the addition of foreign languages, and under the dull spur of discipline, without the aid of any such necessities as stimulate the pupils of what we are pleased to call a normal (!) school.

In private schools for girls of what I may call the leisure class of society overwork is of course much more rare than in our normal schools for girls, but the precocious claims of social life and the indifference of parents as to hours and systematic living needlessly add to the ever-present difficulties of the school-teacher, whose control ceases when the pupil passes out of her house.

As to the school in which both sexes are educated together a word may be said. Surely no system can be worse than that which complicates a difficult problem by taking two sets of beings of different gifts, and of unlike physiological needs and construction, and forcing them into the same educational mould.

It is a wrong for both sexes. Not much unlike the boy in childhood, there comes a time when in the rapid evolution of puberty the girl becomes for a while more than the equal of the lad, and, owing to her conscientiousness, his moral superior, but at this era of her life she is weighted by periodical disabilities which become needlessly hard to consider in a school meant to be both home and school for both sexes. Finally, there comes a time when the matured man certainly surpasses the woman in persistent energy and capacity for unbroken brain-work. If then she matches herself against him, it will be, with some exceptions, at bitter cost.

It is sad to think that the demands of civilized life are making this contest almost unavoidable. Even if we admit equality of intellect, the struggle with man is cruelly unequal and is to be avoided whenever it is possible.

The colleges for women, such as Vassar, are nowadays more careful than they were. Indeed, their machinery for guarding health while education of a high class goes on is admirable. What they still lack is a correct public feeling. The standard for health and endurance is too much that which would be normal for young men, and the sentiment of these groups of women is silently opposed to admitting that the feminine life has necessities which do not cumber that of man. Thus the unwritten code remains in a measure hostile to the accepted laws which are supposed to rule.

As concerns our colleges for young men I have little to say. The cases I see of breakdown among women between sixteen and nineteen who belong to normal schools or female colleges are out of all proportion larger than the number of like failures among young men of the same ages, and yet, as I have hinted, the arrangements for watching the health of these groups of women are usually better than such as the colleges for young men provide. The system of professional guardianship at Johns Hopkins is an admirable exception, and at some other institutions the physical examination on matriculation becomes of the utmost value, when followed up as it is in certain of these schools by compulsory physical training and occasional re-examinations of the state of health.