12036	----	Team. This file was produced from images generously made available by the Bibliothèque nationale de France (BnF/Gallica) at http://gallica.bnf.fr HYGEIA A CITY OF HEALTH BY BENJAMIN WARD RICHARDSON M.D., F.R.S. 1876 [Illustration] TO EDWIN CHADWICK, C.B. MY DEAR MR. CHADWICK, _I wrote this Address with the intention of dedicating it to you, as a simple but hearty acknowledgment by a sanitary student, himself well ripened in the work, of your pre-eminent position as the living leader of the sanitary reformation of this century. The favour the Address has received indicates notably two facts: the advance of public opinion on the subject of public health, and the remarkable value and influence of your services as the sanitary statesman by whom that opinion has been so wisely formed and directed. In this sense of my respect for you, and of my gratitude, pray accept this trifling recognition, and believe me to be, Ever faithfully yours_, B.W. RICHARDSON. PREFATORY NOTE. The immediate success of this Address caused me to lay it aside for some months, to see if the favour with which it was received would remain. I am satisfied to find that the good fortune which originally attended the effort holds on, and that in publishing it now in a separate form I am acting in obedience to a generally expressed desire. Since the delivery of the Address before the Health Department of the Social Science Congress, over which I had the honour to preside, at Brighton, in October last, every day has brought some new suggestion bearing on the subjects discussed, and the temptation has been great to add new matter, or even to recast the essay and bring it out as a more compendious work. On reflection I prefer to let it take its place in literature, in the first instance, in its original and simple dress. 12 HINDE STREET, W.: _August_ 18, 1876. HYGEIA, A CITY OF HEALTH We meet in this Assembly, a voluntary Parliament of men and women, to study together and to exchange knowledge and thought on works of every-day life and usefulness. Our object, to make the present existence better and happier; to inquire, in this particular section of our Congress:--What are the conditions which lead to the pain and penalty of disease; what the means for the removal of those conditions when they are discovered? What are the most ready and convincing methods of making known to the uninformed the facts: that many of the conditions are under our control; that neither mental serenity nor mental development can exist with an unhealthy animal organisation; that poverty is the shadow of disease, and wealth the shadow of health? These objects relate to ourselves, to our own reliefs from suffering, to our own happiness, to our own riches. We have, I trust and believe, yet another object, one that relates not to ourselves, but to those who have yet to be; those to whom we may become known, but whom we can never know, who are the ourselves, unseen to ourselves, continuing our mission. We are privileged more than any who have as yet lived on this planet in being able to foresee, and in some measure estimate, the results of our wealth of labour as it may be possibly extended over and through the unborn. A few scholars of the past, like him who, writing to the close of his mortal day, sang himself to his immortal rest with the '_Gloria in excelsis_,' a few scholars might foresee, even as that Baeda did, that their living actual work was but the beginning of their triumphant course through the ages,--the momentum. But the masses of the nations, crude and selfish, have had no such prescience, no such intent. 'Let us eat and drink, for to-morrow we die!' That has been the pass, if not the password, with them and theirs. We, scholars of modern thought, have the broader, and therefore more solemn and obligatory knowledge, that however many to-morrows may come, and whatever fate they may bring, we never die; that, strictly speaking, no one yet who has lived has ever died; that for good or for evil our every change from potentiality into motion is carried on beyond our own apparent transitoriness; that we are the waves of the ocean of life, communicating motion to the expanse before us, and leaving the history we have made on the shore behind. Thus we are led to feel this greater object: that to whatever extent we, by our exertions, confer benefits on those who live, we extend the advantage to those who have to live; that one good thought leading to practical useful action from one man or woman, may go to the virtue of thousands of generations; that one breath of health wafted by our breath may, in the aggregate of life saved by it, represent in its ultimate effect all the life that now is or has been. At the close of a Parliamentary session, an uneventful leader of a section of Parliament banters his more eventful rival, and enlivening his criticism by a sneer at our Congress, challenges the contempt of his rival, as if to draw it forth in the same critical direction. Alas! it is too true that great congresses, like great men, and even like Parliaments, do live sometimes for many years and talk much, and seem to miss much and advance little; so that in what relates to the mere present it were wrong, possibly, to challenge the sally of the statesman who, from his own helpless height, looked down on our weakness. But inasmuch as no man knoweth the end of the spoken word, as that which is spoken to-day, earnestly and simply, may not reappear for years, and may then appear with force and quality of hidden virtue, there is reason for our uniting together beyond the proof of necessity which is given in the fact of our existence. Perchance some day our natural learning, gathered in our varied walks of life, and submitted in open council, may survive even Parliamentary strife; perchance our resolutions, though no sign-manual immediately grace them, are the informal bills which ministers and oppositions shall one day discuss, Parliaments pass, royal hands sign, and the fixed administrators of the will of the nation duly administer. These thoughts on the future, rather than on the passing influence of our congressional work, have led me to the simple design of the address which, as President of this Section, I venture to submit to you to-day. It is my object to put forward a theoretical outline of a community so circumstanced and so maintained by the exercise of its own freewill, guided by scientific knowledge, that in it the perfection of sanitary results will be approached, if not actually realised, in the co-existence of the lowest possible general mortality with the highest possible individual longevity. I shall try to show a working community in which death,--if I may apply so common and expressive a phrase on so solemn a subject,--is kept as nearly as possible in its proper or natural place in the scheme of life. HEALTH AND CIVILISATION. Before I proceed to this task, it is right I should ask of the past what hope there is of any such advancement of human progress. For, as my Lord of Verulam quaintly teaches, 'the past ever deserves that men should stand upon it for awhile to see which way they should go, but when they have made up their minds they should hesitate no longer, but proceed with cheerfulness,' For a moment, then, we will stand on the past. From this vantage-ground we gather the fact, that onward with the simple progress of true civilisation the value of life has increased. Ere yet the words 'Sanitary Science' had been written; ere yet the heralds of that science (some of whom, in the persons of our illustrious colleagues, Edwin Chadwick and William Fair, are with us in this place at this moment), ere yet these heralds had summoned the world to answer for its profligacy of life, the health and strength of mankind was undergoing improvement. One or two striking facts must be sufficient in the brief space at my disposal to demonstrate this truth. In England, from 1790 to 1810, Heberden calculated that the general mortality diminished one-fourth. In France, during the same period, the same favourable returns were made. The deaths in France, Berard calculated, were 1 in 30 in the year 1780, and during the eight years, from 1817 to 1828, 1 in 40, or a fourth less. In 1780, out of 100 new-born infants, in France, 50 died in the two first years; in the later period, extending from the time of the census that was taken in 1817 to 1827, only 38 of the same age died, an augmentation of infant life equal to 25 per cent. In 1780 as many as 55 per cent. died before reaching the age of ten years; in the later period 43, or about a fifth less. In 1780 only 21 persons per cent. attained the age of 50 years; in the later period 32, or eleven more, reached that term. In 1780 but 15 persons per cent, arrived at 60 years; in the later period 24 arrived at that age. Side by side with these facts of the statist we detect other facts which show that in the progress of civilisation the actual organic strength and build of the man and woman increases. As in the highest developments of the fine arts the sculptor and painter place before us the finest imaginative types of strength, grace, and beauty, so the silent artist, civilisation, approaches nearer and nearer to perfection, and by evolution of form and mind developes what is practically a new order of physical and mental build. Peron,--who first used, if he did not invent, the little instrument, the dynamometer, or muscular-strength measurer,--subjected persons of different stages of civilisation to the test of his gauge, and discovered that the strength of the limbs of the natives of Van Diemen's Land and New Holland was as 50 degrees of power, while that of the Frenchmen was 69, and of the Englishmen 71. The same order of facts are maintained in respect to the size of body. The stalwart Englishman of to-day can neither get into the armour nor be placed in the sarcophagus of those sons of men who were accounted the heroes of the infantile life of the human world. We discover, moreover, from our view of the past, that the developments of tenacity of life and of vital power have been comparatively rapid in their course when they have once commenced. There is nothing discoverable to us that would lead to the conception of a human civilisation extending back over two hundred generations; and when in these generations we survey the actual effect of civilisation, so fragmentary and overshadowed by persistent barbarism, in influencing disease and mortality, we are reduced to the observation of at most twelve generations, including our own, engaged, indirectly or directly, in the work of sanitary progress. During this comparatively brief period, the labour of which, until within a century, has had no systematic direction, the changes for good that have been effected are amongst the most startling of historical facts. Pestilences which decimated populations, and which, like the great plague of London, destroyed 7,165 people in a single week, have lost their virulency; gaol fever has disappeared, and our gaols, once each a plague-spot, have become, by a strange perversion of civilisation, the health spots of, at least, one kingdom. The term, Black Death, is heard no more; and ague, from which the London physician once made a fortune, is now a rare tax even on the skill of the hardworked Union Medical Officer. From the study of the past we are warranted, then, in assuming that civilisation, unaided by special scientific knowledge, reduces disease and lessens mortality, and that the hope of doing still more by systematic scientific art is fully justified. I might hereupon proceed to my project straightway. I perceive, however, that it may be urged, that as mere civilising influences can of themselves effect so much, they might safely be left to themselves to complete, through the necessity of their demands, the whole sanitary code. If this were so, a formula for a city of health were practically useless. The city would come without the special call for it. I think it probable the city would come in the manner described, but how long it would be coming is hard to say, for whatever great results have followed civilisation, the most that has occurred has been an unexpected, unexplained, and therefore uncertain arrest of the spread of the grand physical scourges of mankind. The phenomena have been suppressed, but the root of not one of them has been touched. Still in our midst are thousands of enfeebled human organisms which only are comparable with the savage. Still are left amongst us the bases of all the diseases that, up to the present hour, have afflicted humanity. The existing calendar of diseases, studied in connection with the classical history of the diseases written for us by the longest unbroken line of authorities in the world of letters, shows, in unmistakable language, that the imposition of every known malady of man is coeval with every phase of his recorded life on the planet. No malady, once originated, has ever actually died out; many remain as potent as ever. That wasting fatal scourge, pulmonary consumption, is the same in character as when Coelius Aurelianus gave it description. The cancer of to-day is the cancer known to Paulus Eginæta. The Black Death, though its name is gone, lingers in malignant typhus. The great plague of Athens is the modern great plague of England, scarlet fever. The dancing mania of the Middle Ages and the convulsionary epidemic of Montmartre, subdued in their violence, are still to be seen in some American communities, and even at this hour in the New Forest of England. Small-pox, when the blessed protection of vaccination is withdrawn, is the same virulent destroyer as it was when the Arabian Rhazes defined it. Ague lurks yet in our own island, and, albeit the physician is not enriched by it, is in no symptom changed from the ague that Celsus knew so well. Cholera, in its modern representation is more terrible a malady than its ancient type, in so far as we have knowledge of it from ancient learning. And that fearful scourge, the great plague of Constantinople, the plague of hallucination and convulsion which raged in the Fifth Century of our era, has in our time, under the new names of tetanoid fever and cerebro-spinal meningitis, been met with here and in France, and in Massachusetts has, in the year 1873, laid 747 victims in the dust. I must cease these illustrations, though I could extend them fairly over the whole chapter of disease, past and present. Suffice it if I have proved the general propositions, that disease is now as it was in the beginning, except that in some examples of it it is less virulent; that the science for extinguishing any one disease has yet to be learned; that, as the bases of disease exist, untouched by civilisation, so the danger of disease is ever imminent, unless we specially provide against it; that the development of disease may occur with original virulence and fatality, and may at any moment be made active under accidental or systematic ignorance. A CITY OF HEALTH. I now come to the design I have in hand. Mr. Chadwick has many times told us that he could build a city that would give any stated mortality, from fifty, or any number more, to five, or perhaps some number less, in the thousand annually. I believe Mr. Chadwick to be correct to the letter in this statement, and for that reason I have projected a city that shall show the lowest mortality. I need not say that no such city exists, and you must pardon me for drawing upon your imaginations as I describe it. Depicting nothing whatever but what is at this present moment easily possible, I shall strive to bring into ready and agreeable view a community not abundantly favoured by natural resources, which, under the direction of the scientific knowledge acquired in the past two generations, has attained a vitality not perfectly natural, but approaching to that standard. In an artistic sense it would have been better to have chosen a small town or large village than a city for my description; but as the great mortality of States is resident in cities, it is practically better to take the larger and less favoured community. If cities could be transformed, the rest would follow. Our city, which may be named _Hygeia_, has the advantage of being a new foundation, but it is so built that existing cities might be largely modelled upon it. The population of the city may be placed at 100,000, living in 20,000 houses, built on 4,000 acres of land,--an average of 25 persons to an acre. This may be considered a large population for the space occupied, but, since the effect of density on vitality tells only determinately when it reaches a certain extreme degree, as in Liverpool and Glasgow, the estimate may be ventured. The safety of the population of the city is provided for against density by the character of the houses, which ensures an equal distribution of the population. Tall houses overshadowing the streets, and creating necessity for one entrance to several tenements, are nowhere permitted. In streets devoted to business, where the tradespeople require a place of mart or shop, the houses are four stories high, and in some of the western streets where the houses are separate, three and four storied buildings are erected; but on the whole it is found bad to exceed this range, and as each story is limited to 15 feet, no house is higher than 60 feet. The substratum of the city is of two kinds. At its northern and highest part, there is clay; at its southern and south-eastern, gravel. Whatever disadvantages might spring in other places from a retention of water on a clay soil, is here met by the plan that is universally followed, of building every house on arches of solid brickwork. So, where in other towns there are areas, and kitchens, and servants' offices, there are here subways through which the air flows freely, and down the inclines of which all currents of water are carried away. The acreage of our model city allows room for three wide main streets or boulevards, which run from east to west, and which are the main thoroughfares. Beneath each of these is a railway along which the heavy traffic of the city is carried on. The streets from north to south which cross the main thoroughfares at right angles, and the minor streets which run parallel, are all wide, and, owing to the lowness of the houses, are thoroughly ventilated, and in the day are filled with sunlight. They are planted on each side of the pathways with trees, and in many places with shrubs and evergreens. All the interspaces between the backs of houses are gardens. The churches, hospitals, theatres, banks, lecture-rooms, and other public buildings, as well as some private buildings such as warehouses and stables, stand alone, forming parts of streets, and occupying the position of several houses. They are surrounded with garden space, and add not only to the beauty but to the healthiness of the city. The large houses of the wealthy are situated in a similar manner. The streets of the city are paved throughout with the same material. As yet wood pavement set in asphalte has been found the best. It is noiseless, cleanly, and durable. Tramways are nowhere permitted, the system of underground railways being found amply sufficient for all purposes. The side pavements, which are everywhere ten feet wide, are of white or light grey stone. They have a slight incline towards the streets, and the streets have an incline from their centres towards the margins of the pavements. From the circumstance that the houses of our model city are based on subways, there is no difficulty whatever in cleansing the streets, no more difficulty than is experienced in Paris. That disgrace to our modern civilisation, the mud cart, is not known, and even the necessity for Mr. E.H. Bayley's roadway moveable tanks for mud sweepings,--so much wanted in London and other towns similarly built,--does not exist. The accumulation of mud and dirt in the streets is washed away every day through side openings into the subways, and is conveyed, with the sewage, to a destination apart from the city. Thus the streets everywhere are dry and clean, free alike of holes and open drains. Gutter children are an impossibility in a place where there are no gutters for their innocent delectation. Instead of the gutter, the poorest child has the garden; for the foul sight and smell of unwholesome garbage, he has flowers and green sward. It will be seen, from what has been already told, that in this our model city there are no underground cellars, kitchens, or other caves, which, worse than those ancient British caves that Nottingham still can show the antiquarian as the once fastnesses of her savage children, are even now the loathsome residences of many millions of our domestic and industrial classes. There is not permitted to be one room underground. The living part of every house begins on the level of the street. The houses are built of a brick which has the following sanitary advantages:--It is glazed, and quite impermeable to water, so that during wet seasons the walls of the houses are not saturated with tons of water, as is the case with so many of our present residences. The bricks are perforated transversely, and at the end of each there is a wedge opening, into which no mortar is inserted, and by which all the openings are allowed to communicate with each other. The walls are in this manner honeycombed, so that there is in them a constant body of common air let in by side openings in the outer wall, which air can be changed at pleasure, and, if required, can be heated from the firegrates of the house. The bricks intended for the inside walls of the house, those which form the walls of the rooms, are glazed in different colours, according to the taste of the owner, and are laid so neatly, that the after adornment of the walls is considered unnecessary, and, indeed, objectionable. By this means those most unhealthy parts of household accommodation, layers of mouldy paste and size, layers of poisonous paper, or layers of absorbing colour stuff or distemper, are entirely done away with. The walls of the rooms can be made clean at any time by the simple use of water, and the ceilings, which are turned in light arches of thinner brick, or tile, coloured to match the wall, are open to the same cleansing process. The colour selected for the inner brickwork is grey, as a rule, that being most agreeable to the sense of sight; but various tastes prevail, and art so much ministers to taste, that, in the houses of the wealthy, delightful patterns of work of Pompeian elegance are soon introduced. As with the bricks, so with the mortar and the wood employed in building, they are rendered, as far as possible, free of moisture. Sea sand containing salt, and wood that has been saturated with sea water, two common commodities in badly built houses, find no place in our modern city. The most radical changes in the houses of our city are in the chimneys, the roofs, the kitchens, and their adjoining offices. The chimneys, arranged after the manner proposed by Mr. Spencer Wells, are all connected with central shafts, into which the smoke is drawn, and, after being passed through a gas furnace to destroy the free carbon, is discharged colourless into the open air. The city, therefore, at the expense of a small smoke rate, is free of raised chimneys and of the intolerable nuisance of smoke. The roofs of the houses are but slightly arched, and are indeed all but flat. They are covered either with asphalte, which experience, out of our supposed city, has proved to last long and to be easily repaired, or with flat tile. The roofs, barricaded round with iron palisades, tastefully painted, make excellent outdoor grounds for every house. In some instances flowers are cultivated on them. The housewife must not be shocked when she hears that the kitchens of our model city, and all the kitchen offices, are immediately beneath these garden roofs; are, in fact, in the upper floor of the house instead of the lower. In every point of view, sanitary and economical, this arrangement succeeds admirably. The kitchen is lighted to perfection, so that all uncleanliness is at once detected. The smell which arises from cooking is never disseminated through the rooms of the house. In conveying the cooked food from the kitchen, in houses where there is no lift, the heavy weighted dishes have to be conveyed down, the emptied and lighter dishes upstairs. The hot water from the kitchen boiler is distributed easily by conducting pipes into the lower rooms, so that in every room and bedroom hot and cold water can at all times be obtained for washing or cleaning purposes; and as on every floor there is a sink for receiving waste water, the carrying of heavy pails from floor to floor is not required. The scullery, which is by the side of the kitchen, is provided with a copper and all the appliances for laundry work; and when the laundry work is done at home the open place on the roof above makes an excellent drying ground. In the wall of the scullery is the upper opening to the dust-bin shaft. This shaft, open to the air from the roof, extends to the bin under the basement of the house. A sliding door in the wall opens into the shaft to receive the dust, and this plan is carried out on every floor. The coal-bin is off the scullery, and is ventilated into the air through a separate shaft, which also passes through the roof. On the landing in the second or middle stories of the three-storied houses there is a bathroom, supplied with hot and cold water from the kitchen above. The floor of the kitchen and of all the upper stories is slightly raised in the centre, and is of smooth, grey tile; the floor of the bath-room is the same. In the living-rooms, where the floors are of wood, a true oak margin of floor extends two feet around each room. Over this no carpet is ever laid. It is kept bright and clean by the old-fashioned bees'-wax and turpentine, and the air is made fresh and is ozonised by the process. Considering that a third part of the life of man is, or should be, spent in sleep, great care is taken with the bed-rooms, so that they shall be thoroughly lighted, roomy, and ventilated. Twelve hundred cubic feet of space is allowed for each sleeper, and from the sleeping apartments all unnecessary articles of furniture and of dress are rigorously excluded. Old clothes, old shoes, and other offensive articles of the same order, are never permitted to have residence there. In most instances the rooms on the first floor are made the bed-rooms, and the lower the living-rooms. In the larger houses bed-rooms are carried out in the upper floor for the use of the domestics. To facilitate communication between the kitchen and the entrance-hall, so that articles of food, fuel, and the like may be carried up, a shaft runs in the partition between two houses, and carries a basket lift in all houses that are above two stories high. Every heavy thing to and from the kitchen is thus carried up and down from floor to floor and from the top to the basement, and much unnecessary labour is thereby saved. In the two-storied houses the lift is unnecessary. A flight of outer steps leads to the upper or kitchen floor. The warming and ventilation of the houses is carried out by a common and simple plan. The cheerfulness of the fireside is not sacrificed; there is still the open grate in every room, but at the back of the firestove there is an air-box or case which, distinct from the chimney, communicates by an opening with the outer air, and by another opening with the room. When the fire in the room heats the iron receptacle, fresh air is brought in from without, and is diffused into the room at the upper part on a plan similar to that devised by Captain Galton. As each house is complete within itself in all its arrangements, those disfigurements called back premises are not required. There is a wide space consequently between the back fronts of all houses, which space is, in every instance, turned into a garden square, kept in neat order, ornamented with flowers and trees, and furnished with playgrounds for children, young and old. The houses being built on arched subways, great convenience exists for conveying sewage from, and for conducting water and gas into, the different domiciles. All pipes are conveyed along the subways, and enter each house from beneath. Thus the mains of the water pipe and the mains of the gas are within instant control on the first floor of the building, and a leakage from either can be immediately prevented. The officers who supply the commodities of gas and water have admission to the subways, and find it most easy and economical to keep all that is under their charge in perfect repair. The sewers of the houses run along the floors of the subways, and are built in brick. They empty into three cross main sewers. They are trapped for each house, and as the water supply is continuous, they are kept well flushed. In addition to the house flushings there are special openings into the sewers by which, at any time, under the direction of the sanitary officer, an independent flushing can be carried out. The sewers are ventilated into tall shafts from the mains by means of a pneumatic engine. The water-closets in the houses are situated on the middle and basement floors. The continuous water-supply flushes them without danger of charging the drinking water with gases emanating from the closet; a danger so imminent in the present method of cisterns, which supply drinking as well as flushing water. As we walk the streets of our model city, we notice an absence of places for the public sale of spirituous liquors. Whether this be a voluntary purgation in goodly imitation of the National Temperance League, the effect of Sir Wilfrid Lawson's Permissive Bill and most permissive wit and wisdom, or the work of the Good Templars, we need not stay to inquire. We look at the fact only. To this city, as to the town of St. Johnsbury, in Vermont, which Mr. Hepworth Dixon has so graphically described, we may apply the description Mr. Dixon has written: 'No bar, no dram shop, no saloon defiles the place. Nor is there a single gaming hell or house of ill-repute.' Through all the workshops into which we pass, in whatever labour the men or women may be occupied,--and the place is noted for its manufacturing industry,--at whatever degree of heat or cold, strong drink is unknown. Practically, we are in a total abstainers' town, and a man seen intoxicated would be so avoided by the whole community, he would have no peace to remain. And, as smoking and drinking go largely together, as the two practices were, indeed, original exchanges of social degradations between the civilised man and the savage, the savage getting very much the worst of the bargain, so the practices largely disappear together. Pipe and glass, cigar and sherry-cobbler, like the Siamese twins, who could only live connected, have both died out in our model city. Tobacco, by far the most innocent partner of the firm, lived, as it perhaps deserved to do, a little the longest; but it passed away, and the tobacconist's counter, like the dram counter, has disappeared. The streets of our city, though sufficiently filled with busy people, are comparatively silent. The subways relieve the heavy traffic, and the factories are all at short distances from the town, except those in which the work that is carried on is silent and free from nuisance. This brings me to speak of some of the public buildings which have relation to our present studies. It has been found in our towns, generally, that men and women who are engaged in industrial callings, such as tailoring, shoe-making, dressmaking, lace-work and the like, work at their own homes amongst their children. That this is a common cause of disease is well understood. I have myself seen the half-made riding-habit that was ultimately to clothe some wealthy damsel rejoicing in her morning ride act as the coverlet of a poor tailor's child stricken with malignant scarlet fever. These things must be, in the ordinary course of events under our present bad sanitary system. In the model city we have in our mind's eye, these dangers are met by the simple provision of workmen's offices or workrooms. In convenient parts of the town there are blocks of buildings, designed mainly after the manner of the houses, in which each workman can have a work-room on payment of a moderate sum per week. Here he may work as many hours as he pleases, but he may not transform the room into a home. Each block is under the charge of a superintendent, and also under the observation of the sanitary authorities. The family is thus separated from the work, and the working man is secured the same advantages as the lawyer, the merchant, the banker now possesses: or to make the parallel more correct, he has the same advantage as the man or woman who works in a factory, and goes home to eat and to sleep. In most towns throughout the kingdom the laundry system is dangerous in the extreme. For anything the healthy householder knows, the clothes he and his children wear have been mixed before, during, and after the process of washing, with the clothes that have come from the bed or the body of some sufferer from a contagious malady. Some of the most fatal outbreaks of disease I have met with have been communicated in this manner. In our model community this danger is entirely avoided by the establishment of public laundries, under municipal direction. No person is obliged to send any article of clothing to be washed at the public laundry; but if he does not send there he must have the washing done at home. Private laundries that do not come under the inspection of the sanitary officer are absolutely forbidden. It is incumbent on all who send clothes to the public laundry from an infected house to state the fact. The clothes thus received are passed for special cleansing into the disinfecting rooms. They are specially washed, dried and prepared for future wear. The laundries are placed in convenient positions, a little outside the town; they have extensive drying grounds, and, practically, they are worked so economically, that homewashing days, those invaders of domestic comfort and health, are abolished. Passing along the main streets of the city we see in twenty places, equally distant, a separate building surrounded by its own grounds,--a model hospital for the sick. To make these institutions the best of their kind, no expense is spared. Several elements contribute to their success. They are small, and are readily removable. The old idea of warehousing diseases on the largest possible scale, and of making it the boast of an institution that it contains so many hundred beds, is abandoned here. The old idea of building an institution so that it shall stand for centuries, like a Norman castle, but, unlike the castle, still retain its original character as a shelter for the afflicted, is abandoned here. The still more absurd idea of building hospitals for the treatment of special organs of the body, as if the different organs could walk out of the body and present themselves for treatment, is also abandoned. It will repay us a minute of time to look at one of these model hospitals. One is the _fac simile_ of the other, and is devoted to the service of every five thousand of the population. Like every building in the place, it is erected on a subway. There is a wide central entrance, to which there is no ascent, and into which a carriage, cab, or ambulance can drive direct. On each side the gateway are the houses of the resident medical officer and of the matron. Passing down the centre, which is lofty and covered in with glass, we arrive at two sidewings running right and left from the centre, and forming cross-corridors. These are the wards: twelve on one hand for male, twelve on the other for female patients. The cross-corridors are twelve feet wide and twenty feet high, and are roofed with glass; The corridor on each side is a framework of walls of glazed brick, arched over head, and divided into six segments. In each segment is a separate, light, elegant removable ward, constructed of glass and iron, twelve feet high, fourteen feet long, and ten feet wide. The cubic capacity of each ward is 1,680 feet. Every patient who is ill enough to require constant attendance has one of these wards entirely to himself, so that the injurious influences on the sick, which are created by mixing up, in one large room, the living and the dying; those who could sleep, were they at rest, with those who cannot sleep, because they are racked with pain; those who are too nervous or sensitive to move, or cough, or speak, lest they should disturb others; and those who do whatever pleases them:--these bad influences are absent. The wards are fitted up neatly and elegantly. At one end they open into the corridor, at the other towards a verandah which leads to a garden. In bright weather those sick persons, who are even confined to bed, can, under the direction of the doctor, be wheeled in their beds out into the gardens without leaving the level floor. The wards are warmed by a current of air made to circulate through them by the action of a steam-engine, with which every hospital is supplied, and which performs such a number of useful purposes, that the wonder is, how hospital management could go on without the engine. If at any time a ward becomes infectious, it is removed from its position and is replaced by a new ward. It is then taken to pieces, disinfected, and laid by ready to replace another that may require temporary ejection. The hospital is supplied on each side with ordinary baths, hot-air baths, vapour baths, and saline baths. A day sitting-room is attached to each wing, and every reasonable method is taken for engaging the minds of the sick in agreeable and harmless pastimes. Two trained nurses attend to each corridor, and connected with the hospital is a school for nurses, under the direction of the medical superintendent and the matron. From this school, nurses are provided for the town; they are not merely efficient for any duty in the vocation in which they are always engaged, either within the hospital or out of it, but from the care with which they attend to their own personal cleanliness, and the plan they pursue of changing every garment on leaving an infectious case, they fail to be the bearers of any communicable disease. To one hospital four medical officers are appointed, each of whom, therefore, has six resident patients under his care. The officers are called simply medical officers, the distinction, now altogether obsolete, between physicians and surgeons being discarded. The hospital is brought, by an electrical wire, into communication with all the fire-stations, factories, mills, theatres, and other important public places. It has an ambulance always ready to be sent out to bring any injured persons to the institution. The ambulance drives straight into the hospital, where a bed of the same height on silent wheels, so that it can be moved without vibration into a ward, receives the patient. The kitchens, laundries, and laboratories are in a separate block at the back of the institution, but are connected with it by the central corridor. The kitchen and laundries are at the top of this building, the laboratories below. The disinfecting-room is close to the engine-room, and superheated steam, which the engine supplies, is used for disinfection. The out-patient department, which is apart from the body of the hospital, resembles that of the Queen's Hospital, Birmingham,--the first out-patient department, as far as I am aware, that ever deserved to be seen by a generous public. The patients waiting for advice are seated in a large hall, warmed at all seasons to a proper heat, lighted from the top through a glass roof, and perfectly ventilated. The infectious cases are separated carefully from the rest. The consulting rooms of the medical staff are comfortably fitted, the dispensary is thoroughly officered, and the order that prevails is so effective that a sick person, who is punctual to time, has never to wait. The medical officers attached to the hospital in our model city are allowed to hold but one appointment at the same time, and that for a limited period. Thus every medical man in the city obtains the equal advantage of hospital practice, and the value of the best medical and surgical skill is fairly equalised through the whole community. In addition to the hospital building is a separate block, furnished with wards, constructed in the same way as the general wards, for the reception of children suffering from any of the infectious diseases. These wards are so planned that the people, generally, send sick members of their own family into them for treatment, and pay for the privilege. Supplementary to the hospital are certain other institutions of a kindred character. To check the terrible course of infantile mortality of other large cities,--the 76 in the 1,000 of mortality under five years of age, homes for little children are abundant. In these the destitute young are carefully tended by intelligent nurses; so that mothers, while following their daily callings, are enabled to leave their children under efficient care. In a city from which that grand source of wild mirth, hopeless sorrow and confirmed madness, alcohol, has been expelled, it could hardly be expected that much insanity would be found. The few who are insane are placed in houses licensed as asylums, but not different in appearance to other houses in the city. Here the insane live, in small communities, under proper medical supervision, with their own gardens and pastimes. The houses of the helpless and aged are, like the asylums, the same as the houses of the rest of the town. No large building of pretentious style uprears itself for the poor; no men badged and badgered as paupers walk the place. Those poor who are really, from physical causes, unable to work, are maintained in a manner showing that they possess yet the dignity of human kind; and that, being worth preservation, they are therefore worthy of respectful tenderness. The rest, those who can work, are employed in useful labours, which pay for their board. If they cannot find work, and are deserving, they may lodge in the house and earn their subsistence; or they may live from the house and receive pay for work done. If they will not work, they, as vagrants, find a home in prison, where they are compelled to share the common lot of mankind. Our model city is of course well furnished with baths, swimming baths, Turkish baths, playgrounds, gymnasia, libraries, board schools, fine-art schools, lecture halls, and places of instructive amusement. In every board-school drill forms part of the programme. I need not dwell on these subjects, but must pass to the sanitary officers and offices. There is in the city one principal sanitary officer, a duly qualified medical man elected by the Municipal Council, whose sole duty it is to watch over the sanitary welfare of the place. Under him, as sanitary officers, are all the medical men who form the poor law medical staff. To him these make their reports on vaccination and every matter of health pertaining to their respective districts; to him every registrar of births and deaths forwards copies of his registration returns; and to his office are sent, by the medical men generally, registered returns of the cases of sickness prevailing in the district. His inspectors likewise make careful returns of all the known prevailing diseases of the lower animals and of plants. To his office are forwarded, for examination and analysis, specimens of foods and drinks suspected to be adulterated, impure, or otherwise unfitted for use. For the conduction of these researches the sanitary superintendent is allowed a competent chemical staff. Thus, under this central supervision, every death, every disease of the living world in the district, and every assumable cause of disease, comes to light and is subjected, if need be, to inquiry. At a distance from the town are the sanitary works, the sewage pumping works, the water and gas works, the slaughter-houses and the public laboratories. The sewage, which is brought from the town partly by its own flow and partly by pumping apparatus, is conveyed away to well-drained sewage farms belonging to, but at a distance from, the city where it is utilised. The water supply, derived from a river which flows to the south-west of the city, is unpolluted by sewage or other refuse, is carefully filtered, is tested twice daily, and if found unsatisfactory is supplied through a reserve tank, after it has been made to undergo further purification. It is carried through the city everywhere by iron pipes. Leaden pipes are forbidden. In the sanitary establishment are disinfecting rooms, a mortuary, and ambulances for the conveyance of persons suffering from contagious disease. These are at all times open to the use of the public, subject to the few and simple rules of the management. The gas, like the water, is submitted to regular analysis by the staff of the sanitary officer, and any fault which may be detected, and which indicates a departure from the standard of purity framed by the Municipal Council, is immediately remedied, both gas and water being exclusively under the control of the local authority. The inspectors of the sanitary officer have under them a body of scavengers. These, each day, in the early morning, pass through the various districts allotted to them, and remove all refuse in closed vans. Every portion of manure from stables, streets, and yards is in this way removed daily, and transported to the city farms for utilisation. Two additional conveniences are supplied by the scientific work of the sanitary establishment. From steam-works steam is condensed, and a large supply of distilled water is obtained and preserved in a separate tank. This distilled water is conveyed by a small main into the city, and is supplied at a moderate cost for those domestic purposes for which hard water is objectionable. The second sanitary convenience is a large ozone generator. By this apparatus ozone is produced in any required quantity, and is made to play many useful purposes. It is passed through the drinking water in the reserve reservoir whenever the water shows excess of organic impurity, and it is conveyed into the city for diffusion into private houses, for purposes of disinfection. The slaughter-houses of the city are all public, and are separated by a distance of a quarter of a mile from the city. They are easily removable edifices, and are under the supervision of the sanitary staff. The Jewish system of inspecting every carcase that is killed is rigorously carried out, with this improvement, that the inspector is a man of scientific knowledge. All animals used for food,--cattle, fowls, swine, rabbits,--are subjected to examination in the slaughter-house, or in the market, if they be brought into the city from other depôts. The slaughter-houses are so constructed that the animals killed are relieved from the pain of death. They pass through a narcotic chamber, and are brought to the slaughterer oblivious of their fate. The slaughter-houses drain into the sewers of the city, and their complete purification daily, from all offal and refuse, is rigidly enforced. The buildings, sheds, and styes for domestic food-producing animals are removed a short distance from the city, and are also under the supervision of the sanitary officer; the food and water supplied for these animals comes equally, with human food, under proper inspection. One other subject only remains to be noticed in connection with the arrangements of our model city, and that is the mode of the disposal of the dead. The question of cremation and of burial in the earth has been considered, and there are some who advocate cremation. For various reasons the process of burial is still retained. Firstly, because the cremation process is open to serious medico-legal objections; secondly, because, by the complete resolution of the body into its elementary and inodorous gases in the cremation furnace, that intervening chemical link between the organic and inorganic worlds, the ammonia, is destroyed, and the economy of nature is thereby dangerously disturbed; thirdly, because the natural tendencies of the people lead them still to the earth, as the most fitting resting-place into which, when lifeless, they should be drawn. Thus the cemetery holds its place in our city, but in a form much modified from the ordinary cemetery. The burial ground is artificially made of a fine carboniferous earth. Vegetation of rapid growth is cultivated over it. The dead are placed in the earth from the bier, either in basket work or simply in the shroud; and the monumental slab, instead of being set over or at the head or foot of a raised grave, is placed in a spacious covered hall or temple, and records simply the fact that the person commemorated was recommitted to earth in those grounds. In a few months, indeed, no monument would indicate the remains of any dead. In that rapidly-resolving soil the transformation of dust into dust is too perfect to leave a trace of residuum. The natural circle of transmutation is harmlessly completed, and the economy of nature conserved. RESULTS. Omitting, necessarily, many minor but yet important details, I close the description of the imaginary health city. I have yet to indicate what are the results that might be fairly predicted in respect to the disease and mortality presented under the conditions specified. Two kinds of observation guide me in this essay: one derived from statistical and sanitary work; the other from experience, extended now over thirty years, of disease, its phenomena, its origins, its causes, its terminations. I infer, then, that in our model city certain forms of disease would find no possible home, or, at the worst, a home so transient as not to affect the mortality in any serious degree. The infantile diseases, infantile and remittent fevers, convulsions, diarrhoea, croup, marasmus, dysentery, would, I calculate, be almost unknown. Typhus and typhoid fevers and cholera could not, I believe, exist in the city except temporarily, and by pure accident; small-pox would be kept under entire control; puerperal fever and hospital fever would, probably, cease altogether; rheumatic fever, induced by residence in damp houses, and the heart disease subsequent upon it, would be removed. Death from privation and from purpura and scurvy would certainly cease. Delirium tremens, liver disease, alcoholic phthisis, alcoholic degeneration of kidney and all the varied forms of paralysis, insanity, and other affections due to alcohol, would be completely effaced. The parasitic diseases arising from the introduction into the body, through food, of the larvae of the entozoa, would cease. That large class of deaths from pulmonary consumption, induced in less favoured cities by exposure to impure air and badly ventilated rooms, would, I believe, be reduced so as to bring down the mortality of this signally fatal malady one third at least. Some diseases, pre-eminently those which arise from uncontrollable causes, from sudden fluctuations of temperature, electrical storms, and similar great variations of nature, would remain as active as ever; and pneumonia, bronchitis, congestion of the lungs, and summer cholera, would still hold their sway. Cancer, also, and allied constitutional diseases of strong hereditary character, would yet, as far as I can see, prevail. I fear, moreover, it must be admitted that two or three of the epidemic diseases, notably scarlet fever, measles, and whooping cough, would assert themselves, and, though limited in their diffusion by the sanitary provisions for arresting their progress, would claim a considerable number of victims. With these last facts clearly in view, I must be careful not to claim for my model city more than it deserves; but calculating the mortality which would be saved, and comparing the result with the mortality which now prevails in the most favoured of our large English towns, I conclude that an average mortality of eight per thousand would be the maximum in the first generation living under this salutary _régime_. That in a succeeding generation Mr. Chadwick's estimate of a possible mortality of five per thousand would be realised, I have no reasonable doubt, since the almost unrecognised, though potent, influence of heredity in disease would immediately lessen in intensity, and the healthier parents would bring forth the healthier offspring. As my voice ceases to dwell on this theme of a yet unknown city of health, do not, I pray you, wake as from a mere dream. The details of the city exist. They have been worked out by those pioneers of sanitary science, so many of whom surround me to-day, and specially by him whose hopeful thought has suggested my design. I am, therefore, but as a draughtsman, who, knowing somewhat your desires and aspirations, have drawn a plan, which you in your wisdom can modify, improve, perfect. In this I know we are of one mind, that though the ideal we all of us hold be never reached during our lives, we shall continue to work successfully for its realisation. Utopia itself is but another word for time; and some day the masses, who now heed us not, or smile incredulously at our proceedings, will awake to our conceptions. Then our knowledge, like light rapidly conveyed from one torch to another, will bury us in its brightness. _By swift degrees the love of Nature works And warms the bosom: till at last, sublimed To rapture and enthusiastic heat, We feel the present DEITY, and taste The joy of GOD to see a happy world!_ 
