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- Transcriber's Note: Inconsistent hyphenation in the original document has been preserved. Some text in this document has been moved to avoid multi-page tables being inserted mid-paragraph. Obvious typographical errors have been corrected in this text. For a complete list, please see the end of this document. -
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CIVICS AND HEALTH
WILLIAM H. ALLEN
SECRETARY, BUREAU OF MUNICIPAL RESEARCH
FORMER SECRETARY OF THE NEW YORK COMMITTEE ON PHYSICAL WELFARE OF SCHOOL CHILDREN, AUTHOR OF "EFFICIENT DEMOCRACY" AND "RURAL SANITARY ADMINISTRATION IN PENNSYLVANIA," JOINT AUTHOR OF "SCHOOL REPORTS AND SCHOOL EFFICIENCY"
WITH AN INTRODUCTION
WILLIAM T. SEDGWICK
PROFESSOR OF BIOLOGY IN THE MASSACHUSETTS INSTITUTE OF TECHNOLOGY
GINN AND COMPANY BOSTON . NEW YORK . CHICAGO . LONDON
ENTERED AT STATIONERS' HALL
COPYRIGHT, 1909 BY WILLIAM H. ALLEN
ALL RIGHTS RESERVED
The Athenaeum Press GINN AND COMPANY . PROPRIETORS . BOSTON . U.S.A.
It is a common weakness of mankind to be caught by an idea and captivated by a phrase. To rest therewith content and to neglect the carrying of the idea into practice is a weakness still more common. It is this frequent failure of reformers to reduce their theories to practice, their tendency to dwell in the cloudland of the ideal rather than to test it in action, that has often made them distrusted and unpopular.
With our forefathers the phrase mens sana in corpore sano was a high favorite. It was constantly quoted with approval by writers on hygiene and sanitation, and used as the text or the finale of hundreds of popular lectures. And yet we shall seek in vain for any evidence of its practical usefulness. Its words are good and true, but passive and actionless, not of that dynamic type where words are "words indeed, but words that draw armed men behind them."
Our age is of another temper. It yearns for reality. It no longer rests satisfied with mere ideas, or words, or phrases. The modern Ulysses would drink life to the dregs. The present age is dissatisfied with the vague assurance that the Lord will provide, and, rightly or wrongly, is beginning to expect the state to provide. And while this desire for reality has its drawbacks, it has also its advantages. Our age doubts absolutely the virtues of blind submission and resignation, and cries out instead for prevention and amelioration. Disease is no longer regarded, as Cruden regarded it, as the penalty and the consequence of sin. Nature herself is now perceived to be capable of imperfect work. Time was when the human eye was referred to as a perfect apparatus, but the number of young children wearing spectacles renders that idea untenable to-day.
Meanwhile the multiplication of state asylums and municipal hospitals, and special schools for deaf or blind children and for cripples, speaks eloquently and irresistibly of an intimate connection between civics and health. There is a physical basis of citizenship, as there is a physical basis of life and of health; and any one who will take the trouble to read even the Table of Contents of this book will see that for Dr. Allen prevention is a text and the making of sound citizens a sermon. Given the sound body, we have nowadays small fear for the sound mind. The rigid physiological dualism implied in the phrase mens sana in corpore sano is no longer allowed. To-day the sound body generally includes the sound mind, and vice versa. If mental dullness be due to imperfect ears, the remedy lies in medical treatment of those organs,—not in education of the brain. If lack of initiative or energy proceeds from defective aeration of the blood due to adenoids blocking the air tides in the windpipe, then the remedy lies not in better teaching but in a simple surgical operation.
Shakespeare, in his wildwood play, saw sermons in stones and books in the running brooks. We moderns find a drama in the fateful lives of ordinary mortals, sermons in their physical salvation from some of the ills that flesh is heir to, and books—like this of Dr. Allen's—in striving to teach mankind how to become happier, and healthier, and more useful members of society.
Dr. Allen is undoubtedly a reformer, but of the modern, not the ancient, type. He is a prophet crying in our present wilderness; but he is more than a prophet, for he is always intensely practical, insisting, as he does, on getting things done, and done soon, and done right.
No one can read this volume, or even its chapter-headings, without surprise and rejoicing: surprise, that the physical basis of effective citizenship has hitherto been so utterly neglected in America; rejoicing, that so much in the way of the prevention of incapacity and unhappiness can be so easily done, and is actually beginning to be done.
The gratitude of every lover of his country and his kind is due to the author for his interesting and vivid presentation of the outlines of a subject fundamental to the health, the happiness, and the well-being of the people, and hence of the first importance to every American community, every American citizen.
WILLIAM T. SEDGWICK
MASSACHUSETTS INSTITUTE OF TECHNOLOGY
PART I. HEALTH RIGHTS
CHAPTER PAGE I. HEALTH A CIVIC OBLIGATION 3
II. SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS 11
III. WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY? 23
IV. THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL WELFARE OF SCHOOL CHILDREN 33
PART II. READING THE INDEX TO HEALTH RIGHTS
V. MOUTH BREATHING 45
VI. CATCHING DISEASES, COLDS, DISEASED GLANDS 57
VII. EYE STRAIN 72
VIII. EAR TROUBLE, MALNUTRITION, DEFORMITIES 83
IX. DENTAL SANITATION 89
X. ABNORMALLY BRIGHT CHILDREN 104
XI. NERVOUSNESS OF TEACHER AND PUPIL 107
XII. HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING 115
XIII. VITALITY TESTS AND VITAL STATISTICS 124
XIV. IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS? 139
XV. THE TEACHER'S HEALTH 152
PART III. COOePERATION IN MEETING HEALTH OBLIGATIONS
XVI. EUROPEAN REMEDIES: DOING THINGS AT SCHOOL 159
XVII. AMERICAN REMEDIES: GETTING THINGS DONE 166
XVIII. COOePERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES 174
XIX. SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE 184
XX. PHYSICAL EXAMINATION FOR WORKING PAPERS 190
XXI. PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE 201
XXII. HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY 208
XXIII. INDUSTRIAL HYGIENE 218
XXIV. THE LAST DAYS OF TUBERCULOSIS 229
XXV. THE FIGHT FOR CLEAN MILK 252
XXVI. PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER 268
PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
XXVII. DEPARTMENTS OF SCHOOL HYGIENE 283
XXVIII. PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY 296
XXIX. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS 302
XXX. SCHOOL AND HEALTH REPORTS 310
XXXI. THE PRESS 322
PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION
XXXII. DO-NOTHING AILMENTS 329
XXXIII. HEREDITY BUGABOOS AND HEREDITY TRUTHS 335
XXXIV. INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM 343
XXXV. IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS OF ALCOHOLISM TO TELL THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH? 357
XXXVI. FIGHTING TOBACCO EVILS 363
XXXVII. THE PATENT-MEDICINE EVIL 369
XXXVIII. HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH 378
XXXIX. IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE? 384
XL. THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND 391
XLI. "A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE" 398
CIVICS AND HEALTH
PART I. HEALTH RIGHTS
HEALTH A CIVIC OBLIGATION
In forty-five states and territories the teaching of hygiene with special reference to alcohol and tobacco is made compulsory. To hygiene alone, of the score of subjects found in our modern grammar-school curriculum, is given statutory right of way for so many minutes per week, so many pages per text-book, or so many pages per chapter. For the neglect of no other study may teachers be removed from office and fined. Yet school garrets and closets are full of hygiene text-books unopened or little used, while of all subjects taught by five hundred thousand American teachers and studied by twenty million American pupils the least interesting to both teacher and pupil is that forced upon both by state legislation. To complete the paradox, this least interesting subject happens also to be the most vital to the child, to the home, to industry, to social welfare, and to education itself.
Whether the subject of hygiene is necessarily dull, whether the statutes requiring regular instruction in the laws of health are violated with impunity, whether health principles are flaunted by health practice at school,—these are questions of immediate concern to parents as a class, to employers as a class, to every pastor, every civic leader, every health officer, every taxpayer.
Interviews with teachers and principals regarding the present apathy to formal hygiene instruction have brought out the following points that merit the serious consideration of those who are struggling for higher health standards.
