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[Illustration: LOUIS AGASSIZ
"A natural law is as sacred as a moral principle"]
CIVICS AND HEALTH
BY
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
BY
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
910.4
The Athenæum Press
GINN AND COMPANY · PROPRIETORS · BOSTON · U.S.A.
INTRODUCTION
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 aëration 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
CONTENTS
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. COÖPERATION IN MEETING HEALTH OBLIGATIONS
XVI. EUROPEAN REMEDIES: DOING THINGS AT SCHOOL 159
XVII. AMERICAN REMEDIES: GETTING THINGS DONE 166
XVIII. COÖPERATION 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
INDEX 405
CIVICS AND HEALTH
PART I. HEALTH RIGHTS
CHAPTER I
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
coöperation 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.
CHAPTER II
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.
TABLE I
TYPHOID A RURAL DISEASE[1]
==========================================+============+==============
| 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.
TABLE II
COST IN LIFE CAPITAL OF PREVENTABLE DISEASES[2]
=============+============+===========================================
| | 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.
[Illustration: A COUNTRY MENACE TO CITY HEALTH]
_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.
FOOTNOTES:
[1] Prepared by Dr. John S. Fulton, secretary of the state board of
health, Maryland, and quoted by Dr. George C. Whipple in _Typhoid
Fever_.
[2] Marshall O. Leighton, quoted in Whipple's _Typhoid Fever_.
CHAPTER III
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.[3] 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.
[Illustration: A DAIRY INSPECTOR'S OUTFIT]
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).
TABLE III
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° | | | |
% 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° | | | |
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 | | | |
======================================+===============+===============
TABLE IV
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° F. within two | |
hours after milking and kept below 50° F. | |
until delivered to the creamery ... ° | 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:
TABLE V
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.
[Illustration: THE BABY, NOT THE LAW, IS THE TEST OF INFANT
PROTECTION IN COUNTRY AND IN CITY]
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.
FOOTNOTES:
[3] A striking demonstration of law enforcement that followed lawmaking
is given in _The Real Triumph of Japan_, L.L. Seaman, M.D.
CHAPTER IV
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.[4]
[Illustration: (Facsimile) PHYSICAL RECORD.]
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 reëxamined 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 anæmic. 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.
[Illustration: LOOKING FOR ENLARGED TONSILS AND BAD TEETH
Note the mouth breather waiting]
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.
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.
TABLE VII
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 coöperate 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.
FOOTNOTES:
[4] 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