54454	----	TRANSCRIBER'S NOTE Italic text is denoted by _underscores_. Some minor changes are noted at the end of the book. DIRTY DUSTBINS AND SLOPPY STREETS. _A PRACTICAL TREATISE ON THE SCAVENGING AND CLEANSING OF CITIES AND TOWNS._ BY H. PERCY BOULNOIS, M. INST. C. E., _Member (by Exam.) of the Sanitary Institute of Great Britain_, CITY SURVEYOR OF EXETER. E. & F. N. SPON, 16, CHARING CROSS. NEW YORK, 446, BROOME STREET. 1881. JAMES TOWNSEND, PRINTER, EXETER. PREFACE. Some portions of the following pages have already appeared in the monthly numbers of the _Sanitary Engineer_, and the complete work is now published with a view to assist Surveyors of Towns and others who are directly engaged in providing that house dustbins shall be regularly cleared, and streets kept clean; and also in the hope that it may be the means of drawing some public attention to the question, thus showing the householder something of what is being done for his welfare by Sanitary Authorities, and how each individual may assist in the good work, instead of, as is now frequently the case, inadvertently or purposely retarding the execution of some very necessary though unostentatious sanitary measures. I am not aware that any book, or even pamphlet, has yet been written on this subject, and I venture to believe that in these pages there may be found something to interest all readers. H. P. B. EXETER, _May, 1881_. CONTENTS. CHAPTER I. SCAVENGING. _Page_ Town Scavenging or Scavengering--Subject divided into 13 heads--Public Health Act, 1875, and its bearings upon the question 1 CHAPTER II. HOUSE REFUSE. Definition of house refuse--The law on the subject--Whether trade and garden refuse must be removed by the scavenger--Statistics on this point--Disputes as to what is trade, garden refuse, or house refuse--Suggestions to settle the question--Other waste materials 5 CHAPTER III. THE DUSTBIN. The Public Health Act, 1875, on the subject of ashpits--The model bye-laws and six clauses on the same subject--Position of the dustbin in respect of the adjacent dwelling-houses--Suggestions to burn some of the waste products of a house--Objections to the _fixed_ ashpit recommended by the Public Health Act--Suggestions for improvements in this direction--Movable dust boxes recommended 10 CHAPTER IV. THE COLLECTION OF HOUSE REFUSE. Three methods by which this is effected--The law on the subject--Statistics on the subject--Lay stall accommodation, objections, and advantages--Dirty habits of the lower classes--A house to house visitation by the scavengers the best system--If universal, great expense incurred--The bell or signal system--Objectionable character of temporary receptacles under this system--State of streets in consequence--Suggestions for improvements-- Specially constructed conveyance and receptacles--Advantages of this system both on sanitary and economical grounds--Delaying the scavenger--The D signal--Convenient hours for the scavengers' visits 17 CHAPTER V. THE SCAVENGERS' CART. Its form and construction--Description of the "tip cart"--Splashing and dust therefrom--Other objections to this form of cart on sanitary and economical grounds--Introduction of many new forms of carts and waggons--General description of improvements in their construction--Some names of makers of sanitary carts and waggons 27 CHAPTER VI. DISPOSAL OF HOUSE REFUSE. Position of a town with respect to the surrounding district-- Sale of refuse to farmers and others the most ready and economical means of disposal--Site of the refuse depôt--Loss of bulk in the refuse at the depôt--Difficulty in disposing of old tins, crockery, &c.--Replies from 90 towns on the question of disposal of house refuse--Condemnation of practice of building over tipped house refuse--Destruction by fire--Fryer's patent carboniser--Dealing with house refuse on a gigantic scale at Manchester 31 CHAPTER VII. STREET CLEANSING. Prosperous appearance of a town--Danger of inhaling dust--The law on the subject--Who ought to cleanse private courts and alleys?--Statistics with reference to this point--Number of times streets ought to be cleansed--Hand labour or machinery--Durability of machines and hand brooms--Materials of brooms--Construction of streets and traffic affect the question of cleansing materially--Returns prepared by the Superintendent of Scavenging, Liverpool--His further remarks on the subject--Disposal of road scrapings--Street cleansing in Paris--The use of disinfectants in Paris 46 CHAPTER VIII. SNOW. The density of snow--The amount of snow to be removed in an ordinary street in England--The removal of snow in Milan--The removal of snow in Paris--Suggestions for its removal in England--Clearing footways--The effect of salt upon snow--Removal of snow in Liverpool 61 CHAPTER IX. STREET WATERING. Watering necessary on sanitary grounds as well as to prevent damage from dust--Watering in London--Watering by horse and cart--The points of importance to be considered in connection with this service--The diary of a water cart--Bayley's hydrostatic van--A description of this machine--Its great advantages over the old-fashioned water cart--Mr. Scott on the subject--A trial in Edinburgh-- Mr. Tomkins and Bayley's van--A comparative table of effective work by one of these vans--Watering streets by ponding water in channel gutters--Brown's system of watering--Its advantages and objections--Watering by hose and reels or by portable iron pipes--Watering at Reading--Watering at Paris--Use of salt water and other chemicals--Watering with disinfectants 73 CHAPTER X. CONTRACTS _V._ ADMINISTRATION BY LOCAL AUTHORITY. Opinions on this subject by surveyors of towns--The dust contractor--A model specification of a contract for removal of house refuse--The system of contracts for such work condemned--Sanitation first, economy afterwards 86 CHAPTER XI. _£ s. d._ The cost of scavenging--Difficulty in fixing any standard of cost--Physical character of a town and other causes must be taken into consideration--Statistics show very various results--Average cost per head of population per annum about one shilling--Is hiring horses cheaper than keeping a stud?--Reasons in favour of the latter plan--Cost of carts, horses, stables, land, &c.--Wages of scavengers and carters--Depreciation of horse flesh and of plant--A specimen estimate where a stud is kept--Another estimate where teams are hired--Mr. Williams' returns as to cost-- List of questions on the subject of scavenging--Conclusion 90 CHAPTER I. "SCAVENGING." The word "Scavenging," or "Scavengering," as it is frequently styled, is a very comprehensive term, as it includes that of house scavenging or the removal of house refuse, and also that of street scavenging, or the sweeping and cleansing of streets, and the carting away of all such materials removed from their surface. In dealing with this subject it will be necessary to consider the following heads, viz.:--(1) What is house refuse, (2) How and in what manner shall it be temporarily stored pending the visit of the Scavenger, (3) What are the best methods for its collection, (4) In what manner shall it be eventually disposed of, and (5) the cost of the whole work; (6) Which are the best methods for sweeping and cleansing streets, (7) Whether machinery is more economical than hand labour, (8) The extra work involved by the ill construction of streets and the materials of which they are formed, (9) Whether private courts and alleys not repairable by the Sanitary Authority should be swept and cleansed by them, (10) The ultimate disposal of excessive accumulations of mud, (11) The removal and disposal of snow, (12) The watering of streets, and (13) The cost of all such work. The Public Health Act of 1875 contains several clauses bearing on the subject of scavenging and the cleansing of streets, and sec. 42, part III., enacts as follows:-- "Every local authority may, and when required by order of the Local Government Board shall, themselves undertake or contract for-- "The removal of house refuse from premises; "The cleansing of earth closets, privies, ashpits, and cesspools; either for the whole or any part of their district. "Moreover, every urban authority and rural authority invested by the Local Government Board with the requisite powers may, and when required by order of the said Board shall, themselves undertake or contract for the proper watering of streets for the whole or any part of their district. "All matters collected by the local authority or contractor in pursuance of this section may be sold or otherwise disposed of, and any profits thus made by an urban authority shall be carried to the account of the fund or rate applicable by them for the general purposes of this Act; and any profits thus made by a rural authority in respect of any contributory place shall be carried to the account of the fund or rate out of which expenses incurred under this section by that authority in such contributory place are defrayed. "If any person removes or obstructs the local authority or contractor in removing any matters by this section authorised to be removed by the local authority he shall for each offence be liable to a penalty not exceeding _five pounds_: provided that the occupier of a house within the district shall not be liable to such penalty in respect of any such matters which are produced on his own premises and are intended to be removed for sale or for his own use and are in the meantime kept so as not to be a nuisance." Section 45 also enacts that "any urban authority may, if they see fit, provide in proper and convenient situations receptacles for the temporary deposit and collection of dust, ashes, and rubbish; they may also provide fit buildings and places for the deposit of any matters collected by them in pursuance of this part of this Act." The Act also gives the power to local authorities to make bye-laws with respect to the cleansing of footpaths and pavements, the removal of house refuse and the cleansing of earth closets, privies, ashpits, and cesspools, and the prevention of nuisances arising from snow, filth, dust, ashes, and refuse. It will thus be seen that the Legislature find it necessary to frame laws for the proper execution of scavenging by every local authority, and we shall see in the following chapters how further clauses in the Public Health Act, as well as in many private Improvement Acts and also in Bye-laws, detail the manner in which this work ought to be properly carried out. I shall further endeavour to show where errors in the working now exist, and give some suggestions that would, in my opinion, be, if carried out, improvements upon the present systems. CHAPTER II. HOUSE REFUSE. Now the first question that presents itself to us is: what is house refuse? and how is it to be defined? for unless this point is satisfactorily settled, great onus and expense will be put on the local authority if they are to be compelled to remove all trade, garden, and other refuse in addition to what may be legally entitled house refuse. Section 4, part I., Public Health Act, 1875, contains the following definition of the word house: "House" includes schools, also factories and other buildings in which more than twenty persons are employed at one time. But all that is apparently said in reference to the definition of refuse is to be found in "Glenn's Public Health Act," 1875, where in a foot note to section 44, part III. of the before named Act, is the negative argument "what is not refuse:" and describes one or two cases in which it was held that certain ashes from furnaces, etc., were to be designated as "trade refuse," and further says "that the intention of the Act was that only the rubbish arising from the domestic use of houses should be removed." On reference, however, to some local Improvement Acts, it appears that the definition is given more in detail, for we find that house refuse is there described as "all dirt, dust, dung, offal, cinders, ashes, rubbish, filth, and soil." We may thus, we imagine, be fairly content with these definitions, and may assume that all house refuse legally so designated, and which it is the duty of the scavenger to remove, is really so removed by the direction of the local authority without dispute, but that the following articles, which frequently find their way into a domestic dustbin, are not in the strict terms of the Act expected to be removed by the scavenger, viz., (1) plaster from walls and brick bats, (2) large quantities of broken bottles and flower pots, (3) clinkers and ashes from foundries and greenhouses, (4) wall papers torn from the rooms of a house, (5) scrap tin (but not old tins which have contained tinned meats and which, although very objectionable and bulky, may be fairly assumed to be house refuse), and (6) all garden refuse such as grass cuttings, dead leaves, and the loppings from trees and shrubs. The Bromley Local Board issue a card on which is printed, amongst other information with reference to the contract for the removal of house refuse, the following:--"It is hoped that householders will as far as possible facilitate the systematic removal of refuse by providing suitable dustbins, and directing their servants that ordinary house refuse only shall be deposited in such receptacles. The following are some of the items of refuse which the contractors are bound to remove, viz.:--cinder ashes, potatoe peelings, cabbage leaves, and kitchen refuse generally. But the contractors are not required to remove the refuse of any trade, manufacture, or business, or of any building materials or any garden cuttings or sweepings." Some valuable statistics have recently been prepared by me from answers obtained from upwards of ninety of the principal cities, and towns in England, in reply to a series of questions which I addressed to the local surveyors on the subject of scavenging, and on referring to these statistics it is found that out of these ninety towns, the authorities of only thirteen of them direct the removal of both trade and garden refuse without any special extra payment being made by the householder, but that this is only done when these materials are placed in the ordinary dustbin or ashpit attached to a house. Several towns, however, it appears remove such materials on special payments being made of sums varying from 1s. 6d. to 3s. per load. Disputes frequently arise between the men employed in scavenging and the householder on these vexed questions as to the difference between house, trade, or garden refuse, a dispute often raised by the scavengers themselves, in the hope of obtaining a gratuity or reward for the clearance of a dustbin which no doubt, legally, they are perfectly justified in refusing to empty, and in order to lessen the chance of such disputes and to attempt to settle this question the following suggestions may be of value. It would no doubt be vexatious if any sanitary authority were to absolutely refuse to remove the "garden" refuse from those houses to which a small flower garden was attached, whilst it would on the contrary be an unfair tax upon the general community if the refuse of large gardens was removed without payment. A good rule would therefore be to remove only such _garden_ refuse as was contained in the ordinary dustbin or ashpit attached to a house, and that as the removal of any kind of _trade_ refuse would no doubt lead to abuses if done gratuitously by the sanitary authority, that this material should only be removed on payment of some sum, which should be previously fixed by the Local Authority, and each case should be reported to the officer superintending the work before it was removed. There are, of course, in addition to the ordinary house refuse the waste materials from the surface of the streets, and from markets and slaughter-houses, which have to be collected and disposed of by the Local Authority, but these materials should be collected in a special manner, independently of the ordinary removal of the house refuse. CHAPTER III. THE DUSTBIN. The next question that we have to consider, having thus far discussed the subject of "what is house refuse," is the important one of the manner and place in which it shall be temporarily stored pending the visit of the scavenger. I will begin as I did in the former case by turning to the law on the subject, and find out if it can help us. Section 40, part III., of the Public Health Act of 1875 enacts that: "Every local authority shall provide that all drains, water-closets, earth-closets, privies, _ashpits_, and cesspools within their district be constructed and kept so as not to be a nuisance or injurious to health." And section 35 of the above Act states, "It shall not be lawful newly to erect any house or to rebuild any house pulled down to or below the ground floor without a sufficient water-closet, earth-closet, or privy, and an ashpit furnished with proper doors and coverings. Any person who causes any house to be erected or rebuilt in contravention of this enactment shall be liable to a penalty not exceeding twenty pounds." The Act also gives power to local authorities to enforce provision of ashpit accommodation for houses where such accommodation does not already exist, and to frame bye-laws with respect to ashpits. In the year 1877 the Local Government Board issued a series of model bye-laws for the use of sanitary authorities, and No. IV. of this series, which is upon "New Streets and Buildings," contains the following six lengthy clauses, regulating the position of an ashpit with reference to a dwelling-house or public-building, or to any water supply, and for the purpose of removing its contents without carrying them through any dwelling-house, &c.:-- "80. Every person who shall construct an ashpit in connection with a building shall construct such ashpit at a distance of _six feet_ at the least from a dwelling-house or public building, or any building in which any person may be, or may be intended to be employed in any manufacture, trade, or business. "81. A person who shall construct an ashpit in connexion with a building shall not construct such ashpit within the distance of __ _feet_ from any water supplied for use, or used or likely to be used by man for drinking or domestic purposes, or for manufacturing drinks for the use of man, or otherwise in such a position as to endanger the pollution of any such water. "82. Every person who shall construct an ashpit in connexion with a building shall construct such ashpit in such a manner and in such a position as to afford ready means of access to such ashpit for the purpose of cleansing such ashpit, and of removing the contents thereof, and, so far as may be practicable, in such a manner and in such a position as to admit of the contents of such ashpit being removed therefrom, and from the premises to which such ashpit may belong, without being carried through any dwelling-house or public building, or any building in which any person may be, or may be intended to be employed in any manufacture, trade, or business. "83. Every person who shall construct an ashpit in connection with a building shall construct such ashpit of a capacity not exceeding in any case _six cubic feet_, or of such less capacity as may be sufficient to contain all dust, ashes, rubbish, and dry refuse which may accumulate during a period not exceeding _one week_ upon the premises to which such ashpit may belong. "84. Every person who shall construct an ashpit in connection with a building shall construct such ashpit of flagging, or of slate, or of good brickwork, at least _nine inches_ thick, and rendered inside with good cement or properly asphalted. "He shall construct such ashpit so that the floor thereof shall be at a height of not less than _three inches_ above the surface of the ground adjoining such ashpit, and he shall cause such floor to be properly flagged or asphalted. "He shall cause such ashpit to be properly roofed over and ventilated, and to be furnished with a suitable door in such a position and so constructed and fitted as to admit of the convenient removal of the contents of such ashpit, and to admit of being securely closed and fastened for the effectual prevention of the escape of any of the contents of such ashpit. "85. A person who shall construct an ashpit in connexion with a building shall not cause or suffer any part of such ashpit to communicate with any drain." There can be no doubt that the position of the dustbin or ashpit, as regards its site with reference to the main dwelling-house, is of primary sanitary importance, for if the garbage and domestic accumulations therein are allowed to remain for a few days, especially when the weather is close, damp, and warm, they become very offensive, and the emanations therefrom may even be highly deleterious and dangerous to health; this effect is aggravated by persons emptying vegetable refuse and other matters which are _wet_ into the dustbin, as decomposition of these matters is greatly assisted by this addition, and it would be well that all such matters should be burnt on the kitchen or scullery fire along with a large percentage of the ashes which could be sifted and saved from those which too readily find their way into the dustbin, and are thus wasted. Care would of course have to be taken in this process that no smell or nuisance was caused by burning this refuse, but the greatest difficulty would arise in overcoming the time-honoured prejudices of the domestic servant who usually finds the dustbin or ashpit the most convenient and least troublesome place to dispose of nearly everything that to her may be entitled rubbish. Now with all due respect to those who framed Section 35 of the Public Health Act of 1875, it is open to considerable doubt whether the _fixed_ dustbin or ashpit, as it is there styled, is the best and most sanitary receptacle for the house refuse. They may be necessary and suitable for Public Institutions, or for large isolated private dwellings, or for schools or any places where excessive quantities of refuse may accumulate, but where this refuse is systematically and properly removed by the order of the local authority, at such times and in such manner as will be hereafter pointed out, a movable or portable dustbin, box, or basket, is far preferable to the large immoveable inconvenient fixed ashpit, recommended and enforced under the Act. This portable dustbox should be of such dimensions that the men employed in removing the refuse could easily carry it out and empty its contents into the cart, and there is nothing to prevent more than one being provided, if it is found insufficient for the requirements of the household. The box should be made of iron, or wood or basket lined with tin, or some equally impervious material, so that it can easily be washed out and thoroughly cleansed and disinfected when found necessary to do so, a matter very difficult to accomplish with the fixed ashpit. The _whole_ of its contents could be quickly emptied, which is more than can be easily effected with the fixed ashpit, and then only when very special arrangements are made for its drainage. The movable dustbox can, in addition to these advantages, be placed in any part of the premises, and may be covered or not as may be deemed desirable, and need not, like many of the existing ashpits, be fixed in such a position as to appear to have been thus placed for the express purpose of poisoning with its foul smell the whole of the inhabitants in its vicinity. The movable box can also be readily taken out to the scavenging cart by the householder himself, a very essential requisite, as will be shown in the next chapter. CHAPTER IV. THE COLLECTION OF HOUSE REFUSE. The collection of house refuse should be done satisfactorily, expeditiously, and economically. At the present time there seem to be only three methods by which this is attempted to be effected; they are as follows:-- (1.) By a house to house call at intermittent periods. (2.) By the scavengers giving notice of their approach by ringing a bell or by other signal, and requiring the householder to bring out the refuse to the cart, and (3.) By placing public dustbins in different localities, and expecting householders in their vicinity to place the house refuse in these dustbins, which would then be cleared from time to time by the local authority. The law is silent on the subject of what may be considered as an efficient collection and removal of house refuse, and experience only can teach us the best manner of thoroughly effecting this work without losing sight of the economical side of the question; but it appears, on again referring to the table of statistics which have been previously mentioned, that nearly all the towns adopt the two first methods mentioned above for the removal of the house refuse, but that very few of them are able to adopt any public dustbins or "lay stall" accommodation for the temporary reception of the refuse, not only on account of their first cost, but also from the difficulty of finding suitable positions for them. This latter objection to the adoption of public dustbins arises in great measure from the fact that they are usually constructed of galvanised iron in the form of open boxes or troughs, which are readily accessible to young children and poultry, who often scatter their contents in every direction, and they are also generally open to the view of the inhabitants of the courts, and to passers by, whose "morale" it is found is certainly not improved by constant familiarity with the sight of filth. If these dustbins were constructed with properly balanced self-closing lids, these objections would be overcome, and their first cost would be but trifling when compared with the benefit to be derived by placing them in some of the thickly populated courts and alleys which are unfortunately to be found in nearly every town. Where there are no public dustbins the inhabitants of these courts throw their waste products upon the surface of the streets or courts, from time to time throughout the day, as it cannot be expected nor desired that such materials should remain, even for twenty-four hours, in their one living room, which is frequently over crowded, and has but little spare space even for the common necessities of life; but that these waste products should be thus strewn over the surface of the street or court is almost equally objectionable, and points to the enormous advantage to be gained by placing in convenient situations the covered dustbins that are described above, the contents of which could be easily emptied once a day. The greatest difficulty would be found to be that of inducing the inhabitants to take the trouble to carry their house refuse to the dustbin, but they might be gradually educated up to this standard of cleanliness, and a few persons judiciously summoned and punished "pour encourager les autres," when detected in throwing any of their waste products on to the surface of the street or court, would no doubt have a very beneficial effect in assisting their education. With reference to the question of a house to house call or visitation by the scavengers for the purpose of removing the refuse. This is no doubt the method "par excellence" of all the systems for its effectual removal without much trouble to the householder, but except in suburban districts and for the collection of refuse from the better class of dwelling-houses and public institutions, the expense, delay, and difficulty which would be incurred in calling at every house throughout a town, would make it almost impracticable, and consequently this system is universally combined with that which is known as the bell or signal system, which simply means that the scavenging cart in going its rounds has a bell attached to it, or the horse, which bell rings automatically as the cart proceeds on its way; or the man in charge blows a trumpet, or calls in stentorian tones, "Dust oh!" On hearing this signal, _but not before_, the householder is expected to bring out the refuse in some convenient receptacle, which is then emptied into the cart by the scavenger. As a matter of fact, the receptacles containing all the waste products of these householders are brought out and are placed in the gutter of the street close to the kerb, long before the cart makes its appearance or can be reasonably expected to do so. These temporary receptacles are, as may be easily imagined of various sizes and shapes, and are composed of various materials. On one side you may see a well and suitably constructed galvanized iron box, with handles and cover complete, on the other an old band box, cigar box, or tin saucepan. The result of these inappropriate receptacles filled with heterogeneous collections of house refuse being left unprotected in the public streets, is that their contents are quickly strewn about the surface of the street, either by their being upset accidentally, or purposely, by persons who gain a precarious livelihood by abstracting therefrom, and selling rags, bones, and similar articles, or by the dogs, ever on the alert for a hasty and disgusting meal, and the appearance of the street which has probably been carefully swept and garnished during the night or early in the morning, quickly assumes, especially in a high wind, a very offensive character, and probably has to be entirely re-swept and cleansed before the ordinary traffic of the day commences. To obviate these evils arising from this practice almost universally adopted, I suggest the following plan:-- A specially designed frame or carriage must be constructed somewhat similar in appearance to a timber waggon; this must be furnished with a number of strong iron hooks, with or without simple lifting gear, according to the strength and sizes of the receptacles hereafter described. Upon these hooks are to be hung cylindrical shaped galvanized iron boxes with balanced covers, and hopper-shaped mouths, and of such cubical capacity as may be found to meet the requirements of any district choosing to adopt my system. The _modus operandi_ would be as follows:--The waggon should be drawn through certain selected streets at about 6.30 a.m.; the boxes or cylinders unhung from it, and placed in such suitable and convenient positions as may be found necessary; their distance apart may be about that of the ordinary street lamp posts, and their position may be in the street channel gutter close to the kerb of the footpath; they should be allowed to remain about a couple of hours, during which time the householders in the vicinity of the boxes would be expected to empty into them all the sweepings, garbage, and house refuse from their premises; at the end of this time the waggon would again appear, and the boxes or cylinders would be attached to the hooks, and be taken to the nearest refuse depôt. There are many advantages to be gained by adopting my proposed system, the principal one being that of preventing the disgusting practice of allowing the foul refuse from houses, to be openly displayed in the public streets, in the manner previously described, and in preventing the possibility of such refuse being allowed to stay for a single instant upon the surface of the street, where even if it is afterwards carefully removed, an ugly stain is almost sure to remain for many hours afterwards. Another advantage would be the great convenience to householders of that of having a ready receptacle for their refuse, only a few yards at the most from their doors. The saving of time also in the collection would be considerable, as the scavengers need not wait one single moment beyond the time required to attach the cylinder to the waggon, and there is in addition the cleanliness with which this operation could be performed, thus conferring a great boon on the foot passengers in the streets, who, under the present system, are often half smothered by the dust when the scavengers are engaged in emptying the contents of the usual inappropriate receptacles into the ordinary dust cart. The facilities also for cleansing or disinfecting the cylinders would be undoubted, and the economy, not only in time but in actual expense over the existing system, would be considerable, for the cylinders would last a long time without repairs being needed; not so the ordinary dust cart, which speedily wears out, principally from the fact that the "tipping" necessary to empty it of its contents, is highly detrimental to its stability. Having thus shown a method by which the collection of house refuse in crowded streets, where a house-to-house visit is impracticable, can be materially improved, I will pass on to the present system of the collection of refuse in the suburban and rural districts of a town by a house-to-house call. A great improvement in this system would no doubt be effected by adopting the movable dust boxes I suggest in the chapter on "The Dustbin," as great delay and consequent expense would be saved thereby, and the work would be altogether more effectually and properly performed, but it is also found that very frequently the scavengers on calling at a house for the purpose of removing the accumulated refuse, are told by the servant that they cannot be admitted, either because it is an inconvenient hour, or that it is washing day, or that being a wet day the scavengers' boots are too dirty to walk over their clean passages or floor, or that the dustbin is not full, and that they must call another day, or some other equally plausible excuse, so that the visit is a useless one, and time is lost. Another evil arising out of this is also the fact that as the scavenger's cart has usually a regular round, a fruitless visit as described, results in the dustbin remaining uncleared for perhaps another week, or even more, a state of things not at all to be desired. In order to assist in obviating the chances of such useless visits by the scavengers, I would suggest a very simple remedy, which has already been tried in some towns with considerable success. It consists in the householder placing a card bearing the letter D, or some other distinguishing mark, in a conspicuous place in a window, when the services of the scavengers are required; these cards should be printed and circulated by the Sanitary Authority of the district, who should state on the back of the card the days on which the scavengers would visit each neighbourhood, with the approximate hour of the day in which they would appear, in each road or street if practicable, in order that the householder may not be unnecessarily inconvenienced by being obliged to keep the card for any length of time in his window. The scavengers in passing, observe the signal, and call at the house, otherwise they pass on, unless specially called in by the occupants, thus avoiding any unnecessary delay in their rounds. A visit from the scavengers either before seven or after ten in the morning is generally very inconvenient for households of a superior class, and should be, if possible, carefully avoided by the Sanitary Authority. CHAPTER V. THE SCAVENGER'S CART. The next question that presents itself to our notice is that of the form, style, and construction of the cart usually employed in this work of house refuse collection, and whether it is well suited for the requirements of the work or otherwise. The cart usually employed is that known as the ordinary "tip cart," strongly, if not clumsily, constructed of an oak frame, with elm or deal sides of considerable height; it holds about a couple of cubic yards of materials, and generally costs from sixteen to twenty pounds. These carts are not only clumsy and heavy, but they give an overweighted diminutive appearance to the horse between the shafts, especially as the quality of horse employed for work of this character is frequently none of the best, and as a matter of fact the cart is so ill-balanced that the bulk of its weight is thrown upon the back of the horse. The height, too, of the cart is often so great as to necessitate the use of a short ladder, up which the scavenger has to climb, before he can discharge the contents of his basket into the cart, sending in the process a shower of offensive dust in every direction, far from pleasant for those unfortunate persons who happen to be passing near the spot at the time. When used as "slop" carts the same objections arise, as in this case the liquid mud is splashed in every direction, owing to the height to which it has to be thrown by the shovel of the scavenger. Some difficulty is also experienced in thoroughly covering over the contents of the cart, so that not only shall it be hidden from the eye, but that it shall prevent either the liquid mud from being spilled on the ground, or if the cart is being used to convey either dust or house refuse, to prevent the contents being blown about, or dropped upon the surface of the street. The imperfect mode at present adopted is to cover the cart with a tarpaulin, which is tied down as tightly as the circumstances of the case will admit, but which as a rule does not effectually answer the purpose for which it is intended. In towns where the house refuse is not collected separately from the road scrapings, a judicious mixture of the two in the cart considerably assists in preventing any mud slopping or dust blowing. The material being wood of which these carts are constructed, it becomes a difficult matter either to effectually cleanse them after use, or to properly disinfect them, which in times of any serious outbreak of an epidemic is essential to the sanitary well-being of a community. The employment also of wooden carts for this work is bad economy, their rough usage, and the mode adopted for emptying them by "tipping," rendering their life but a short one, a cart in constant work frequently costing from four to five pounds per annum in repairs, and having but very little of the original material of which it was constructed left in it at the end of six years. With a view to obviate these and other objections, several improved carts and waggons have been introduced by different makers, who have styled them by a variety of names, in order to recommend them to the notice of the public. Amongst other names they are called dust carts, general purpose carts, sanitary carts, slush carts, tumbler carts, mud waggons, tip waggons, slop waggons, &c. They are generally constructed with iron bodies fixed upon wooden frames on wheels; they are of various forms and designs, the principal objects aimed at being lightness of construction combined with strength, so balanced as to bear with a minimum of weight upon the horse; economy in their cost has not been lost sight of, and they are usually provided with some special means for emptying, either by being completely inverted by a chain and windlass, or by some mechanical arrangement of the tailboard; they are built very low upon their axles, so as to be easily filled, are either completely covered over with a moveable lid, or are fitted with hinged side boards, so as to prevent any splashing over of their contents, and as they are nearly all constructed with iron, they are easily cleansed and disinfected whenever it is thought necessary to do so. Amongst others I may mention the following firms who have made the construction of these sanitary carts and waggons a speciality:--Messrs. Bayley & Co., Newington Causeway, London; Messrs. Cocksedge & Co., of Stowmarket; the Bristol Waggon Works Company; and Messrs. Smith & Son, of Barnard Castle, Yorkshire. CHAPTER VI. DISPOSAL OF HOUSE REFUSE. Having proceeded thus far with my subject, the very important question next arises as to the manner of the disposal of the house refuse after it has been collected by the Local Authority, both with regard to its sanitary aspect and also to that of economy. So much depends upon the position of every town and the character of the district in which it is situated, that no hard and fast lines can be laid down in reply to this question, if, however, the town is fortunate enough to be the centre of an agricultural district, or there are ready and economical means of conveying the refuse there, no difficulty should be experienced in disposing of it, if not altogether at a profit, at least at a small loss upon the cost of collection, as farmers and market gardeners will readily buy house refuse at prices varying from sixpence to three shillings a load to use as a top dressing or manure upon their land, and a very rich and fertilizing manure it makes, notwithstanding the outcry that is sometimes raised against it that it produces rank weeds, owing to the seeds of such vegetation being found in every domestic dustbin, the fact really being that all manures will foster and help the growth of weeds, as well as cereals or roots, and the appearance of a prolific crop of weeds points rather to bad and careless farming than to the use of inferior manure. In order to suit the convenience of the customers for refuse, and in order to prevent any delay in its collection from the houses, it is necessary for every town to provide one or more depôts in which the refuse may be so deposited from day to day as it is collected. The site of each depôt should be very carefully selected, bearing the following requisitions in