1. There is many a slip 'twixt the making of a law and its enforcement. If laws regarding hygiene instruction are not enforced, we should not be surprised. It has been nobody's business to see whether and how hygiene is being taught. The moral crusade spent itself in forcing compulsory laws upon the statute books of every state and territory. Making a fetish of Legislation, the advocates of anti-alcohol and anti-tobacco instruction failed to see the truth that experienced political reformers are but slowly coming to see—Legislation which does not provide machinery for its own enforcement is apt to do little good and frequently will do much harm. Machinery, however admirably adapted to the work to be done, will get out of order and become useless, or even harmful, unless constantly watched and efficiently directed. Of what possible use is it to say that state money may be withheld from any school board which fails to enforce the law regarding instruction in hygiene, if state officials never enforce the penalty? So long as the penalty is not enforced for flagrant violation, what difference does it make whether the reason is indifference, ignorance, or desire to thwart the law? Fortunately, it is easy for each one of us to learn how often and in what way the children in our community are being taught hygiene, and how the schools of our state teach and practice the laws of health. If either the spirit or the letter of the law regarding instruction in hygiene is being violated, we can measure the penalty paid in health and morals by our children and our community. We can learn whether law, text-book, curriculum, or teacher should be changed. We can insist upon discussion of the facts and upon remedies suggested by the facts.
2. Teachers give as one reason for neglecting hygiene, that they are often compelled to struggle with a curriculum which requires more than they are able to teach and more than pupils are able to learn in the time allowed. While an overcharged curriculum may explain, it surely does not justify, the violation of law and the dropping of hygiene from our school curriculum. If there is any class of citizen who should teach and practice respect for law as law, it is the teacher. Parents, school directors, county and state superintendents, university presidents, social workers, owe it not only to themselves, but to the American school-teacher, either to repeal the laws that enjoin instruction in hygiene or else so to adjust the curriculum that teachers can comply with those laws. The present situation that discredits both law and hygiene is most demoralizing to teacher, pupil, and community. Many of us might admire the man teacher who frankly says he never explains the evils of cigarettes because he himself is an inveterate smoker of cigarettes. But what must we think of the school system that shifts to such a man the right and the responsibility of deciding whether or not to explain to underfed and overstimulated children of the slums the truth regarding cigarettes? If practice and precept must be consistent, shall the man be removed, shall he change his habits, shall the law regarding instruction in hygiene be changed, or shall other provision be made for bringing child and essential facts together in a way that will not dull the child's receptivity?
3. Teachers are made to feel that while arithmetic and reading are essential, hygiene is not essential. Whatever may be the facts regarding the relative value of arithmetic and hygiene, whether or not our state legislators have made a mistake in declaring hygiene to be essential, are questions altogether too important for child and state to be left to the discretion of the individual teacher or superintendent. It is fair to the teachers who say they cannot afford to turn aside from the three R's to teach hygiene, to admit that they have not hitherto identified the teaching of hygiene with the promotion of the physical welfare of children. Teachers awake to the opportunity will sacrifice not only hygiene but any other subject for the sake of promoting children's health. They do not really believe that arithmetic is more important than health. What they mean to say is that hygiene, as taught by them, has not heretofore had an appreciable effect upon their pupils' health; that other agencies exist, outside of the school, to teach the child how to avoid certain diseases and how to observe the fundamental laws of health, whereas no other agencies exist to give the child the essentials of arithmetic, reading, and geography. "We teach (or try to teach) what our classes are examined in. If you want a subject taught, you must test a class in it and hold a teacher responsible for results, and examinations are mercilessly unhygienic, you know."
4. Teachers believe that they get better results for their children from teaching hygiene informally and indirectly than from stated formal lessons. Whether instruction should be informal or formal is merely a question of method to be determined by results. What the results are, can be determined by principals, superintendents, and students of education. It is easy to understand how at the time of a fever epidemic children could be taught as much in one week about infection, disease germs, antiseptics, value of cleanliness, etc., as in five or ten months when vivid illustration is lacking. Physicians themselves learn more from one epidemic of smallpox than from four years of book study. To make possible and to require a daily shower bath will undoubtedly do more to inculcate habits of health than repeated lessons about the skin, pores, evaporation, and discharge of impurities.
If one illustration is better than ten lessons, if an open window is worth more than all that text-books have to say about ventilation, if a seat adjusted to the child is better than an anatomical chart, this does not mean that instruction in hygiene should cease. On the contrary, it means that provision should be made for every teacher to open windows, to adjust desks, to use the experience of individual children for the education of the class. If the rank and file of teachers have not hitherto been sufficiently observant of physiological and hygienic facts, if they are unprepared from their own lives to detect or to furnish illustrations for the child, this again does not mean that the child should be denied the illustrations, but that the teacher should either have instruction and experience to incite interest and to stimulate powers of observation, or else be asked to give place to another teacher who is able to furnish such qualifications.
5. Children, like adults, can be interested in other people, in rules of conduct, in social conditions, in living and working relations more easily than in their own bodies. The normal, healthy child thinks very little of himself apart from the other boys and girls, the games, the studies, the animals, the nature wonders, the hardships that come to him from the outside. So true is this that one of the best means of mitigating or curing many ailments is to divert the child's attention from himself to things outside of himself that he can look at, hear, enjoy. The power to concentrate attention upon oneself is a sign either of a diseased body, a diseased mind, or a highly trained mind. To study others and to recognize the similarity between others and oneself is as natural as the body itself. Teachers are consulting this line of easiest access to children's attention when they honor children according to cleanliness of hands, of teeth, of shoes. Human interest attaches to what parks or excursions are doing for sickly children, how welfare work is improving factory employees, how smallpox is conquered by vaccination, how insurance companies refuse to take risks upon the lives of men or women addicted to the excessive use of alcohol or tobacco.
Other people's interests—tenement conditions, factory rules—can be described in figures and actions that appeal to the imagination and impress upon the mind pictures that are repeatedly reawakened by experience and observation on the playground, at home, on the way to school or to work. "Once upon a time—" will always arrest attention more quickly than "The human frame consists—." What others think of me helps me to obey law—statutory, moral, or hygienic—more than what I know of law itself. How social instincts dominate may be illustrated by an experience in advertising a public bath near a thoroughfare traveled daily by thousands of working girls. I prepared a card to be distributed among these girls that began: "A cool, refreshing bath, etc." This card was criticised by one who knows the ways of girls and women, as follows: "Of course you get no success when you have a man stand on the street corner and pass out cards telling girls to get clean. Every girl that is worth while is affronted by the insinuation." Acting upon this expert advice, we then got out a neatly printed card reading as follows: "For a clear complexion, sprightly step, and bounding vitality, visit the Center Market Baths, open from 6 A.M. to 9 P.M. daily." The board of managers shook their sage masculine heads and reluctantly gave permission to issue these appeals. Woman's judgment was vindicated, however, and the advantage was proved of urging health for "society's" sake rather than for health's sake, when the patronage of the bath jumped at once to considerable proportions.
6. Other people's habits of health influence our well-being quite as much, if not more, than our own. Because we are social beings, ability to get along with our families, our friends, our employers, is—at least so it seems to most of us—quite as important as individual health. For too many of us, living hygienically is absolutely impossible without inconveniencing and bothering the majority of persons with whom we live. I remember a girl in college,—a fresh-air fiend,—who every morning, no matter how cold, threw the windows wide open. Then, with forty others, I thought this girl a nuisance as well as a menace to health, but now, twenty years afterwards, I find myself wanting to do the same thing. Professor Patten, the economist, whom I shall quote many times because he is particularly interested in the purpose of this book, was recently dining at my house and illustrated from his own health the importance of teaching hygiene so as to affect social as well as personal standards. "To be true to my own health needs, I ought to have declined nearly everything that has been offered me for dinner, but in the long run, if I am going to visit, my eating what is placed before me is better for society than making those who entertain me feel uncomfortable."