mind:-- They should not be at greater distances from the town than would allow the carts to make from three to four journeys a day, and it is evident that their position should, so much as possible, avoid the necessity for the carts to pass _through_ the town when full; they must also be placed so as to be readily accessible to the carts and waggons of the farmers, the customers, and above all, they must be so situated with regard to any dwelling-houses or public roads as not to cause any nuisance, or be injurious to health in any possible manner, and for this purpose a knowledge of the prevailing wind in that neighbourhood would be useful, and care must also be taken that no stream or water-course from which the supply of any drinking water is obtained is likely to become polluted by having such an unpleasant neighbour as a "refuse depôt." The depôt need only be an open field securely railed off against trespassers or pilferers, but as it generally swarms with countless numbers of rats, it is just as well that no stacks or barns should be erected in its vicinity, if their owner has any wish to preserve his corn. In this depôt, the site of which has been selected with all due care, the refuse should be made up into measured heaps, a convenient size for them being found to be twelve feet square by six feet high; these heaps are then sold as they stand to farmers and others who send their carts and waggons to remove them, thus preventing any possibility of mistake or dispute arising as to the number of loads each customer pays for and receives. The refuse, when first brought into the depôt, is far more bulky than it afterwards becomes, and it shrinks nearly twelve per cent. after a few months' exposure to wind and rain; it is therefore necessary to unload each cart as it arrives from the town on to an enormous heap or mound, from the other end of which the measured heaps are made up after the material has become stale and sunken. Another cause for the shrinkage and reduction of bulk of house refuse after reception at the depôt is the necessary removal of all the old tins, broken crockery, broken flower pots, &c., before it can be sold to the farmer, and a very difficult matter it is to know how to deal with this heterogeneous mass of absolutely useless articles thus left behind, unless they can be used for bottoming roads, or for agricultural or for deep land drainage, or for filling up hollows of land not afterwards intended to be built upon, when these materials would be very useful and acceptable for such purposes, otherwise they must be kept and allowed to cumber the ground until some such use can be assigned to them. All towns are not so conveniently situated with regard to their surrounding neighbourhood, as will permit their authorities to sell the collected house refuse to farmers, market-gardeners, or others, for use as manure, and in such cases, where they cannot do so, other measures must be resorted to, in order to dispose of it in the most economical and sanitary manner. Among the numerous questions that I addressed to the various towns of England when engaged in preparing the returns to which reference has already been made, was one to the following effect:--"How is the refuse disposed of after collection?" Many and various were the replies to this. Amongst them were the following:-- In many towns it is stated that the whole of the refuse is used by brick makers, in others it is simply "tipped to waste." In one case the answer is, "Sold by auction twice a year," but to whom it is sold, and for what purpose, does not transpire. In some towns it appears to be mixed with lime and used as manure upon the fields, and in others it is mixed with the sludge of the sewage farms, and is then ploughed or dug into the soil of the farm. This seems a better plan than that of another town, where it is "given or thrown away," although the difficulty of disposing of the old iron, tins, &c., is not touched upon in any of the foregoing answers. The next reply states that "it is riddled, and the cinders and vegetable refuse are burnt to generate steam, the fine dust is used with the manure manufactory (tub system), the old iron is sold, and the pots, &c., used for the foundations of roads." In one case the whole of the refuse is taken out to sea in hopper barges, and sunk in deep water. In a great number of towns it is sold by tender for the year, but what eventually becomes of it does not transpire. But the most favoured methods, where it cannot be sold as manure to farmers, seem to be either that of carting it away to some spot outside the town, and there using it for the purpose of filling up hollows and depressions, or that of giving or selling it to brick-makers. The practice of filling up hollow places with either house refuse or street sweepings cannot be too strongly deprecated, as it stands to reason that some object is in view when these hollows are thus filled up, and we may be sure that the object is that of transforming inconvenient and impracticable pieces of ground into convenient building sites, whereon, sooner or later, eligible villas make their sudden appearance, almost with the rapidity of Aladdin's Palace, under the magic hand of a jerry builder, and woe betide the unfortunate being who, struck with the pretentious appearance and low rent of one of these eligible family residences, takes up his abode therein, for so surely will disease, and perhaps death, be his visitor. I will not here enter into the details, or describe the medical reasons why such sites are unhealthy for dwelling-houses, as the fact is almost self-evident, and the practise of using either house refuse or street sweepings for such a purpose has been condemned by sanitary experts over and over again. But I will pass on to describe a method of disposal of town refuse which is now gaining some popularity in localities where difficulties are experienced in getting rid of the refuse by any of the means to which reference has been made, and which up to the present time seems to be the best solution of the difficulty. I allude to the process of the destruction of the refuse by fire. With this object in view a Mr. Fryer has invented an apparatus which he styles a "Patent Carboniser, for the conversion of garbage, street, and market sweepings, also other vegetable refuse into charcoal." This apparatus consists of a structure somewhat resembling, externally, a brick kiln. It is divided into hopper-shaped compartments, which at the bottom are furnished with a furnace, fitted with a reverbatory arch. A fire is lighted in this furnace, the necessary combustion being obtained, and the heat maintained, by burning the cinders, which are sifted out of the house refuse for this purpose. All the street sweepings, refuse, garbage, &c., is then thrown in at the top of the kiln, and it is there and then completely destroyed by the action of the fire, and converted into charcoal, which is withdrawn through a sliding door fixed at the bottom of the kiln. The inventor further contends that his Carboniser not only burns everything within it so thoroughly and completely as to produce effectual deodorisation, but also that in the process all noxious gases which may be driven off the burning organic matters contained in the refuse are themselves burnt and destroyed. Mr. Fryer has also patented another apparatus which he calls a "Destructor for reducing the bulk for purifying and fusing mineral refuse of towns, the residue to be converted into concrete or mortar." This apparatus is somewhat similar in construction and mode of action to the "Carboniser," except that it has no tall kiln containing the hopper-shaped compartments. Great heat is, however, necessary in order to fuse the mass of heterogeneous articles that are thrown into it, and its success is greatly dependant upon such heat being constantly and efficiently maintained. It is said that the cost of an establishment to dispose of the refuse by this means, consisting of one six celled Destructor and an eight-celled Carboniser, boiler, steam engine, mortar pans, cooler, chimney, shaft, and buildings, is about £4,500. Each cell is stated to deal with about 50 cwt. of refuse in every twenty-four hours, and that no nuisance is experienced in the vicinity of the depôts. This apparatus has, I understand, been adopted in Kralingen, Leeds, Blackburn, Bradford, Warrington, and Derby, and is about to be adopted in other important places. It is not my intention here to describe or to discuss the question of the collection and disposal of night soil, which in many towns is intimately connected and amalgamated with the collection of house refuse and the cleansing of streets. It is a subject of sufficient importance to be dealt with separately. The following particulars, however, with reference to the collection of house refuse in connection with the pail system at Manchester will not be out of place, especially with regard to the reference which is made to Fryer's Carbonisers and Destructors, and it must be borne in mind that the refuse here spoken of is _wet_, which makes the difficulties connected with its destruction by fire greater than it would be if only dry, or comparatively dry, house refuse had to be destroyed. These particulars are gleaned from a report contained in a copy of the _British Architect_, of 1876, of a visit by the members of the Manchester Scientific and Mechanical Society to the works of the Manchester Corporation Health Committee, the figures being altered so as to conform more closely with the growth of the work since that year. There are about 56,000 closets in Manchester, 44,000 of which have been constructed on the cinder sifter principle, and are emptied during the day, the remainder are emptied during the night. The contents of the new closets are brought away by vans specially constructed for the purpose, having five compartments, one of which is open and uncovered, and this receives the dry refuse; the other four compartments are covered and enclosed with tightly fitting doors. Each of these compartments holds six galvanised iron pails, which are also covered with closely fitting lids. The van bottoms are panelled, and the inside of each panel is filled with a layer of carbolic acid powder, one inch thick, and they are thoroughly cleansed after each journey. The Health Committee employ 100 of these vehicles, each one making four journeys per day. The contents of the closets which are emptied during the night are taken away in open carts, two-thirds to the tips and the remainder along with the refuse brought into the yard by the vans, is sent each night into the country. The amount of material dealt with each week by the Health Committee is about 3,000 tons, and may be described as follows:--Paper, 1 ton; rags, 3 tons; dead animals, dogs, cats, rats, mice, guinea pigs, &c., 2 tons; stable manure, 17 tons; meat tins, old tin and iron, 33 tons; refuse from slaughter-houses and fish shops, &c., 60 tons; broken pots, bottles, and glasses, 80 tons; vegetable refuse, door mats, table covers, floorcloths, old straw mattresses, 100 tons; fine ashes, 1,230 tons; cinders, 1,400 tons. The Committee employ in this department over 500 men, including clerks, inspectors, wheelwrights, smiths, saddlers, tinmen, engineers, mechanics, manure and mortar makers, stablemen, and labourers. They have 156 horses, and about the same number of vehicles of various descriptions. When the loaded vans reach the yard, they are first weighed, afterwards they are taken on to the first floor of a two-storey building, where the dry refuse from the open part of each van is unloaded and shovelled on to sieves worked by steam power. By this arrangement the fine dust widely diffusing itself in its descent, falls on to the floor below, covering the contents of the pails, which are, at the same time, being emptied on to grids fixed in the floor. At one end of these grids the bars are set much more closely together than at the other, and serve to convey the liquid portion of the contents of the pails by means of troughs to a tank where it is further dealt with. The solid portion of the excreta falls through the wide-barred portion of the grid into suitable receptacles. The rough portion of the dry refuse, after being separated from the fine, is carried along a movable and endless table to the mortar mills, the boiler, or to one of the various furnaces, of which there are several in the yard. This dry refuse is of such a heterogeneous character as to require various modes of treatment. It is made up of paper, rats, meat tins, straw, cabbage leaves, onions, apples, turnips, fish bones, dead cats, rabbits, guinea pigs, fowls, brush heads, old boots, old books, knives, forks, spoons, children's toys, old hats, old bonnets, crinoline wires, umbrella frames, broken pots, broken bottles, preserve jars, medicine bottles, old mattresses, cinders, bits of coal, firewood, bass, broken bricks, and a host of other articles too numerous to mention. When this mass of rubbish is somewhat assorted, the cinders are separated and used for fuel for the boilers and furnaces (no coal whatever is allowed in the yard), the remaining portion of the rubbish along with some most vile and abominable matter which occasionally comes to the yard in the pails, is taken to the Carbonisers (of which there is a nest of eight in the yard), and the obnoxious material is therein carbonised and is resolved into a perfectly harmless material. In another part of the yard is a second set of furnaces which are called destructors, and are used for the purpose of destroying rubbish, which before-time, for many years past, has been deposited in large heaps in every suburb of the city, to the great annoyance of the inhabitants whose fate it was to live in the vicinities of these deposits. These destructors not only consume this objectionable material, but they furnish heat to a concretor which is placed in close contiguity. The spent fuel is carted to the mills, and is there converted into mortar--a mortar, too, of the best description--as the samples of brickwork built with it and exhibited abundantly testify. This concretor, which is driven by steam power, is a large cylinder of a peculiar internal construction, which exposes an extensive evaporating surface to the heat from the destructor, which passes through the cylinder from end to end. The work of this concretor is to subject the urine or liquid portion of the contents of the pails fed by means of the troughs already spoken of in connection with the tank. The urine is pumped from this tank into the concretor at the rate of about 150 gallons per hour. The concentrated urine, which contains a large quantity of ammonia, is mixed with two-thirds its weight of charcoal, and the composition forms a most valuable manure. The carboniser, the destructor, and the concretor have all been invented and patented by Mr. Alfred Fryer, of the firm of Manlove, Alliot & Co., engineers, Nottingham. The process of carbonising is patented by the Universal Charcoal Company, Limited, who are to receive a royalty, we understand, from the Health Committee for the use of their patent. There is a tall and noble-looking chimney in the centre of the yard surrounded by many new buildings and sheds, and this has been built with the concrete mortar manufactured by the Health Committee. Such is the gigantic scale upon which these matters are dealt with in the City of Manchester. The other methods, to which reference has been made, for the disposal of town refuse require no further comment, as it is evident that unless a ready sale for the refuse can be effected, by far the best method of disposing of it seems to be that by which it is completely annihilated by fire in the manner that has been described, or in some other similar manner. Having thus far followed the house refuse from its first appearance in its cradle, the dustbin, through its chequered career after collection down to its decease, either by burial, or by cremation, the question of the cost of the whole of this work must be deferred until the final chapter, after I have dealt with the subject of street sweeping and cleansing, the removal of snow, and a short chapter upon street watering, which is somewhat analagous to scavenging, and is frequently included in the accounts of that work in the estimates which are prepared by a Local Authority. CHAPTER VII. "STREET CLEANSING." Clean well-swept streets not only add materially to the prosperous appearance of a town, but they also have a very marked influence upon its health and upon the morale of its inhabitants; wet, and muddy, badly formed, ill-drained streets, cause dampness in the subsoil of the dwelling-houses in the vicinity, and a humidity in the atmosphere, both of which tend to produce a low standard of health in their neighbourhood, irrespective of the wet surface through which pedestrians have to wade whenever they are obliged to cross such streets. Dusty streets, too, are very injurious from the fact of persons inhaling the gritty silicate loaded air arising from them; such an atmosphere is known to produce disease of the lungs, even when it is free from the dust arising from horse droppings or other organic impurities. Professor Tyndall, in his beautiful experiments, has proved that dusty air is alive with the germs of the bacteria of putrefaction, whilst the pure fresh air which he gathered on a mountain peak in the Alps is innocent of such germs, and is absolutely powerless to produce any organisms. Persons living in streets that are improperly swept or watered are unable to open the doors or windows of their houses with impunity by reason of the dust. The definition of the word _street_, as given in the Public Health Act, 1875, is as follows:--"Street includes any highway (not being a turnpike road), and any public bridge (not being a county bridge), and any road, lane, footway, square, court, alley, or passage, whether a thoroughfare or not." With reference to turnpike roads the Act further states that any Urban Authority may by agreement with the Trustees of any turnpike road, or with the Surveyor of any county bridge, take on themselves the maintenance, repair, cleansing, or watering of such street or road. It is very questionable, however, whether the onus of cleansing private courts and alleys which are not repairable by the Urban Authority should be borne by them, although for the sake of the public health it is highly desirable that such work should be so undertaken. The great difficulty attached to this duty arises from the fact that as a rule these private courts and alleys are very badly paved, if paved at all, full of pits, where pools of stagnant mud and water collect, and even in the best cases, the interstices between the pebbles, or other paving, are filled with filth arising in great measure from the dirty habits of the people, and this filth it is found exceedingly difficult to dislodge. The remedy for this is to compel the owners of the abutting properties to have the courts and alleys properly paved with asphalte, or other equally impervious material, after which it would be easy for the Urban Authority to cause them to be swept at least once a day, and flushed with water in the hot weather once a week, but in order to compel the owners to execute this very desirable work it would be necessary to put the complicated machinery of section 150 of the Public Health Act, 1875, in force, and the expense to the landlords would be in many cases very disproportionate to the value of their property. Out of the ninety towns to which reference has before been made, the authorities of only nineteen of them cleanse the private courts and alleys in their jurisdiction. The sweeping and cleansing of streets should be effected either at night or very early in the morning; if, however, the bad practice of bringing the house refuse out into the streets in inappropriate receptacles is in vogue, it becomes necessary to sweep the street later in the day, after the contents of these receptacles has been removed. In most cases it is necessary to cleanse the principal streets of a town at least once a day, and this appears to be the practice of nearly all the ninety towns referred to, but only seven of them appear to have this operation repeated more frequently; in several cases, however, the horse droppings, &c., are removed at once, under what is called the "orderly" system, and this is especially necessary in streets that are paved with such materials as wood paving, asphalte, or granite setts. The suburban streets of a town need only be cleansed once or twice a week, except in special cases of extremes of mud or snow. It is important, however, that the gully pits in all parts of the town should be cleared out constantly, and men should be employed for this purpose, as well as to cleanse and disinfect all the cabstands and public urinals at least once every day. Street cleansing is effected either by hand-sweeping and hand-scraping, or by machinery. As to which is the most economical much depends upon the value of labour, and also upon the condition of the roads to be dealt with, but in point of time and as a general rule the value of a horse rotary brush-sweeping machine is undoubted, the only time at which such a machine fails to do effective work is on the occasions when the mud to be removed (owing to a peculiar condition of the atmosphere), has attained a semi-solidity, and is of a stiff and sticky consistency, when it either adheres to and clogs the brushes of the machine, or is flattened by them on to the road instead of being removed. The simplest and best of these machines, in my opinion, is that manufactured by Messrs. Smith & Sons, of Barnard Castle. It sweeps a clear width of six feet, the rotary brush, which is divided into four or more parts, works diagonally, it is drawn easily by one horse, clearing itself of mud or dust in its progress, and the makers say that it can sweep 15,000 square yards of road surface in one hour, this being equivalent to the ordinary work of about 50 men in the same time! The price of this machine is £30, and being of very simple construction it costs little or nothing in repairs, except for the brushes, which last for about 180 hours when in constant work. These can, however, be replaced at a cost of £2 15s. per set, or the old stocks can be refilled with bass, at a more moderate figure. It is, of course, necessary to sweep the ridge of dust or mud which is left by the machine at the side of the street into heaps by hand labour, and to remove it by carts; other machines have been invented for cleansing streets, which by means of elevators, or other gear, profess to raise the mud or dust direct into the carts, which are to be attached at the back of the machine, but hitherto these machines have been found to be too cumbersome, costly, and complicated for the purpose, and they have not consequently found much favour with Sanitary Authorities. Messrs. Smith & Sons also construct a patent road scraping machine, which is drawn by one horse, and which will, they say, scrape upwards of 10,000 square yards of road surface in an hour. The strength and durability of the hand brooms purchased by an Urban Authority for the work of sweeping the streets is of some importance, as affecting the ultimate cost of the work, and some care and skill is required in their selection. Bass brooms are better than birch brooms for this purpose, and the bass of which the brooms are made should be sufficiently stout and of regular thickness; it should be tough and elastic, not old, dry, and brittle, each knot should be of uniform size and be firmly set, and the number of knots in each broom head is also a matter of choice. A convenient and fair test of the soundness of a broom is to soak it for a few days in water before issuing it to the sweeper, and then note the time it will last. The handles of the brooms should be made of alder wood. The mode of construction of streets, and the materials of which they are formed, makes a considerable difference in the amount of cleansing necessary, and upon the quantity of mud or dust that has to be removed from their surface. In making any investigations for the purpose of deciding what difference exists in the question of cleansing various forms and descriptions of pavements, climatic influence introduces a rather disturbing element, which may seriously affect any conclusions that may be drawn; it may, however, be taken for granted that a street, the surface of which is metalled on the macadam principle with stones of a soft or gritty character, will require more cleansing and be more costly to scavenge (under the same conditions of climate and traffic), than a street paved with the hardest granite setts or with blocks of wood, or with asphalte, and at the same time much care will have to be taken not to _over_ sweep or _over_ scrape a road with a macadamised surface, or much injury will be done to it. Amongst the influences that disturb the results of any investigations made with respect to street cleansing, that of the amount and character of the traffic over it must not be lost sight of, and the state of repair and gradient of the street are both of considerable importance in affecting the results, the practice too, of bringing out the house refuse into the streets in improper receptacles pending the arrival of the scavengers' cart, must also cause a varying amount of refuse to be swept from its surface, depending upon the habits of the persons living in the street. The Superintendent of the Scavenging Department at Liverpool has made some observations and obtained some valuable information on these points, which he has detailed in a report he presented to the Health Committee of that borough in the year 1877, an abstract of which is as follows:-- GROSS COST FOR EACH TIME OF CLEANSING 10,000 YARDS SUPERFICIAL OF DIFFERENT DESCRIPTIONS OF ROADWAY IN THE BOROUGH OF LIVERPOOL. [Part 1 of 2] +----------------+-------------------+-----------------+---------+ | | | | | | | | |Condition| | | | |of repair| | Street. | Description of | When paved. | of | | | pavement. | |roadway. | | | | | | +----------------+-------------------+-----------------+---------+ | | | | | |Lord St. |{ Granite setts, }| 1877 |Very good| | |{ asphalte joints }| | | | | | | | |North John St. | Ditto | 1872 | Good | | | | | | |Tithebarn St. |{ Granite setts, }| 1872 and 1874 | Bad | | |{ ordinary joints }| | | | | | | | |West Derby Rd. |{ Ditto, asphalte }| 1876 |Very good| | |{ joints }| | | | | | | | |Great Howard St.| Ditto | 1877 | Good | | | | | | |Great Homer St. |{ Ditto, ordinary }|Not ascertainable|Moderate | | |{ joints }| | | | | | | | |Kensington St. |{ Macadam breasted}| Ditto | Good | | |{ with setts }| | | | | | | | |Stanley Rd. | Ditto | Ditto | Bad | +----------------+-------------------+-----------------+---------+ [Part 2 of 2] +----------------+--------------+-------+--------+--------------+ | | | | | Gross cost | | | Area | Loads | Times | per 10,000 | | | of |removed| swept | yards | | Street. | carriage- |in one | in one | superficial | | | way. | month.| month. | for each | | | | | | cleansing. | +----------------+--------------+-------+--------+--------------+ | | Yds. supr. | | | £ s. d. | |Lord St. | 4,503 | 15 | 26 | 0 6 5½ | | | | | | | | | | | | | |North John St. | 3,287 | 17½ | 26 | 0 8 10½ | | | | | | | |Tithebarn St. | 5,150 | 38 | 26 | 0 11 2 | | | | | | | | | | | | | |West Derby Rd. | 11,980 | 35 | 13 | 0 9 4¾ | | | | | | | | | | | | | |Great Howard St.| 16,860 | 85 | 13 | 0 14 4½ | | | | | | | |Great Homer St. | 15,900 | 85 | 13 | 0 14 1 | | | | | | | | | | | | | |Kensington St. | 14,540 | 76 | 13 | 0 14 3¾ | | | | | | | | | | | | | |Stanley Rd. | 16,534 | 186 | 13 | 1 8 9¼ | +----------------+--------------+-------+--------+--------------+ He adds that the full benefit of the impervious pavements as regards the cost of scavenging has not yet been felt, for almost all the lines of streets so paved are intersected at short distances by streets of ordinary jointed granite setts or macadam, whence a quantity of mud and refuse is dragged by the traffic on to the asphalted jointed roadways, which are consequently debited with the cost of removal of some effete material not intrinsically belonging to them. He further adds that the credit reductions to be made in respect of the value of manure obtained from each description of carriageway is not readily ascertainable. In dry weather the value of manure collected from granite setts, with or without impervious joints, is about equal, but when the sweepings are wet, and consequently of little value for sale, the quantity yielded by the ordinary pervious jointed pavement is greater than from the impervious, and therefore the total value is relatively favourable to the latter class, whilst to get rid of the sweepings from macadamised streets is a source of additional expense. He concludes this portion of his valuable report by observing that the advantages of the new impervious pavements over the old kinds are especially shown after frost and snowfall, the results of which cause the setts of ordinarily jointed roadways to become loose, and allow a vast amount of mud to ooze up between the softened joints. The comparison is still more apparent in regard to macadam, which, unless a heavy rainfall succeeds the thaw, cannot be swept for some days without great destruction being caused to the metalling of the roadway. The ultimate disposal of the material removed from the surface of a macadamised roadway, being principally composed of silicate, and consequently valueless as a manure, is a difficult matter. In small towns, except during abnormally muddy weather, it may be mixed with the house refuse and sold to farmers, or the road scrapings themselves may be used as an excellent sand, if thoroughly washed, to mix with lime or cement to form mortar for public works; excessive accumulations of mud, however, must be got rid of in the most economical and speedy manner, and this is effected either by filling up old disused quarries with it, or depositing it upon waste lands, or forming embankments for new roads, but in no case should it be used, as I have before stated, upon building sites; it is difficult and expensive to destroy it or partially convert it into other matters by fire, so that if these methods which I have enumerated are impracticable, the only other method left for the disposal of the sweepings or scrapings from the streets is to take them out to sea in hopper barges and sink them in deep water. In the City of Paris an area of about 13,000,000 square yards of streets are cleansed between three and six a.m. in the summer months and four and seven in the winter. This work in connection with the collection of the house refuse employs 2,200 men, 950 women, and 30 boys, besides 190 mechanical sweepers. The Paris mud is said to no longer possess the manurial strength of former times, and in consequence the receipts derived by the municipality from this source have greatly diminished. At the present time it is disposed of by public tender to responsible contractors, who manage to take between them some 2,500 cubic yards daily. The following additional particulars of the manner in which this work is carried out in Paris will, I think, prove of interest, especially with regard to the use of disinfectants, which are largely used in that city in connection with the cleansing of the streets, a practice which might be followed with advantage by the Sanitary Authorities of this country. The cleansing of the public thoroughfares in Paris, which was formerly undertaken by the Prefect of Police, is now a function of the Prefect of the Seine. The staff consists of two chief engineers, one for each group of arrondissements, one group being sub-divided into three sections, each under the charge of an executive engineer, and the other into five sections similarly supervised. These sectional engineers have under them 51 superintendents and 61 overseers, whose employment costs annually £10,400. The scavenging plant is kept in a central depôt, where materials of every description are stored and classified for ordinary and extraordinary service, when snow and ice render additional assistants necessary. The depôts contain supplies of chloride of lime, sulphate of zinc, sulphate of iron, and carbolic acid, as disinfectants; and hydrochloric acid and nitrobenzide, as cleansing agents. The chloride of lime, of a strength of 100° to 105°, is successfully employed for the disinfecting of places tainted with urine or faecal matter, also for cleansing gutters carrying any sewage water. Sulphate of iron and sulphate of zinc are both used under the same conditions. Sulphate of iron has the disadvantage of rusting objects to which it is applied, sulphate of zinc is stronger in its action, but it costs a little more; it produces no smell, nor does it leave any stain; it is much employed in summer for washing and watering the basements of the "Halles Centrales," which are used for fish, poultry, and offal. At a strength of one-eighth, and mixed with three per cent. of sulphate of copper, sulphate of zinc makes a good disinfecting liquor, which preserves its qualities a long time, and is of great use in private houses. Carbolic acid is not, strictly speaking, a disinfectant; it does not act like chloride on putrid matter, but it arrests and prevents fermentation, doubtless by destroying the spores, it is, therefore, always employed when it is desired to destroy the germs of putrid fermentation. It is used at a strength of about one-fortieth, say a gallon of acid to 40 gallons of water. At strengths of one-one hundredth and one-two hundredth it gives good results for watering once or twice a week in summer those parts of the "Halles Centrales" liable to infection; it is even used as low as one-one thousandth for watering streets and gutters. Hydrochloric acid is applied to urinals and slaughter-houses, in places much encrusted with tartar; it is used at a strength of one-sixth, lowered to one-tenth, it cleans smooth walls and flags efficiently, in ordinary rinsings a strength of one-fifteenth suffices; it leaves a disagreeable odour behind, which is, however, quickly dissipated. Nitrobenzide is more energetic than the foregoing, but it produces a disagreeable smell of bitter almonds and leaves a white film, which has to be washed off; it is used at the same strengths as hydrochloric acid. The annual cost for plant and disinfecting materials of all descriptions is £8,800. CHAPTER VIII. "SNOW." The unthinking ratepayer frequently exclaims, "Why cannot the authorities order this abominable snow to be immediately carted away?" when the footpath and roadway in front of his domicile lie hidden under a thick coating of snow crystals. Signor E. Bignami Sormani, assisted by Professor Clericetti, have made several most interesting investigations and observations upon the density of fresh fallen snow in Milan by means of a simple balance and compressing box. The range of weight of the snow was found to vary as much as eleven times the minimum. A cubic yard from one snowstorm, weighing as much as 814 pounds, while an equal bulk from another fall only weighed 71 pounds. The weight consequently of a cubic foot of the densest snow is 30.14 pounds, whilst a cubic foot of water weighs 62.5 pounds, or only about double the weight of this dense snow, but which was in all probability little different from ice. For my purposes, however, I will take a mean between these extreme weights, and assume that the weight of a cubic foot of snow is 16.38 pounds, and that a fall of three inches of snow during the night has caused the ejaculation with which I commenced this chapter to proceed from the aforesaid ratepayer. The ordinary width of an English street may be taken at thirty-six feet, including the footpaths, so that on every one hundred yards in length of every street of that width 2,700 cubic feet of snow have fallen, the total weight of which amounts to 44,226 pounds, or very nearly 20 tons, which in actual bulk would represent 100 cubic yards. But as the snow would soon become compressed after falling, I assume that this bulk would be diminished by one-half, and that consequently (without reckoning the snow which has fallen upon roofs and into courts, passages, and alleys, and which has been quickly shovelled therefrom to the street by the occupiers) about 40 ordinary cartloads, weighing half a ton each, would have to be removed from this length of street. Assuming that there are 30 miles of street in a town from which the snow must be _immediately_ removed, 21,144 loads must be carted somewhere, at a cost of at least £1,500, assuming that each cart could make ten trips a day, and even then it would take 352 carts a whole week to effect it. It may be contended that I have taken an extreme case, and that, of course, the snow does not lie for very long upon the ground in the condition in which it fell, and that hourly it is reducing in bulk and weight by being ground up by the traffic, and finding its way in the form of water into the sewers, but I have simply advanced the few facts which I have stated in order to give some idea of the labour and cost of snow clearing in a city or town, and I think I cannot do better than at once describe how this important work is carried out in the city of Milan, where the organization and arrangements by which it is accomplished with marvellous despatch, and efficiency, could with advantage be copied by the authorities of any of our towns which are occasionally visited by excessive falls of snow. In Milan the snow carts are emptied into the navigable canals and numerous watercourses by which the city is intersected; and latterly also into the new sewers in the central portion of the city, which are promptly flushed whenever it snows. During the winter of 1879-80 the cost of clearing the 1,656,200 square yards total area of squares, streets, and lanes within the city walls, averaged £200 per inch depth of snow fallen, and for the 502,800 square yards outside the walls the average cost was £62 per inch depth, equivalent in each case to about 1.05d. per cubic yard. Ordinarily the clearing of the more frequented streets is completed within eight or ten hours after it has stopped snowing; and of the rest within 24 hours, not reckoning night. The city is parcelled out into small districts, numbering 112 for last winter, of varying extent according to the importance of the work in each. An average rate of pay per inch depth of snow fallen is settled for the whole area of each separate district, according to its extent and the particular conditions affecting the several streets and squares comprised within it. Each district is allotted to a contractor, who usually associates with himself six to ten partners, besides the labourers whom he employs. He has to find carts, horses, and carters; the necessary implements--spades, shovels, brooms, scrapers, mattocks, barrows, &c.--are furnished by the city, under suitable stipulations for ensuring proper care in their use. The contracts are made annually, and the same persons almost always apply for them again year after year. The contractors come principally from the trades that are interrupted by winter, viz.:--Paviors, bricklayers and masons, and gravel quarrymen. For the direction and supervision of the work the whole city is divided into four sections, over each of which is appointed an engineer, with an assistant, who are aided in the general arrangements by the police surveillance. Payment is made only for work effectually done. In each snowstorm the depth of snow falling, which is the basis of pay, is ascertained by means of a number of stone posts, fixed in suitable open spaces, clear of shelter from buildings, and each capped with a flat horizontal slab of stone. As soon as it stops snowing, or two or three times during a storm of several hours, the depth of snow caught on the slabs is measured by the engineer in the presence of two of the contractors in his section. The number of men ordinarily engaged in snow clearing on a winter's day is not less than two thousand, and has sometimes risen to three thousand. The stock of implements found by the city, representing a capital of about £1,600, is housed in two stores in opposite quarters of the city. In the winter of 1874-75 the total fall of snow amounted to 40¾ inches, and the whole expenditure for clearing it within the city walls exceeded £8,400; while in 1877-78 the fall was only 5¼ inches, involving an expenditure of less than £1,040 for a slightly larger area. The small cost at which this work is carried out in Milan is accounted for by the low rate of wages and cart hire, and the perfect organization of the system. When a fall of snow occurs in Paris, attention is first directed to clearing the footpaths and crossings, so as to ensure uninterrupted foot passenger traffic. The town scavengers sand the roads whenever it is necessary for the carriage traffic, at the same time numerous auxiliaries are organised to remove the snow from the principal thoroughfares in the order of their relative importance. To assist in removing the snow the General Omnibus Company are bound by their concession to furnish 50 waggons, and carts are specially arranged for with the providers of sand and gravel at the beginning of winter, the contractors for maintaining the public roads being also bound to hold their carts at the disposition of the sectional engineers. In certain cases the half-melted snow is swept into the sewers, especially into those carrying warm water. Melting by steam has been tried, when a continuous jet was turned on to a mass of banked snow, but it melted very slowly at first, and the melting ceased after the cavity had increased to a certain size. Two descriptions of snow ploughs are kept in store, one for manual, the other for horse power, but they have never been used, as the coating of snow seldom attains sufficient thickness, and it is too quickly compressed and hardened by the traffic. As a rule, the sum allowed in the budget, about £7,000, suffices for the extra labour incurred, but occasionally severe winters cause this to be greatly exceeded, as in 1875-76, when the increase amounted to £8,000, and no doubt in the winter that has just passed, 1880-81, the estimate must also have been largely exceeded. In England one of the greatest difficulties we have to contend against is the disposal of the snow after it has been placed in the cart. If there is a river close by, it can be taken there and tipped, but this is objectionable if it is a navigable river where dredging has to be done, as it is surprising what a quantity of road scrapings and other matters are always removed with the snow, and these materials naturally sink to the bottom, and add considerably to the cost of dredging. If there are public parks the snow may be heaped in them, provided no damage is done to the grass or paths, as the snow thus heaped takes a considerable time to melt, the first effect of a thaw being to consolidate it, but a better plan is to deposit it upon any waste spots, if these are not too far from the streets which have to be cleared. Tipping the snow down the manholes into the sewers has been tried in London and other cities, but has failed through the snow consolidating, and although lighted gas jets have been turned on to the snow, it has still melted too slowly to be of any practical utility. It has been suggested that a steam jet should be turned on the snow as it lies in the streets, or after it has been heaped, but I very much doubt the efficacy of this plan, although Messrs. Merryweather & Co., of London, have, I understand, melted a cartload of snow in seven minutes. It might, however, be possible to melt the snow by the heat generated in the furnaces that are destroying the house refuse by fire, and this could be effected without any large expense beyond the cost of cartage of the snow to the depôts, which would, of course, be necessary. Failing an organization such as that of Milan, the following suggestions may be of use to those who have sometimes to grapple with this unproductive work:-- Do not attempt to cart away the snow while it is yet falling, but try to make clear crossings for the foot passengers and to keep the traffic open. If there should be a high wind at the time, and the snow drifts in consequence, cut through the drifts so as to allow the vehicular traffic to continue. Directly the snow ceases to fall put on all available hands to clear the channel gutters and street gratings, in preparation for a sudden thaw, when, if these precautions were not taken, serious flooding and great damage to property might ensue; for the same reason cart away all the snow you can at the bottom of gradients and in the valleys, and also from very narrow streets and passages, &c. In the wider streets use the snow plough, or with gangs of men (in the snow season there is generally plenty of labour obtainable), shovel the snow into a long narrow heap on each side of the street, taking care to leave the channel gutters and gratings quite clear, and a sufficient space between the heaps for at least two lines of traffic. Passages must also be cut at frequent intervals through the heaps, in order to allow foot passengers to cross the street, and also to let the water reach the channel gutters as soon as the snow begins to melt. With regard to the question of clearing the snow from the footpaths irrespective of the larger duty of clearing it from the streets, it is often a disputed point in a town as to whether this should be done by the Urban Authority at the expense of the rates, or by the householders themselves, and this can only be settled where the town has a private improvement act, in which a clause or clauses may be inserted throwing the onus of such cleansing and sweeping of the footpaths upon the several and respective occupiers of houses and buildings. But on whoever the duty rests there is no doubt that the easiest and quickest method of effecting a thorough cleansing of a footpath from snow is by an application of salt, and then to sweep off the slush that is engendered with a broom. Medical men and others, however, assert that the practice of putting salt with the snow is to make a freezing mixture, which is detrimental to the health of persons walking on such a mixture, and there can be no doubt that excessive cold is caused by this practice, often sufficiently severe to crack the flagstones of the foot pavement. In the City of London the footways are swept once daily by men in the employment of the Commissioners of Sewers, and in wet weather those in the main streets are cleansed repeatedly during the day, and this has been done, I believe, since the year 1872, although the occupiers are legally liable for the execution of this work. In Liverpool, also, this is done after a fall of snow, as will appear from the following interesting remarks on the subject, contained in a report by the Superintendent of the Scavenging Department in that borough:-- "The only way to compass the removal of snow from the footwalks of the principal thoroughfares within a comparatively short time is by sprinkling them with salt such as is commonly used for agricultural purposes. It is certain that, unaided by the salt, a sufficient number of men cannot be procured for the emergency of clearing snow from the footways of the most important thoroughfares. It has been stated by medical authorities that the application of salt to snow is detrimental to the health of people who have to walk through the 'slush' produced by the mixture, and that the excessive cooling of the air surrounding the places where the application has been made is injurious to delicate persons. It, therefore, seems that the application of salt to snow should not be undertaken during the day time, but should be commenced not before 11 p.m., nor continued after 6 a.m., and that only such an area of footwalks should be so treated on any one night as the available staff of men can clear by an early hour the following morning. "To sweep snow from the footwalks whilst the fall of snow continues, and especially during business hours, appears to be wasteful and futile, and to apply salt during the same periods may be held to be injurious to health. "That the snow of an ordinary fall can be removed from the footwalks by an application of salt an hour or so before they are scraped is an ascertained fact, except at least when a moderately severe frost has preceded, accompanied, or followed the snow fall, or when the snow has drifted into extensive accumulations. Were it not for the danger to health by excessive cooling of the air, and for the expense attending the operation, all the impervious pavements could be cleared of snow (unless the fall was a heavy one) in a comparatively short time by a liberal application of salt and the employment of the horse sweeping machines as soon as the snow had become sufficiently softened to admit of their use." To these remarks I have nothing to add, except to suggest that in addition to clearing the snow from the footpaths care should also be taken to scrape out and thoroughly clear the roof water trunks, which are frequently found crossing the footpavements; if these remain choked damage may ensue to the adjoining property when a thaw commences. CHAPTER IX. "STREET WATERING." The effective watering of streets and roads in any town during the summer months is an important matter, not only on sanitary grounds, but also from the fact that considerable damage may be caused in the neighbouring shops, warehouses, and dwellings, if something is not done to prevent the clouds of detritus and decaying refuse, of which the dust is composed, from being blown about. In the metropolis of London alone, the watering of the streets and roads employs, in addition to a staff of surveyors, inspectors, and foremen, about 1,500 men, and an equal number of horses and carts; and in order to lay the dust effectually, about 30,000 tons of water must be spread upon the streets every dry day, the cost of this gigantic work being nearly £200,000 per annum upon an average of 120 days, when watering becomes necessary. The most commonly known method in this country for watering the streets and roads of our towns is that of carrying the water in wheeled barrels, carts, or vans, and distributing it therefrom through a perforated pipe upon the surface of the road as the vehicle is drawn along by a horse attached to the shafts. The points of importance to be considered under this system are as follows:-- (1.) The number and position of the stand posts or hydrants, from which the water carts are to be filled, and whether they shall be "swan neck" stand posts or "valve" hydrants. (2.) The size and form of the body of the water carts, as regards its cubical capacity, its weight, strength, lightness of draught, durability, width of spread, and shape of jet, so as to ensure evenness of supply without leaving pools of water or dry patches after it has passed, or causing that unpleasant cloud of dust which so often follows the cart. A wonderful improvement in all these respects has been lately effected by the introduction of Mr. E. H. Bayley's Patent Hydrostatic Van, of which I shall speak more in detail hereafter. (3.) Another point of some importance is the material of which the hose shall be constructed, if valve hydrants and not swan necks are existing. My opinion is that it should be of leather, as being roughly handled and little cared for; canvass hose, although the cheapest, is not sufficiently durable, and is consequently the dearest in the end; and (4), lastly, the driver and horse should both be of some intelligence. A check should also, if possible, be kept upon the former to see that he performs his allotted task, and does his proper number of rounds. Mr. Bayley has also introduced for this purpose a "Tell Tale Indicator," which records automatically the quantity of water used; it cannot be tampered with, and registers on a dial outside the van each load of water delivered, so that the surveyor or other officer can see at a glance whether the driver is attending to his work, or whether the hot weather has made him find his throat drier than the roads, and he has been spending some of his time in moistening it. In the year 1856, Mr. Scott, C.E., the chief surveyor of the parish of St. Pancras, kept an account of the daily round of an ordinary water cart, when he found that through an average working day of 10¼ hours, exclusive of the breakfast and dinner hours, the cart took one hour and twenty minutes filling, fifty minutes only in distributing the water on the roads, and eight hours and seven minutes in travelling to spread the water and back to the stand posts. It was obvious that these were placed too far apart, and by the subsequent introduction of additional standposts Mr. Scott found, in the year 1867, that the filling occupied two hours, the distribution one hour and thirty minutes, and the travelling to and fro six hours and thirty minutes, so that it may be assumed, with an ordinary two-wheeled water cart, that two-thirds of the day is spent in travelling, one-fifth in filling, and about one-seventh in the actual spreading. To many of my readers Bayley's Van is probably as familiar as it is to me, but it may notwithstanding be well to describe it. It is a handsome vehicle in appearance, the body being made of wrought iron plates, and measures 8 ft. in length by 4 ft. 8 in. in breadth, and 2 ft. in depth, holding 450 gallons. It is mounted on springs upon four wheels hung upon Bayley's patent axles, and has a pair of light shafts; it can easily be fitted with a break for hilly roads, and there being no weight at any time upon the horse's back, he is relieved from any severe strains. By means of an adjustable valve the flow of water can be regulated according to the state of the roads, and, if necessary, a double valve can be inserted, so that either side of the distributor can be at work when only half the width is required, or when passing a carriage or narrow spaces. The branch pipe is of uniform size, except close to the spreader, where it enlarges in order to avoid friction, and this is assisted by the branch pipe being shaped into a cycloidal curve on each side. In order to obtain as great a pressure as possible upon the jets of the distributing pipe, and thus to give the side jets a greater trajectory than they otherwise would have, the tank is elevated as high as is consistent with the conditions of draught. At the same time, the distributing pipes are placed as near to the ground as convenient, so that the maximum extent of distribution is obtained, and that with less dust and splashing than in the ordinary system. The holes in the distributing pipe instead of being drilled in straight lines, are on a curved line, which rises along the length of the pipe from the centre towards the ends. This has been found necessary, in order that the distributing pipe may be placed low, and at the same time advantage be taken of the width of the trajectory of the jets. Comparing the work of one of these vans with that reported upon by Mr. Scott, it is found that the van occupies nine minutes in filling, six minutes in spreading the water, and only three hours and fifteen minutes in travelling to and fro, so that in seven hours it accomplishes as much work as the ordinary water cart effects in ten hours. In Edinburgh, where a trial of one of these vans took place against one of the old carts, it was found that the van spread the water a width of 20 feet, while the old cart only covered 14 feet; the van conveyed the water 1,731 feet, and the cart only 951 feet. The superficial area watered by one load of the van was 34,620 feet, and by the old system only 13,314 feet. When we consider the time that is lost in travelling to and from the stand pipe, what a large saving this represents in the cost of this work. Mr. Tomkins, C.E., the surveyor of the important Metropolitan parish of St. George, Hanover Square, has made the following comparative experiments with one of Bayley's vans as against an ordinary cart:-- +-----------+--------+--------+---------+----------+-----------+------+ | |Contents| No. of | Total | | | Gain | | | in |Loads to|quantity | Time. |Difference.| per | | |Gallons.| cover |of Water.| | | Cent.| | | | beat. | | | | | +-----------+--------+--------+---------+----------+-----------+------+ | | | | |Hrs. Mnts.| Hrs. Mnts.| | |Van | 450 | 5½ | 2475 | 1 23 | -- | -- | |No. 4 Cart | 225 | 11 | 2475 | 1 50 | 0 27 | 24½ | | | | | | | | | |Van | 450 | 5½ | 2475 | 1 38 | -- | -- | |No. 9 Cart | 237 | 11 | 2607 | 2 10 | 0 32 | 25 | | | | | | | | | |Van | 450 | 6 | 2700 | 1 45 | -- | -- | |No. 15 Cart| 290 | 11 | 3190 | 2 10 | 0 25 | 19¼ | | | | | | | | | |Van | 450 | 8 | 3600 | 2 15 | -- | -- | |No. 19 Cart| 260 | 17 | 4420 | 3 30 | 1 15 | 36 | +-----------+--------+--------+---------+----------+-----------+------+ This shows a mean gain of 26 per cent. in favour of the van, and the following tables made by an inspector in 1873, showing the actual occupation of the ordinary carts and Bayley's vans during a day's work, are extremely interesting, as showing that while the van is engaged in spreading the water the time of the cart is wasted in travelling to and from the stand posts, and when it is borne in mind also that the van spreads water more widely than the cart, there can be no doubt that a saving of at least 30 per cent. can be effected by the substitution of these vans for the old-fashioned cart. CARTS. +--------------+--------+----------+----------+------------+----------+ | | |Travelling|Travelling| | | | |Filling.| Full. | Empty. |Waiting, &c.|SPREADING.| +--------------+--------+----------+----------+------------+----------+ | | H. M. | H. M. | H. M. | H. M. | H. M. | | Paddington | 1 45 | 2 9 | 1 58 | 0 20 | 1 30 | | St. Saviour's| 1 29 | 2 16 | 2 4 | 0 26 | 1 29 | | Strand | 1 11 | 2 30 | 2 18 | 0 17 | 1 3 | | Kensington | 4 40 | 2 2 | 1 57 | 0 0 | 1 54 | | Chelsea | 2 44 | 1 15 | 2 14 | 0 35 | 1 6 | +--------------+--------+----------+----------+------------+----------+ VANS. +--------------+--------+----------+----------+------------+----------+ | Paddington | 3 33 | 1 9 | 1 3 | 0 0 | 3 0 | | St. Saviour's| 2 20 | 1 4 | 1 21 | 0 23 | 2 58 | | Strand | 2 30 | 1 25 | 1 14 | 0 20 | 2 23 | +--------------+--------+----------+----------+------------+----------+ One of the earliest methods for watering streets, but one which has, I think, almost entirely died out on account principally of the large quantity of water used in the process, was that of allowing the water to run down the channel gutters, ponding it back by means of canvass or leather aprons placed across the gutter, and then spreading the water on to the surface of the street by throwing it with wooden shovels. This method, although at first sight may appear clumsy, is an exceedingly good one upon sanitary grounds. It not only lays the dust, but it washes the surface of the streets, and it most effectually scours out the gutters and at the same time flushes the sewers, which at the season that watering is necessary is also of great importance to any town. By this process a delightful freshness is given to the air, and the appearance of the cool and limpid water rushing along on each side of the street acts favorably upon the inhabitants. The great objections to this system are the enormous quantity of water that is used in the process, and the difficulty of doing the work after the traffic of the day has commenced. Somewhat of a modification of this process is what is known as "Brown's System of Street Watering," which may be described as follows:--A lead pipe is laid in the footpath at the back of the kerb on each side of the street to be watered, small gratings or shields being fixed in the pipe at intervals of twelve inches, and the remaining space filled with asphalte; small holes are then bored in the pipe through the openings in the shields. The pipe is connected with the water main in the street, and is provided with the necessary stopcocks, &c. On the water being turned on, fine jets are thrown in different directions upon the surface of the street. The width of roadway that can be watered by this process depends upon the pressure of the water, but it may be fairly assumed that in most towns streets of fifty feet width could be effectually watered in a few minutes by a pipe on each side of the street. This process has not gained much favour hitherto, principally on account of the large first cost involved, which would amount to upwards of £800 per mile of street, but the expense afterwards should not much exceed the wages of one man at about 3s. 6d. per day to manipulate the necessary work, and the interest on the outlay and depreciation of the pipes, &c. The other objections to this system are:-- (1.) The liability of the pipes and perforations to get out of order, especially when allowed to lie idle for so many months in each year. (2.) The unpleasantness to pedestrians which must be caused whilst the watering is proceeding. (3.) The inconvenience to the traffic during the process. (4.) The effect upon the water by high winds, when in all probability it would be blown back across the foot pavements. (5.) In very broad streets it would be inoperative. In Paris and other continental cities, and also in several towns in this country, the watering is effected by hose and reels, or by portable iron tubes. Mr. Parry, C.E., the borough surveyor of Reading, has given the following particulars of the system of hand watering adopted in that borough, in which he gives the cost, and describes the utility of that method as compared with the use of water carts:-- A water cart (he states) will water twice a day a superficial area of 23,849 yards, and for a length watered one width that means 5,962 lineal yards, or for a double width 2,981 yards, the cost per day of laying on being as follows:--Horse, cart, and man, 8s.; cost of maintenance of cart, harness, shoeing, &c., 1s. 5d., making 9s. 5d. per day. With respect to the hand machines he states that he has one of Headley's drum machines, and three of special make, somewhat similar to those used in Paris. They are equal in point of work; and one machine will water 23,740 square yards twice a day, which, it will be observed, is very close to the amount of work performed by a cart. "Headley's machine cost us (he continues), five years ago when new, £31 7s. 3d., and the repairs and maintenance since that date have been £22, or an average of £4 8s. per annum, and is just now almost past repair. The other description of hand machine cost each when new £20, and the repairs and maintenance have amounted to an average of £3 18s. each year. They were in use sometime before Headley's was obtained, and they will be of use for a long time yet. The cost of labour per day by the hand machines is for two men at 2s. 10d. each--5s. 8d.--as it requires two men to work the machine properly, one to distribute the water, and the other to move the machine and to attach and detach the apparatus to and from the hydrants; add to this 7d. per day for maintenance and repairs, will make 6s. 3d. per day. The quantity of water delivered by the water carts is 0.51 gallon per square yard, and by the hand machine 1.30 gallons." It will thus be seen that in the case of the cart 24,324 gallons of water are used per diem, and 61,724 gallons by the hand machines, the surface watered being very nearly the same in both cases. Assuming that the water has a commercial value of 6d. per 1,000 gallons, and adding this to the cost per diem in each case, the total cost stands thus:-- Hand machines £1 10s. 10d. Carts £1 1s. 7d. the advantage in point of cost being in favour of the carts, but the hand machine may water better, especially in broad streets, although in narrow streets or where there is much traffic, this method would be impracticable. In Paris both hose and carts are used for watering the thoroughfares, the former for the boulevards, the avenues, and a certain number of first-class streets. The watering plant belongs to the municipality, and they have various forms of carts, containing 220, 242 and 286 gallons respectively, and will water from 2,400 to 3,350 square yards. The watering by hose is attended to by the ordinary street cleaners, who can easily water 24,000 square yards in about thirty-five minutes, deducting the time necessary to connect the apparatus with the mains, but this requires a gymnastic performance, which, if once seen, is not easily forgotten. Watering the streets with sea water should be adopted whenever it is feasible, as it not only gives a delightful freshness to the air and dispels iodine, but it also causes the surface of the street to maintain its humidity for a longer period than when fresh water is used, as it impregnates the soil with hygrometric matter. This has been often attempted artificially, not only by adding common salt to the water used for watering, but also by adding chloride of calcium, notably in Rouen, where this material is obtained from the manufactories of pyroligenous acid in the neighbourhood. It is stated that on a mile of road, 16 feet in width, 5,630 gallons of water were necessary daily, but that the same result was attained with 1,480 gallons of chloride solution, marking 30° Beaumé, and costing about ½d. per gallon, the humectation remaining good for five or six days with the solution of chloride. With water only in 1,093 yards, in four rounds daily, 3,520 gallons were used, the cost being 48s.; with chloride of calcium the cost was 32s. per day. Watering the roads with a largely diluted disinfectant, such as "Sanitas" in the liquid form, is frequently of great benefit, and where it can be afforded, it should be occasionally done, especially in the narrower streets and more crowded districts of a city or town. CHAPTER X. CONTRACTS _V._ ADMINISTRATION BY LOCAL AUTHORITY. Amongst the questions which I addressed to the surveyors of the principal towns of England was the following:--"Is the house refuse collected by the Sanitary Authority or by a Contractor?" and out of the ninety towns from which I received replies, only thirty were found to employ contractors for this purpose, and of these the authorities of two of them proposed to dispense with the services of the contractor, and to administrate the work with their own staff, as they found the existing state of things was thoroughly unsatisfactory. This is hardly to be wondered at when the nature of such contracts comes to be considered. The "dust" or "slopping" contractor, or whatever he may be designated, can hardly be expected to be a philanthropist, whose principal object in carrying out his contract is that of benefiting his fellow creatures and not himself; on the contrary, it may fairly be assumed that the contractor's object is to serve his own interests, and to make his contract pay. It is but natural, although the result may not be eminently satisfactory either to the ratepayers, who require a careful and systematic cleansing of their dustbins and streets, or to the Sanitary Authority and their officers who have to look after him. The officers, if they do their strict duty, will probably be engaged in constant disputes and litigation with the contractor as to the due and proper observance of the terms of his contract, and the consequence of their time being thus occupied instead of in other more important matters, is naturally detrimental to the interests of the ratepayers. If we turn to the articles of agreement or contract usually drawn up between a Sanitary Authority and a contractor for scavenging, we find that they are generally very binding in their phraseology, and enter fully into the details of the work; they should state very clearly the number of times in every week that the contractor shall cause all the ashpits in the districts enumerated to be emptied and cleansed, the manner in which this work shall be performed, and how the materials thus removed shall be disposed of and the place of their ultimate destination. The conditions should further specify what amount of manual, team labour, and carts, are necessary for the work, and also what plant the contractor must keep in the way of ladders, baskets, shovels, and brooms, &c. The conditions should also contain a carefully prepared list of the streets to be swept, and the manner and number of times this work must be executed, and arrange for the disposal of the materials thus removed. In many such contracts it is found necessary to insert clauses binding the contractor under all sorts of fearful penalties, to be always at the disposal and under the commands of the inspector of nuisances, or such other officer or officers as the Sanitary Authority may appoint. The contractor's men also are forbidden to refuse gratuities (an order which they no doubt fully carry out?) and are directed on no account to remove either trade or garden refuse, and they are also enjoined to be "careful to consult the convenience of the householders in their visits, and to thoroughly clean up all dirt and litter that they may cause in the discharge of their duties." If they fail in any or either of these injunctions and commands, or for any other dereliction of duty, the inspector of nuisances, or such other officer as the Sanitary Authority shall appoint, may summarily dismiss them, without any reference being made on the subject to their employer the contractor, and in fact the conditions have necessarily to be made so stringent and binding as to be either totally inoperative or open to grave abuses, or, on the other hand, the work can be carelessly and improperly executed by the contractor. I am, therefore, strongly of opinion that the work of the collection of house refuse and cleansing the streets should be carried out by the Local Authority with their own officers and staff, and that executing this work by contract is a mistake and a false economy. It is, perhaps, true that it may be done in the latter manner at less actual cost to the ratepayers, but all public work should be done in the best manner possible, irrespective of cost, thoroughly, but without extravagance, and the result of such work, especially where it affects the cleanliness and the appearance of a town, soon fully repays any moderate extra cost that may thus have been incurred, irrespective of the enormous benefit that is conferred upon any community by the reduction of disease and the death-rate by a proper attention to such necessary sanitary work. CHAPTER XI. "_£ s. d._" A question of the greatest importance to the ratepayers, and one in which they often take the most lively interest, is that of the cost of maintaining the necessary staff for the purpose of carrying out the scavenging of the town, or for paying the contracts for a similar work. It is, of course, not possible to lay down any hard and fast line as to the cost of scavenging in any city or town, as it must necessarily vary considerably according to circumstances; much depends upon whether the district to be scavenged is an urban one, consisting of houses closely packed together, or whether it is suburban, with scattered villas and mansions standing in their own grounds; the question, also, of the distance of the depôts to which the material has to be carted, considerably affects the result of any estimate, as also does the cost of horse hire, the rate of wages, and whether the district is of a hilly or flat nature, and, as I have before shown, the manner in which the streets are formed and paved, the habits of the people, and last, but not least, the manner of the eventual disposal of the rubbish after removal; all these points must bear with great weight upon any question of cost, and make the results widely different. On referring to the returns to which I have more than once alluded, it is found that the cost of removing the house refuse and cleansing and sweeping the streets combined, varies considerably in different localities, in one case the sum amounts only to the rate of one half-penny per annum per head of the population of the town, whereas in another case the amount is at the rate of three shillings and sixpence per head. On calculating the average cost per head of population per annum of the ninety towns from which I received replies on this point, I find that it amounts to about tenpence half-penny, after giving credit for any sum of money realised by the sale of the refuse to farmers and others; so that if this work is costing the ratepayers of a town or city anything under a shilling per head of the whole population every year they have no cause to grumble, as they are so frequently found to do that their rates are higher, and what they have to show for them less than any other town in England. I have discussed the question of "contracts" or "administration" in a former chapter, but there is still another question which is also closely connected and intermingled with the question of cost, and that is when the Sanitary Authority carry out the collection and removal of the house refuse and cleanse the streets with their own staff, whether it is better and more economical for them to keep their own stud of horses or to hire them. To do thorough justice to the work I am of opinion that both the horses and carts should be the property of the Sanitary Authority for the following reasons:-- (1.) The horses and their drivers should be under the control of the town surveyor or superintendent, in the same manner as the scavengers who accompany the cart. This is not the case if the horses are hired. (2.) The carts can be started on their rounds and leave work at such time as may be found most convenient, and all the horses being kept in one stable greatly facilitates this arrangement. (3.) The horses hired for this kind of service are frequently quite unfit to draw the bulky loads in the lofty carts behind them, and opprobrium is thrown upon the Sanitary Authority and the officials in consequence. (4.) Economy in working is secured, for not only will good horses properly kept do a much better day's work than bad ones ill kept, but there is no one making a profit out of them as is the case when the horses are hired. With regard to the question as to the comparative cost of scavenging where a stud of horses is kept and where they are hired, the figures that I am about to give can only be speculative, as the conditions of each town are so widely different, but the figures may serve as a guide for forming an estimate of the kind, and they may be altered to suit the requirements of any city or town. I will, therefore, assume that a town with a population of about 35,000 inhabitants will require at least seven scavengers' carts constantly at work, without reckoning those which will be required after a fall of snow or in exceptionally muddy weather, and for which purposes auxiliary horses and carts must be hired, as also those which are engaged in hauling stones and other materials used for roads or public works. I have already stated that the value of an ordinary dust cart is about £18, so I will retain that figure for my estimate. The value of a new set of cart harness, including a loin cloth, should not exceed £7. To work seven carts properly, eight horses will be required, which may be estimated to cost about £50 each. The first cost of the necessary stabling for eight horses, including purchase of land, erection of buildings with a foreman's house, corn and hay lofts and machinery and tools, may be reckoned at about £1,500. With regard to the wages to be paid to the scavengers and the carters, it may be reasonably assumed that their rate of wages may be much lower than that paid to navvies, or what are known as "pick and shovel" men, for the following reasons:-- In all house refuse there is always present a quantity of such materials as rags, bones, pieces of iron, and other articles, which have a commercial value, and behind each scavenger's cart hangs a sack, into which all such articles are placed by the men engaged in the removal of the house refuse, and are subsequently sold, and the spoil divided between them as perquisites. I have been credibly informed that in some localities the amount thus realised averages more than four shillings a week throughout the year. It is also a notable fact that although the householders are most particularly requested not to give gratuities to the men employed by the Sanitary Authority in this work, yet a considerable number of them constantly give the men a gratuity or bribe to ensure the dustbin being regularly and properly cleared, although the less generous, or poorer members of the community probably suffer in consequence; again at Christmas the scavenger feels himself entitled to demand and receive a handsome present in the form of a Christmas-box, which, in a rich neighbourhood, amounts in the aggregate to no inconsiderable sum. For these reasons I put the wages both of the scavenger and the carter at 16s. each per week, and adding a guinea a week for the foreman, who has in addition to this a house to live in rent free, and a stableman at 18s. a week, the total expenses are accounted for except those of the keep of the horses, shoeing, veterinary attendance, lighting the stable, &c. This also is a sum very difficult to estimate, as fodder, bedding, &c., varies so widely in different districts, but for the purposes of this calculation it may be estimated that 17s. per horse per week should be sufficient to cover all expenses under these heads. For the purposes of this calculation it will be necessary to assume that the £1,500 has been borrowed at 4½ per cent. in perpetuity, although as a matter of fact any monies borrowed for such a purpose as this would probably carry a sinking fund, so as to liberate the debt at the end of thirty or perhaps fifty years, but if I were to reckon the interest in this way in my estimate, it would complicate it unnecessarily. I have assumed that to meet the depreciation of horse flesh it will be necessary to put aside the value of one horse each year, without reckoning anything per contra for the sale of those worn out or injured in the work, as I think this will be found to be what would be necessary. I have allowed £50 per annum for repairs and depreciation of the buildings and machinery, as I consider this should be quite sufficient for a well-managed and cared-for property. I have allowed 15 per cent. per annum for repairs and depreciation of the harness, and 12 per cent. for the carts. The estimate will consequently stand thus:-- SPECIMEN ESTIMATE of the cost per annum involved by any Urban Sanitary Authority of a town of 35,000 inhabitants, in executing the work of collection of house refuse and the cleansing of streets, with their own staff of men and horses and carts. Annual Cost. £ s. d. Capital borrowed £1,500, yearly interest at 4½ per cent 67 10 0 Do. do. for 8 horses at £50 £400 Do. do. for 7 carts at £18 £126 Do. do. for 7 sets of harness at £7 £49 ---- £575 at 4½ per cent. 25 17 6 Repairs to buildings, machinery, &c. 50 0 0 Depreciation of horse flesh, say 50 0 0 Do. of 7 carts, costing £126, at 12 per cent. 15 2 2 Do. of 7 sets of harness, costing £49, at 15 per cent. 7 7 0 Wages of 7 carters at 16s. each per week 291 4 0 Do. of 7 scavengers at do. do. 291 4 0 Do. of 7 sweepers of roads at do. do. 291 4 0 Do. of 1 foreman at 21s. per week 54 12 0 Do. of 1 stablekeeper at 18s. do. 46 16 0 Keep, &c., of 8 horses at 17s. per week each 353 12 0 -------------- Total estimated cost £1,544 8 11 ============== If the foregoing estimate is compared with the standard of one shilling per head of the population per annum, which I have fixed as a fair average cost of such work, it is found to be less by £205 than that of a town of 35,000 inhabitants, for this latter case amounts to £1,750, and nothing has been allowed for the possible sale of the house refuse thus collected, but, on the other hand, I have allowed nothing for any emergency, such as a very rainy season or a deep fall of snow. If the horses and drivers had been hired the estimate might stand thus:-- Annual Cost. £ s. d. Hire of 7 horses and drivers at 8s. per diem for six days a week 873 12 0 Hire of 4 horses and drivers on Sunday, half-a-day each 41 12 0 Foreman to superintend (no free house rent as in former case) 65 0 0 Wages of scavengers as before 291 4 0 Do. of sweepers do. 291 4 0 -------------- £1,562 12 0 ============== This shows that the cost of hiring would be slightly in excess of that of keeping a stud of horses, and when we consider the unquestionable benefit to be derived by adopting this method, I think most Urban Authorities who are now hiring their team labour would do well to consider the question of purchasing and keeping their own stud. Great care, however, would have to be exercised in the supervision, or the expenditure would speedily increase, as in all stable establishments without such supervision, grave abuses, and even fraud, may go undetected for a considerable period. The figures that I have given in my estimates must not be criticised, for they are not intended to fix the value of such work, but simply to act as a guide to anyone interested in making an estimate of the kind, in which case prices more in accordance with the district could be inserted. The following table, however, gives the actual cost of collecting house refuse and cleansing and watering streets in fourteen large English towns:-- +-------------+----------------------+----------------------------+ | | Annual cost of col- | This amounts to the | | | lecting house refuse | following:-- | |Name of Town.| and cleansing and +--------------+-------------+ | | watering streets and | Per 1,000 of | Per mile of | | | courts. | population. | streets. | +-------------+----------------------+--------------+-------------+ | | £ | £ | £ | | Bedford | 900 | 45.0 | 45.9 | | Bristol | 13,005 | 63.1 | 108.3 | | Cambridge | 2,350 | 67.1 | 83.9 | | Cardiff | 5,545 | 65.2 | 95.6 | | Carlisle | 2,261 | 64.6 | 113.0 | | Exeter | 2,100 | 52.5 | 60.0 | | Gloucester | 1,478 | 36.9 | 49.3 | | Liverpool | 82,284 | 151.2 | 316.2 | | Northampton | 2,820 | 51.3 | 104.4 | | Oxford | 2,750 | 63.9 | 85.9 | | Portsmouth | 5,276 | 39.0 | 101.4 | | Southampton | 1,999 | 33.3 | 45.4 | | Southport | 4,077 | 119.9 | 97.0 | | Swansea | 4,200 | 60.0 | 76.3 | +-------------+----------------------+--------------+-------------+ _These figures are taken from a return prepared by Mr. Williams, C.E., Engineer to the Borough of Cardiff._ I have frequently referred to some returns which I have obtained on the subject of the collection of house refuse and cleansing of streets, and it may be interesting and of use to others who wish to obtain information on these subjects if before closing this book I give a list of the questions that were asked. They were as follows:-- (1.) Name of city or town. (2.) Number of inhabitants. (3.) Area of district scavenged. (4.) Is the house refuse collected by the Urban Authority. (5.) Or by a contractor. (6.) How often is the house refuse removed. (7.) Do the scavengers make a house to house call. (8.) Or do they give notice of their approach by ringing a bell or otherwise, and require the householder to bring out the refuse to the cart. (9.) Do the scavengers remove garden or trade refuse, and, if so, under what conditions. (10.) Are the house dustbins, as a rule, fixed or movable. (11.) Have you any public dustbins, and, if so, are they merely isolated instances, or have you a regular system. (12.) Number of depôts for the refuse collected, and the distance they are from the town. (13.) How is the refuse disposed of. (14.) Approximate mileage of streets cleansed. (15.) Are all the streets swept daily, or only the principal ones. (16.) Have you any provision for sweeping streets oftener than once a day, or for the frequent removal of horse dung, &c. (17.) Are private courts and alleys swept and cleansed by the Urban Authority, and, if so, how frequently. (18.) What number of men, horses, and carts respectively, do you employ. (19.) Net cost of your system after giving credit for any money realised by sale of refuse. In concluding this little book on "Dirty Dustbins and Sloppy Streets," I hope that what has been said may be of some use to my readers, and that they will themselves supply any omissions that they have found, and kindly correct all the errors, which are only too ready to creep into a work of this description. FINIS. TRANSCRIBER'S NOTE Obvious typographical errors and punctuation errors have been corrected after careful comparison with other occurrences within the text and consultation of external sources. The Table on page 54 entitled 'GROSS COST FOR ...' was large in width, and has been split into two parts. The first column (Street.) is repeated in the second part. Except for those changes noted below, all misspellings in the text, and inconsistent or archaic usage, have been retained. For example, brick makers, brick-makers; pervious; potatoe; unhung; rinsings. Pg 7, 'ash pit attached' replaced by 'ashpit attached'. Pg 11, 'distance of ' replaced by 'distance of __. Pg 30, 'a specialite' replaced by 'a speciality'. Pg 56, 'of sillicate' replaced by 'of silicate'. Pg 66, 'clearing the foothpaths' replaced by 'clearing the footpaths'. 
53974	----	TRANSCRIBER'S NOTE Italic text is denoted by _underscores_. Bold text is denoted by =equal signs=. Obvious typographical errors and punctuation errors have been corrected after careful comparison with other occurrences within the text and consultation of external sources. Misspellings in the text, and inconsistent or archaic usage, have been retained. PRINCIPLES OF PUBLIC HEALTH A SIMPLE TEXT BOOK ON HYGIENE PRESENTING THE PRINCIPLES FUNDAMENTAL TO THE CONSERVATION OF INDIVIDUAL AND COMMUNITY HEALTH BY THOS. D. TUTTLE, B.S., M.D. SECRETARY AND EXECUTIVE OFFICER OF THE STATE BOARD OF HEALTH OF MONTANA [Illustration: (publisher's colophon)] YONKERS-ON-HUDSON, NEW YORK WORLD BOOK COMPANY 1910 CONSERVATION OF HEALTH "Our national health is physically our greatest asset. To prevent any possible deterioration of the American stock should be a national ambition."--THEODORE ROOSEVELT. _The conservation of individual and national health is the keynote of these books_ PRINCIPLES OF PUBLIC HEALTH By THOS. D. TUTTLE, M.D., Secretary and Executive Officer of the State Board of Health of Montana. Illustrated. Cloth. vii + 186 pages. List price 50 cents, mailing price 60 cents. PRIMER OF HYGIENE By JOHN W. RITCHIE, of the College of William and Mary in Virginia, and JOSEPH S. CALDWELL, of the George Peabody College for Teachers, Nashville, Tennessee. Illustrated. Cloth. vi + 184 pages. List price 40 cents, mailing price 48 cents. PRIMER OF SANITATION By JOHN W. RITCHIE. Illustrated. Cloth. vi + 200 pages. List price 50 cents, mailing price 60 cents. HUMAN PHYSIOLOGY By JOHN W. RITCHIE. Illustrated in black and colors. Cloth. vi + 362 pages. List price 80 cents, mailing price 96 cents. WORLD BOOK COMPANY CASPAR W. HODGSON, _Manager_ YONKERS-ON-HUDSON, NEW YORK _Copyright, 1910, by World Book Company. All rights reserved_ INTRODUCTION The earliest history of remote ages describes methods employed in combating disease, and down through all the centuries the struggle against infection has been going on. The science of health as applied in recent years reveals wonderful progress in the avoidance of disease, and in the control of the violent epidemics by which in the past nations were almost exterminated. Modern methods of hygiene and sanitation as applied to public health have robbed smallpox and diphtheria of their death-dealing power; cholera and yellow fever have been forced to retreat before the victorious hosts of applied medical science; tuberculosis, the greatest foe of human life, is slowly but surely receding before the determined efforts of modern preventive medicine. By nature man is endowed with resistive power sufficient to ward off most forms of disease, provided he keeps his health at a normal standard by right living. If, however, he allows his health to become impaired by reason of overwork, bad habits, wilful exposure to contagion or unhealthful surroundings, he readily falls a prey to disease. The author of _Principles of Public Health_ has here set forth the general rules of life by the observance of which every adult and every child not only can do much to preserve his own health but also can prove himself a prominent factor in raising the standard of public health. A campaign of education is demanded to arrest the enormous loss of life which is carrying so many to untimely graves, and the instruction given in this volume will be of inestimable value in teaching people how to avoid avoidable disease. The author has not attempted to deal with all the diseases that may be classed as preventable; as the work is intended for use in the public schools, only such diseases are mentioned as it seems fitting to present to school children. To teach our children a proper respect for their own health and for the community welfare is to fit them for the best citizenship. E. A. PIERCE, M. D. PORTLAND, OREGON ACKNOWLEDGMENTS The author wishes to express his sincere appreciation of the valuable assistance rendered in the preparation of this work by Dr. S. T. Armstrong, of New York City; Dr. H. Wheeler Bond, Commissioner of Health, St. Louis, Missouri; Dr. H. M. Bracken, Secretary and Executive Officer of the State Board of Health of Minnesota; J. S. Caldwell, Professor of Biology, George Peabody College for Teachers, Nashville, Tennessee; R. J. Condon, Superintendent of Schools, Providence, Rhode Island; Mrs. Nona B. Eddy, of the Public Schools of Helena, Montana; Dr. F. M. McMurray, of Teachers College, Columbia University, New York City; Miss Jessie B. Montgomery, Supervising Critic in Training School, State Normal School, Terre Haute, Indiana; Dr. E. A. Pierce, Secretary and Executive Officer of the State Board of Health of Oregon. CONTENTS PART I--THE FIGHT FOR HEALTH CHAPTER PAGE I. CONSTANT DANGER OF ILLNESS 1 II. THE NECESSITY OF CARING FOR THE BODY 4 III. HOW CLOTHING AFFECTS HEALTH 9 IV. THE USES OF FOOD 14 V. CARE OF FOOD--MEATS 18 VI. CARE OF FOOD--MILK 22 VII. DECOMPOSITION OF FOOD 30 VIII. HARM DONE BY IMPROPER COOKING 34 IX. HOW NEATNESS, CHEERFULNESS, AND GOOD MANNERS PROMOTE HEALTH 37 X. DANGERS FROM POOR TEETH 41 XI. NECESSITY FOR PURE AIR AND HOW TO SECURE IT 45 XII. REST ESSENTIAL TO HEALTH 51 XIII. CARE OF THE EYE AND EAR 56 XIV. CARE OF THE SKIN 60 XV. COMMON POISONS TO BE AVOIDED 64 PART II--THE ENEMIES OF HEALTH XVI. DISEASE GERMS 73 XVII. ENCOURAGEMENT OF DISEASE BY UNCLEANLY HABITS 75 XVIII. FLIES AS CARRIERS OF DISEASE 79 XIX. HOW DISEASE GERMS GET INTO WATER 85 XX. TRANSMISSION OF DISEASE THROUGH THE AIR 89 XXI. INSECTS AS CARRIERS OF DISEASE 92 XXII. HOW TO KEEP GERMS OUT OF WOUNDS 95 XXIII. TRANSMISSION OF DIPHTHERIA 100 XXIV. THE CURE OF DIPHTHERIA 108 XXV. HOW TYPHOID FEVER GERMS ARE CARRIED 113 XXVI. HOOKWORM DISEASE AND AMOEBIC DYSENTERY 120 XXVII. HOW SCARLET FEVER IS CARRIED 123 XXVIII. MEASLES AND WHOOPING COUGH DANGEROUS DISEASES 128 XXIX. HOW SMALLPOX IS PREVENTED 131 XXX. WHY VACCINATION SOMETIMES SEEMS A FAILURE 138 XXXI. CONSUMPTION, THE GREAT WHITE PLAGUE 142 XXXII. HOW CONSUMPTION IS SPREAD AND HOW PREVENTED 150 XXXIII. HOW CONSUMPTION IS CURED 157 APPENDIX--SUMMARY OF ANATOMY 163 SUGGESTIONS TO THE TEACHER 182 INDEX 183 PART I THE FIGHT FOR HEALTH CHAPTER I CONSTANT DANGER OF ILLNESS Every boy and girl confidently expects to grow into a strong and healthy man or woman. How often we hear a child say, "When I am a man," or "When I am a woman;" but I have never heard a boy or a girl say, "If I live to be a man or woman." When you think of what you will do when you are grown into men or women, it never occurs to you that you may be weak and sickly and therefore not able to do the very things that you would most like to do. This suggests that sickness is not natural, else the thought that you may perhaps become sick would enter your mind. As a matter of fact, most sickness is not natural. [Sidenote: The fight for life] There is a constant struggle going on in the world. You see a fight about you every day among the animals. You see the spider catch the fly, the snake catch the frog, the bird catch the insect, and the big fish catch the minnow; and you have heard of wars where men kill one another. The greatest enemies that men have to fight, however, are not other men, or wild animals, but foes that kill more men, women and children every year than were ever killed in the same length of time by war. These foes are small, very small, but you must not think that because things are small they are not dangerous. We call these foes _disease germs_. [Illustration: FIG. 1. Looking at cells through a microscope.] [Illustration: FIG. 2. Some skin cells as seen through a microscope.] [Sidenote: The nature of a germ] The germ is a very, very small body; it is the smallest living body that we know. Later we shall learn that our bodies are made up of cells, and that these cells are extremely small--so small that it takes a very powerful microscope to see one of them. The germ is still smaller than the cells in our bodies, and it is made of a single cell. There are a great many kinds of germs in the world. Fortunately, most of them are not harmful. Some germs cause disease, but there are other germs that not only are not harmful, but are actually helpful to men. Among the helpful germs are those that enrich the ground, and these should be protected; but all germs that cause disease should be destroyed as rapidly as possible. These germs are fighting all the time against our health. They are not armed with guns and cannon, neither do they build forts from which to fight; but they get inside our bodies and attack us there. [Sidenote: How to fight germs] There are three principal ways by which we fight disease germs: _first_, by keeping our bodies so well and strong that germs cannot live in them; _second_, by keeping germs out of our bodies; _third_, by preventing germs from accumulating in the world--that is, by killing as many of them as possible. If it is possible to keep so well and strong that disease germs cannot live in our bodies, you will naturally infer that there are other causes of sickness besides disease germs. That is true, for there are a great many things beside germs that cause our bodies to get into such a condition that disease germs can enter and grow and make us ill. We sometimes call this a "run-down" condition. Before we begin, then, to study the germs that cause disease, we must learn how to keep our bodies strong and ready to fight these germs. =Questions.= 1. What evidence have we that sickness is not natural? 