Most of us know what uphill work it is to live hygienically in an unhygienic environment. I remember how hard it was to eat happily when sitting beside a college professor who took brown pills before each meal, yellow pills between each course, and a dose of black medicine after the meal was over. Mariano, an Italian lad cured of bone tuberculosis by out-of-door salt air at Sea Breeze, returned to his tenement home an ardent apostle of fresh air day and night, winter and summer. His family allowed him to open the window before going to bed, but closed it as soon as he was asleep. Lawrence Veiller, our greatest expert on tenement conditions, says: "To bathe in a tenement where a family of six occupy three rooms often involves the sacrifice of privacy and decency, which are quite as important to social betterment as cleanliness."
To live unhygienically where others live hygienically is quite as difficult. Witness the speedy improvement of dissipated men when boarding with country friends who eat rationally and retire early. It must have been knowledge of this fact that prompted the tramways of Belfast to post conspicuous notices: "Spitting is a vile and filthy habit, and those who practice it subject themselves to the disgust and loathing of their fellow-passengers." It is almost impossible to have indigestion, blues, and headache when one is camping, particularly where action and enjoyment fill the day. Our practical question is, therefore, not "What shall I eat, how many hours shall I sleep, what shall I wear," but "How can I manage to get into an environment among living and working conditions where the people I live with and want to please, those who influence me and are influenced by me, make healthy living easy and natural?"
7. Because the problems of health have to do principally with environment,—home, street, school, business,—it is worth while trying to relate hygiene instruction to industry and government, to preach health from the standpoint of industrial and national efficiency rather than of individual well-being. Since healthful living requires the cooeperation of all persons in a household, in a group, or in a community, we must find some working programme that will make it easy for all the members of the group to observe health standards. A city government that spends taxes inefficiently can produce more sickness, wretchedness, incapacity in one year than pamphlets on health can offset in a generation. Failure to enforce health laws is a more serious menace to health and morals than drunkenness or tobacco cancer. Unclean streets, unclean dairies, unclean, overcrowded tenements can do more harm than alcohol and tobacco because they can breed an appetite that craves stimulants and drugs. Others have taught how the body acts, what we ought to eat, how we should live. We are concerned here not with repeating the laws of health, but with a consideration of the mechanism that will make it possible for us so to work together that we can observe those laws.
SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS
In making a health programme as in making a boat, a garden, or a baseball team, the first step is to look about and see what material there is to work with. A baseball team will fail miserably unless the captain places each man where he can play best. Gardening is profitless when the gardener does not know the habits of plants and the possibilities of different kinds of soil. So in planning a health programme we must study our materials and use each where it will fit best. The materials of first importance to a health programme in civilized countries are men; for men working together can control water sources, drainage, and ventilation, or else move away to surroundings better suited to healthful living. Therefore the first concern of the leader in a health crusade is the human kind he has to work for and work with.
Seven kinds of man are to be found in every community, seven different points of view with regard to health administration. Each individual, likewise, may have seven attitudes toward health laws, seven reasons for demanding health protection. These seven points of view, seven stages of development, are clearly marked in the evolution of sanitary administration throughout the civilized world. With few exceptions, it is possible, by examining ourselves, our friends, and our communities, to see where one motive begins and leaves off, giving way to or mixing with one or more other motives. A friend once asked me if I could keep this number seven from growing to eight or nine. Perhaps not. Perhaps there are more kinds of people, more health motives, more stages in health progress; but I am sure of these seven, and certain that they have been of great help to me in planning health crusades for the state of New Jersey and for New York City. The number seven was not reached hit-or-miss fashion, nor was it chosen for its biblical prestige. On the contrary, it came as the result of studying health administration in twoscore British and American cities, and of reading scores of books on sanitary evolution.
Seven catchwords make it easy to remember the characteristics and the source of every motive, every kind of person, and every stage in the evolution of sanitary standards. These seven catchwords are: Instinct, Display, Commerce, Anti-nuisance, Anti-slum, Pro-slum, Rights. By the use of these catchwords any teacher, parent, public official, educator, or social worker should be able to size up the situation, the needs, and the opportunity of the individuals or the communities for whom a health crusade is planned.
Instinct was the first health officer and made the first health laws. Instinct warns us against unusual and offensive odors, sights, and noises, just as it causes us to seek that which is agreeable. Primitive man in common with other animals learned by sad experience to avoid certain herbs as poisons; to bury or to move away from the dead; to shun discolored drinking water. During the roaming period sun and air and water acted as scavengers. When tribes settled down in one spot for long periods, habits that had hitherto been inoffensive and safe became noticeably injurious and unpleasant. Heads of tribes gave orders prohibiting such habits and restricting disagreeable acts and objects to certain portions of the camp. Instinct places outhouses on our farms and then gradually removes them farther and farther from dwellings. In many school yards, more particularly in country districts and small towns, outhouses are a crying offense against animal instinct. In visiting slum districts in Irish and Scotch cities, and in London, Paris, Berlin, and New York, I never found conditions so offensive to crude animal instinct as those I knew when a boy in Minnesota school yards, or those I have since seen in a Boy Republic. But the evil is not corrected because it is not made anybody's business to execute instinct's mandates. In the Boy Republic the leaders were waiting for the children themselves to revolt, as does primitive man.
TYPHOID A RURAL DISEASE
============================================================ Average Average Per Cent Typhoid Fever of Rural Death Rate Population per 100,000 Five states in which the urban population was more than 60% of the total 30 25 Six states in which the urban population was between 40% and 60% 49 42 Seven states in which the urban population was between 30% and 40% 67 38 Eight states in which the urban population was between 20% and 30% 75 46 Twelve states in which the urban population was between 10% and 20% 87 62 Twelve states in which the urban population was between 0 and 10% 95 67 ============================================================
Among large numbers of persons, in city as well as country, washing the body is still a matter of instinct, a bath not being taken until the body is offensive, the hands not being washed until their condition interferes with the enjoyment of food or with one's treatment by others. There is a point of neglect beyond which instinct will not permit even a tramp to go. If cleanliness is next to godliness, the average child is most ungodly by nature, for it loathes the means of cleanliness and otherwise observes instinct's health warnings only after experience has punished or after other motives from the outside have prompted action. The chief form of legislation of the instinct age is provision of penalties for those who poison food, water, or fellow-man. There are districts in America where hygiene is supposed to be taught to children that are conscious of no other sanitary legislation but that which punishes the poisoner.
Display has always been an active health crusader. Professor Patten says the best thing that could happen to the slums of every city would be for every girl and woman to be given white slippers, white stockings, a white dress, and white hat. Why? Because they would at once notice and resent the dirt on the street, in their hallways, and in their own homes. People that have nothing to "spoil" really do not see dirt, for it interferes in no way with their comfort so far as they can see. Their windows are crusted with dust, their babies' milk bottles are yellow with germs. Who cares? Similar conditions exist among well-to-do women who live on isolated farms with no one to notice their personal appearance except others of the family who prefer rest to cleanliness. But let the tenement mother or the isolated farmer's wife entertain the minister or the school-teacher, the candidate for sheriff or the ward boss, let her go to Coney Island or to the county fair, and at once an outside standard is set up that requires greater regard for personal appearance and leads to "cleaning up."
Elbow sleeves and light summer waists have led many a girl to daily bathing of at least those parts of the body that other people see. Entertainments and sociables, Saturday choir practice and church have led many a young man to bathe for others' sake when quite satisfied to forego the ordeal so far as his own comfort and health were concerned. Streets on which the well-to-do live are kept clean. Why? Not because Madam Well-to-do cares so much for health, but because she associates cleanliness with social prestige. It is necessary for the display of her carriages and dresses, just as paved streets and a plentiful supply of water for public baths and private homes were essential to the display of Rome's luxury. Generally speaking, residence streets are cleaned in small towns just as waterworks are introduced, to gratify the display motive of those who have lawns to water and clothes to show.
Instinct strengthens the display motive. As every one can be interested in instinct hygiene, so every one is capable of this display motive to the extent that his position is affected by other people's opinion. It was love of display quite as much as love of beauty that gave Greece the goddess Hygeia, the worship of whom expressed secondarily a desire for universal health, and primarily a love of the beautiful among those who had leisure to enjoy it.