2. Name some of the fights going on in the animal world. 3. What can you say of the amount of illness caused by germs? 4. Tell what you have learned about germs. 5. Name three ways of fighting germs. =Remember.= 1. Most sickness comes from failure to observe Nature's laws. 2. We must keep up a constant fight against germs that cause sickness. 3. We fight germs by killing as many of them as we can, and by keeping our bodies so strong that if a disease germ enters it cannot grow. CHAPTER II THE NECESSITY OF CARING FOR THE BODY [Illustration: FIG. 3. The organs of the body.] [Sidenote: How the body is like an automobile] These bodies of ours are built somewhat like automobiles. An automobile is made up of a framework, wheels, body, gasoline tank, engine, and steering-gear. The human body has much the same form of construction. We have a frame, which is made of the bones of the body. We have arms and legs, which correspond to the wheels of the automobile. We have many little pockets in our bodies in which fat is stored, and these little pockets answer to the gasoline tank of the automobile. We have an engine which, like the automobile engine, is made up of many parts; and we have a head or brain, that plays the same part as the steering-gear of the automobile. The automobile has a tank in which is carried the gasoline necessary to develop power for the machine. If the gasoline gives out, the engine will not run, and before the owner starts on a trip, he is always careful to see that the tank is well filled. In the same way, if we do not provide new fat for the pockets in our bodies in which the fat is stored, our supply will soon give out and our bodies will refuse to work, just as the engine of the automobile will refuse to work when the gasoline is used up. [Sidenote: What cells are like] The automobile is made of iron and wood and rubber, and each bit of iron and wood and rubber is made up of tiny particles. The body is made of bones and muscles, covered with skin, and all these are made up of very fine particles that we call cells. Every part of the body is made of these fine cells. The cells are so small that they can be seen only with a powerful microscope. If you look at your hand you cannot see a cell, because it takes a great many cells to make a spot large enough for you to see. In Figure 1 you see a boy looking through a microscope, and beside him you see a picture of what he sees. This picture does not look like the skin on your hand, neither does it look like the skin on the boy's hand; but it is nothing more nor less than a piece of skin taken from that boy's hand, and it looks just as a piece of skin from your own hand would look if you were to see it through a very strong microscope. [Sidenote: Why cells must not be killed] The whole body is made up of just such little cells as you see in Figure 4, and each cell is alive and has a certain work to perform. It is very important that we keep these cells from dying and that they perform the work for which they are intended, for if these cells die or fail to act, the body becomes sick or dies. [Illustration: FIG. 4. A cell. (a) Cell body; (b) nucleus; (c) nucleolus.] You can scratch some of the paint from your automobile and the machine will work just as well as ever. Apparently no harm has been done, but an opening has been made through which moisture and germs can enter and cause the wood to rot and the iron to rust. You can remove certain parts of the automobile and still the machine will do its work; but you cannot take away too much of any one part without weakening the automobile, and if certain parts are missing (such as the sparker, the battery, or the steering-gear), the usefulness of the machine is destroyed. So it is with the body. You can scratch off some of the skin and not do any apparent harm, but you have made an opening through which germs may get into the body. You can remove certain parts of the body, such as the arm or leg, and still the body will do efficient service. But there are certain parts of the body that are necessary to life, just as certain parts of the automobile are necessary to the usefulness of the machine. You cannot remove the heart and live; you cannot remove the brain and live. [Sidenote: How cells are killed] You are probably thinking that it must be easy to kill such a little thing as a cell; and so it is. Cells can be killed by too much heat or too much cold. When you skin your hand, you kill many cells, and at the same time make an opening for germs to get in and cause sickness. You can kill cells also by starving them, for they must have not only enough food, but the right kind of food. If you feed your bodies on nothing but candy, pie, and cake, most of the cells will refuse to perform their work and many of them will die. These cells must have also an abundance of air, and the air must be pure and fresh. If you breathe the air that others have breathed or that contains poison of any kind, you will soon find that you are not feeling well. This simply means that so many of the cells are being starved for fresh air, that not enough strong ones are left to do the necessary work. You can kill these cells by overwork, for they must have a proper amount of rest. If you go to school all day long and then sit up until midnight every night, you must not expect the cells of your body to keep strong and well. You can kill these cells by the use of certain things that act as poisons to them, such as tobacco, beer, wine, or whisky. =Questions.= 1. In what way is the body like an automobile? 2. What are cells like? 3. Why must cells not be killed? 4. Name five ways by which we kill cells. =Remember.= 1. Each part of the body is important to the welfare of the whole body. 2. Each part of the body is made up of very small particles that we call cells; each cell in the body is alive and has a certain work to perform. 3. Cells are very easily weakened and killed. 4. There are five principal ways by which we kill the cells in our bodies: by too much heat or cold; by not giving them the proper kinds of foods; by not giving them enough fresh air; by giving them too much work to do; and by poisoning them. CHAPTER III HOW CLOTHING AFFECTS HEALTH [Illustration: FIG. 5. Warm, dry clothing necessary for health.] [Sidenote: Why the body should be equally covered] The body should always be kept at as nearly uniform a temperature as possible. In order to do this we wear clothing. Clothing keeps out the heat on a hot day, just as it keeps the heat in and the cold out on a cold day. The clothing should be equally heavy on all parts of the body. It is not right to wear a thick dress over your chest and leave your shoulders and arms bare, or nearly so. People who do this are killing a great many cells by letting part of their bodies become chilled while the rest is warm, probably too warm. [Sidenote: Why clothing should not be too heavy] The clothing should be just heavy enough to keep the body warm. If you wear such heavy clothing indoors that you are constantly perspiring, your underclothes become damp, and when you go out, even though you put on your overcoat, your body becomes chilled. If you begin to sneeze, that is Nature's way of telling you that you are killing many of your cells by too much cold. People sometimes get warm from exercising, and then take off their coats. They should have removed their coats before they began to exercise. If you take off your coat after you are too warm, your body becomes chilled. Baseball pitchers know this, and if you watch a good pitcher, you will see that he always puts on his sweater as soon as he stops pitching, even though he is very warm. He knows that if he cools off too quickly, he will become stiff and sore and cannot pitch good ball. [Sidenote: When a draft is dangerous] Sometimes a person sits in a warm room until he begins to perspire freely. Then he opens a window and sits in the draft. Under ordinary conditions, the cool wind alone would chill the body, but now the rapid drying of the perspiration makes the body cool still more quickly. The sudden chill causes the person to take cold, which is simply another way of saying that he has killed many cells and caused others to fall sick, so that they cannot perform their work. We cannot get too much fresh air. Drafts do not hurt us if we are thoroughly wrapped up; but it is very dangerous to allow the wind to strike the body when it is not well protected, and especially when it is damp with perspiration. [Illustration: FIG. 6. Properly prepared for wet weather.] [Sidenote: Why damp clothing is dangerous] Damp clothing chills the body very rapidly and kills many cells. Indeed, if a single one of the germs that cause pneumonia were to enter your lungs while you were wearing damp clothing, it would grow so rapidly that you might have pneumonia in a very little while. That is why it is important to change your shoes and stockings as soon as you get them wet, and to take off immediately any clothing that becomes damp. It is hard for boys and girls to keep their feet dry in the winter and spring months, and rubbers are a nuisance; but if you expect to grow into the strong man or woman you picture yourself becoming, you must take care to wear your rubbers. Otherwise you may become weak and sickly, and never be able to do the things you hope to do. The feet are not the only part of the body that needs to be kept dry. A wet coat is just as harmful as wet shoes and stockings; hence, you should always carry an umbrella or wear a raincoat when you go out into the rain. Umbrellas are unhandy for boys and girls to carry, but if you will remember that thousands of little cells in your body are being injured when you get wet and chilled, you will be willing to take your umbrella. [Sidenote: When to wear an overcoat] In cold weather the same amount of clothing should not be worn in the house and outdoors; for this reason, we have overcoats. If you wear your overcoat in the house, you will become overwarm and your underclothing will then become damp with perspiration; when you go outdoors into the cold air, this dampness will have just the same effect as would dampness that comes from outside. [Illustration: FIGS. 7 and 8. If you keep your overcoat on in the house, your underclothes become damp from perspiration, and when you go outdoors your body becomes chilled.] As soon as the weather gets cold, put on your overcoat every time you go outdoors, and take it off as soon as you come into the house. This is troublesome for boys and girls to do, because they want to run in and out of the house so often; but on the other hand, think of all the cells you will kill if you do not do this, and you will certainly consider it worth while to take off your coat and put it on again. =Questions.= 1. How does keeping the body equally covered protect the cells? 2. Give reasons for not wearing too heavy clothing. 3. When is it safe to sit in a draft, and when dangerous? 4. What is the danger of keeping on wet shoes or other damp clothing? 5. When and why should overcoats be worn? =Remember.= 1. Clothing should be just heavy enough to keep the body warm all the time. 2. Never take off your coat or sit in a draft when you are too warm. 3. Since wearing damp clothing causes a great deal of sickness, change your clothes as soon as they become wet or damp. 4. Do not forget to take your umbrella when it is raining and to wear your rubbers when the ground is wet. 5. In cold weather wear your overcoat when you are outdoors, but take it off when you come into the house. CHAPTER IV THE USES OF FOOD We kill a great many of the cells in our bodies by starving them; either we do not give them enough food or we do not supply the right kind of food. [Sidenote: Why the body needs new cells] Not only must we feed the cells in our bodies, but we must be constantly making new ones, for in all our work or play, awake or asleep, we are constantly using up certain cells. These cells are used to make the body go, just as the engine uses coal to form the steam that gives it power to run. Boys and girls grow fast and, of course, if they expect to become well men and women, they must make a great many new cells all the time, in addition to those used in doing the work of the body. If we are to make new cells we must have the right kind of food with which to make them. [Sidenote: How the body keeps itself warm] We want to do something besides make new cells; we want to keep warm and well the cells we already have. No amount of clothing would keep you warm if you were not making heat inside your body all the time, any more than you could make a telephone post warm by putting your coat on it. Therefore it is necessary to have food that makes heat in the body, in addition to food that builds cells. We eat a great many kinds of foods, and all that we eat is used either for building new cells or for producing heat in the body. Thus we can divide all our foods into two classes--building material and heat-producing material. The type of building material is lean meat, and the type of heat-producing material is fat meat and starches, such as potatoes and bread. Milk contains much building material as well as heat-producing material. That is why a baby grows and keeps warm while he takes nothing but milk. [Sidenote: The building foods] Lean meat is the best of all building foods. Eggs are largely a form of lean meat, and hence constitute a good article of food for building purposes. Certain vegetables contain a large per cent of building material; this is especially true of dried beans and peas. Wheat flour and corn meal (particularly when made of whole wheat and unbolted meal) contain much building material. It is possible for one to live and grow when eating only vegetable matter. But the boy or girl who tries to become a strong man or woman by eating only vegetables will be disappointed; these are mostly heat-producing foods and will not make strong bodies. Experience has proved that the best results are obtained by eating what is called "a mixed diet," that is, a diet composed partly of lean meats and partly of fats and vegetables. [Sidenote: The heat-producing foods] Of the heat-producing foods, fat is the most powerful. Most of the fat that we eat is used immediately for producing in the body heat, and therefore power, but a part of it is stored up for future use. We see it in all healthy young persons. It is this stored-up fat that gives the body its rounded form. When any one has been sick he is thin, because, to produce heat and power while he was sick, he has had to use the fat stored up in his body. To have such a supply of fat is like having a bank account to draw on when out of work. We might call the deposits of fat in our bodies our health banks. Fat meat is not the only form in which we eat fats; we eat them in a great many other ways. Certain vegetables, such as beans, contain an oil that forms fat. Ripe olives contain a great deal of fatty oil. Butter is a very important form of fat, and cream contains a large amount of it. [Sidenote: Cost of suitable foods] In selecting our foods we should think of two things: _first_, the value of the food as a heat-producer or as a building material; and _second_, the cost of the food. We may like butter much better than bacon, but we should remember that, pound for pound, bacon has a greater nourishing power than butter, and a pound of bacon will cost far less than a pound of butter.[1] Vegetable foods produce heat by means of the starch which they contain. All vegetables contain starch. This starch is changed into a kind of sugar in the body, and when thus changed it is used to produce heat and power. All vegetable foods do not have the same heat-producing power. There is more heat-producing power in a pound of oatmeal than there is in ten pounds of cabbage. Ten cents' worth of dried beans will produce more heat in the body than will a dollar's worth of lettuce. Thirty cents' worth of corn meal will do more building in the body than will a piece of mutton worth a dollar and a half; but you would have to eat a large amount of corn meal in order to secure the building effect that would result from eating a small quantity of mutton. In most fruits the only nourishing quality is in the sugar they contain. This sugar produces heat in the body just as starch does. [Sidenote: The real value of advertised foods] You will see some foods advertised as possessing a wonderful nourishing power. Do not let such statements deceive you, for no food can have a greater nourishing power than the things from which it is made. If the particular food advertised is made from wheat flour, its nourishing power is just the same as that of an equal quantity of wheat flour. If it is made from corn meal, it can have no greater nourishing power than has the meal itself. We have learned something about the materials necessary in food and why they are needed. We must now learn why foods that contain these materials sometimes do not give us as good results as we might hope for. =Questions.= 1. What use does the body make of new cells? 2. How does the body keep itself warm? 3. Name two uses that the body makes of food. 4. What foods are especially useful for making cells? 5. What foods are chiefly used for making heat? 6. Select articles of food for two meals of equal nourishing value, one meal to be expensive and the other inexpensive. 7. How would you determine the real value of any food? =Remember.= 1. Foods are used to make heat and power in the body and to make the body grow. 2. The foods that make the body grow are called building materials, and lean meat is the best kind of building material. 3. The foods that produce heat and power in the body are called heat-producing materials, and fats and starches are the best heat-producers. 4. All vegetables contain starch, some of them contain a fatty oil, and most of them contain some building material. 5. You can get as much building and heat-producing material from cheap foods as you can from expensive foods. CHAPTER V CARE OF FOOD--MEATS [Sidenote: Value of meat as a food] Meat is one of the most important articles of our diet. It furnishes essential materials for building cells, and it furnishes fat for making heat and power in the body. [Illustration: FIG. 9. A double menace to health; the slaughterhouse is dirty, and the filth is drained into a stream.] [Sidenote: Characteristics of good meat] Since meat is so important an article of food, we should be very careful to see that it is handled in a way to keep it always perfectly clean. We should make sure that it comes from animals absolutely free from any kind of disease, and that no germs have been allowed to develop poisons in it. [Sidenote: How meat may be kept clean] While people know that they ought to pay attention to these things, as a matter of fact they do not do it. They take very little interest in the way the meat that they are to eat is handled, and very few ever go to the slaughterhouse or into the back room of the butcher shop to see whether things are kept clean or not. Some people say, "Oh, we do not like to go there because it is such a horrid place." If these places were kept clean, as they should be, they would not be "horrid." And if the people who buy the meat would occasionally visit them, these places would be kept clean. [Illustration: FIG. 10. Properly displayed foods, protected from handling and from dirt and flies.] If the slaughterhouse and the butcher shop where your meats are handled are not kept clean, the meat is sure to have germs growing in it, and these germs will cause poisons called _ptomaines_ to form in the meat. There may not be enough of them to make you sick, but there will be enough to injure some of the cells of your body, and to deprive you of much of the nourishment that you would otherwise get from the meat. All boys and girls should belong to a "Clean Meat League" and should try to persuade their parents not to buy meat from any butcher who does not keep his slaughterhouse and butcher shop clean. [Sidenote: Dangers from diseased meat] Sometimes butchers are anxious to make money fast and take little thought for the number of people they may make ill. They can buy sick cows very much cheaper than well ones. The meat from a sick cow looks just like the meat from a healthy cow, and the dishonest butcher sells both at the same price. The meat from the diseased cow is not suitable for food. It may cause you to have the same disease that the cow had, or it may only be changed to such an extent that it will not give you the nourishment that you should get from good meat. The butcher who sells you meat from a sick cow is of course dishonest. [Illustration: FIG. 11. Improperly displayed foods, exposed to handling and to dirt and flies.] [Sidenote: How to prevent the sale of diseased meats] Ask your father to visit the slaughterhouse where your meat is killed. The only thing you need to do is to persuade him to go and see whether the cattle are sick or not. If the cattle look sick, you will not have to ask him not to buy the meat. No person should ever eat meat that comes from a diseased animal, no matter what the nature of the sickness may be. People who will take the trouble to visit the slaughterhouses occasionally, to investigate these things for themselves, will not have such meat offered them. [Sidenote: Importance of giving animals clean food] Animals that are fed on filthy food are not fit for human consumption. Butchers often feed the offal (the insides) of animals to the hogs. This makes the hogs fatten quickly, but it also makes them diseased. When you go to the slaughterhouse with your father, ask him to go around to the back door, and if you see hogs eating this filth, do not buy any more meat from that butcher. =Questions.= 1. What use does the body make of meat? 2. What conditions are essential for good meat? 3. How can meat be kept clean? 4. Why is meat from a diseased animal unfit for food? 5. How can you help in preventing the sale of meat from diseased animals? 6. Why should animals not be fed with offal? =Remember.= 1. Meat that is not handled in a clean manner is sure to contain germs that cause a poison to form in the meat. 2. Never buy meat from a butcher who does not keep his slaughterhouse and butcher shop clean. 3. Meat from a diseased animal is not fit for food. 4. Meat from animals fed on filthy food should not be eaten. 5. Form a "Clean Meat League" and visit the slaughterhouse where your meat is killed. CHAPTER VI CARE OF FOOD--MILK [Sidenote: Value of milk as a food] Milk is another important article of food. The Department of Agriculture at Washington says that milk furnishes sixteen per cent of the nourishment of the people of the country. Milk is an excellent food when it is pure, but when it is not pure it is very dangerous. [Illustration: FIG. 12. A clean dairy.] [Sidenote: Milk as a carrier of germs] Milk has carried the germs of every disease of which the germ is known; it has also carried many diseases of which we do not know the germ. Disease germs grow rapidly in milk, and they do not make the milk look different or taste different from milk that is perfectly pure. If you could take two bottles of milk entirely free from disease germs and put typhoid fever germs in one, and should set both bottles in an ice box for twenty-four hours, you would not then be able to tell into which one you had put the germs. The milk in both bottles would look and taste just the same. The only difference between the milk in the two bottles would be that if you drank from one it would make you stronger and would furnish you with both building material and power-producing material, while if you drank from the other you would become very ill and would probably die. [Sidenote: How disease germs get into milk:] Since we cannot tell from the taste or the appearance of milk whether or not there are disease germs in it, we must take every precaution possible to keep them out. The first step is to learn where the disease germs come from and how they get into the milk. [Illustration: FIG. 13. Polluted milk is sure to come from a dairy where cleanliness is not observed.] [Sidenote: (_1_) By dirt on the cow] Every cow has more or less dirt on her sides and udder; some have a great deal. When the cow is milked, much of the dirt falls into the milk bucket. This dirt always contains a great many germs of different kinds, and many of them are germs that cause disease. Straining the milk will take out much of the dirt, but disease germs will go through the finest strainer that was ever made. In Figure 13 we see a man milking a dirty cow. The owner has allowed his lot to become so dirty that the cow cannot find a clean place in which to lie down. If the man kept his lot clean, and if before milking the light dirt on the cow's sides and udder were wiped off with a damp cloth, no germs would fall into the milk. [Sidenote: (_2_) By dirt in the cow barn] Another source of dirt and disease germs in milk is the barn. The walls of a barn where cows are milked should always be kept clean and should be whitewashed frequently. If this is done, there will be comparatively little dirt on the walls to fall into the milk. [Illustration: FIG. 14. Only clean milk will come from a dairy where proper precautions are taken.] Of course the walls and floors of a barn cannot be kept absolutely clean. There will always be some dirt, and the movements of the cows shifting their position and switching their tails, will stir up the dust; so it is important to remove the milk from the barn as soon as possible. Milk cans should never be kept in the barn. The milk should be taken directly from the barn to a cooling house and there strained. All barns where cows are kept should have plenty of windows, that there may be an abundance of light and fresh air. Cows need fresh air just as much as people do, while a barn that is not supplied with plenty of light is very likely to be a dirty barn. Keep dirt and disease germs out of the milk by keeping the barn clean and by taking the milk away from the barn as soon as possible. [Illustration: FIG. 15. A dirty, insanitary milk-house.] [Illustration: FIG. 16. A clean, inexpensive milk-house.] [Sidenote: (3) By dirt on the milkman] Another source of dirt and disease germs in milk is the milkman or milkmaid. No matter how careful we may be, our clothes hold more or less dust, and all dust contains germs, very often disease germs. When a person is milking a cow, the dust from his clothes is shaken off into the milk. The only way to avoid this is to wear, while milking, a special suit of clothes made of white cloth, which may be washed as soon as it shows the least particle of dirt. The milker's hands, too, are often dirty. Perhaps he carefully washes his hands after milking, but not before. It is a common custom for milkers to moisten their hands with milk while milking, and to do this frequently. The result is that dirty milk from their hands is constantly dropping into the milk pail. This is a very bad habit, and doubly bad if the milkman has not washed his hands before milking. Sometimes there are sick people at the dairy farm. Often some one nurses a sick person until milking time and then goes out and milks the cows. When this is done, the milker is almost sure to plant the germs of the disease in the milk. No milk should ever be used from any dairy where there is an infectious disease; and no one who has charge of a sick person, no matter what the nature of the sickness, should ever handle milk that is to be used by others. [Illustration: FIG. 17. A model bottling establishment.] [Sidenote: (4) By dirt in cans and bottles] The cans and bottles in which the milk is placed are frequently sources of dirt and germs. Milk cans and bottles are supposed to be thoroughly washed before milk is put into them, and they should be thoroughly scalded after they are washed. This is not always done, and sometimes the bottles are not washed at all. Some dairymen will tell you that the bottles and cans are always washed and scalded just before the milk is put into them, and that this is never neglected by any dairyman. That is what a dairyman once told me. Then I asked him how he accounted for the fact that I had found a milk ticket in the bottle with the fresh milk. Of course he could not explain this, though I thought I could explain it for him. The old milk bottle was returned to the milkman with the ticket for the new milk inside it. The deliveryman left the fresh milk, but forgot to take the ticket out of the bottle; and the man who "washed" the bottles must have forgotten to take out the ticket too. Of course, the bottle was not washed at all, and if one bottle goes unwashed, it is reasonable to assume that others are neglected in the same way. Milk bottles and cans should always be thoroughly washed before fresh milk is put into them. This washing cannot be done by little children; it is work for a man or woman, and careful work at that. [Sidenote: (5) By polluted water] I have just told you that milk vessels should be thoroughly washed. It is true, however, that disease germs may get into the milk through this very process of washing the vessels. Water sometimes contains disease germs, especially the germs that cause typhoid fever, cholera, and other diseases of the intestines. Such water is said to be polluted. When milk vessels are washed with polluted water, the germs are left in them and thus get into the milk. If the water used to wash the cans is thoroughly boiled, the germs will be killed; hence it is important to scald all milk vessels. All water used about a dairy should be perfectly pure. If there is the least suspicion about the quality of the water, it should be examined by a chemist; and if it is not pure, the milk from such a dairy should not be used. In order to prevent the possibility of any infection, all water used to wash milk vessels should be thoroughly boiled even when the water is known to be pure, and the vessels should afterward be scalded, to kill any germs that may be left after washing. [Sidenote: (6) By flies falling into the milk] Flies very frequently get into the milk. Later we shall learn more about how flies carry germs, but at present it is enough to know that on every fly there are a great many germs, and whenever a fly gets into milk it plants those germs and they grow very rapidly. As soon as a cow is milked, the milk should be taken to a clean cooling house, with screens at all the windows and doors, and there strained into a vessel and cooled. [Sidenote: (7) By disease in the cow] The last way that we will mention by which germs get into milk is by disease in the cow herself. Cows suffer from many diseases, just as men do; and when a cow is sick, her milk is very likely to contain the germs of the disease that is making her sick. Especially is this true of tuberculosis, or consumption, as it is called. A great many children get consumption by drinking milk from consumptive cows. No milk should ever be used from a cow that is not healthy. All dairy cows should be examined at frequent intervals by a competent veterinarian to make sure that they are free from any disease. =Questions.= 1. Milk forms what per cent of the food of the people of the United States? 2. Why is it important that milk should be kept clean? 3. Name some ways by which germs get into milk. 4. What is the danger from a dirty cow and barn? 5. How can this danger be prevented? 6. How does the milkman allow germs to get into the milk, and how can he avoid doing so? 7. How should milk cans and bottles be washed? 8. Why is it important that only pure water be used about the dairy? 9. How can flies be kept out of milk? 10. How should milch cows be tested to make sure that they are free from tuberculosis? =Remember.= 1. Milk is a very important article of food; it is both a building and a heat-producing material. 2. When milk is not properly handled, it contains many disease germs. 3. Disease germs often get into milk from unwashed bottles and cans; from dirty barns; from dirty milkmen; from dirty water used to wash the cans and bottles; from flies falling into the milk; from diseased cows. CHAPTER VII DECOMPOSITION OF FOOD [Illustration: FIG. 18. Partially decayed fruit is not fit for food.] [Sidenote: Why partially decomposed foods should not be eaten] Vegetables and fruits that are partially decayed should not be eaten. Even if an orange is decayed only on one side, the products of decomposition--that is, the poisons produced by decay--have extended all through the orange. You cannot see them, but they are there. It is the same with a decaying apple, potato, or melon. It never pays to buy partially decayed or stale fruits or vegetables, for not only are they dangerous to health, but they are so reduced in nourishing qualities by decomposition that you get little value for the money you spend. It is always better economy to buy fresh fruits and vegetables, or even canned vegetables, when the latter are properly put up. [Sidenote: What causes decomposition] All decomposition (rotting) in fruits and vegetables is due to the action of germs. If you will look at a bunch of old grapes, you will notice that some of the grapes are rotten, while others have dried up. Now, if you examine them very carefully, you will find that all the decomposed grapes have breaks in the skin. The break may be very small, but it is there, and through this break the germs that cause decomposition have entered. You will find also that there is not the slightest break in the skin of any grape that has dried up. The germs could not enter, hence there has been no decomposition. It is the same with other fruits and vegetables: if the germs that cause decomposition cannot get inside, the fruit or vegetable will dry up, but will not rot. [Illustration: FIG. 19. Fruits displayed for sale, but properly protected from flies, dust, and dirty hands.] Germs can go through a very small opening--so small that you may not be able to find it; but if there is decomposition, the hole is there. The skin of the body acts in the same way as the skin of the grape and keeps out a great many germs that would make us sick were they able to get through the skin. They often get through the skin when we cut ourselves. Meats decompose as well as fruits and vegetables, and the decomposition is due to the presence of germs in the meat. We cannot keep all germs out of meat, but we can keep out a great many of them by having everything clean about the meat, by keeping it covered as much of the time as possible, and by handling it only with clean hands. [Illustration: FIG. 20. Fruits for sale, not properly protected from flies, dirt, and other sources of filth.] [Sidenote: Why foods do not decompose in very cold places] When meat is kept so cold that it is almost frozen, the germs cannot grow, and decomposition is prevented. In this way meat can be kept perfectly free from decomposition for several weeks. After the meat is taken from the cold storage room, it should be cut as soon as possible into steaks, roasts, and other pieces for cooking; and when taken to your home, it should be kept in an ice box until the time to cook it. You cannot keep meat very long at home without decomposition starting, because small ice boxes are not cold enough to check entirely the growth of germs. Unless the meat is to be eaten hot, it should be cooled after cooking and placed again in the ice box as soon as possible. Cooking kills the germs that are in the meat before it is cooked; but unless it is kept in a very cold place and protected from flies after it is cooked, germs will get into it again as soon as it is cold. Cooked meat will decompose just the same as uncooked meat. [Sidenote: What is formed in food by decomposition] When germs are allowed to grow in meat, as always happens when it is not kept in a very cold place, these germs cause the poisons that we call ptomaines. The people who eat such meat become sick, and in many cases do not recover. Cooking meat that contains ptomaines will kill the germs that caused the poison, but it will not destroy the poison that has already been formed. [Sidenote: Why some canned meats are poisonous] People not infrequently are poisoned by eating canned meat. Sometimes you will hear it said that the poison formed because the meat was in cans. This is not true; the cans had nothing to do with the forming of the poison. This was caused by germs that were allowed to grow in the meat before it was cooked. When the meat was cooked the germs were killed, but the poison was not destroyed. In other words, the poison developed before the meat was canned, and not after it was put into the cans. =Questions.= 1. What is the objection to eating fruits when they are partially decayed? 2. Why do some foods shrivel while others decay? 3. Why does decomposition not go on in cold places? 4. What are ptomaines? 5. When are ptomaines formed in canned meats? =Remember.= 1. Partially decomposed fruits or vegetables are not suitable for foods. 2. Meats in which germs have been allowed to grow should not be eaten. 3. Cooking meat kills the germs in it, but does not destroy the poisons that the germs have formed. 4. When canned meats are poisonous, it is because the poison was formed before the meat was canned; the poison is not caused by the can. CHAPTER VIII HARM DONE BY IMPROPER COOKING [Sidenote: Effects of improper cooking] Nearly all food should be cooked before it is eaten; but if the cooking is not properly done, much of the nourishing power of the food is destroyed, and in some instances the food is rendered actually injurious. [Sidenote: Why starchy foods should be thoroughly cooked] Starchy foods should be thoroughly cooked in order that the coverings which surround the little granules may be broken or made soft. If starchy foods are not thoroughly cooked, the little grains go into the stomach as hard as grains of sand; then most of them are not digested at all, but pass out of the system without furnishing any nourishment to the body. If starchy foods are fried in fats, as is the case with doughnuts, the granules of starch become coated with fat. As the fat is not digested until it comes to the intestines, the saliva never reaches the coverings of the starch, and more work is thrown on the other juices of the body. The result is that the little glands which make these other juices are overworked, or else the starch is not digested at all and therefore furnishes no nourishment to the body. When bread is sticky (we sometimes call it soggy) in the middle of the loaf, it is because the flour has not been thoroughly cooked and the little grains or granules of starch are still hard. You cannot feel these granules between your fingers, but they are hard just the same, and very little of such food is made use of in the body. Remember that all starchy foods should be thoroughly cooked, and remember, too, that all vegetables are chiefly starchy in character. [Sidenote: How fats should be cooked] When fats are cooked over a very hot fire, an acid is developed that is injurious to the body. This does not mean that when the fire is hot enough to broil a steak well, it causes this acid to form; neither does it mean that heat sufficient to boil the grease for cooking doughnuts will cause it to form. Every cook knows that when she fries fat meat over a fire that is too hot, it has a bitter taste. This bitter taste is caused by an acid which will destroy a part of the usefulness of the food in the body and will cause many of the cells to stop doing their work properly. [Sidenote: How meats should be cooked] There is a great difference of opinion in regard to cooking foods, especially meats. Some people will tell you that meats should not be cooked at all; that man originally ate his meat raw and that this is the proper way. Others will tell you that all meat should be cooked until it does not show a particle of red, even until it is dry throughout. These are the two extremes; and it is never well to go to extremes in anything, especially in matters that concern the health. Meat should always be cooked, because by being cooked it is made more easily digestible; but it should not be cooked, until all the juices, which contain much of the nourishing matter, are dried up and the meat made hard. Meat that is cooked until it is dry and hard is more difficult to digest than meat that is not cooked at all. =Questions.= 1. What effect has improper cooking on foods? 2. Why should starches be thoroughly cooked? 3. What is the objection to starchy foods fried in grease? 4. What changes take place in fatty food when it is fried over a very hot fire? 5. Why should all meats be cooked? 6. What is the objection to cooking meat until the juices are dried out? =Remember.= 1. Starchy foods should be thoroughly cooked so that the fine grains may be softened and the food thus made more easy to digest. 2. Fats should not be fried over a very hot fire because too much heat causes a poison to form in the fat. 3. Meats should be cooked, but never until they become dry, as the juices in the meat contain most of the nourishing material. CHAPTER IX HOW NEATNESS, CHEERFULNESS, AND GOOD MANNERS PROMOTE HEALTH [Sidenote: Why mealtime should be pleasant] The dining table should be the pleasantest and most inviting place in the house. If you are complaining and quarreling during the meal, you cannot enjoy the food; you cannot eat it properly; and your ill temper will so affect your body that you cannot properly digest what you eat. A dirty table, with flies swarming over the food, is not very tempting, and when seated at such a table, one does not eat the things that are best for him and sometimes does not eat anything at all. [Illustration: FIG. 21. A clean, inviting dining-room.] [Sidenote: How uninviting luncheons affect the appetite] The luncheons that boys and girls take to school with them are often prepared in so careless a way that they are extremely uninviting. The substantial school lunch can be made just as appetizing as the dainty refreshments at an afternoon tea or at a party. If the same care is devoted to the preparation of the one as of the other, boys and girls will eat their lunches with enjoyment and good appetites. [Sidenote: Why an attractive table calls for pleasing guests] If the table is made to look clean and inviting, do you not think that you, in your turn, should make yourself as neat and clean as possible before you come to it? Dirt on your hands and face not only does not look well, but contains a great many germs that may get into your food and thus find their way into your body and try to make you ill. [Illustration: FIG. 22. Two lunches. Which is the more tempting?] [Sidenote: How foods should be eaten] Besides being eaten in pleasant surroundings, all food should be eaten slowly. Let us suppose that we are all seated at a clean, inviting table and everyone is clean and happy. Before the children is the very kind of food that is best for them. It looks good and they know it is good, and they want to eat all they can of it. But they think of a game of jacks or of ball that they want to play as soon as dinner is over, so they simply "bolt" their food. What are teeth made for? Why, to chew with, of course. But why are we given some teeth that are sharp like knives, and some that are flat like millstones? It seems probable that these different kinds of teeth are intended for special purposes, and so they are. If our teeth were intended only for cutting our food into bits small enough to swallow without causing pain, there would be no need for any except the sharp, knife-like teeth. But we have the big grinders, which were made to use, and it is very important that they be used in the right way. [Sidenote: Why food should be thoroughly chewed] We do not chew our food simply to make it fine enough to swallow, but for quite another reason as well. In our mouths there is a fluid called _saliva_. Think of something that you are very fond of eating, and the mere thought of it makes the saliva come into your mouth. This saliva has a very important duty to perform in connection with preparing the food for the little cells of the body. Each little grain of starch--and you will remember that all vegetable foods are composed largely of starch--has a capsule about it. This simply means that it is done up in a little package. The saliva helps to open this capsule by making it soft (just as water will soften the paper on a package of candy), so that the other digestive juices can reach the starch and turn it into the kind of sugar that is used in the body. If you do not chew your food very fine, the saliva will not reach the starch granules, the little packages of starch will be hard to open when they go into the stomach, and much of the starch will never be made use of in the body. The saliva has much the same action on the coverings of the little packages of meat, for all the meat that we eat is done up in similar packages. A great Englishman, Mr. Gladstone, who lived to be eighty-three, made a practice of chewing every bite of food twenty times, and he thought this had a great deal to do with his being such a strong and well man and living to such an old age. [Sidenote: When desserts are not harmful] After you have eaten meats, bread, and vegetables, it will do no harm to eat a piece of pie or cake, or a dish of ice-cream or some other dessert. It is not easy, as a rule, to digest these things (that is, to get them into such shape that they can be used as food by the little cells in the body), but a moderate amount of them is very good for boys and girls, as well as for grown people. If you refuse to eat the meat and bread, but wait until the dessert is served and then fill your stomach with sweet things, you will be starving some of the little cells, and you will be reminded of this very soon. Sometimes you may be reminded of it by having a pain in your stomach, but more often by getting low grades in your lessons at school. Your teacher will know it, too, because you will be so restless and inattentive in your classes that she will have to give you a low grade in deportment as well. =Questions.= 1. What kind of topics should be discussed at mealtime? 2. What is the objection to an untidy table? 3. What kind of luncheon do you like best? 4. What does a clean table call for? 5. What is the importance of eating slowly? 6. Why should we chew our food thoroughly? 7. When are desserts not harmful? =Remember.= 1. The dining table should be the most inviting place in the house. 2. Unpleasant subjects should be avoided at mealtime. 3. A clean table calls for clean people. 4. Eat slowly and chew your food thoroughly, that the saliva may reach each grain of starch. 