Commerce brooks no preventable interference with profits, whether by disease, death, impassable streets, or disabled men. The age of chivalry was also the age of indescribable filth, plague, Black Death, and spotted fever that cost the lives of millions. It would be impossible in the civilized world to duplicate the combination of luxury and filthy, disease-breeding conditions in the midst of which Queen Bess and her courtiers held their revels. The first protest was made, not by the church, not by sanitarians, but by the great merchants who were unable to insure against loss and ruin from the plagues that thrived on filth and overcrowding. By an interesting coincidence the first systematic street cleaning and the first systematic ship cleaning—maritime quarantine—date from the same year, 1348 A.D.; the former in the foremost German trading town, Cologne, and the latter in Venice, the foremost trading town of Italy. The merchants of Philadelphia and New York started the first boards of health in the United States. For what purpose? To prevent business losses from yellow fever. Desire for passable streets, drains, waterworks, and strong boards of health has generally started with merchants. For commercial reasons many of our states vote more money for the protection of cattle than for the protection of human life, and the United States votes millions for the study of hog cholera, chicken pip, and animal tuberculosis, while neglecting communicable diseases of men. No class in a community will respond more quickly to an appeal for the rigid enforcement of health laws than the merchant class; none will oppose so bitterly as that which makes profits out of the violation of health laws.
COST IN LIFE CAPITAL OF PREVENTABLE DISEASES
================================================================ Multiply by the number of deaths for each Estimated age group to learn the cost in life Value of capital to your community in loss of life Age Human Life from one or all preventable diseases. - - 0-5 years $1,500 5-10 " 2,300 10-15 " 2,500 15-20 " 3,000 20-25 " 5,000 25-30 " 7,500 30-35 " 7,000 35-40 " 6,000 40-45 " 5,500 45-50 " 5,000 50-55 " 4,500 55-60 " 4,500 60-65 " 2,000 65-70 " 1,000 70- " 1,000 ============================================================
Anti-nuisance motives do not affect health laws until people with different incomes and different tastes try to live together. In a small town where everybody keeps a cow and a pig, piggeries and stables offend no one; but when the doctor, the preacher, the dressmaker, the lawyer, and the leading merchant stop keeping pigs and cows, they begin to find other people's stables and piggeries offensive. The early laws against throwing garbage, fish heads, household refuse, offal, etc., on the main street were made by kings and princes offended by such practices. The word "nuisance" was coined in days when neighbors lived the same kind of life and were not sensitive to things like house slops, ash piles, etc. The first nuisances were things that neighbors stumbled over or ran into while using the public highway. Next, goats and other animals interfering with safety were described as nuisances, and legal protection against them was worked out. It has never been necessary to change the maxim which originally defined a nuisance: "So use your own property that you will not injure another in the use of his property." The thing that has changed and grown has been society's knowledge of acts and objects that prevent a man from enjoying his own property. To-day the number of things that the law calls nuisances is so great that it takes hundreds of pages to describe them. Stables and outhouses must be set back from the street. Every man must dispose of garbage and drainage on his own property. Stables and privies must be at least a hundred feet from water reservoirs. Factories may not pollute streams that furnish drinking water. Merchants may be punished if they put banana skins in milk cans, or if they fail to scald and cleanse all milk receptacles before returning them to wholesalers. Automobile drivers may be punished for disturbing sleep. Anything that injures my health will be declared a nuisance and abolished, if I can prove that my health is being injured and that I am doing all I can to avoid that injury. No educational work will accomplish more for any community than to make rich and poor alike conscious of nuisances that are being committed against themselves and their neighbors. The rich are able to run away from nuisances that they cannot have abated. If proper publicity is given to living conditions among those who do not resist nuisances, the presence of such conditions will itself become offensive to the well-to-do, who will take steps to remove the nuisance. Jacob Riis in this way made the slums a nuisance to rich residents in New York City and stimulated tenement reform, building of parks, etc.
Anti-slum motives originated in cities where there is a clear dividing line between the clean and the unclean, the infected and the uninfected, the orderly and the disorderly, high and low vitality. As soon as one district becomes definitely known as a source of nuisance, infection, and disease, better situated districts begin to make laws to protect themselves. A great part of our existing health codes and a very large part of the funds spent on health administration are designed to protect those of high income against disease incident to those of low income, high vitality against low vitality, houses with rooms to spare against houses that are overcrowded. To the small town and the country the slum means generally the near-by city whose papers talk of epidemic scarlet fever, diphtheria, or smallpox. Cities have only recently begun to experience anti-slum aversion to country dairies whose uncleanliness brings infected milk to city babies, or to filthy factories and farms that pollute water reservoirs and cause typhoid. The last serious smallpox epidemic in the East came from the South by way of rural districts that failed to notify the Pennsylvania state board of health of the outbreak until the disease was scattered broadcast. Every individual knows of some family or some district that is immediately pictured when terms like "disease," "epidemic," "slum," are pronounced. The steps worked out by the anti-slum motive to protect "those who have" from disease arising from "those who have not" are given on page 31.
Pro-slum motives are not exactly born of anti-slum motives, but, thanks to the instinctive kindness of the human heart, follow promptly after the dangers of the slum have been described. You and I work together to protect ourselves against neglect, nuisance, and disease. In a district by which we must pass and with which we must deal, one of us or a neighbor or friend will turn our attention from our danger to the suffering of those against whom we wish to protect ourselves. Charles Dickens so described Oliver Twist and David Copperfield that Great Britain organized societies and secured legislation to improve the almshouse, school, and working and living conditions. When health reports, newspapers, and charitable societies make us see that the slum menaces our health and our happiness, we become interested in the slum for its own sake. We then start children's aid societies, consumer's leagues, sanitary and prison associations, child-labor committees, and "efficient government" clubs.
Rights motives are the last to be evolved in individuals or communities. The well-to-do protect their instinct, their comfort, their commerce, but run away from the slums and build in the secluded spots or on the well-policed and well-cleaned avenues and boulevards. Uptown is often satisfied with putting health officials to work to protect it against downtown. Pro-slum motives are shared by too few and are expressed too irregularly to help all of those who suffer from crowded tenements, impure milk, unclean streets, inadequate schooling. So long as those who suffer have no other protection than the self-interest or the benevolence of those better situated, disease and hardship inevitably persist. Health administration is incomplete until its blessings are given to men, women, and children as rights that can be enforced through courts, as can the right to free speech, the freedom of the press, and trial by jury. There is all the difference in the world between having one's street clean because it is a danger to some distant neighbor, or because that neighbor takes some philanthropic interest in its residents, and because one has a right to clean streets, regardless of the distant neighbor's welfare or interest. When the right to health is granted health laws are made, and all men within the jurisdiction of the lawmaking power own health machinery that provides for the administration of those laws. A system of public baths takes the place of a bathhouse supported by charity; a law restricting the construction and management of all tenements takes the place of a block of model tenements, financed by some wealthy man; medical examination of all school children takes the place of a private dispensary; a probation law takes the place of the friendly visitor to the county jail.
Most of the rights we call inalienable are political rights no longer questioned by anybody and no longer thought of in connection with our everyday acts, pleasures, and necessities. When our political rights were formulated in maxims, living was relatively simple. There was no factory problem, no transportation problem, no exploitation of women and children in industry. Our ancestors firmly believed that if the strong could be prevented from interfering with the political rights of the weak, all would have an equal chance. The reason that our political maxims mean less to-day than two hundred years ago is that nobody is challenging our right to move from place to place if we can afford it, to trial by jury if charged with crime, to speak or print the truth about men or governments. If, however, anybody should interfere with our freedom in this respect, it would be of tremendous help that everybody we know would resent such interference and would point to maxims handed down by our ancestors and incorporated in our national and state constitutions as formal expressions of unanimous public opinion.
The time is past when any one seriously believes that political freedom or personal liberty will be universal, just because everybody has a right to talk, to move from place to place, to print stories in the newspapers. The relation of man to man to-day requires that we formulate rules of action that prevent one man's taking from another those rights, economic and industrial, that are as essential to twentieth-century happiness as were political rights to eighteenth-century happiness. Political maxims showed how, through common desire and common action, steps could be taken by the individual and by the whole of society for the protection of all. Health rights, likewise, are to be obtained through common action. A modern city must know who is accountable when an automobile runs over a pedestrian, when a train load of passengers lose their lives because of an engineer's carelessness, when an employee is incapacitated for work by an accident for which he is not responsible, or when fever epidemics threaten life and liberty without check. How can a child who is prevented by removable physical defects from breathing through his nose be enthusiastic over free speech? Of what use is freedom of the press to those who find reading harder than factory toil? How futile the right to trial by jury if removable physical defects make children unable to do what the law expects! Who would not exchange rights of petition for ability to earn a living? Children permanently incapacitated to share the law's benefits cannot appreciate the privilege of pursuing happiness.
Succeeding chapters will enumerate a number of health rights and will show through what means we can work together to guarantee that we shall not injure the health of our neighbor and that our neighbor shall not injure our health. The truest index to economic status and to standards of living is health environment. The best criterion of opportunity for industrial and political efficiency is the conditions affecting health. The seven catchwords that describe seven motives to health legislation and health administration, seven ways of approaching health needs, and seven reasons for meeting them, should be found helpful in analyzing the problem confronting the individual leader. Generally speaking, we cannot watch political rights grow, but health rights are evolved before our eyes all the time. If we wish, we can see in our own city or township the steps taken, one by one, that have slowly led to granting a large number of health rights to every American.
 Prepared by Dr. John S. Fulton, secretary of the state board of health, Maryland, and quoted by Dr. George C. Whipple in Typhoid Fever.
 Marshall O. Leighton, quoted in Whipple's Typhoid Fever.
WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?
Laws define rights. Men enforce them. For definitions we go to books. For record of enforcement we go to acts and to conditions. What health rights a community pretends to enforce will, as a rule, be found in its health code. What health rights are actually enforced can be learned only by studying both the people who are to be protected and the conditions in which these people live. A street, a cellar, a milk shop, a sick baby, or an adult consumptive tells more honestly the story of health rights enforced and health rights unenforced than either sanitary code or sanitary squad. Not until we turn our attention from definition and official to things done and dangers remaining can we learn the health progress and health needs of any city or state.
The health code of one city looks very much like the health code of every other city. This is natural because those who write health codes generally copy other codes. Even small cities are given complicated sanitary legislative powers by state legislatures. Therefore those who judge a community's health rights by its health laws will get as erroneous an impression as those who judge hygiene instruction in our public schools from printed statements about the frequency and character of such instruction. Advocates of health codes have thought the battle won when boards of health were given almost unlimited power to abate nuisances and told how to exercise those powers.
The slip 'twixt law making and law enforcement is everywhere found. In 1864 New York state prohibited the sale of adulterated milk. Law after law has been made since that time, giving health officials power to revoke licenses of milk dealers and to send men to jail who violated milk laws. We now know that no law will ever stop the present frightful waste of infant lives, counted in thousands annually, unless dairies are frequently inspected and forced to be clean; unless milk is kept at a temperature of about fifty degrees on the train, in the creamery, at the receiving station, and in the milk shop; unless dealers scald and thoroughly cleanse cans in which milk is shipped; unless licenses are taken from farmers, creameries, and retailers who violate the law; unless magistrates use their power to fine or imprison those who poison helpless babies by violating milk laws; and unless mothers are taught to scald and thoroughly cleanse bottles, nipples, cups, and dishes from which milk is fed to the baby. We know that these things are not being done except where men or women make it their business to see that they are done. Experience tells us that inspectors will not consistently do their duty unless those who direct them have regular records of their inspections, study those records, find out work not done properly or promptly, and insist upon thorough inspection.
Whether work is done right, whether inspectors do their full duty, whether babies are protected, can be learned only from statements in black and white that show accurately the conditions of dairies and milk shops, the character of milk found and tested by inspectors, and the number of babies known to have been sick or known to have died from intestinal diseases chiefly due to unsafe milk. Any teacher or parent can learn for himself, or can teach children to learn, what steps are taken to guarantee the right to pure milk by using a table such as Table III. Whether conditions at the dairy make pure milk impossible can be told by any one who can read the score card used by New York City (Table IV).
MILK INSPECTION WITHIN NEW YORK CITY, 1906
============================================================== New York Each borough - - - - Stores Wagons Stores Wagons - - - - FIELD Permits issued during 1906 Permits revoked during 1906 For discontinuance of selling For violation of law Average permits in force in 1906 INSPECTION Regular inspections Inspections at receiving stations Total Average inspections per permit per year Specimens examined Samples taken CONDITIONS FOUND Inspections finding milk above 50 deg. % of such discoveries to total inspections Inspections finding adulteration Warning given Prosecuted % of adulterations found to inspections Rooms connected contrary to sanitary code Ice box badly drained Ice box unclean Store unclean Utensils unclean Milk not properly cooled Infectious disease Persons found selling without permit ACTION TAKEN DESTRUCTION OF MILK Lots of milk destroyed for being over 50 deg. Quarts so destroyed Lots of milk destroyed for being sour Quarts so destroyed Lots of milk destroyed for being otherwise adulterated Quarts so destroyed Total quarts destroyed NOTICES ISSUED To drain and clean ice box To clean store CRIMINAL ACTIONS BEGUN For selling adulterated milk For selling without permit For interference with inspector Total ==================================================================
Perfect Score 100% Score allowed ...% File No............
DEPARTMENT OF HEALTH (Thirteen items are here omitted)
Dairy Inspection Division of Inspections
1 Inspection No. ...... Time ...... A. P. M. Date ...... 190 2 All persons in the households of those engaged in producing or handling milk are ...... free from all infectious disease ...... 3 Date and nature of last case on farm ...... 4 A sample of the water supply on this farm taken for analysis ...... 190... and found to be ......
================================================================== STABLE Perfect Allow - - 5 COW STABLE is ... located on elevated ground with no stagnant water, hog pen, or privy within 100 feet 1 ... 6 FLOORS are ... constructed of concrete or some nonabsorbent material 1 ... 7 Floors are ... properly graded and water-tight 2 ... 8 DROPS are ... constructed of concrete, stone, or some nonabsorbent material 2 ... 9 Drops are ... water-tight 2 ... 10 FEEDING TROUGHS, platforms, or cribs are ... well lighted and clean 1 ... 11 CEILING is constructed of ... and is ... tight and dust proof 2 ... 12 Ceiling is ... free from hanging straw, dirt, or cobwebs 1 ... 13 NUMBER OF WINDOWS ... total square feet ... which is ... sufficient 2 ... 14 Window panes are ... washed and kept clean 1 ... 15 VENTILATION consists of ... which is sufficient 3, fair 1, insufficient 0 3 ... 16 AIR SPACE is ... cubic feet per cow which is ... sufficient (600 and over 3) (500 to 600 2) (400 to 500 1) (under 400 0) 3 ... 17 INTERIOR of stable painted or whitewashed on ... which is satisfactory 2, fair 1, never 0 2 ... 18 WALLS AND LEDGES are ... free from dirt, dust, manure, or cobwebs 2 ... 19 FLOORS AND PREMISES are ... free from dirt, rubbish, or decayed animal or vegetable matter 1 ... 20 COW BEDS are ... clean 1 ... 21 LIVE STOCK, other than cows, are ... excluded from rooms in which milch cows are kept 2 ... 22 There is ... direct opening from barn into silo or grain pit 1 ... 23 BEDDING used is ... clean, dry, and absorbent 1 ... 24 SEPARATE BUILDING is ... provided for cows when sick 1 ... 25 Separate quarters are ... provided for cows when calving 1 ... 26 MANURE is ... removed daily to at least 200 feet from the barn ( ... ft.) 2 ... 27 Manure pile is ... so located that the cows cannot get at it 1 ... 28 LIQUID MATTER is ... absorbed and removed daily and ... allowed to overflow and saturate ground under or around cow barn 2 ... 29 RUNNING WATER supply for washing stables is ... located within building 1 ... 30 DAIRY RULES of the Department of Health are ... posted 1 ... COW YARD 31 COW YARD is ... properly graded and drained 1 ... 32 Cow yard is ... clean, dry, and free from manure 2 ... COWS Perfect Allow 33 COWS have ... been examined by veterinarian ... Date ... 190 Report was 3 ... 34 Cows have ... been tested by tuberculin, and all tuberculous cows removed 5 ... 35 Cows are ... all in good flesh and condition at time of inspection 2 ... 36 Cows are ... all free from clinging manure and dirt. (No. dirty ... ) 4 ... 37 LONG HAIRS are ... kept short on belly, flanks, udder, and tail 1 ... 38 UDDER AND TEATS of cows are ... thoroughly cleaned before milking 2 ... 