5. Desserts are not harmful if eaten at the end of a meal composed of good building and heat-producing materials. CHAPTER X DANGERS FROM POOR TEETH We have learned that chewing is not merely a process of cutting our food into such lumps as we can swallow without hurting ourselves; but that the food must be ground up fine and thoroughly mixed with the saliva, that the saliva may reach every particle of starch. If we do not have good teeth, we cannot grind our food as fine as it ought to be ground, and, as a result, a great deal of the starch will not be reached by the saliva. Nature starts every child with a full set of good, strong, clean teeth. These teeth, which we call first, or milk, teeth, are not very large, but they are perfect in every respect and last until the second, or permanent, teeth come in. That is, they will last so long _if they are taken care of_. If they are not taken care of, they will decay just as the later teeth will decay, and they must be cared for in the same way. [Sidenote: Why we have baby or milk teeth] Boys and girls sometimes wonder why they have a set of teeth that come out before they can have the teeth that must last them the rest of their lives. This is simply because there is not room enough in a child's mouth for the big, permanent teeth. We must have teeth while our jaws are growing, so we have first a set of little teeth. Then just as soon as our jaws get large enough for the big teeth, the little teeth come out and the big ones come in. Teeth are about the hardest substance in the body. If we take care of our second teeth, they should last as long as we live. The only reason they do not last is because we do not take care of them. If a person would keep his teeth clean all the time, he would rarely be obliged to have a single permanent tooth pulled. [Sidenote: Why teeth break easily] Teeth are so hard that they are brittle, that is, they break easily. Glass is brittle, and you can chip off a piece of glass with a pin by sticking the pin into a crack in the glass. In just the same way you can chip off a piece of a tooth by sticking a pin between two teeth. That is what often happens when people pick their teeth with pins, or with any other hard substance. A metal toothpick is just as bad as a pin. [Illustration: FIG. 23. Teeth were not intended for nutcrackers.] Another way by which little pieces are chipped off the teeth is by biting hard things. Sometimes we see boys and girls cracking nuts with their teeth; again we see them trying to bite wires in two. They put their teeth to many uses for which teeth were never made. They do not realize, while they are abusing their teeth in this way, that they are probably chipping the enamel, which is the hard, shiny covering of the tooth, and are destroying the one protection that their teeth have against decay. [Sidenote: Why teeth decay] When a little piece is chipped off a tooth, an opening is made through the enamel. Through this opening germs may lodge in the inner part of the tooth, which is soft. When this happens, a little black speck appears on the tooth, and after a while the tooth begins to ache. If you have a toothache, you go to a dentist, and he probably finds that germs have caused the tooth to decay until there is a hole extending into the very center of it. Teeth grow very close together, but there is always a little space between them. Whenever you eat anything, particles of the food get into these spaces and if allowed to remain there, soon decompose. These decomposing particles of food between the teeth will gradually soften even the enamel, and in this way little openings are made for germs to get into the teeth. [Sidenote: How to care for the teeth] Never pick the teeth. You cannot make them clean by picking them. Every morning and night brush your teeth with a stiff toothbrush and a little tooth powder. Brush them both crosswise and up and down, to get out everything from between them. Do not think you have done your duty if you brush only your front teeth, the ones that show. Brush the back teeth just as thoroughly as you do the front teeth. Very few people will see your back teeth, but these decay just as fast as your front teeth, if they are not kept clean. [Illustration: FIG. 24. A sanitary wash-basin with a separate bowl for washing the teeth.] [Sidenote: How often one should go to the dentist] Twice each year you should have a dentist examine your teeth, to see if there are any little spots where decay has started. If you have kept your teeth perfectly clean all the time, and have not chipped off little pieces, there will be none of these decayed spots. But it is a safe plan to have the teeth looked over at least twice a year, for you may have broken a tooth without knowing it, and by the time a decayed spot is large enough to cause pain, or has made a hole that you can feel with your tongue, it has advanced much farther than it should have been permitted to do. =Questions.= 1. Why should you chew your food thoroughly? 2. Why is it necessary to have baby teeth? 3. How are teeth easily broken? 4. Why do teeth decay? 5. What must you avoid in order to protect your teeth? 6. How should your teeth be brushed? 7. Why should you have your teeth examined twice each year by a dentist? =Remember.= 1. Take care of your teeth and they will last you as long as you live. 2. Do not pick them with pins, or toothpicks of any kind. 3. Do not use them for nutcrackers or wire-cutters. 4. Do not use them for tack pullers. 5. Keep them clean at all times. 6. Brush them up and down as well as crosswise. CHAPTER XI NECESSITY FOR PURE AIR AND HOW TO SECURE IT We have learned how the cells of the body are killed by starvation. Now let us learn how they are choked to death, or killed by lack of air. [Sidenote: How air is changed in the body] The cells of the body need _oxygen_, and the only way we can give it to them is by means of air. Every time we take air into our lungs we are giving oxygen to the red corpuscles or cells in the blood, which distribute it to the other cells in the body. The air that goes into our lungs, if it is fresh and pure, contains a great deal of oxygen and a very little of another gas called _carbon dioxid_. The air that comes out of the lungs contains a very little oxygen and a great deal of carbon dioxid. The blood not only takes the oxygen out of the air, but gives carbon dioxid to the air. This carbon dioxid is very poisonous, and would kill the cells if it remained in the blood; hence we should never breathe the same air twice. There is no lack of fresh air in the world, and no excuse for anyone's ever breathing air that is not pure. [Sidenote: Effects of impure air] If you close all the windows and doors in the schoolroom and shut up the ventilators, you will soon find that you are not able to pay close attention to your studies, and in a little while you will begin to feel drowsy. This is because you have used up so much of the oxygen in the air that there is no longer enough to supply the demands of the little cells, and because, in addition, you are taking into your bodies the poisonous carbon dioxid that has been breathed out into the room. It takes a great deal of fresh air to supply the body with oxygen--about 1,250 cubic feet of air each hour. With thirty or forty children in a room, it does not take long to use up all the oxygen. So there should be a constant supply of fresh air coming into the room. [Illustration: FIG. 25. Results of breathing good and bad air.] [Sidenote: Methods of ventilation] It is not only in the schoolroom that you need oxygen. When you are out-of-doors you get an abundance of fresh air, but from a great many houses every bit of fresh air is shut out. It is always possible to let an abundance of fresh air into any house without causing a draft. A piece of board can be made to fit into a window frame so that when the window is raised, the air will be directed upward and will not cause a draft. Hot-air furnaces are made with cold-air pipes. The fresh air from outdoors comes through these cold-air pipes and, after being heated, is driven into the rooms of the house. Some people think they will save coal by closing these drafts. Not only do they not save coal (for the furnace does not give as much heat when this draft is closed), but they kill their body cells by refusing to give them oxygen. The cold-air pipe in a hot-air furnace should always be kept wide open. In houses heated with steam or hot water, either the windows must be kept open, or some other way must be provided for admitting fresh air and taking out foul air. These arrangements constitute a system of ventilation. Houses heated with stoves must also be provided with some means of ventilation. The stove, by its draft, takes out a little of the foul air, but it will not take out more air than one person poisons. [Illustration: FIG. 26. Restfulness: Effect of good ventilation in a sleeping-room, with the right position for sleeping.] [Illustration: FIG. 27. Restlessness: Effect of poor ventilation in a sleeping-room, with the wrong position for sleeping.] [Sidenote: Why windows should be kept open at night] Many people seem to think that they do not need fresh air at night, and they close their bedroom windows as tight as they can. Those people do not sleep well and often have bad colds. You should always sleep with your windows open. If it is impossible for you to have your windows open without having a draft, choose the draft; it will do you no harm if you are well covered, and under no circumstances will it do you as much harm as the foul air that you breathe if your window is closed. Some persons (fortunately they are few nowadays) will tell you that night air is dangerous. I wonder what kind of air these people expect to breathe at night. Do they expect to fill the room in the daytime with enough air for use at night? Such air would certainly not be very fresh. Night air is the only kind of air that it is possible to breathe at night. [Sidenote: The ventilation of public assembly rooms] Churches, theaters, and ten-cent shows are often very poorly ventilated. You can always tell a poorly ventilated room by the foul odor when you go into it from the fresh air, and it is not wise to stay in such a room. You are killing the cells in your body when you do so, and you will very probably come out of it with a bad cold. When the fresh air strikes you, you feel chilly and you may think you are taking cold then, but in reality you took cold in that room full of foul air. [Sidenote: Ventilation of workshops] Workshops are often poorly ventilated. No person should ever work in a badly ventilated place. The labor unions frequently strike for higher wages, but until recently a strike for better ventilation was rarely heard of. Better ventilation would be practically equal to an increase in wages, because there would be fewer doctors' bills to pay, and less likelihood of losing work through illness. Always have plenty of pure, fresh air wherever you are--in school, in bed, at work, or at play. [Sidenote: Why we should breathe through the nose] The cells in the skin of the nose secrete a watery fluid, and this fluid serves to moisten the air as it passes through the nose. Dry air irritates the mucous membrane which lines the nose, throat, and lungs, and it is very important that the air be moistened before it reaches the throat. Air is also warmed as it passes through the nose. Cold air is irritating to the throat and lungs. The small hairs in the nose catch the dust and dirt in the air and prevent it from going into the lungs. The nose was made to breathe through, and all the air that goes into your lungs should pass through your nose, in order that it may be moistened, warmed, and cleansed. [Illustration: FIG. 28. Showing position of adenoids and tonsils in the throat.] [Sidenote: Why some children breathe through the mouth] Frequently we see boys and girls breathing through the mouth. They do this because there is something in the nose that prevents the air from passing freely through it. If there were nothing in the way, the child would breathe through the nose instead of the mouth, because the natural way of breathing is through the nose. The most common reason for mouth-breathing is the growth of small lumps in the throat just behind the nose. These little lumps are called adenoids. They are not natural, and should be taken out. We do not know why they grow in some children and not in others, but we do know that they should be taken out so that the child can breathe easily through the nose. Large tonsils also cause boys and girls to breathe through the mouth. Tonsils that are large enough to cause the child to breathe through the mouth ought always to be taken out. Large tonsils and adenoids are often found in the same child. [Sidenote: Effects of mouth-breathing] When a child breathes through his mouth all the time, his face takes on a peculiar shape. His upper lip grows long, his lower jaw drops back, and his whole face looks flat. His voice has a peculiar sound, and he finds it very hard to keep up in his classes at school. Children with adenoids and large tonsils are always backward in their school work, and may become deaf if the adenoids and tonsils are not removed. If you breathe through your mouth instead of through the nose, go to the doctor and let him see if you have adenoids or large tonsils; if you have, let him take them out. You cannot possibly grow into a strong, healthy man or woman if you have adenoids and do not have them removed. =Questions.= 1. What does the body take out of the air? 2. What does the body put into the air? 3. What effect does impure air have on the body? 4. Why should one sleep with windows open? 5. What causes the unpleasant odor in a crowded room? 6. How would workmen benefit by properly ventilated workshops? 7. Name the helpful ways in which the air is changed while passing through the nose. 8. Why do some children breathe through the mouth? 9. What effect comes from mouth-breathing? =Remember.= 1. Impure air destroys health. 2. Never sleep in a room where the window is closed. 3. Avoid going into public places or workshops that are not well ventilated. 4. Air must pass through the nose before it is fit for the lungs. 5. Mouth-breathing is not natural and is usually due to some defect that can easily be cured. CHAPTER XII REST ESSENTIAL TO HEALTH [Sidenote: Why exercise is necessary] Exercise is necessary to make our bodies grow and become strong. If we stayed in bed all the time, our muscles would not grow and we could not even walk. If we did not exercise them, the cells in our brains would not grow and we should not know anything. Every part of our body must have exercise, that is, each part must do some work every day. If we used only one part of the body and did not give the other parts any work to do, only the part that we used would grow, while all the rest of the body would be small and weak. [Sidenote: Proportion of rest required] While every part should do some work each day, the whole body needs also to have a proper amount of rest. Even the heart, which seems to be working all the time, must rest. It rests between each beat. The muscles with which we breathe rest between each breath. Every person must have a certain amount of rest each day. A man should have at least eight hours' sleep in every twenty-four hours; boys and girls should have from nine to ten hours' sleep in every twenty-four. It is only while we are sleeping that we have complete rest. [Sidenote: Effect of overwork] Everybody should have some work to do. Boys and girls should learn that work is a part of life, though they should not be expected to do too much. They should not be required to get up at four o'clock in the morning and work until eight, then go to school until four in the afternoon, and then work again until dark. They cannot do this and keep well. Such children will surely neglect their lessons and will fail to keep up in their classes. It is not the children's fault, but the fault of the people who give them so much to do outside of school. Sometimes bright children fall behind in their classes and seem to be sleepy during school hours. Very often these children do not have to do any work at home, but play all the time they are out of school. We usually find that these children not only play all the afternoon, but also go to parties at night and often stay up until midnight. [Illustration: FIG. 29. Children work when they play. The little girl skipping rope is killing the body cells by overwork; she has skipped more than one hundred times and is exhausted.] [Sidenote: Ways in which children overwork their bodies] You may think it is not work to go to a party, but it really is. You are working the muscles and the cells of your brain when you are playing games, and these get tired from play work just as they do from working. It is more fun to do play work than to do real work, but the cells are tired and need rest after either kind of exercise. When you go to a party and stay up until midnight, you do not get nine hours of sleep. How do you expect the cells of your bodies to get enough rest when you treat them in this way? Another thing you do at parties is to eat food that tastes good, but which is not good building material or nourishing for the cells of the body. These things eaten late at night stay in your stomach long after you have gone to bed, and the cells of your stomach do not have a chance to rest at all. Children should have their parties in the afternoon. You can have just as much fun at a party in the afternoon as you can at night, and then your stomach will have time to dispose of the cake and candies you have eaten, and will be ready to rest when you go to bed. Small children should be in bed by eight o'clock at night, and even big girls and boys should be asleep by ten o'clock every night. If you do not give your bodies rest, you can never grow into strong men and women. [Sidenote: The importance of regular meals] We have learned that every part of the body needs regular rest. Your stomach is a part of your body. In the stomach and intestines all the food is changed so that the little cells can make use of it. Do you think the cook would serve good meals if she were kept cooking all the time, both night and day? You know she would soon stop cooking for you if you did not give her time to rest. Your stomach does work that is even more important to you than cooking. [Sidenote: Why meals should be at least four hours apart] It takes about four hours for your stomach to dispose of what you give it at a single meal. If you eat your breakfast at eight o'clock, your stomach is going to be kept busy to get rid of it by noon. Of course you expect to give it more work to do at noon; that is, you expect to eat a good luncheon. It will be after four o'clock by the time your stomach has finished the task you put on it at noon, and there will be only about an hour and a half for the stomach to rest before you will be ready to give it another four hours' task, digesting your supper. This means that your stomach cannot go to sleep until ten o'clock. If you eat three meals a day, you will give your stomach just about two hours' rest between eight in the morning and ten at night. If you let it rest from ten at night until eight in the morning, it is not likely to give you any trouble. [Sidenote: When and why candy eating is harmful] Some people will not let their stomachs rest at all. Often boys and girls give their stomachs extra work to do by eating sweetmeats in the middle of the morning while their stomachs are still busy with breakfast. Then, as soon as school is out in the afternoon, they want to eat more cake and candy, and thus take away from the stomach the little rest it has a right to expect before it goes to work on supper. Then suppose they go to a party and eat again about midnight. How much time will the stomach have to rest before breakfast? [Sidenote: When candy eating is not harmful] Now, I have not said that boys and girls must not eat candy; and what is more, I am not going to say any such thing. You may go home and tell your mother that candy is good for girls and boys and that they like it so well they ought to have it--no, not all the time. Here is the part that some of you will not like. Girls and boys ought to have all they want just after eating luncheon or dinner. If you have eaten a hearty meal, it is entirely safe for you to eat candy then; you will not be giving extra work to your stomach, for the candy will be taken care of along with the rest of the meal. =Questions.= 1. Why should we all take exercise? 2. How much rest is needed each day? 3. Name some of the effects of overwork. 4. How do children overwork their bodies? 5. Why should children have their parties in the afternoon? 6. Why should meal hours be regular? 7. When and why is candy eating harmful? 8. When is candy eating not harmful? =Remember.= 1. Proper rest is necessary to health. 2. Rest from play is as necessary as rest from work. 3. You must give the stomach rest by having regular meal hours and by eating nothing between meals. CHAPTER XIII CARE OF THE EYE AND EAR [Sidenote: The loss of sight] Sight is one of the greatest blessings we have. Think how dreadful it is to be blind. If you take care of your eyes, there is no reason why you should be blind; but if you do not take care of your eyes, there is a possibility that you may lose your sight. Most of the blind people in the world became blind because their eyes were not given proper care, and most of this lack of care happened when these people were babies. [Illustration: FIGS. 30 and 31. The roller towel is a common source of infection of eyes in schools; every school should have properly constructed wash-rooms, with individual towels.] [Sidenote: How germs get into the eyes] Many of the diseases that affect the eyes are catching. They are not carried through the air, but are transmitted by the use of a towel or handkerchief used by someone who had the disease. Never use the towel or handkerchief that another has used. Germs may be rubbed into the eyes. Keep your hands away from your eyes. Your hands may have disease germs on them, and when you rub your eyes you may put the disease germs into them. [Sidenote: How eyes are overworked] Many boys and girls ruin their eyes by making them do too much work. They do this by reading in a poor light, by reading where the light strikes into the eyes, or by reading in a bad position, as when in bed or lying down. When you are reading, drawing, or doing any work with the eyes, always have the best light possible, which means that the light should fall on your book or work over your left shoulder. If you are only reading, it does not make much difference which shoulder the light comes over, provided it comes from behind. If you are writing or drawing, and the light comes over your right shoulder, it makes the shadow of your hand fall just where you want to see. [Illustration: FIGS. 32 and 33. Correct positions for reading and writing.] Another way of working your eyes too much is by trying to see when the eyes are not focused right. Sometimes people are said to be near-sighted, because they cannot see very well at a distance. This is due to the fact that the eyeball is too long, so that the lens does not cause the rays of light to focus on the retina. Some people are called far-sighted. This means that they can see well at a distance, but that it is hard for them to see things close to them. Far-sighted children can usually see things near by, but they do this by making the muscle that rules the lens of the eye work too hard. [Sidenote: Method of testing the eyes] Probably your teacher has a test chart and can tell you whether your eyes are properly focused. If your eyes are not focused right, that is, if you cannot see the line of letters marked =20= when you are twenty feet from this chart, there is something wrong with your eyes. In that case, you are not only injuring them by trying to study, but you are hurting the whole body by overworking a part of it. If you cannot see the letters on the test card clearly at a distance of twenty feet, ask your father to send you to a specialist who will fit you with the proper glasses or will treat your eyes so that you can see well. [Sidenote: How to test the hearing] Sometimes children are backward in their school work because they cannot hear well. Your teacher can test your hearing by holding a watch near your ear. If you cannot hear a watch tick when it is held six feet from your ear, ask your father to take you to your doctor, that he may treat your ears. [Sidenote: How to care for the ears] If your hearing is perfect, the best way to take care of the ears is to let them alone. Never try to dig into the canal that leads to the middle ear. The ears must of course be washed to keep them clean, but in washing the ear you should not touch the delicate canal leading to the drum. A great specialist once said, "Never put anything smaller than your elbow into your ear," to which another great specialist added, "And wrap a towel around your elbow." Never try to dig the wax out of your ears; it belongs in your ears; it is there for a purpose, so let it alone. If it becomes hardened, you cannot get it out and will only injure your ears in trying to do so. An ear spoon is a dangerous thing. =Questions.= 1. State the chief cause of loss of sight. 2. How can you keep germs out of your eyes? 3. Name three ways by which you may overwork the eyes. 4. Tell how to take care of the ears. =Remember.= 1. Overworking the eyes is as injurious as overworking the stomach. 2. Keep your hands away from your eyes; germs on your hands may get into your eyes and cause them to become sore. 3. You overwork your eyes when you try to read or write in a poor light or in a bad position, as when lying down. 4. You overwork your eyes when you try to study with eyes that are not properly focused. 5. Keep your fingers out of your ears. 6. Take care of your ears by letting them alone. CHAPTER XIV CARE OF THE SKIN If you break or cut the skin on your body, you make an opening through which germs can get in. You cannot always help breaking your skin, but you can always wash the break with soap and water, and put a clean cloth over it to keep out germs. [Sidenote: The work of the sweat glands] The work of the little sweat glands is very important to your health. These glands are just as important as the kidneys, and if they did not do their work, you would die very quickly. If your body is covered with dirt, the work of these glands is seriously interfered with; and when the sweat glands are not doing their full amount of work, the kidneys must do more than their share. It is never right to make one part of your body do the work intended for another part. [Illustration: FIG. 34. A model bathroom.] When the body is dirty, not only are the sweat glands interfered with, but the little sebaceous (oil) glands become plugged up, and blackheads appear on the face and body. [Sidenote: Importance of bathing] In order that the various glands of the skin may be kept in good health, it is necessary for us to keep clean. To do this we wash our faces and hands and bathe our bodies. Someone may ask, "How often ought a person to take a bath?" The question cannot be answered, except to say, "Just as often as may be necessary for you to keep absolutely clean." Some people do not have to bathe as often as others, but no one can keep clean unless he takes a bath at least twice a week. [Sidenote: Hot or cold baths] Another question that is frequently asked is, "Is it better to take a bath in cold or hot water?" This is another question that cannot be answered in the same way for every person. A cold bath is more stimulating than a warm bath. If, after you have taken a cold bath and rubbed yourself briskly with a rough towel, the skin becomes red and warm, a cold bath is best for you. But if, after you have taken a cold bath and rubbed yourself for not more than ten minutes, the skin appears bluish and cold, a cold bath is not good for you, and you should not take it. A cold bath should always be taken in the morning, just after getting out of bed, and a warm bath should always be taken in the evening, just before going to bed. [Illustration: FIG. 35. A nail properly cared for, and a nail not properly cared for. Which should you prefer to have?] [Sidenote: How to care for the nails] The finger nails and toe nails are a part of the skin and they also need to be taken care of. You will see at the root of your finger nails a thin layer of skin that is inclined to grow out with the nail. If this skin is not kept pushed back it becomes rough, breaks into little shreds, and forms "hang nails." This little band of skin should always be kept carefully pushed back. The finger nails should be kept evenly and neatly trimmed, but they should not be cut so close to the skin that the ends of the fingers project beyond the nails. The nails are for the protection of the ends of the fingers and toes. Nails that are trimmed unevenly and nails that are bitten off are ugly and indicate untidy habits. The shape of the nails should follow the outline of the ends of the finger. Neither is it a sensible fashion to trim the nails to points or to let them grow very long. The toe nails need attention just as much as do the finger nails. They should be trimmed to follow the shape of the toe. Failure to trim the toe nails properly will result in ingrowing nails. Dirt is very likely to collect under the nails. This should always be carefully cleaned out. You cannot wash this dirt out unless you use a stiff nail brush. If you clean your nails just after you wash your hands, you will find that it will be much easier to get the dirt out while the dirt and the nail are both softened by the soap and water. In cleaning your nails, use a dull nail cleaner or a smooth wooden stick. Do not scrape the inside of the nail with a sharp knife. This scraping of the inside of the nails will cause them to catch the dirt more easily, as well as to grow thicker and thicker until they become very ugly. Neat, clean finger nails help to make pretty hands; dirty, untidy nails spoil the prettiest hands. =Questions.= 1. What are the uses of the sweat glands? 2. How often should people take baths? 3. How can you tell whether a hot or a cold bath is better for you? 4. Tell how finger nails should be cared for. 5. How should toe nails be treated? =Remember.= 1. If you do not keep your body clean, the glands of the skin cannot do their work properly. 2. Every person should take a bath at least twice a week; some persons need a bath every day in order to keep clean. 3. If you take a bath in cold water, and the skin does not become warm and pink when you rub it with a rough towel, a cold bath is not good for you. 4. Cold baths should be taken in the morning on getting up. 5. Warm baths should be taken in the evening before going to bed. 6. Finger nails should always be kept clean and neat; dirty, untidy nails make ugly hands. CHAPTER XV COMMON POISONS TO BE AVOIDED Many people are killing the cells of their bodies by taking certain poisons into them. There are many kinds of poisons that can be taken into the body, but we are going to learn now about only two. These are tobacco and alcohol. [Illustration: FIG. 36. Effect of cigarette smoking.] [Sidenote: Proof that tobacco is a poison] Tobacco is a poison. Those of you who have tried to smoke know this, because it made you sick the first time you tried it. There are many other indications that tobacco is a poison. We know that it affects the red blood cells in such a way that they do not carry the oxygen as well as do those of people who do not smoke. We know that it has a very bad effect on the heart and that it interferes with the action of the nervous system. [Sidenote: The extra work caused by tobacco] When certain poisons get into the body, the blood makes something that will counteract the effects of those poisons. After one has used tobacco for some time, the cells of the body will take care of the tobacco poison by making an antidote for it. More than this, they begin to want it all the time. The tobacco user forces the cells of his body to make an antidote for this poison every time he uses tobacco. Thus he makes the cells do work that is unnecessary, and keeps them from doing work that is necessary. [Sidenote: Other bad effects of tobacco: (_1_) On the nose and throat] Tobacco smoke irritates the cells that line the throat and nose and causes inflammation. This is why so many smokers have catarrh. Smoking is not the only cause of catarrh, for people who do not smoke often have this trouble, but it is one of the most frequent causes. Smoking also irritates the throat so badly that many of those who smoke have "smoker's throat." This is a bad form of sore throat that can be cured only by stopping the use of tobacco. [Illustration: FIG. 37. The athlete knows that alcohol and tobacco are foes to speed, strength, and nervous control. (_From photograph of "The Sprinter," modelled by Dr. R. Tait McKenzie._)] [Sidenote: (_2_) On the blood] People who smoke a great deal have fewer red corpuscles (the little red cells of the blood) than those who do not smoke. Especially is this true of cigarette smokers. It is the lack of red blood cells that causes the cigarette smoker to look pale and sallow. It is probably not the direct effect of tobacco that causes the loss of red blood cells, but something that is connected with the act of smoking. When you take smoke into your mouth, you take in at the same time a gas known as _carbon monoxid_. This gas is very poisonous to the body, and combines with the red blood cells in such a way that they cannot take up the oxygen in the lungs and carry it to the rest of the cells in the body. The cigarette smoker almost always inhales the smoke, and thus he absorbs a great deal more of the carbon monoxid than the man who does not inhale the smoke. Of course, the more of this gas he takes into his body, the more red blood cells will be affected and the less oxygen will be taken to the other cells. [Sidenote: (_3_) On the nervous system] We do not know just how tobacco affects the cells of the nervous system. It may be that they are affected mostly by being deprived of oxygen, or it may be that the tobacco affects them directly. However the harm is done, we know that the cells of the nervous system are affected by tobacco. One of the nerves that is most commonly affected by the use of tobacco is the nerve of the eye, the nerve that enables us to see. We know that when people use tobacco a great deal they sometimes lose their sight. This does not happen to everyone who uses tobacco, but you can never tell whom it will affect in this way. The only safe thing to do is not to use tobacco, and then you will know that you will not lose your sight from this cause. [Sidenote: (_4_) On the stomach] The use of tobacco affects the stomach. People who use tobacco a great deal are likely to have indigestion. The tobacco causes this probably by depriving the stomach cells of oxygen through its effect on the blood cells. [Sidenote: (_5_) On the heart] Tobacco has a very bad effect on the heart. People who use much tobacco have what they call "palpitation of the heart," but doctors call it "tobacco heart," because it is caused by the use of tobacco. No insurance company will insure a person who has "tobacco heart." Most boys grow up to be men before they manage to use enough tobacco to cause tobacco heart. However, long before they are grown, they show that the tobacco has affected their hearts, because they are short of breath and stand about as much chance of winning a race as does a mouth-breather. [Sidenote: Effects of alcohol:] The effect of alcohol is a subject on which I want to speak very plainly and frankly, because I do not want the boys and girls who read this to get the same idea that I got when I was in school, or to be affected by it as I was. When I was a little boy I was taught that if a person drank alcohol in any form the lining of his stomach would be eaten up. In proof of this statement I was shown a picture of an ulcerated stomach that was said to have resulted from drinking whisky. Naturally I expected to find that people who drank whisky would not be able to eat anything at all, or would be troubled a great deal with pain in their stomachs. To my surprise, I found that many people had ulcers of the stomach who never took an alcoholic drink, while many of those who drank a great deal seemed to have the best of appetites and were never troubled with their stomachs. As a result, I came to the conclusion that all this talk about the evil effects of alcohol was foolishness. Later I studied medicine, and learned that the effect of alcohol on the stomach is, in reality, the least of its evils. But I want to impress upon you that, as a result of forty years' study, I consider alcohol the most dangerous thing in the world to-day. By "alcohol" we mean any drink that contains alcohol, such as whisky, wine, brandy, beer, etc. [Sidenote: (_1_) On the stomach] When alcohol is taken into the stomach, it first causes a congestion; that is, it causes an increase in the quantity of blood in the blood vessels of the stomach. It might seem that this would aid digestion in the stomach, but it does not, because alcohol affects the food in the stomach in such a way that it prevents the gastric juice from acting on the food. If the use of alcohol is persisted in, it causes the little cells in the stomach that make the gastric juice to become filled with fat, and then those cells cannot make the gastric juice. Thus, continued use of alcohol causes a smaller supply of gastric juice, and the food passes from the stomach into the intestines without having been acted upon by the gastric juice, as it should have been. The result is that the food decomposes in the intestines and a poison is formed. This poison is taken up by the vessels that carry the food from the intestines and kills a great many of the cells of the body. Alcohol does not burn holes in the stomach, but it destroys the usefulness of the stomach by its action on the cells that secrete the gastric juice. [Sidenote: (_2_) On the liver] When alcohol is taken into the stomach, very little of it reaches the intestines. It is rapidly absorbed by the lining of the stomach and passes into the blood. The blood from the stomach goes directly to the liver. The alcohol makes the cells of the liver hard and causes them to become filled with fat, as it does the cells of the stomach. In this way it destroys the action of these cells and prevents their doing the work for which they are intended. From the liver the alcohol goes with the blood to all parts of the body, and it has its influence on all the cells in the body. This influence is always harmful. [Sidenote: (_3_) On the body's powers of resistance] We know that when a man who is in the habit of drinking gets pneumonia, he is far more likely to die than is one who is not in the habit of using alcoholic drinks. The man who drinks cannot resist the effects of disease as can one who does not drink. This shows that the use of alcohol reduces our resisting powers, and puts our cells in such condition that we cannot overcome the effects of disease. People who are sick with a slow disease like consumption are often advised by their friends to take whisky to brace them up. It is true that the immediate effect of the whisky is to make the patient feel a little better, but the final effect is to leave him in a much weaker condition than before. More than this, the cells are much less able to resist the disease germs than they were before the alcohol was taken. When people are exposed to such diseases as scarlet fever and smallpox, they may think that if they take a drink of whisky they will not be so liable to contract the disease. It is just the other way. The alcohol reduces the resisting powers of the cells of the body, and anything that does this renders a person more liable to contract any disease to which he is exposed. [Sidenote: (_4_) On the nervous system] The effect of alcohol on the cells of the nervous system is very marked. Continued use will injure the nervous system and result in a kind of insanity called delirium tremens. It will also cause other forms of insanity. The effect of alcohol on the parent is passed on to the children of the next generation, and even beyond this. A large percentage of idiotic children are the offspring of alcoholic parents. [Sidenote: (_5_) On the morals] The use of alcohol numbs the sense of right and wrong. More young men have become criminals from the use of alcohol than from any other one cause. Anyone who reads the daily papers can see that many criminals give the use of alcohol as an excuse for having committed a crime. [Sidenote: (_6_) On brain work] Some people will tell you that alcohol stimulates the brain, so that one can work faster and better. This is not true. Tests have been made in this matter, and it has been found that men doing mental work will work about one tenth slower and make one fourth more mistakes when given one drink of whisky a day, than they will when not given any whisky. If _one_ drink of whisky a day thus reduces a man's power and accuracy in doing mental work, what do you think three drinks, or ten drinks will do? [Illustration: FIG. 38. The mind not clouded by alcohol works quickly and makes few mistakes.] [Illustration: FIG. 39. The mind clouded by alcohol works slowly and makes many mistakes.] [Sidenote: What business men think of men who drink] Many business men drink, and they know the results of alcohol not only from the effects they have observed in others, but also from the effect they know it to have on themselves. When a man applies to them for a position, these business men almost invariably ask him if he drinks. The man who does not drink stands nine chances in ten of securing the position, while the man who drinks stands only one chance in ten. This shows what business men think of the effect of alcohol, even when taken in moderate quantities. They know that it reduces a man's power to do mental as well as physical work, that it causes him to make mistakes, and that it may finally destroy his morals and result in his becoming a thief or a criminal. =Questions.= 1. How do we know that tobacco is a poison? 2. How does tobacco make extra work for the body? 3. What effect does tobacco have on the nose and throat? 4. What is the effect of tobacco on the blood? 5. On the nervous system? 6. On the heart? 7. Mention some of the false ideas about the effect of alcohol. 8. How does alcohol affect the stomach? 9. The liver? 10. In what ways does alcohol reduce the resisting powers of the body? 11. How does alcohol affect the nervous system? 12. How does it influence mental work? 13. What do business men think of drinkers? 14. What influence has alcohol on the next generation? =Remember.= 1. Tobacco is a poison that has a very bad effect on the nervous system, the blood, the heart, the stomach, the nose, and the throat. 2. Alcohol is a poison and not a food. 3. Alcohol injures the stomach, the liver, and the nervous system. 4. Alcohol reduces the power to do accurate mental work. 5. Alcohol numbs the sense of right and wrong, and encourages crime. PART II THE ENEMIES OF HEALTH CHAPTER XVI DISEASE GERMS We have learned that the body is made up of cells, and that each cell is alive. The cells in our bodies cannot live separately. There are, however, certain animals and plants that are each made up of a single cell. These animals and plants are called germs, and some of them cause disease. [Sidenote: Different germs cause different diseases] These germs are so exceedingly small that we can see them only with the aid of a microscope. They differ in appearance one from another, as a pine tree differs from an ash, or an American child from a Chinese child. When you plant your garden, you put sweet peas in one place and asters in another, and you know that you will have sweet peas growing where you planted the pea seeds, and asters growing where the aster seeds were put. So it is with these little germs; you will no more get tuberculosis from typhoid fever germs than you would get asters from pea seeds. Now, while there are many, many kinds of germs in the world, there are only certain ones that cause certain diseases, and we have learned where these germs like to live and how to kill them. We also know that they come only from some person or animal sick with the particular disease which they cause. Typhoid fever germs are not given off by a person suffering with tuberculosis, nor are diphtheria germs given off by a typhoid fever patient, but the germ of each disease is given off by some person or animal suffering from that particular disease. [Sidenote: How sickness due to germs can be prevented] If we kill all the germs that come from people sick with a certain disease, no one else can catch that disease. Knowing this, it seems unnecessary for anyone ever to be sick with disease that is caused by a germ. This is literally true, and the only reason that we have germ diseases is because we do not kill the germs that come from the sick people. Professor Irving Fisher of Yale University has said, "It is entirely possible to wipe out consumption within a single generation." It may not actually be done so quickly, but it is certain that the disease can finally be wiped out, though it may require many generations to accomplish it. Why, then, are germ diseases allowed to exist? Simply because so many people do not know the facts; and because many who do know will not take the trouble to kill the germs, even when they realize that some one else may get the disease as a result of their carelessness. What do you think of a woman who said, "I do not care if my neighbor's children do get scarlet fever from us; she is not a friend of mine, any way"? A woman has been heard to make such a statement to a health officer. It is just such people as this who spread disease. =Questions.= 1. How may germs be compared to seeds? 2. What do we know about disease germs that will help us to get rid of them? 3. How is it possible for us to get rid of consumption and other germ diseases? =Remember.= 1. While there are many kinds of germs in the world, only a few cause disease. 2. The germ that causes a certain disease will cause that disease and no other. 