39 ALL FEED is ... of good quality and all grain and coarse fodders are ... free from dirt and mold 1 ... 40 DISTILLERY waste or any substance in a state of fermentation or putrefaction is ... fed 1 ... 41 WATER SUPPLY for cows is ... unpolluted and plentiful 2 ... MILKERS AND MILKING 42 ATTENDANTS are ... in good physical condition 1 ... 43 Special Milking Suits are ... used 1 ... 44 Clothing of milkers is ... clean 1 ... 45 Hands of milkers are ... washed clean before milking 1 ... 46 MILKING is ... done with dry hands 2 ... 47 FORE MILK or first few streams from each teat is ... discarded 2 ... 48 Milk is strained at ... and ... in clean atmosphere 1 ... 49 Milk strainer is ... clean 1 ... 50 MILK is ... cooled to below 50 deg. F. within two hours after milking and kept below 50 deg. F. until delivered to the creamery ... deg. 2 ... 51 Milk from cows within 15 days before or 5 days after parturition is ... discarded 1 ... UTENSILS 52 MILK PAILS have ... all seams soldered flush 1 ... 53 Milk pails are ... of the small-mouthed design, top opening not exceeding 8 inches in diameter. Diameter ... 2 ... 54 Milk pails are ... rinsed with cold water immediately after using and washed clean with hot water and washing solution 2 ... 55 Drying racks are ... provided to expose milk pails to the sun 1 ... MILK HOUSE 56 MILK HOUSE is ... located on elevated ground with no hog pen, manure pile, or privy within 100 feet 1 ... 57 Milk house has ... direct communication with ... building 1 ... 58 Milk house has ... sufficient light and ventilation 1 ... 59 Floor is ... properly graded and water-tight 1 ... 60 Milk house is ... free from dirt, rubbish, and all material not used in the handling and storage of milk 1 ... 61 Milk house has ... running or still supply of pure clean water 1 ... 62 Ice is ... used for cooling milk and is cut from ... 1 ... WATER 63 WATER SUPPLY for utensils is from a ... located ... feet deep and apparently is ... pure, wholesome, and uncontaminated 5 ... 64 Is ... protected against flood or surface drainage 2 ... 65 There is ... privy or cesspool within 250 feet ( ... feet) of source of water supply 2 ... 66 There is ... stable, barnyard, or pile of manure or other source of contamination within 200 feet ( ... feet) of source of water supply 1 ... - 100 - -
It is a great pity that we Americans have taken so long to learn that laws do not enforce themselves, that even good motives and good intentions in the best of officials do not insure good deeds. Thousands of lives are being lost every year, millions of days taken from industry and wasted by unnecessary sickness, millions of dollars spent on curing disease, the working life of the nation shortened, the hours of enjoyment curtailed, because we have not seen the great gap between health laws and health-law enforcement. In our municipal, state, and national politics we have made the same mistake of concentrating our attention upon the morals and pretensions of candidates and officials instead of judging government by what government does. Gains of men and progress of law are useful to mankind only when converted into deeds that make men freer in the enjoyment of health and earning power. In protecting health, as in reforming government, an ounce of efficient achievement is worth infinitely more than a moral explosion. One month of routine—unpicturesque, unexciting efficiency—will accomplish more than a scandal or catastrophe. Such routine is possible only when special machinery is constantly at work, comparing work done with work expected, health practice with health ideals. Where such machinery does not yet exist, volunteers, civic leagues, boys' brigades, etc., can easily prove the need for it by filling out an improvised score card for the school building, railroad station, business streets, "well-to-do" and poor resident streets, such as follows:
SCORE CARD FOR CITIZEN USE
================================================================== Perfect Allow - - Schoolhouse Well ventilated, 20; badly, 0-10 20 ... Cleaned regularly, 20; irregularly, 0-10 20 ... Feather duster prohibited, 10 10 ... No dry sweeping, 10 10 ... Has adequate play space, 10; inadequate, 0-5 10 ... Has clean drinking water, 10 10 ... Has clean outbuildings and toilet, 20: unclean, 0-10 20 ... 100 Church and Sunday School Well ventilated, 20; badly, 0-10 20 ... Heat evenly distributed, 20; unevenly, 0-10 20 ... Cleaned regularly, 20; irregularly, 0-10 20 ... Without carpets, 20 20 ... Without plush seats, 20 20 ... 100 Streets Sewerage underground, 20; surface, 0-10 20 ... No pools neglected, 10 10 ... No garbage piled up, 10 10 ... Swept regularly, 20; irregularly, 0-10 20 ... Sprinkled and flushed, 10 10 ... Has baskets for refuse, 10 10 ... All districts equally cleaned, 20; unequally, 0-10 20 ... 100 - -
Until recently the most reliable test of health rights not enforced was the number of cases of preventable, communicable, contagious, infectious, transmissible diseases, such as smallpox, typhoid fever, yellow fever, scarlet fever, diphtheria, measles, whooping cough. By noticing streets and houses where these diseases occurred, students learned a century ago that the darker and more congested the street the greater the prevalence of fevers and the greater the chance that one attacked would die. The well-to-do remove from their houses and their streets the dirt, the decomposed garbage, and stagnant pools from which fevers seem to spring. It was because fevers and congestion go together that laws were made to protect the well-to-do, the comfortable, and the clean against the slum. It is true to-day that if you study your city and stick a pin in the map, street for street, where infection is known to exist, you will find the number steadily increase as you go from uncongested to congested streets and houses, from districts of high rent to districts of low rent. Because it is easier to learn the number of persons who have measles and diphtheria and smallpox than it is to learn the incomes and living conditions prejudicial to health, and because our laws grant protection against communicable diseases to a child in whatever district he may be born, the record of cases of communicable diseases has heretofore been the best test of health rights unenforced. Even in country schools it would make a good lesson in hygiene and civics to have the children keep a record of absences on account of transmissible disease, and then follow up the record with a search for conditions that gave the disease a good chance.
But to wait for contagion before taking action has been found an expensive way of learning where health protection is needed. Even when infected persons and physicians are prompt in reporting the presence of disease it is often found that conditions that produced the disease have been overlooked and neglected.
For example, smallpox comes very rarely to our cities to-day. Wherever boards of health are not worried by "children's diseases," as is often the case, and wait for some more fearful disease such as smallpox, there you will find that garbage in the streets, accumulated filth, surface sewers, congested houses, badly ventilated, unsanitary school buildings and churches are furnishing a soil to breed an epidemic in a surprisingly short time. Where, on the other hand, boards of health regard every communicable disease as a menace to health rights, you will find that health officials take certain steps in a certain order to remove the soil in which preventable diseases grow. These steps, worked out by the sanitarians of Europe and America after a century of experiment, are seen to be very simple and are applicable by the average layman and average physician to the simplest village or rural community. How many of these steps are taken by your city? by your county? by your state?
1. Notification of danger when it is first recognized.
2. Registration at a central office of facts as to each dangerous thing or person.
3. Examination of the seat of danger to discover its extent, its cost, and new seats of danger created by it.
4. Isolation of the dangerous thing or person.
5. Constant attention to prevent extension to other persons or things.
6. Destruction or removal of disease germs or other causes of danger.
7. Analysis and record, for future use, of lessons learned by experience.
8. Education of the public to understand its relation to danger checked or removed, its responsibility for preventing a recurrence of the same danger, and the importance of promptly recognizing and checking similar danger elsewhere.
With a chart showing what districts have the greatest number of children and adults suffering from measles, typhoid fever, scarlet fever, consumption, one can go within his own city or to a strange city and in a surprisingly short time locate the nuisances, the dangerous buildings, the open sewers, the cesspools, the houses without bathing facilities, the dark rooms, the narrow streets, the houses without play space and breathing space, the districts without parks, the polluted water sources, the unsanitary groceries and milk shops. In country districts a comparison of town with town as to the prevalence of infection will enable one easily to learn where slop water is thrown from the back stoop, whether the well, the barn, and the privy are near together.
Testing health rights requires not only that there be a board of health keeping track of and publishing every case of infection, but it requires further that one community be compared with other communities of similar size, and that each community be compared with itself year for year. These comparisons have not been made and records do not exist in many states.
 A striking demonstration of law enforcement that followed lawmaking is given in The Real Triumph of Japan, L.L. Seaman, M.D.
THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL WELFARE OF SCHOOL CHILDREN
Compulsory education laws, the gregarious instinct of children, the ambition of parents, their self-interest, and the activities of child-labor committees combine to-day to insure that one or more representatives of practically every family in the United States will be in public, parochial, or private schools for some part of the year. The purpose of having these families represented in school is not only to give the children themselves the education which is regarded as a fundamental right of the American child, but to protect the community against the social and industrial evils and the dangers that result from ignorance. Great sacrifices are made by state, individual taxpayer, and individual parent in order that children and state may be benefited by education. Almost no resistance is found to any demand made upon parent or taxpayer, if it can be shown that compliance will remove obstructions to school progress. If, therefore, by any chance, we can find at school a test of home conditions affecting both the child's health and his progress at school, it will be easy, in the name of the school, to correct those conditions, just as it will be easy to read the index, because the child is under state control for six hours a day for the greater part of the years from six to fourteen.
What, then, is this test of home conditions prejudicial to health that will register the fact as a thermometer tells us the temperature, or as a barometer shows moisture and air pressure? The house address alone is not enough, for many children surrounded by wealth are denied health rights, such as the right to play, to breathe pure air, to eat wholesome food, to live sanely. Scholarship will not help, because the frailest child is often the most proficient. Manners mislead, for, like dress, they are but externals, the product of emulation, of other people's influence upon us rather than of our living conditions. Nationality is an index to nothing significant in America, where all race and nationality differences melt into Americanisms, all responding in about the same way to American opportunity. No, our test must be something that cannot be put on and off, cannot be left at home, cannot be concealed or pretended, something inseparable from the child and beyond his control. This test it has been conclusively proved in Chicago, Boston, Brookline, Philadelphia, and particularly in New York City, is the physical condition of the school child. To learn this condition the child must be examined and reexamined for the physical signs called for by the card on page 34. Weight, height, and measurements are needed to tell the whole story.
When this card is filled out for every child in a class or school or city, the story told points directly to physical, mental, or health rights neglected. If for every child there is begun a special card, that will tell his story over and over again during his school life, noting every time he is sick and every time he is examined, the progress of the community as well as of the child will be clearly shown. Such a history card (p. 314) is now in use in certain New York schools, as well as in several private schools and colleges.
Have you ever watched such an examination? By copying this card your family physician can give you a demonstration in a very short time as to the method and advantage of examination at school. The school physician goes at nine o'clock to the doctor's room in the public school, or, if there is no doctor's room, to that portion of the hall or principal's office where the doctor does his work. The teacher or the nurse stands near to write the physician's decision. The doctor looks the child over, glances at his eyes, his color, the fullness of his cheeks, the soundness of his flesh, etc. If the physician says "B," the principal or nurse marks out the other letter opposite to number 1, so that the card shows that there is bad nutrition.
In looking at the teeth and throat a little wooden stick is used to push down the tongue. There should be a stick for every child, so that infection cannot possibly be carried from one to the other. If this is impossible, the stick should be dipped in an antiseptic such as boric acid or listerine. If, because of swollen tonsils, there is but a little slit open in the throat, or if teeth are decayed, the mark is Y or B. The whole examination takes only a couple of minutes, but the physician often finds out in this short time facts that will save a boy and his parents a great deal of trouble. Very often this examination tells a story that overworked mothers have studiously concealed by bright ribbons and clean clothes. I remember one little girl of fourteen who looked very prosperous, but the physician found her so thin that he was sure that for some time she had eaten too little, and called her anaemic. He later found that the mother had seven children whom she was trying to clothe and shelter and feed with only ten dollars a week. A way was found to increase her earnings and to give all the children better living conditions,—all because of the short story told by the examination card. In another instance the card's story led to the discovery of recent immigrant parents earning enough, but, because unacquainted with American ways and with their new home, unable to give their children proper care.
The most extensive inquiry yet made in the United States as to the physical condition of school children is that conducted by the board of health in New York City since 1905. From March, 1905, to January 1, 1908, 275,641 children have been examined, and 198,139 or 71.9 per cent have been found to have defects, as shown in Table VI.
PHYSICAL EXAMINATION OF SCHOOL CHILDREN—PERFORMED BY THE DEPARTMENT OF HEALTH IN THE BOROUGH OF MANHATTAN, 1905-1907
============================================================== Total Percentage - - Number of children examined 275,641 100 Number of children needing treatment 198,139 71.9 Defects found: Malnutrition 16,021 5.8 Diseased anterior or posterior cervical glands 125,555 45.5 Chorea 3,776 1.3 Cardiac disease 3,385 1.2 Pulmonary disease 2,841 1.0 Skin disease 4,557 1.6 Deformity of spine, chest, or extremities 4,892 1.7 Defective vision 58,494 21.2 Defective hearing 3,540 1.2 Obstructed nasal breathing 43,613 15.8 Defective teeth 136,146 49.0 Deformed palate 3,625 1.3 Hypertrophied tonsils 75,431 27.4 Posterior nasal growths 46,631 16.9 Defective mentality 7,090 2.5 ============================================================
It is generally believed that New York children must have more defects than children elsewhere. If this assumption is wrong, if children in other parts of the United States are as apt to have eye defects, enlarged tonsils, and bad teeth as the children of the great metropolis, then the army of children needing attention would be seven out of ten, or over 14,000,000.
Whether these figures overstate or understate the truth, the school authorities of the country should find out. The chances are that the school in which you are particularly interested is no exception. To learn what the probable number needing attention is, divide your total by ten and multiply the result by seven.
The seriousness of every trouble and its particular relation to school progress and to the general public health will be explained in succeeding chapters. The point to be made here is that the examination of the school child discloses in advance of epidemics and breakdowns the children whose physical condition makes them most likely to "come down" with "catching diseases," least able to withstand an attack, less fitted to profit fully from educational and industrial opportunity.
The only index to community conditions prejudicial to health that will make known the child of the well-to-do who needs attention is the record of physical examination. No other means to-day exists by which the state can, in a recognized and acceptable way, discover the failure of these well-to-do parents to protect their children's health and take steps to teach and, if necessary, to compel the parents to substitute living conditions that benefit for conditions that injure the child.
Among the important health rights that deserve more emphasis is the right to be healthy though not "poor." A child's lungs may be weak, breathing capacity one third below normal, weight and nutrition deficient, and yet that child cannot contract tuberculosis unless directly exposed to the germs of that disease. But such a child can contract chronic hunger, can in a hundred ways pay the penalty for being pampered or otherwise neglected. Physical examination is needed to find every child that has too little vitality, no zest for play, little resistance, even though sent to a private school and kept away from dirt and contagion.
The New York Committee on the Physical Welfare of School Children visited fourteen hundred homes of children found to have one or more of the physical defects shown on the above card. While they found that low incomes have more than their proper share of defects and of unsanitary living conditions, yet they saw emphatically also that low incomes do not monopolize physical defects and unsanitary living conditions. Many families having $20, $30, $40 a week gave their children neither medical nor dental care. The share each income had in unfavorable conditions is shown by the summary in the following table.