3. It is entirely possible to kill all the germs that cause disease. CHAPTER XVII ENCOURAGEMENT OF DISEASE BY UNCLEANLY HABITS We shall not try to learn here all the ways by which it is possible to destroy the germs of disease as they come from sick people. But there are certain rules (we sometimes call them fundamental principles) that you must know, if you hope to keep well and to prevent others from getting sick. [Illustration: FIG. 40. How diseases are frequently transmitted to children.] [Sidenote: Why we should stay away from the sickroom] The first of these rules is: _Do not go into the room where any one is sick unless it is absolutely necessary_. No one but the nurse should sleep in the room with a sick person. We know that certain diseases are communicable (catching), but it has not yet been determined whether some others are communicable or not. It has not been proved, for instance, that we cannot catch rheumatism from another person. Only a few years ago it was believed that one could not take consumption from another person, but now we know that this is the very way to get it. Therefore, stay away from sick people as much as possible. It is not good for the patient to have people around him, and it is dangerous for the well to come in contact with the sick. [Sidenote: Not using things used by the sick] The second rule is: _Do not use anything used by a sick person until it has been washed_. This is a good rule to apply to things used by a well person also. It is neither safe nor pleasant to eat from the spoon or fork, or to use the napkin or towel which has been used by someone else. Sometimes children think the food prepared for a sick person is ever so much nicer than that set before themselves, and wish they could have a little of it. How often have we seen a sick mother give her little ones "a taste" from the spoon with which she is eating. This is very dangerous, and if she knew it, the mother would cut her hand off before exposing her children to this danger. [Sidenote: Reason for scalding things used by the sick] Third: _Everything taken from a sickroom should be boiled before it is used again_. The knives, forks, and plates should not be put with other dishes until after they have been separately washed and boiled. Towels, napkins, bedding, and clothing from a sickroom should not be washed with other bedding and clothing, but should be washed and boiled separately. Some people send out the clothes from the sickroom with the rest of their washing, and in this way give disease to others. [Sidenote: How excreta from the sick should be treated] Fourth: _All discharges (sputum, urine, bowel discharges, and matter from sores) from any sick person should be thoroughly disinfected before being finally disposed of_. The sputum should be received on little rags or paper napkins, and burned; and the other discharges should be disinfected with some poison that will kill the germs. We shall say more about disinfection when we come to study the prevention of special diseases. [Sidenote: Necessity of washing the hands after touching the sick] Fifth: _Every person who touches a sick person, or handles anything that comes from a sickroom, should immediately wash his hands_. Unless he washes his hands at once, the germs which may be on them may get into his mouth. [Sidenote: How dirt causes disease] Sixth: _Dirt, which is an indirect cause of disease, must not be allowed to accumulate_. If your yard were full of dirt, garbage, and manure, it would not cause disease unless the germs of some disease became planted there. But such a place is an indirect cause of disease, in that it furnishes a fine place for germs to grow in. If a fly with typhoid germs on its feet were to alight in such a yard, the germs would be planted in a most favorable spot and would grow very fast. [Illustration: FIG. 41. A place that is an indirect cause of disease, since it furnishes a fine place for germs to grow in.] None of the disease germs like sunshine; neither do they like dry places. They die very quickly in the sunlight, and grow very slowly, if at all, in dry places; but in damp, dark places they grow very fast. Dirty back yards make ideal gardens for germs. Let a fly with germs on its feet alight in a clean yard where sunshine can reach every corner, and what chance will the germs have to grow? They will not even get a start. Hence, while disease cannot be caused by dirt, disease germs stand a very good chance of living where there is plenty of dirt and no sunshine. Filthy habits are on an equality with filthy conditions, and go hand in hand with them. One of the worst of habits, and a cause of much sickness, is that of answering Nature's calls in places other than the closet. =Questions.= 1. Why should you never make unnecessary visits to a sick person? 2. Why should you avoid anything used by a sick person? 3. Why should everything taken from a sickroom be scalded? 4. What should be done with all discharges from a sick person? 5. How is dirt a source of disease? =Remember.= 1. Unless it is necessary, do not go into a room where anyone is sick. 2. Never sleep in a room with a sick person. 3. Never eat from a spoon or plate that has been used by another. 4. Boil all the articles taken from the room of a sick person. 5. Always wash your hands after touching a sick person or anything that comes from his room. 6. Sunshine kills germs; let the sunshine into every corner of your house. CHAPTER XVIII FLIES AS CARRIERS OF DISEASE [Sidenote: How germs get into our bodies] Disease germs get into our bodies in three principal ways: they are eaten with our food; they are taken in with the air we breathe; and they get in through breaks in our skin, even though these breaks be very small, as when made by the bite of a mosquito or other insect. [Sidenote: How germs get into our food:] [Sidenote: (_1_) From the air] How do germs get into our food or drink? You must remember that these germs are extremely small, so small that many of them can be carried by a particle of dust that you can see only in a ray of sunshine. When the germs become dried, they float about on these particles of dust, the dust alights on our food, which is moist and warm, and the germs immediately begin to grow. [Sidenote: (_2_) From the hands] Another way by which germs get on food is from the hands through which it passes. Did you ever think how many people handle an apple? First, the man who picks it from the tree; then the examiner in the packing house where apples are taken to see that they are the right kind to be packed in a certain box. Then it is wiped off by a boy or girl--handling number three; then it is wrapped in paper--number four. Next it is packed in a box, but in this case the paper protects the apple from dirty hands. When the merchant buys the apples he feels several of them, and puts them out on the display shelf; this makes handling number five. Everyone who thinks of buying apples will touch one or more of them, and when they are sold the clerk handles them again. In other words, every apple goes through the hands of at least seven people before you get it. Do you not think it needs washing? Go into a butcher shop and see how many people will put their dirty fingers on the meat. Some of them even keep their gloves on when they do this. Imagine how many germs may be planted on the finger of a glove. Our whole method of displaying foods for sale is wrong. The customer can see the fruits, vegetables, and meats just as well in a glass case as when they are on an open counter or shelf, and nothing is gained by poking a dirty finger into a piece of beef, or by rubbing your hands over the apples. A glass case not only will protect the fruits and meats from such practices, but will keep out germ-laden dust and flies whose feet are covered with germs. [Illustration: FIG. 42. The foot of a fly, highly magnified.] [Sidenote: (_3_) From flies] _Probably the most common source of germs on food is the fly._ Did you ever watch a fly very closely for a long time? Did you ever happen to see a manure pile early in the morning and notice how many tiny flies are on it? These flies have just been hatched. [Sidenote: Breeding places of flies] Flies like manure because it is the best place they can find in which to lay their eggs. Each female fly lays about three hundred eggs. They do not hatch directly into flies, as hen's eggs hatch into chickens, but when the fly's eggs hatch you find maggots, and these maggots later hatch into flies. [Sidenote: The journey of the fly] Turn over the manure some spring morning, and you will see it full of white specks. These specks are maggots that will hatch into flies. Watch the flies as they leave the manure pile and see where they go. If there is a dead dog or cat or a filthy garbage can near, they will fly to it. Then they will go into the water-closet and crawl over the filth there. Their next trip will probably bring them to the kitchen, where they will crawl over the food. From here they will go to the cuspidor and take a drink of water, and will get their feet covered with the dirt that is in the cuspidor. Next they will try a walk over the nipple of the baby's bottle, or they will light on your face, or get into the butter or milk. After the fly has been in dirty places, he "washes" his face and hands, that is, he rubs his feet together and then rubs them over his head. Did you ever see a fly wash himself with water? No, you never did. [Illustration: FIG. 43. Where a fly has walked; each little spot represents a growth of germs left by the fly.] After a fly has made his journey, you would suppose that his feet would be covered with dirt and germs, and so they are. Not only does he carry germs on his feet and body but he also eats dirty and diseased things. Moreover, fly specks contain the germs of disease, and the fly is not at all particular about where he puts his specks. [Sidenote: Proof that the fly is a germ carrier] If you let a fly walk over a culture plate, there will be a growth of germs wherever his feet touch. A culture plate is simply a glass plate covered with gelatine or something else in which these germs like to grow, and where they can easily be seen. Each germ will multiply so fast that there will soon be a spot of them large enough to be seen readily with the naked eye. In the picture showing a culture plate over which a fly has walked (Fig. 43), the little specks are not single germs, but each speck represents a growth containing many thousands of germs. [Illustration: FIG. 44. Flies go from filth to food.] [Sidenote: How to get rid of the fly:] How are we going to get rid of flies? We cannot get rid of them entirely, but there are a great many ways by which we can prevent there being so many of them, and whereby we may keep them out of our houses and away from our food. [Sidenote: (_1_) By removal of manure] We have learned that flies are always found about horse manure, because it makes a good place in which to hatch their eggs. If we could dispose of the manure, there would be one place less for the fly to lay her eggs. Behind barns we usually find piles of manure. It is in these heaps that the fly lays her eggs, not in the little lumps found in the streets. Now, there is no sense in keeping this great pile of manure about any barn. In towns the manure can be put into a box with a cover, so that the flies cannot get at it. In the country every well-managed farm has the barns cleaned out every day, and it would not be much more trouble for the farmer to throw the manure into a wagon and take it to the fields with him, than it is to pile it up beside his barn. If he did this, he would find that there would be few flies about his house. [Sidenote: (_2_) By covering garbage cans] Even if we were to take every particle of manure away as fast as possible, we should still have some flies, for when flies do not find manure for their hatching places, they will take the next best thing. It must be something dirty; clean things will not answer at all for a fly's home. Next to the manure pile, the fly likes a dirty garbage can, a dead animal, or anything that is decomposing. If she cannot find anything better, she will take a rotting apple; but she does not really like this, and if she cannot find anything better than an old apple in your yard, she will probably go elsewhere to lay her eggs. [Sidenote: (_3_) By keeping clean yards] We cannot entirely stop the hatching of flies, but if we do away with the old manure piles, keep fresh manure and garbage cans covered, and keep our yards free from everything that can decompose, we shall have very few flies about our houses. [Sidenote: How to keep flies out of the house] Since we cannot get rid of all the flies, the next best thing is to keep the few that may be left out of our houses and away from our food. This we can do by means of wire screens and netting. Wire screens are very cheap, and if there are no wire screens on your house, you should persuade your father to buy some. But a screen will not keep flies out unless it is kept closed, so do your part by never leaving the screen door open for a second longer than is necessary for you to go in or out. Our houses are not the only places that need screens. Slaughterhouses, butcher shops, candy stores, grocery stores--every place where any kind of food is handled or sold--should be screened. Flies should never be allowed to alight on anything which is to be eaten. =Questions.= 1. Name three ways by which germs get into our bodies. 2. How do germs get into our food? 3. Why should foods be screened? 4. Trace the fly from his birth-place to our food. 5. How do we know that flies have germs on their feet? 6. Tell how we can get rid of most of the flies. 7. How can we keep flies out of the house? 8. What can boys and girls do to help keep them out? =Remember.= 1. Always wash an apple, pear, or any other fruit before you eat it. 2. All foods are handled by many people, and are not clean until they have been washed. 3. Flies like to live in dirty places, and their feet and legs are covered with germs; get rid of the flies. 4. Flies hatch in manure piles and other dirty places; keep your yard and lot clean so that flies will have no place to lay their eggs. 5. Put screens on the house to keep flies out, and keep the screens closed. CHAPTER XIX HOW DISEASE GERMS GET INTO WATER The water that we drink frequently contains disease germs. It is not always the clearest water that is freest from disease germs, for the germs do not make the water cloudy. [Illustration: FIG. 45. An improperly located well; notice lines of seepage.] [Sidenote: Why sewage should not be put into streams] Water does not get disease germs from the ground, but from man. Almost every town has a sewer system that empties into some stream. This practice was started a long time ago when men thought that running water would purify itself in the course of a few miles. We have learned, however, that this is not true. Germs will continue to live in running water just as they do in any other water, and disease germs will live in a stream from twenty-five to thirty-five days. Estimate how far a stream will flow in that length of time, and you will know how far disease germs will travel in that way. No sewage should ever be allowed to get into a stream until the germs in the sewage have been killed. [Sidenote: Other sources of germs in streams] Sewage is not the only means by which disease germs are carried into streams. Often we find people building barns, slaughterhouses, and mills on the banks of a stream. The filth from barns and slaughterhouses always contains disease germs, and often the filth of mills contains poisons that are just as harmful as germs when taken into our bodies. None of these things should ever be allowed to get into a stream. Water is a very important article of food, and we should take every care to keep it pure. [Illustration: FIG. 46. A properly located well.] [Sidenote: How germs get into wells] The water from most wells is clear and cool, but nevertheless may contain many disease germs. "How does this happen?" you ask. Because the well is too close to an out-house or some other source of filth. When a man in the country or in a small town builds a house, he immediately thinks of digging a well just as close to the house as he can, so that he need not carry the water far. Next he thinks of locating the closet, and this, too, he wants near the house. The well and the closet are often near each other, and often the closet is on higher ground than the well. The vault under the closet is seldom water-tight. In fact, the intention of the owner is that a great part of the vault contents shall soak away. In many localities the ground is an open gravel, and the vault contents run through this gravel into the well, carrying disease germs with them. In one little town, with wells as a source of drinking water, the health officers found that the closet of every house was draining directly into its well. In some countries vaults can be used; but in any region where there is a gravel subsoil, the contents of the closet will find their way into the well, unless the closet is lower than the bottom of the well. In such places the vault must be made water-tight, in order to keep the vault contents out of the well.[2] [Sidenote: Why springs are not always pure] Springs are usually sources of pure water, but do not think that every particle of water that oozes from the ground is a spring. Near a certain town is a so-called "very fine spring." This "spring" appeared after a man had made a cesspool on the hill above, and is simply the drainage from the cesspool. Springs that come from deep sources, however, nearly always contain pure water. [Sidenote: The safest sources of water] The safest source of water for domestic use is a stream that is known to be free from contamination, or a well so deep in the ground that it is hard for any polluting matter to reach it. But remember that sewage may follow a well pipe along the outside and thus reach even a deep well, if the well is not properly protected at the top. Keep disease germs out of your drinking water. You cannot drown them out and you cannot strain them out, so do not let them get in, for you cannot drink water containing disease germs without running the risk of becoming sick. =Questions.= 1. Mention more than one way in which germs get into streams. 2. How long may disease germs live in running water? 3. Mention some instances showing that running water does not purify itself. 4. How do disease germs get into milk? 5. Describe the proper location of a well in regard to refuse. 6. How may springs become polluted? 7. What are the best sources of water for domestic use? =Remember.= 1. Disease germs get into water from dirty places along the banks of the streams; they do not come from the ground. 2. Clear water is not always pure; germs do not make the water cloudy or muddy. 3. Wells often become infected by matter from closets seeping into them; make your closet water-tight. 4. Spring water is usually pure, but not all water that oozes out of the ground is spring water. CHAPTER XX TRANSMISSION OF DISEASE THROUGH THE AIR [Sidenote: Disease germs in the air] We take germs into our bodies with the air that we breathe. Since we cannot stop breathing and live, we must see to it that the air we breathe is kept pure. [Illustration: FIG. 47. (a) Prevalence of germs in air of thickly populated districts. (b) Prevalence of germs in air of sparsely populated districts.] There are always more germs in the air of places in which people live closely crowded together than where there are only a few people. This is proved by Figure 47, which shows that many more germs were found on a culture plate exposed in the downtown part of New York City than on another plate exposed far uptown, where there are not so many people. Remember, however, that all germs are not disease germs. [Sidenote: How we may keep disease germs out of the air:] How do the disease germs get into the air? When one sneezes, a spray of droplets is thrown into the air. If the person sneezing has the grip, these droplets contain the germs that cause grip. Whenever a person with consumption coughs, he sprays droplets which contain the germs that cause consumption. [Sidenote: (_1_) When coughing or sneezing] If a person would hold a handkerchief before his mouth when he coughs or sneezes, these droplets of moisture would not be sprayed into the air, and the disease germs in them would not be scattered about. You ask, "Shall everyone who is sick hold a handkerchief before the mouth when sneezing or coughing?" Everyone, whether sick or well, ought to hold a handkerchief before the mouth when sneezing or coughing. Learn to do this at once, and never forget it. [Sidenote: (_2_) When spitting] Another way by which disease germs get into the air is from the sputum. People spit on the floor or the sidewalk, and the sputum becomes dried; it is then blown about as dust. The germs of disease are not killed by drying, and when they get into our bodies with the dust which we breathe in, they immediately begin to grow. Disease germs get into the air chiefly through careless habits of coughing, sneezing, and spitting, and these careless habits can easily be prevented. [Sidenote: Why well people should not spit on floor or sidewalk] A boy once said that if he saw a consumptive spit on the sidewalk, he would want to hit him, and to emphasize his remarks he spat on the floor of the room, just as you have seen boys spit on the ground when they were thinking of fighting. There might have been some germs of consumption in the sputum this boy left on the floor. Of course he was very positive that he did not have consumption, but this was no proof that his sputum was free from the germs of this disease. Remember that it is not only the sick who should never spit on the floor or sidewalk, but that no person should ever spit on any floor or sidewalk, or into any place except into a cuspidor, handkerchief, or spit-cup of some kind. If you spit into a handkerchief, a paper napkin, or a bit of cloth, be sure to burn it as soon as you can, before it becomes dry. =Questions.= 1. In what places do we find germs most abundant in the air? 2. How do well-bred people avoid putting disease germs into the air? 3. Why is it important for well people to take the same precautions as sick people? =Remember.= 1. Every person should hold a handkerchief before the face when coughing or sneezing. 2. Never spit except into a cuspidor, handkerchief, spit-cup, or other special receptacle. 3. If well people will practice clean habits, the sick will be helped and encouraged to follow their example. 4. Remember: No spit, no consumption. CHAPTER XXI INSECTS AS CARRIERS OF DISEASE [Sidenote: Some insects that carry disease] Certain diseases are given to human beings by the bites of insects. We know that certain ticks and mosquitoes carry certain germs. It is also probable that disease germs are transferred from diseased to well persons by bedbugs and other insects that bite. [Sidenote: How yellow fever is transmitted] For a long time it was thought that yellow fever was carried through the air, but now it has been proved that yellow fever is not carried in this way. A well person can sleep with one who has yellow fever and not catch the disease. Yellow fever infection is carried from a yellow fever patient to a healthy person only by a certain mosquito. Keep this mosquito away from the yellow fever patients and there can be no spread of the disease. [Illustration: FIG. 48. The mosquito that carries yellow fever.] It is not many years since yellow fever was one of the most dreaded diseases in warm countries. To-day there is not the same fear of it, for the source of the disease has been discovered and practical methods have been devised to get rid of the mosquito which carries it. [Sidenote: How malaria is transmitted] Malarial fever is another disease transmitted by the bite of a mosquito, but the mosquito that carries malarial fever is not the same as the one that carries yellow fever. For a long time it was supposed that malaria came from the gases which rise from marshes. To-day it is known that it is not the gases that cause the sickness, but a mosquito which lives and grows in the marshes. Many countries that have heretofore been practically worthless on account of malarial fever, are being made valuable by draining the marshes and doing away with places where mosquitoes can hatch. [Illustration: FIG. 49. One of the places where mosquitoes hatch.] [Sidenote: How to get rid of the mosquito] It might seem a very hard task to get rid of mosquitoes in countries where there are so many of them; but it can be done. The mosquito must have still water in which to lay her eggs. In countries where there is danger of yellow fever or malaria, the rain barrel and the cistern should be screened, and the swamps and water holes filled up. Puddles of water should not be allowed to form anywhere, and low places where water might stand should be drained. By giving her no place in which to lay her eggs, we can get rid of the mosquito; and when the mosquito disappears, yellow fever and malaria disappear also. [Sidenote: How wood-ticks transmit disease] In certain portions of Montana, Washington, Idaho, Utah, and Wyoming, there is a peculiar disease known as Rocky Mountain spotted (tick) fever. It is now known that this disease is transmitted to people by the bite of a wood-tick. Not all wood-ticks carry this fever, and for people living in districts where this disease does not exist there is no danger in the bite of a wood-tick; but in a part of the country where the disease prevails, the wood-tick should be avoided. [Sidenote: How disease-bearing insects can be destroyed] All insects that are known to transmit diseases can be destroyed. If we will do away with stagnant water, the mosquito cannot hatch; if we will cut out underbrush and oil the domestic animals, the wood-tick will not find a place to grow. If we wish to get rid of disease, we must spend money and labor; but it is worth while, for human life is at stake. =Questions.= 1. What insects are known to transmit diseases to man? 2. How is yellow fever transmitted? 3. Malarial fever? 4. What disease is transmitted by the wood-tick? 5. How can we get rid of the mosquito? 6. How can we get rid of ticks? =Remember.= 1. It is a proved fact that diseases are transmitted to man by the bites of mosquitoes and wood-ticks. 2. It is possible to do away with both the mosquito and the wood-tick almost completely, although it requires a great deal of work and the expenditure of a large amount of money. 3. Health is the most valuable thing we have, and it is foolish to hesitate in giving the work and money necessary to exterminate disease-bearing insects, as well as the many other causes of sickness. CHAPTER XXII HOW TO KEEP GERMS OUT OF WOUNDS [Sidenote: How germs get through the skin] Germs get into our bodies through breaks in the skin. These breaks may be made by a cut or a scratch, by the bite of an insect, or even by the pulling out of a hair. There are some special germs, such as those which cause yellow fever, which are introduced by the bite of an insect; but at present we will consider only those germs that would naturally enter through any break in the skin. [Illustration: FIG. 50. Small, deep wounds are very liable to become infected.] [Sidenote: Effect of germs in wounds] The skin of the human body acts as an armor against certain germs that are constantly trying to get through it. There are several germs of this class. Some of them cause white pus, or matter, but this is the least dangerous kind of all. Another kind causes boils or even blood poisoning, and another kind causes erysipelas. We cannot get rid of these germs, for they are everywhere, to a greater or less degree; but they are more abundant in dirty than in clean places. They cause every degree of inflammation, from a slight redness of the skin to the blood poisoning that brings death. [Sidenote: Real cause of suppuration] Sometimes you will hear people say that a wound suppurated (that is, became inflamed and full of matter) because the blood was in bad condition. As a matter of fact, there would have been no suppuration if germs had not got into the wound. It was not the condition of the blood that caused the suppuration, but the germs. Sometimes, when only a few germs get into a wound, and when the cells of the body are all in good condition and doing their work properly, the suppuration will be very slight, because the healthy cells of the body will kill the germs. But if very many germs get in, even healthy body cells cannot kill them all. We have said that the germs which cause suppuration are everywhere, so it would seem almost impossible to keep them out of a wound. This is true in a sense; but even after they have got into a wound, you can wash them out if you use plenty of soap and water to cleanse the wound thoroughly. When I said that it is impossible to keep them out of a wound, I meant an accidental wound, for it is quite possible to keep them out of a wound that is made intentionally, as is done by the surgeon. [Sidenote: How the surgeon prevents suppuration] Do you know how a surgeon gets ready to do an operation? The first thing he does is to see that the room is perfectly clean. He has the carpet taken up, the curtains taken down, and the floor and walls washed. This is to get rid of all the dirt and germs in the room. If you should look at the surgeon's instruments, so clean and bright, you would think it impossible for a germ to find a place to live on; but the surgeon knows how closely the germs cling, and therefore he boils all the instruments he is going to use. Then he puts the towels into a place where they are made so hot by steam that all the germs on them are killed. After everything in the room is perfectly clean, the surgeon cleans his patient with a very stiff brush, using plenty of soap and water which has been boiled to kill all the germs in it. He scrubs the part where the wound is to be made and the skin around it until it is red. Even then he is not satisfied, for he washes it off with alcohol and ether, to be sure that any germs that might be sticking in the fat are removed. He scrubs his hands in the same way. After all this is done, he can perform the operation without fear that any of the germs which cause suppuration will get in, for he knows that he has killed all of them that would touch the wound. [Illustration: FIGS. 51 and 52. Always wash the simplest cut with soap and water; failure to do this may result in infection and much suffering.] [Sidenote: How to prevent suppuration] Boys and girls cannot do all this before they cut their hands or skin their shins, but they can do the next best thing--they can keep their hands and the rest of their bodies clean at all times, and thus have as few germs on them as possible. Then, when they have cut themselves, they can go straight to some place where there is soap and water, and can wash the wound thoroughly. After this is done, a clean bandage should be placed on the cut part to prevent any other germs from getting in. If this is done every time you cut yourself, you will probably never have an infection--that is, a wound that suppurates. Two boys were playing together one day. They ran into each other and each got a little cut on his hand. One boy went home at once, washed the wound, and put on a clean bandage. He lost a little time from his play, but was soon back and never had any trouble on account of the cut. The other boy thought it was foolish to quit his play to take care of such a little thing, so he tied his hand up in a dirty handkerchief. Two weeks later he was very ill. His arm was badly swollen and had to be cut open in several places; indeed, he came near losing his arm. It always pays to take care of a wound, be it never so slight. Deep wounds made with small instruments, such as small knives, nails or toy pistols, are especially dangerous, because they are hard to clean and because they quickly heal up on the surface and leave the germs to grow at the bottom of the wound. Such wounds as these are dangerous for another reason. [Sidenote: Where germs of lockjaw grow] There is a germ that gets into wounds but does not cause suppuration. It is the germ of tetanus, or lockjaw. It lives in the ground, especially in the ground about barns, and its peculiar feature is that it will not grow in the air. If it gets into a large, open wound, it is easily killed, because it cannot grow where there is air. But when it gets into a small, deep wound where it cannot be reached, it stays there until the wound heals over on the surface, and then it begins to grow. It does not make the parts swell, as the germs of suppuration do, but quietly continues to grow, without the wound showing any sign of infection. Finally it develops a very severe poison that is taken up by the blood; then the victim suddenly begins to have spasms about the face, and finally these spasms extend to the entire body and kill him. Whenever you get a wound so deep that you cannot wash it thoroughly, go to a doctor and let him clean it out with some medicine that will kill the germs that cannot be reached by washing. [Sidenote: How boils are caused] Sometimes the germs that cause suppuration get under the skin at a point where a hair has been pulled out, or even work down beside the hair itself. When this happens, they cause suppuration under the skin, and the result is a boil. A boil is merely an infection with the germs that cause suppuration. =Questions.= 1. How do germs get through the skin? 2. Can we get rid of all the germs that cause suppuration? 3. Why is it impossible for "bad blood" alone to cause suppuration? 4. How does the surgeon prevent suppuration? 5. How may you prevent suppuration? 6. What is the danger of cutting corns with an ordinary knife or razor? 7. Where do germs of lockjaw grow? 8. What causes boils? =Remember.= 1. Germs and not "bad blood" are the cause of suppuration. 2. Always keep as clean as possible, and immediately wash any cut, no matter how small. 3. If you have a deep wound, go at once to a doctor, and let him clean it out and kill the germs that may be at the bottom of the wound. CHAPTER XXIII TRANSMISSION OF DIPHTHERIA [Sidenote: How germs may cause sickness without entering the body] Some germs that cause disease do not get into the body, but grow upon its surface, that is, they grow on the mucous membranes--the skin of the mouth, the throat, and the nose. As they grow, they develop poisons that are absorbed by the body, and that make us very sick. The germs that cause diphtheria belong to this class. [Sidenote: Prevalence of diphtheria] Diphtheria is one of the most common of all the preventable diseases. It causes more deaths than any of the other diseases that can be prevented, except tuberculosis. The great prevalence of diphtheria is due to lack of care on the part of those who have this disease and of those who come in contact with them. [Sidenote: Where the diphtheria germ comes from] The germ that causes diphtheria always comes from some person or animal that has diphtheria. It never "just happens." If you went into your yard in the morning and found some beets growing in your flower bed, you would know positively that beet seeds had got into your flower bed in some way. You would not say that the beets just happened to grow there. So diphtheria will not "just happen." Diphtheria is always caused by germs that come from some one who has diphtheria. They may have come in a letter that was written in the room with the sick person. They may have come from the library in a book that had been used by some one ill with diphtheria. They may have come on some toy that had been played with by a child that had the disease. There are a thousand ways by which the germs may be brought to you without your knowing where they come from. [Sidenote: How to confine diphtheria germs] The public health officers try hard to keep these germs from being brought to you. In order to do this, they have to shut away from other people those who have diphtheria germs; that is, they make the sick ones stay at home until they are free from the germs of the disease. We call this _quarantine_. Quarantine means that you must stay away from other people when you are sick with a communicable disease, and that other people must stay away from you. People are not put in quarantine because they are sick, but because they are dangerous, and because we are trying to prevent other people from getting the same disease. Do not think the health officers unreasonable when they tell you that you must stay at home and that no one can come in to see you. This is done to protect other people and to keep them from getting the same disease that you have. If you ever have diphtheria, or any other communicable disease, you must remember that if any of your playmates come in to see you, they may get the same disease. [Illustration: FIG. 53. Disease germs are as deadly as guns.] [Sidenote: Seriousness of breaking quarantine] Diphtheria kills a great many children, and to play with your friends after you have had diphtheria, and before the health officer tells you that you may, is almost like trying to kill them. They might be very sick and die, or they might be very sick and get well, or they might not be sick at all; but you never can tell what will happen if they are exposed to the disease. If you were to take a gun and shoot at a friend, you might kill him, or you might shoot his leg off, or you might not hit him at all; but you would be trying to hit him, and it would not be your fault if you did not. It is just the same if you play with a friend when you have a communicable disease; you shoot the disease germ at him, and if you do not hit him, it is not your fault. [Sidenote: Why quarantine is not raised sooner] Sometimes people who have been sick with a communicable disease feel perfectly well, but the health officer tells them he cannot let them out of quarantine. This is because he knows that such people still have in their bodies the germs that cause the disease, and that as long as these germs are there they can give the disease to other people. It is not pleasant to have to stay in quarantine when you feel that you are well, and children, as well as older people, are very likely to become restless under the circumstances. You see an illustration of such a patient in Figure 60, where the little girl, who is under quarantine for scarlet fever, but who is feeling quite well, is giving a book to two of her friends. The book contains the germs that cause scarlet fever, and the boys are very likely to contract the disease by handling the book. [Sidenote: Why some cases of diphtheria escape quarantine:] [Sidenote: (_1_) From failure to detect mild cases] If every case of diphtheria were quarantined, and the people obeyed the health officer, there would soon be no more diphtheria. But how does it happen that every case of diphtheria is not quarantined? Diphtheria is a very peculiar disease. Sometimes it makes people so sick that they die in spite of everything that can be done for them; sometimes it makes the throat only a little sore, and the child seems so slightly ill that his mother says to herself, "He is fretful," and does not call the doctor. In the latter case the child often keeps on going to school, and exposes other children to the disease; some of them catch it, and become very sick or even die. In still other cases, the mother thinks that a child has only a case of tonsillitis and does not call a doctor; the child's brothers and sisters go to school and may carry the germs to other children. I have known a great many cases of diphtheria to be spread in this way. [Illustration: FIG. 54. The old, insanitary slates and sponges have gone out of use, but many people of to-day still follow the dangerous habit of putting pencils into their mouths.] Sometimes a dairyman thinks that his child has nothing more serious than tonsillitis, and goes on selling milk. A great many epidemics have resulted from such cases. Sore throats should not be treated lightly, for the most severe forms of diphtheria may develop from germs that come from a throat that is only slightly sore. If there is a case of diphtheria in the town where you live, and if your throat feels the least bit sore, have your doctor examine it at once. If you do not wish to have your family doctor look at your throat, go to the health officer. Had you not rather stay at home for a week or two than see your best friends ill or dead because of your carelessness? [Sidenote: (_2_) From diphtheria germs in throats that are not sore] There is another peculiar thing about the germ of diphtheria. It will often get into a throat and grow a little, just enough to keep alive, but without making the throat sore at all. The person in whose throat the germs are will have no idea that they are there, but when he comes in contact with some one who has a delicate throat, he may give diphtheria to that person. The disease does not develop in some throats because the body cells are all healthy and doing their work so well that, when the diphtheria germs try to take hold, they are driven off and not allowed to grow. This is the reason that, before he raises the quarantine, the careful health officer takes a "culture" from the throat of everyone in a house where there has been diphtheria. [Sidenote: How mild cases may be detected] The health officer takes a culture by wiping the throat with a little cotton on a long stick, which he then puts down into a long glass tube containing some substance that diphtheria germs like to grow on. If there are any diphtheria germs in the throat, they will soon show on this culture material. Then the health officer will say, "No, we cannot let you out yet, for the germs are still in your throat." No person who has been staying in a house where there is diphtheria should be allowed to go out until a culture proves that his throat is free from the germs of diphtheria. You see how hard it is to quarantine all cases of diphtheria, when children are sometimes allowed even to go to school with sore throats that are really diphtheritic. Only two things are necessary for getting rid of diphtheria: one is to quarantine every case, and the other, to have the people do just what they are told when under quarantine. This latter is just as important as the quarantine itself, for people often do not obey the health officer's directions. Now let us see what are some of these directions. [Illustration: FIG. 55. How pets may become carriers of disease.] [Sidenote: Rules of quarantine] If you are the patient, the health officer will say that you must be put in a room where there is just enough furniture to make you comfortable, and that no one except the nurse and the doctor is to go into that room. He will say that the nurse must stay in your room all the time, or that she must at least not go into any other room in the house; that your meals must be left outside your door, and that the person who brings them must go away before the door is opened by the nurse. Furthermore, as everything in the room that cannot be boiled, or otherwise disinfected, will have to be burned when you are well, your pet books and toys had better not be taken in. Finally, nothing is to be carried from the room until it has been put into a solution that will kill the germs, and this means not only dishes, bedding, and clothing, but even books and letters. The nurse must see that all discharges from the throat and nose are received on little cloths, which are to be burned immediately. [Sidenote: How quarantine rules are broken] These are the things that the health officer will tell your parents must be done. Now let us see what sometimes happens. Your mother will want to see her little child so much that she cannot wait until you are well, so she will slip into your room, kiss your forehead, and hold you tight against her. When a little later she kisses your baby brother, and is so thankful that he is not sick too, she does not realize that she is kissing the very same disease into his little throat. Or, perhaps your mother is the nurse, and in the night she hears your little brother crying; she thinks, "Surely I can slip out and just cover him up; it will not hurt him just for once," and she does so. What happens? In a few days your doctor tells you that your little brother will have to come in and stay with you. Perhaps your father grows anxious to see you, and one morning he says he cannot stand it another minute, so he slips in for a few moments before going to business. In a few days one of his clerks fails to come to work. Your father sends a messenger to see what the trouble is, and the word comes back, "He has diphtheria." Then your father says, "What are these health officers doing that they do not stop this thing?" He is very indignant, but it never occurs to him that he himself has spread the disease by doing just what he promised the health officer he would not do. [Sidenote: How dogs and cats carry disease germs] The doctor told your mother not to take anything from the room until it had been disinfected. But you do not consider Towser, your dog, and Tabby, your cat, "anything," so you persuade your mother to let them come in, and you have a good play with them. You let them rub against your face and romp on your bed, and do everything that pet dogs and cats like to do, and in the meantime their fur is getting full of diphtheria germs. Then Towser and Tabby run out-of-doors and play with the boys and girls of the neighborhood. Soon the parents are wondering why the health officers do not stop the spread of the disease. No dog or cat should ever be permitted to come into a house where there is a contagious disease. These are not all the ways in which people disobey the orders of the health officer and of the doctor, but these are enough to show you that it is a very important thing to do just what they tell you. It is not always easy to follow all these rules, but it is far better to follow these, and many more, than to have to think that you have caused the death of either a friend or a stranger. =Questions.= 1. How does the poison of diphtheria get into the system? 2. Where does the diphtheria germ come from? 3. What is quarantine? 4. What is the danger in breaking quarantine? 5. Why is quarantine continued after you feel well? 6. How does it happen that some cases of diphtheria are not quarantined? 7. What is a diphtheria culture? 8. What rules should you observe while in quarantine? 9. Tell some of the ways by which quarantine is broken. 10. How do pet dogs and cats sometimes get disease germs? =Remember.= 1. The germs that cause diphtheria always come from some person or animal that carries diphtheria germs. 2. Diphtheria is always caused by the diphtheria germ, and the diphtheria germ cannot cause any other disease. 3. People are quarantined to prevent other people from getting the disease. 4. If there is diphtheria in your neighborhood, and your throat becomes sore, have the doctor examine it. 5. Every person who has been staying in a house where there is a case of diphtheria should have his throat examined to make sure he is not carrying germs. 6. Never play with dogs or cats when you have a contagious disease. 7. People who do not obey quarantine regulations cause a great deal of suffering and many deaths. CHAPTER XXIV THE CURE OF DIPHTHERIA [Sidenote: Nature of diphtheria poison] The germs of diphtheria do not get into the blood through the skin, but grow on the surface of the mucous membrane (skin of the throat), and there produce a poison that gets into the blood through this membrane. It is this poison that makes you sick, and it is called a _toxin_. You already know that when people have diphtheria, they are sometimes very sick and sometimes only slightly sick, and that the germ can live in some throats without causing any ill effects whatever. [Sidenote: How diphtheria toxin is fought] As soon as the diphtheria germ begins to grow in a throat, the little cells of the body begin to make a certain substance and to pour it into the blood. This substance we call _antitoxin_, which means opposed to the toxin in the blood. If the little cells make the substance fast enough, the germs will stop growing, or in some cases they never really get started growing, because they cannot exist where there is much antitoxin. Antitoxin looks like clear water. The following experiment will show you something that acts in very much the same way that antitoxin does. If you take a solution of litmus that is made alkaline, it will be very blue, like indigo; but if you drop a few drops of lemon juice into this solution it will turn red.