SHOWING PER CENT SHARE OF PHYSICAL DEFECTS OF CHILDREN, UNFAVORABLE HOUSING CONDITIONS, AND CHILD MORTALITY FOUND AMONG EACH FAMILY-INCOME GROUP
========================+============================================= WEEKLY FAMILY INCOME + -+ + + + + + $30 $0-10 $10-15 $16-19 $20-25 $25-29 and $100 over + -+ + + + + + % % % % % % % + -+ + + + + + Proportion to total families 8.4 32.7 15.2 23.8 3.9 15.6 100 Physical defects: Malnutrition 13.8 43.4 12.4 17.9 3.4 9. " Enlarged glands 8.6 37.4 14.6 22.6 3.6 13.2 " Defective breathing 9.6 32.3 15.5 24.4 2.8 15.4 " Bad teeth 8.1 32.2 15.3 24.5 4.8 15.1 " Defective vision 8.2 34.6 16.5 22.1 1.4 17.3 " Unfavorable housing conditions: Dark rooms 8.2 35.4 18.1 18.4 3.8 15.9 " Closed air shaft 6.9 30.2 18.9 26.4 3.2 19.6 " No baths 10.1 38.5 16.5 19.7 4.4 10.8 " Paying over 25% rent 8.6 27.6 21.7 14.7 ... 27.6 " Child Mortality: Families losing children 10.3 35.5 14.7 20.5 5.4 13.6 " Families losing no children 6.4 30.1 15.7 26.9 2.4 18.6 " Children dead 11.7 36.2 13.1 20.8 6.1 12.1 " Infants dying from intestinal diseases 8.9 37.6 18.3 18.8 4. 12.4 " Children working 4.2 19.5 13.2 30.3 11.5 21.3 " =======================+============================================
The index should be read in all grades from kindergarten to high school and college.
Last winter the chairman of the Committee on the Physical Welfare of School Children was invited to speak of physical examination before an association of high-school principals. He began by saying, "This question does not concern you as directly as it does the grammar-school principals, but you can help secure funds to help their pupils." One after another the high-school principals present told—one of his own daughter, another of his honor girls, a third of his honor boys—the same story of neglected headaches due to eye strain, breakdowns due to undiscovered underfeeding, underexercise, or overwork. Are we coming to the time when the state will step in to prevent any boy or girl in high school, college, or professional school from earning academic honors at the expense of health? Harmful conditions within schoolrooms and on school grounds will not be neglected where pupils, teachers, school and family physicians, and parents set about to find and to remove the causes of physical defects.
Disease centers outside of school buildings quickly register themselves in the schoolroom and in the person of a child who is paying the penalty for living in contact with a disease center. If a child sleeps in a dark, ill-ventilated, crowded room, the result will show in his eyes and complexion; if he has too little to eat or the wrong thing to eat, he will be underweight and undersized; if his nutrition is inadequate and his food improper, he is apt to have eye trouble, adenoids, and enlarged tonsils. He may have defective lung capacity, due to improper breathing, too little exercise in the fresh air, too little food. Existence of physical defects throws little light on income at home, but conclusively shows lack of attention or of understanding. Several days' absence of a child from school leads, in every well-regulated school, to a visit to the child's home or to a letter or card asking that the absence be explained. Even newly arrived immigrants have learned the necessity and the advantage of writing the teacher an "excuse" when their children are absent. Furthermore, neighbors' children are apt to learn by friendly inquiry what the teacher may not have learned by official inquiry, why their playmate is no longer on the street or at the school desk. While physicians are sometimes willing to violate the law that compels notification of infection, rarely would a physician fail to caution an infected family against an indiscriminate mingling with neighbors. Whether the family physician is careless or not, the explanation of the absence which is demanded by the school would give also announcement of any danger that might exist in the home where the child is ill.
If it be said that in hundreds of thousands of cases the child labor law is violated and that therefore school examination is not an index to the poverty or neglect occasioning such child labor, it should be remembered that the best physical test is the child's presence at school. The first step in thorough physical examination is a thorough school census,—the counting of every child of school age. Moreover, a relatively small number of children who violate the child labor law are the only members of the family who ought to be in school. Younger children furnish the index and occasion the visit that should discover the violation of law.
Appreciation of health, as well as its neglect, is indexed by the physical condition of school children. Habits of health are the other side of the shield of health rights unprotected. Physical examination will discover what parents are trying to do as well as what they fail to do because of their ignorance, indifference, or poverty. In so far as parents are alive to the importance of health, the school examination furnishes the occasion of enlisting them in crusades to protect the public health and to enforce health rights. The Committee on the Physical Welfare of School Children found many parents unwilling to answer questions as to their own living conditions until told that the answers would make it easier to get better health environment not only for their own children but for their neighbors' children. Generally speaking, fathers and mothers can easily be interested in any kind of campaign in the name of health and in behalf of children. The advantage of starting this health crusade from the most popular American institution, the public school,—the advantage of instituting corrective work through democratic machinery such as the public school,—is incalculable. To any teacher, pastor, civic leader, health official, or taxpayer wanting to take the necessary steps for the removal of conditions prejudicial to health and for the enforcement of health rights of child and adult, the best possible advice is to learn the facts disclosed by the physical examination of your school children. See that those facts are used first for the benefit of the children themselves, secondly for the benefit of the community as a whole. If your school has not yet introduced the thorough physical examination of school children, take steps at once to secure such examination. If necessary, volunteer to test the eyes and the breathing of one class, persuade one or two physicians to cooeperate until you have proved to parent, taxpayer, health official, and teacher that such an examination is both a money-saving, energy-saving step and an act of justice.
We shall have occasion to emphasize over and over again the fact that it is the use of information and not the gathering of information that improves the health. The United States Weather Bureau saves millions of dollars annually, not because flags are raised and bulletins issued foretelling the weather, but because shipowners, sailors, farmers, and fruit growers obey the warnings. Mere examination of school children does little good. The child does not breathe better or see better because the school physician fills out a card stating that there is something wrong with his eyes, nose, and tonsils. The examination tells where the need is, what children should have special attention, what parents need to be warned as to the condition of the child, what home conditions need to be corrected. If the facts are not used, that is an argument not against obtaining facts but against disregarding them.
In understanding medical examination we should keep clearly in mind the distinction between medical school inspection, medical school examination, and medical treatment at school. Medical inspection is the search for communicable disease. The results of medical inspection, therefore, furnish an index to the presence of communicable diseases in the community. Medical examination is the search for physical defects, some of which furnish the soil for contagion. Its results are an index not only to contagion but to conditions that favor contagion by producing or aggravating physical defects and by reducing vitality. Medical treatment at school refers to steps taken under the school roof, or by school funds, to remove the defects or check the infection brought to light by medical inspection and medical examination. Treatment is not an index. In separate chapters are given the reasons for and against trying to treat at school symptoms of causes that exist outside of school. When, how often, and by whom inspection and examination should be made is also discussed later. The one point of this chapter is this: if we really want to know where in our community health rights are endangered, the shortest cut to the largest number of dangers is the physical examination of children at school,—private, parochial, reformatory, public, high, college.
Apart from the advantage to the community of locating its health problems, physical examination is due every child. No matter where his schooling or at whose expense, every child has the right to advance as fast as his own powers will permit without hindrance from his own or his playmates' removable defects. He has the right to learn that simplified breathing is more necessary than simplified spelling, that nose plus adenoids makes backwardness, that a decayed tooth multiplied by ten gives malnutrition, and that hypertrophied tonsils are even more menacing than hypertrophied playfulness. He has the right to learn that his own mother in his own home, with the aid of his own family physician, can remove his physical defects so that it will be unnecessary for outsiders to give him a palliative free lunch at school, thus neglecting the cause of his defects and those of fellow-pupils.
 Sir John E. Gorst in The Children of the Nation reads the index of the health of school children in the United Kingdom; John Spargo, in The Bitter Cry of the Children, and Simon N. Patten in The New Basis of Civilization, suggest the necessity for reading the index in the United States and for heeding it.
PART II. READING THE INDEX TO HEALTH RIGHTS
If the physical condition of school children is our best index to community health, who is to read the index? Unless the story is told in a language that does not require a secret code or cipher, unless some one besides the physician can read it, we shall be a very long time learning the health needs of even our largest cities, and until doomsday learning the health needs of small towns and rural districts. Fortunately the more important signs can be easily read by the average parent or teacher. Fortunately, too, it is easy to persuade mothers and teachers that they can lighten their own labors, add to their efficiency, and help their children by being on the watch for mouth breathing, for strained, crossed, or inflamed eyes, for decaying teeth, for nervousness and sluggishness. Years ago, when I taught school in a Minnesota village, I had never heard of adenoids, hypertrophied tonsils, myopia, hypermetropia, or the relation of these defects and of neglected teeth to malnutrition, truancy, sickness, and dullness. I now see how I could have saved myself several failures, the taxpayers a great deal of money, the parents a great deal of disappointment, and many children a life of inefficiency, had I known what it is easy for all teachers and parents to learn to-day.