[3] Lemon juice is acid, and is just the opposite of alkali. Now, if you put a few drops of ammonia, which is alkali, into the red solution, it will turn blue again. If you put a little more lemon juice, very carefully, drop by drop, into the blue solution, it will gradually turn lighter, until it is entirely clear. [Sidenote: How antitoxin acts] We will suppose that the blue is due to the toxin produced by the diphtheria germ, and that the lemon juice is the antitoxin produced by the cells in the body. If the antitoxin is made fast enough, the blue disappears; but if the toxin is made faster than the antitoxin, the blue remains. It is the same way in the body, only it is not litmus and acids and alkalies that we have to deal with. If the toxin is made faster than the antitoxin, the germs grow, and we get sicker and sicker; but if the antitoxin is made faster than the toxin, then the germs cannot grow, and we soon get well, or perhaps do not get sick at all. [Sidenote: How antitoxin was discovered] Doctors knew that this was what happened, but for a great many years they could not discover the composition of the antitoxin that is made in the body. One day a doctor suggested, "If we cannot find out the chemical nature of this thing that is made in the body, why can we not make it in the body of some animal and then use the blood of the animal?" And that is just what they did. They put diphtheria germs into beef tea, and let them grow very fast and make all the toxin they could. Then the doctors strained the germs out by passing the beef tea through a fine filter, in this way getting the poison, and not the germs. Then they gave a strong, healthy horse a small quantity of this poison; they did not feed it to him, but injected it into his blood. Of course the horse was sick for a while, but soon he began to get well again, for the cells in his body immediately went to work making antitoxin. When the horse was well, the doctors gave him more of the poison; this time he was not so sick and got well even more quickly. This treatment with toxin was repeated in gradually increasing doses until the poison did not affect the horse at all. Then the doctors said, "His blood is full of antitoxin, and we will see what it will do when injected into some other animal." So they drew off some of the horse's blood and took out all the little red cells, leaving nothing but the clear fluid of the blood. They planted diphtheria germs in a rabbit's throat, and when the rabbit became very sick, they gave him some of the antitoxin from the horse. The rabbit immediately got well. Afterward they gave some of this antitoxin to a little boy who was very sick with diphtheria, and he, too, got well. Ever since then the doctors have been saving many lives by the use of antitoxin. [Illustration: FIG. 56. Showing the number of deaths in 100 cases of diphtheria when antitoxin is used on the first, second, third, fourth, and fifth days.] [Sidenote: Evidences that antitoxin saves lives] Someone may ask, "How do we know that it is the antitoxin that saves lives?" In just this way: before we knew anything about antitoxin, about half of all the people with diphtheria died; but since we have had antitoxin, only about twelve die out of every hundred who have this disease. More than this, we know that when the antitoxin is given within the first twenty-four hours after the patient is taken sick, there is only about one death for every one thousand cases of diphtheria. Do you not think that this is strong proof that antitoxin saves lives? [Sidenote: How antitoxin saves lives] Antitoxin saves lives not only by curing those who have diphtheria, but by preventing others from having it. If a person who has been where there is a case of diphtheria is given a dose of antitoxin, he will not have the disease, because his blood will contain enough antitoxin to destroy the diphtheria toxin present. If you will watch a careful doctor when he makes his first visit to a case of diphtheria, you will notice that, as soon as he gets through treating the patient, he gives all members of the family who have been near the patient a dose of antitoxin to keep them from getting sick. [Sidenote: Antitoxin not a poison] Some people may tell you that antitoxin is a poison and should not be used. The statement that it is in itself a poison is true. But it is also true that in your body there are many things that would poison you if you got too much of them. For instance, there is a gland in your throat (the thyroid) which secretes a substance that is necessary for your health, but if you were to take the secretion of ten such glands it would kill you at once. Now, if the cells in your body make antitoxin when you have diphtheria, it is probable that antitoxin is the very thing needed. And if you can help these cells by giving them antitoxin, ready-made, does it not seem a reasonable thing to do? People who give the name of poison to a substance which is known to have saved many lives are not worthy of attention. Anything may prove a poison if taken in excess; too much play will prove a poison, and too much work also. =Questions.= 1. What is the poison of diphtheria called? 2. What is antitoxin? 3. Compare the action of antitoxin on the blood with the action of an acid on the litmus solution. 4. Tell about the discovery of antitoxin. 5. How do we know that antitoxin saves lives? 6. How does antitoxin prevent diphtheria? 7. Why should antitoxin not be regarded as a poison? =Remember.= 1. Antitoxin is what the cells in your body make when you have diphtheria. 2. By using the antitoxin taken from a horse, you save your own cells the struggle necessary to make it fast enough to kill the diphtheria germs. 3. If you have diphtheria, and antitoxin is given promptly, you will get well. 4. If you have been exposed to diphtheria, antitoxin will prevent your having the disease. 5. Antitoxin is no more a poison than are many other medicines. CHAPTER XXV HOW TYPHOID FEVER GERMS ARE CARRIED [Sidenote: How typhoid fever germs get into the system] There are certain diseases, the germs of which get into bodies through our mouths. That is, we eat or drink them. Some of these diseases are typhoid fever, cholera, the summer complaints of children, tuberculosis, and diphtheria. At present we shall learn about the germ that causes typhoid fever, how it gets into our food and drink, and how we may prevent the disease by getting rid of this germ. Typhoid fever, like all other diseases caused by germs, is caused by one kind of germ, and one kind only. You cannot get typhoid fever by eating cholera germs any more than you can get diphtheria from typhoid germs. [Sidenote: Animals free from typhoid] So far as we know, there is no animal except man that has typhoid fever. Since the germs of any disease must come from an animal suffering from that disease, and as man is the only animal that has typhoid fever, it naturally follows that the only way to get typhoid fever is from some person who has the fever or has had it. [Sidenote: How typhoid germs leave the body] We know that typhoid fever germs get into the body with food, but how do they get out? Once in a great while germs are found in the matter that the patient vomits, or spits up, but this is a rare occurrence, so rare that we need hardly consider it. The germs are present in the blood of the sufferer, but other people do not get his blood on their hands or in their food. There are two things that come from the patient that are loaded with these germs, and these are the urine and bowel discharges. In these two excretions of the body are found practically all the typhoid germs that come from the patient, and these are the causes of other infections. In other words, it is from these two excretions that the germs get into food and drink. [Sidenote: How typhoid germs get into water] How do the typhoid germs get into our food? What is done with the excretions after they come from the body? You will probably say that the nurse throws them into the sewer. Very true; but where do they go when they are thrown into the sewer? The sewer must empty somewhere, and in most instances it empties into a stream, the water of which is used for drinking purposes. [Illustration: FIG. 57. Pollution of a stream with sewage.] [Sidenote: The widespread evil due to the sickness of one person] You may think that the germs from one person would not make much difference, but that is where you are mistaken. There is a town in Pennsylvania of about eight thousand inhabitants, which gets its water from a stream that flows down from the mountains. One cold winter, while the stream was frozen, a man living on the bank of the stream was taken sick with typhoid fever. His nurse threw the urine and the discharges from his bowels on the ice on the bank of the creek. When the ice melted, the typhoid germs in the discharges found their way to the stream that furnished drinking water to people farther down, and in a very short time there were over one thousand cases of typhoid fever in that town. Before the ice melted there had not been a single case of typhoid, and every one of the thousand cases came from the water into which had been allowed to flow the discharges from one man with typhoid fever. You see what germs from one person may do. [Sidenote: How long typhoid fever germs live in a stream] Sometimes people say that a stream purifies itself every few miles. It does purify itself of some things, but disease germs live from twenty-five to thirty-five days in water, and a stream flows a long way in thirty days. [Sidenote: The pollution of streams with sewage] Sometimes we hear people say that it is safe to put sewage into a certain stream, because no town uses that stream for drinking water. But of this they can never be sure. Not long ago certain people said that the water from the river which flowed through their town was used only by two dairymen and a vegetable gardener, and therefore there was no danger in running sewage into the stream. Yet the dairymen and the gardener sold all their produce in that very town. The townspeople never considered that the water into which they ran their sewage was used by the dairymen for washing their milk vessels (and perhaps for diluting the milk), and by the gardener for washing his lettuce and other vegetables. Thus the germs of disease were brought directly back to the town. Do not think that you are safe in polluting a stream with sewage because no town uses the water from that stream. The individual on the farm is entitled to protection just as much as the individual in the town. Always remember that when you pollute with disease the water used by the farmer, he may bring that disease back into the town with the produce of his farm. No sewage, no matter how small the amount, should ever be permitted to go into a stream until all the disease germs it contains have been killed. This can be done, though it will cost something; but we cannot get rid of disease germs without work, and work cannot be done without being paid for. There are other ways of scattering typhoid germs besides running sewage into streams. Sometimes the nurse does not throw the discharges from a typhoid fever patient into a sewer at all, but into a closet vault. Remember how the material from a closet vault goes through open ground into a well, and you will understand what happens. The germs get into the well, and the whole family may then have typhoid fever. Let us suppose that the nurse did not throw the discharges either into the closet or into the sewer, but carelessly threw them out on the ground behind the house, where, as it was winter time, they froze as hard as rocks. It does not seem to hurt typhoid germs in the least to be frozen; when they get warm again they are as lively as ever. Let us suppose these particular germs lay there all winter, but in the spring when everything melted the germs were still alive and ready to spread disease. It happened that they did not get into the well or into the milk, but they did get on your food, and made you ill with typhoid fever. [Sidenote: How flies carry typhoid germs] How did the germs get to your food? About the time that the germs were thawed out, and were beginning to double in number every hour or two, along came a fly and thought that spot an attractive one for a lunch. Accordingly he walked over this mass of filth, collecting a supply of germs on his feet, and then came in and tracked them over your bread and butter or other food. [Illustration: FIG. 58. Flies crawling on the edge of the glass or falling into the milk leave germs that cause disease.] [Sidenote: How typhoid germs get into milk] That is how you got the fever; but the trouble did not stop with you. When you fell sick, your father thought it was time to clean the yard, but he was not very careful what he did with the dirt, including the typhoid fever discharges which the nurse threw out on the snow during the winter. There was a low place in the barnyard and there he dumped the dirt. One of the cows thought this fresh pile of dirt would make a comfortable place to lie down in. The next morning the milkman milked her without first washing her sides and udder, and hundreds of little particles of dirt, each one loaded with germs, fell into the milk. The milk from all the cows was mixed together, and by the time it got to town these germs had grown into many thousands. Some of the people who drank the milk became ill with typhoid fever and wondered afterward where they had taken this disease. [Sidenote: Why the recovered patient is dangerous] The discharges from a typhoid fever patient contain typhoid germs not only while the disease lasts, but for many months after the patient is well. In some cases they are present for years after the illness is over. [Sidenote: The story of the careless nurses] Here is a story about typhoid fever that illustrates the importance of washing and boiling everything that comes from a sickroom. A few years ago there was an epidemic of typhoid fever in a certain town. One of the hospitals was very much crowded, and it became necessary to employ several extra nurses. All the nurses knew the importance of washing their hands after handling the patients, and the old nurses had seen so many bad results from failure to observe this rule that they were very careful. Three of the new nurses, however, thought it a great deal of trouble to be washing their hands all the time, so more and more they neglected this important duty. The result was that all three of these girls got typhoid fever and died. They paid the penalty for neglecting the duty that they well knew they should have performed. Typhoid fever can be wiped out by attention to neglected details--that is, by disinfecting discharges before throwing them away; by disposing of excretions only in places that are made for them; by adding lime to the closet vault every day to kill any germs present; by making the closet in such a way that flies cannot get into it; and by not permitting sewage to enter any stream until all the disease germs have been killed. All these things can be done. It will require a little work; but had you not rather take a little extra care than run the risk of catching or spreading typhoid fever? =Questions.= 1. How do typhoid fever germs get into the body? 2. What is one source of these germs? 3. How do these germs leave the body? 4. Name several ways by which typhoid germs in a stream may get into foods. 5. How do flies carry typhoid fever germs? 6. How do these germs get into milk? =Remember.= 1. Typhoid germs come from people who have typhoid fever; they are found in the urine and bowel discharges. 2. No one should ever answer Nature's calls except in a place provided for that purpose. 3. No sewage should be allowed to go into any stream until all the germs in it have been killed. 4. Disease germs will live in running water fully as long as they will in still water. 5. The discharges from a single person may infect a whole city. 6. When typhoid fever germs get into milk, they grow very rapidly; hundreds of people have been given typhoid fever by drinking the milk from a dairy where there was a single person sick with this disease. 7. People who have had typhoid often carry the germs for several months after they are well. CHAPTER XXVI HOOKWORM DISEASE AND AMOEBIC DYSENTERY Hookworm disease and amoebic dysentery resemble typhoid fever in one respect, in that they, too are spread by the improper disposal of human excreta. [Sidenote: Where hookworm disease prevails] Hookworm disease is found almost exclusively in tropical or subtropical climates. In the United States it is rarely seen north of the Potomac and Ohio rivers. [Illustration: FIG. 59. A full-grown hookworm, magnified; the short line shows the average length of the hookworm.] [Sidenote: What the hookworm is] This disease is not caused by a germ, as is typhoid fever, but by a worm from a quarter to half an inch long, and about as thick as a small hairpin. These worms get into a person's intestinal canal, and there lay their eggs, which are later given off in the bowel discharges. When these discharges are thrown on the ground, or are put into an open water-closet, they may be carried about by chickens, flies, and pigs. Then the eggs hatch in the soil and tiny hookworms result. When human excreta are not properly disposed of, in climates where hookworm disease prevails, the soil becomes practically full of these little worms, and from the soil they find their way into the bodies of the people. [Sidenote: How it enters the body] There are two principal ways by which the hookworm may enter the body. One is through the mouth, which these worms reach in practically the same way as do typhoid fever germs. The hookworm may enter the body through the skin also. Some authorities state that the worm bores its way in; but it is probable that it does not actually bore through sound skin, but enters at some point where there is a small break. [Sidenote: Where it lives in the body] After the worm gets through the skin, it is taken into the blood and carried to the lungs, and from there it finds its way to the throat and is swallowed. It makes no difference whether the hookworm is swallowed or enters the body through the skin; it finally reaches the intestinal canal, where it then makes its home. Sometimes thousands of these worms are found in a single person, and each one of them entered the body through the mouth or through the skin. The worms do not multiply in the body, and the eggs they lay never hatch until after they have left the body. [Sidenote: How it affects the patient] When the hookworm gets into the intestinal canal, it fastens itself to the wall and sucks the blood from it, at the same time giving off a poison that enters the blood of the victim. The loss of blood and the effects of the poison soon cause the person in whose body these worms are living to become weak, pale, and thin. He is not able to do much work, if any, and the result is that people suffering from this disease are often called lazy. They are not lazy; they are sick, and many of them die. [Sidenote: How hookworm disease can be prevented] All this sickness and all these deaths might be prevented simply by the proper disposal of human excreta. No human excreta should ever be put anywhere except into a properly constructed sewer or properly constructed privy. If this rule were always observed, both hookworm disease and typhoid fever would be abolished. [Sidenote: Where amoebic dysentery prevails] Amoebic dysentery is another disease that is confined almost entirely to tropical and subtropical climates, though cases sometimes occur in colder regions. [Sidenote: How it is spread and how it may be prevented] This disease, like typhoid fever, is caused by a germ that leaves the body with the bowel discharges. The germ makes its way into the body in the same way that the typhoid germ enters; that is, it is taken in with food or drink. The various means by which this germ gets into our food are the same as those by which the typhoid germ gets in; and the precautions that will prevent the spread of typhoid fever will also prevent dysentery. Amoebic dysentery kills a great many people in warm climates, though it does not kill as many as does typhoid fever. If it does not cause immediate death, it often leaves the patient very weak and sickly for months or years. =Questions.= 1. In what climates are hookworm disease and amoebic dysentery commonly found? 2. In what respects do they resemble typhoid fever? 3. How does the hookworm enter the body? 4. Where do the hookworm eggs hatch? 5. How can hookworm disease be prevented? 6. What other diseases can be prevented by the same precautions? =Remember.= 1. Typhoid fever, hookworm disease, and amoebic dysentery are all caused by the improper disposal of human excreta. 2. Most of the sickness that can be prevented is the result of dirty habits; if all people would keep clean and see that everything about them was kept clean, a great deal of sickness would be prevented and a great many lives would be saved. CHAPTER XXVII HOW SCARLET FEVER IS CARRIED There are certain diseases that we know to be communicable (that is, "catching"), but as yet we do not know the germ that causes them, and therefore we cannot tell just how they are carried about. We do know that they are transferred from one person to another; but not being able to locate the cause, as we can in the diseases of which we do know the germ, we cannot explain how it is done. [Sidenote: How scarlet fever is like diphtheria] Among the diseases of this class we find scarlet fever. In one respect scarlet fever acts much the same as diphtheria. A person may have it and not be very sick, sometimes hardly sick at all. At night a child may have a high fever, with a slightly sore throat, and the next morning he may feel perfectly well. The mother supposes that the fever was due to an "upset stomach," thinks no more about it, and sends the child to school. The next time the child takes a bath, he perhaps notices that the skin peels off over some parts of the body. This means that the high fever was due to scarlet fever, but the breaking-out (rash) was so fine that it was not noticed. It also means that all the children in the school have been exposed to the disease. These very mild cases are the most dangerous because so often they are not recognized. [Sidenote: Why mild cases are dangerous:] [Sidenote: (_1_) For the severe cases they cause] There are two things to be remembered in connection with these mild forms of scarlet fever, as well as of every other communicable disease. The first is that the same cause which produces a mild form of the disease in one child may produce its most severe form in another child. You can contract a mild form of the disease from exposure to a severe case; and you can contract a severe form from exposure to a mild case. The character of the case to which you are exposed will give no indication of the form the disease will assume in your body. [Sidenote: (_2_) For the bad after effects] The next thing to be remembered about the mild form of scarlet fever is that, though the child may not be made very sick at the time, there may later be very bad results. A child who has had scarlet fever in such a mild form that he hardly knew he was sick, may, for a while, appear to be quite well; then suddenly he has an earache, and an abscess forms. This abscess is due to the scarlet fever germs which have gone from the throat to the ear, and as a result the child may lose his hearing entirely. The child may not, perhaps, have an abscess, but after a time he may begin to lose flesh, and to grow pale. He does not care for his meals, does not care to play, says he is tired, and wants to lie still all the time. Finally his mother thinks it might be a good idea to have a doctor see him. The doctor examines his body carefully, and then asks for a sample of his urine. When he has examined this, he looks very serious and asks the mother when the child was sick last, and what the disease was. Perhaps she has forgotten all about the slight attack of fever, and the doctor must question her very carefully before she recalls it. At length it occurs to her, and then the doctor asks, "After this attack of fever, did you notice that the skin came off his hands and body?" She replies that she did, and then the doctor tells her that the child really had scarlet fever, and, owing to lack of care, he now has kidney disease. This is a very serious trouble, from which he may never recover, or, in case of recovery, he may always be weak and sickly. Even a mild attack of scarlet fever is not to be neglected; it is a severe and dangerous disease in its very mildest form. It not only kills a great many boys and girls, but it makes delicate in health for all their lives many of those who apparently recover. [Illustration: FIG. 60. One of the ways by which quarantine is broken.] [Sidenote: How confusion of names causes mild cases to go undetected] We often hear people speak of two diseases which they think are not scarlet fever. These two diseases are scarlatina and scarlet rash. Now scarlatina is simply the scientific name for scarlet fever. Some doctors will tell you that you have scarlatina and that it is not exactly scarlet fever. A doctor who says this either is deceiving you or does not know any better. In either case, he ought not to be a doctor, for he lets children be exposed to a disease that is likely to kill many of them. It is the same with scarlet rash. This, too, is simply another name for scarlet fever. Changing the name does not change the disease, and you may call it scarlet fever, scarlatina, or scarlet rash--it makes no difference which; the disease is one and the same. [Sidenote: Why quarantine is necessary for scarlet fever] Quarantine is the only way known for preventing the spread of scarlet fever, as well as of diphtheria. If every case of scarlet fever were quarantined, we could soon stop this disease; but every case is not quarantined, because some of them are so mild that they are not recognized. [Sidenote: How breaking quarantine shows selfishness] Even when a case is quarantined, the people sometimes neglect the instructions given, just as they do when there is a case of diphtheria. Then there are cases that are known to be scarlet fever but are not reported to the health officers, because the people do not want to be quarantined. They simply do not want to be put to any inconvenience themselves, and although this seems a very strange way for people to act, it happens very often. There are many selfish people in the world; there are even people who will not report a case of scarlet fever because to do so might prevent their going to a party. Selfishness is at the bottom of it. It is extremely important that a child should be absolutely free from all the little scales of skin which are thrown off after scarlet fever, before he returns to school or mingles again with others. If there is a discharge from the nose or ears after the scales have disappeared from the skin, there is still danger of spreading the disease, for these discharges often retain the infection for many months. =Questions.= 1. Give two reasons why mild cases of scarlet fever should be carefully treated. 2. Why is quarantine necessary? 3. How does selfishness lead people to spread scarlet fever? 4. When is it safe to let a scarlet fever patient mingle with well people? =Remember.= 1. If you have scarlet fever and are not very sick, do not think that you will not be dangerous to others; severe cases sometimes come from exposure to the mildest cases. 2. Mild cases of scarlet fever often leave very bad results, if the patient is not cared for. 3. Be very careful until you are entirely well. 4. Scarlatina and scarlet rash are nothing but scarlet fever; keep away from people who have them. 5. Quarantine is the only way by which we can prevent the spread of scarlet fever; there is no medicine that will prevent it. 6. People who violate quarantine regulations are both selfish and stupid. CHAPTER XXVIII MEASLES AND WHOOPING COUGH DANGEROUS DISEASES Measles is a disease in the same class as scarlet fever. We do not know the cause, but we do know that it is communicable. [Sidenote: Why measles should be avoided] Measles is usually not a severe disease; that is, it does not kill as many persons in proportion to the number of cases as does scarlet fever. It does, however, kill more people than most of us think; a great many little babies die of it. How often we hear mothers say, "I wish my children would have measles and be done with it." It would be very convenient if they could have measles in a mild way and "be done with it." The trouble is, that we cannot tell whether it will take a mild form, and, worse than this, we do not know when they will be done with it. If you should go into the children's wards of a large hospital, you would know why measles should be avoided. There you would hear the doctors questioning the mothers about the previous diseases of the little ones. You would be surprised at the number who replied, "He has not had anything but measles." Then you would hear the question, "How long since he had the measles?" "He was just over it when he was taken sick with this trouble." What is "this trouble"? Follow the doctor along from bed to bed and see the cases of pneumonia that started when the child "was just over measles"; see how many cases of empyema (abscess in the chest) began just after the measles ended; how many cases of abscess in the bone, how many cases of disease of the kidneys appeared after the child recovered from the measles. Then go down into the eye and ear wards and see how many diseased eyes and ears have followed an attack of the measles. The children would not have had these troubles had they not first had measles. [Sidenote: Necessity of care in measles] If you have measles, do not let others come near you, and do not think that, because you do not feel very sick, you can run about as usual. If you do not take good care of yourself, you may have some of the diseases that so often begin when children are getting over measles. Measles causes more deaths than is commonly supposed, especially among young children and very old people; and a great many children die of diseases which they never would have had if they had not first had the measles. Avoid people who have measles, and if you should get the disease, do not treat it as a slight thing, but consult your doctor at once. [Illustration: _Whooping Cough_ _Scarlet Fever_ _Measles_ _Smallpox_ _4,856_ _4,309_ _4,302_ _74_ FIG. 61. Deaths in 1907 from four common communicable diseases reported to the United States Census Bureau.] [Sidenote: Evil effects of whooping cough] Whooping cough is much the same as measles in this respect. It kills many children, and, in cases where it does not kill them, their bodies become so weakened that they are liable to contract some other disease that may prove fatal. Avoid people who have whooping cough. =Questions.= 1. Why should people avoid measles? 2. Why should one take care of himself when he has measles? 3. Why is whooping cough to be avoided? =Remember.= 1. Measles is more fatal, especially among babies, than people realize. 2. Measles causes more diseases of the bones, ears, and eyes than any other communicable disease. 3. Measles is not dangerous if properly cared for, but when neglected, it causes much suffering and many deaths. 4. Whooping cough causes almost as many deaths as does measles. CHAPTER XXIX HOW SMALLPOX IS PREVENTED We now come to the study of a disease, the cause of which has not been positively recognized. We know that it is very communicable; but we know also that there is absolutely no reason for anyone's ever contracting it, since there is a way by which it may easily be prevented. [Sidenote: Fatality of smallpox before the discovery of vaccination] Something over a hundred years ago, smallpox was one of the most fatal diseases known. It is estimated that during the eighteenth century it killed over 60,000,000 people. Up to the time when the Spaniards invaded Mexico, there had been no smallpox there. The Spaniards brought the disease with them, and historians tell us that out of the 12,000,000 people living in Mexico at that time, at least 6,000,000 died from smallpox. At that time the disease was considered fatal throughout the world; when it broke out in a community, people fled without stopping to bury their dead. It was a rare thing to see a person not more or less disfigured by the marks the disease leaves on the face and body. To-day we find a very different condition. There are now fewer fatalities from smallpox than from almost any other communicable disease. During 1906 and 1907 only 169 deaths from smallpox were reported from all over the United States to the Census Bureau at Washington. What has caused this marked falling off in the fatality of the disease? [Sidenote: Discovery of vaccination] During the time that smallpox was killing so many people, all the doctors were trying to find something that would cure the disease or that would prevent it. In the latter part of the eighteenth century Dr. Edward Jenner, an English physician, noticed that milkmaids did not have smallpox as much as did people of other occupations. He also noticed cows with little sores on their udders that looked very much like the sores that come with smallpox. He therefore tried making on the arms of people sores just like those on the udders of the cows. He did this by taking a little of the matter from the sores on the cows and putting it into the scratches on the people's arms. After these sores had healed, the people who had been thus treated did not have smallpox. This simple practice has caused one of the most deadly diseases known to man to become one of the most easily controlled. [Sidenote: Prevention of smallpox by vaccination:] Though it is well known that before the discovery of vaccination smallpox was a fatal disease, there are still some persons who say that vaccination has done nothing to reduce the mortality. When you learn some of the facts, you can judge for yourself whether or not vaccination does prevent smallpox. [Sidenote: (_1_) In the Franco-Prussian War] During the Franco-Prussian War in 1870-71, the German soldiers were all vaccinated, and only a part of the French army was vaccinated. Smallpox broke out in the two armies. As a result, 6,000 of the French died from smallpox and only 278 of the Germans. In many instances, the German and the French soldiers were confined in the same hospitals, with exactly the same opportunities to contract the disease. But, you might ask, if vaccination prevents smallpox, how did it happen that there were _any_ cases among the German soldiers? In order to prevent smallpox, vaccination must be successful; that is, it must "take." We will tell you about different kinds of vaccination a little later. [Illustration: FIG. 62. In Sweden, before vaccination, smallpox caused 2,050 deaths per million population (represented by the large square). Since the introduction of vaccination the death rate has dropped to 2 per million population (represented by the two small squares).] [Sidenote: (_2_) In Sweden] In Sweden we find strong evidence that vaccination prevents smallpox. Up to 1801, before vaccination was introduced into that country, the yearly death rate from smallpox was 2,050 out of each million of the population. In 1801 vaccination was introduced into Sweden, but the people were allowed to be vaccinated or not, just as they pleased. During the ten years ending with 1811, the annual death rate from smallpox had dropped from 2,050 per million of the population to 686 per million. Later, vaccination was made compulsory (that is, everybody in Sweden was obliged to be vaccinated), and in 1894 the death rate had dropped to only two deaths a year per million population. Is it merely a coincidence that this great falling off in deaths from smallpox came after vaccination was discovered, or was it due to vaccination? [Sidenote: (_3_) In the Philippine Islands] Before the Philippine Islands were occupied by the Americans, vaccination was very little practiced, and a large percentage of the deaths in those islands was caused by smallpox. In 1897 smallpox caused about 40,000 deaths. A few years later the Americans enforced vaccination among the inhabitants of the Philippines, and the result was that in 1907 there were only 304 deaths from smallpox. There has been practically no quarantine for smallpox and no disinfection; the only cause of the suppression of the disease in the Philippine Islands is vaccination--nothing else. [Sidenote: (_4_) In Gloucester, England] In Gloucester, England, there used to be a great many people who did not believe in vaccination, though it is doubtful if they themselves could have explained why they did not. They seem to have been much like the man who, when asked, "What do you think of this?" replied, "I don't know anything about it, but I am against it." In 1890 Gloucester had a population of 42,000 people, most of whom had never been vaccinated. In the latter part of 1895, smallpox broke out. Quarantine was strictly carried out, but the disease continued to spread. As the people saw the number of victims rapidly increasing, many of them concluded that they had rather be vaccinated than have smallpox, even though they did not really believe in vaccination. By the first of April, 1896, over 36,000 people had been vaccinated in Gloucester, and by the first of August there was not a case of smallpox in the city. But what had happened in the meantime? There had been 1,979 cases of smallpox; a very large amount of money had been expended in quarantining; hundreds of persons had been disfigured for life; and 439 lives had been lost. And all this simply because the people did not believe in vaccination. Quarantining smallpox is a most expensive luxury, which may possibly retard the progress of this disease, but was never known to check an epidemic of it. Every epidemic of smallpox during the last one hundred years has been checked by vaccination. [Sidenote: Why some diseases do not return] There are certain diseases which you are not likely to have more than once; one attack protects against another. Why and how does one attack of a certain disease protect against another? When a person is taken sick with one of these diseases, the cells of his body immediately begin to make a substance called antitoxin. We learned something about antitoxin when we were studying diphtheria. In diseases like scarlet fever, measles, and smallpox, in which one attack protects against another, the antitoxin that is formed in the body when you are sick stays there for a long time, in some cases as long as you live. While this antitoxin is present in the blood, the cause of the disease cannot live in the body; hence you cannot have the disease again. After some diseases this antitoxin seems to disappear from the blood in a short time; after others, it seems to remain for several years; and after still others it remains as long as you live. After diphtheria it stays in the blood only a short time, so that one may have diphtheria a second time within a few years. Some people have smallpox, measles, or scarlet fever a second time, but with most people these diseases never return. If we knew how to make the cells of our bodies produce this antitoxin and keep it stored up in the blood all the time, we should never have any of these diseases. But in many cases we do not know how to cause the cells to manufacture this antitoxin. However, in one or two diseases we do know how to persuade them to make the antitoxin, and the one in which we know how to accomplish this best is smallpox. This is just what is done by vaccination. [Sidenote: How vaccination prevents smallpox] The object of vaccination is to put the cells of the body to work making antitoxin. To do this, it is necessary to get some of the toxin into the body. We want to get in just enough to make the cells work, and no more. Therefore we make a very small scratch, and put into it some of the vaccine which contains the toxin of smallpox. It is impossible to have these germs in your body and not be affected by them to some degree. If you did not feel a little sick, the cells would not be making antitoxin, for the thing that makes you sick is what makes the cells go to work. But this sickness is only a matter of a day or two, and after the cells have made the antitoxin, it will stay in your body a long time, longer in some cases than in others. Some people, after they have once been vaccinated, can never be successfully vaccinated again; neither can such people ever have smallpox. Most people, however, can be successfully vaccinated every five to seven years, and there are a few people who will "take" if vaccinated every year or two. These conditions indicate the length of time that the antitoxin of smallpox will live in the bodies of these different persons. If vaccination, properly performed, does not take, the person is not in a condition at that time to catch smallpox; and if vaccination, properly performed, does take, it is positive evidence that if this person had been exposed to smallpox, he would have taken the disease. [Sidenote: Necessity of repeated vaccination] It is frequently asked, "How long will vaccination protect against smallpox?" You can no more answer this question than you can tell how long the antitoxin will live in the blood of any particular person. The only safe thing to do is to be vaccinated every few years, and if smallpox is present in your community, get vaccinated every year until the vaccination takes. If it takes, it shows that you were in a condition to catch the disease; and if it does not take, you may feel safe from smallpox for a while, at least. =Questions.= 1. Why was smallpox formerly more widespread and more often fatal than it is now? 2. Tell of the discovery of vaccination. 3. Give instances to show the influence of vaccination on smallpox epidemics. 4. Why must there be repeated vaccinations? 5. Show how vaccinating for smallpox is like taking antitoxin to prevent diphtheria. =Remember.= 1. Before the introduction of vaccination, smallpox was one of the most dangerous diseases known. 2. All evidence of history tends to show that vaccination has caused smallpox to become a very mild disease and a comparatively rare one. 3. Successful vaccination repeated at proper intervals will prevent smallpox. 4. Vaccination must be repeated because we do not know just how long the material developed in the body from a single vaccination will last. CHAPTER XXX WHY VACCINATION SOMETIMES SEEMS A FAILURE [Sidenote: What constitutes a successful vaccination] How does it happen that those who have been recently vaccinated sometimes have smallpox? It is _successful_ vaccination that prevents smallpox, not recent vaccination; there is a vast difference between the two. A _successful_ vaccination is one that results in a sore identical with the sores of smallpox. Such a sore is secured only as a result of the action of the germs that cause smallpox. If the arm is red from the shoulder to the wrist and so swollen that you cannot use it for weeks, it does not necessarily mean that you have had a successful vaccination. Such arms are not the result of vaccination itself, any more than a railroad wreck is the result of the fact that there is steam in the engine. The railroad wreck is caused by carelessness on the part of some operator, and the badly inflamed and swollen arm is due to lack of care or knowledge on the part of the vaccinator or the person vaccinated. [Sidenote: Some pretended vaccinations] A fly blister is not a successful vaccination. Such a statement may not seem necessary, until you hear this story. A man showed a sore on his arm, asserting that it was a successful vaccination. He was told that it was nothing but the result of a blister, and not vaccination, and that the work had been done by putting a small bit of blistering plaster on his arm. He admitted this to be the fact, and said that the "doctor" who did it told him that it was a new way of vaccinating. The doctors who say that vaccination will not prevent smallpox belong to the class who use fly blisters and call them vaccinations. When the patient gets smallpox, those who are opposed to vaccinations say that here is an illustration of their claim that vaccination will not prevent smallpox. [Illustration: FIG. 63. How vaccinated arms are sometimes infected.] Some people who honestly think they were vaccinated have smallpox. There are sometimes instances in which a person recently vaccinated with apparent success nevertheless contracts smallpox; there are still other cases in which the disease develops after a vaccination that would not take. Here is an example: A doctor vaccinates a child in the usual manner. At the end of four or five days, the dressing is taken from the arm, and the only thing to be seen is a little black scab. The child scratches this off. In a few days the spot becomes red and a small abscess forms, resembling a smallpox sore. Naturally, this is taken for a completely successful vaccination, but it is not really so. When the child scratched off the scab, the vaccination wound was nearly healed, and the little abscess was caused by some very mild pus germs, which were under the finger nails with which he scratched the wound. The abscess was in no wise connected with the vaccination, but was simply such an infection as a child might get at any time that he scratched his arm. No one has ever claimed that such an abscess will prevent smallpox any more than that a boil will prevent it. _A successful vaccination will prevent smallpox._ The length of time for which it will prevent the disease varies in different individuals. Some it will protect only for a year or two, while in others it will last through life. Dr. H. W. Bond, Health Commissioner of St. Louis, Missouri, states: "The experience of this department, based on the observation of thousands of cases, is that a well-pitted mark gives at least ten years' immunity. We have never seen a case of smallpox in a person with a well-pitted scar less than ten years old--that is, the scar less than ten years old." [Sidenote: A sore arm not always due to successful vaccination] One of the strongest objections made against vaccination is that the arm sometimes becomes very sore from it. This is true, but the sore arm is not a common occurrence and is never caused by vaccination properly performed. There is always some cause for the bad arm besides the vaccination. [Sidenote: Cause of sore arms] The usual cause of a bad arm is improper vaccination; this means the lack of proper precautions on the part of the person who does the vaccinating. Years ago, before vaccination was performed with the great care which is given it to-day, bad arms could not be prevented; but to-day the cause of the trouble is not the vaccine, but the vaccinator. Sometimes a father thinks he will save a dollar by vaccinating his child himself, and he is likely to injure the child by attempting to vaccinate him without taking antiseptic precautions. The same surgical preparations must be made for a vaccination as for an operation. If this is not done, a bad arm will result, not because of the vaccination, but because of the negligence of the vaccinator. Never allow any person, doctor or otherwise, to vaccinate you until the skin surface has been well washed with soap and water, rinsed clean, and wiped off with alcohol. See that the vaccine is fresh and has been properly kept. When it begins to "take," keep the spot absolutely clean and covered with a clean cloth, renewed daily. _Never scratch or rub it._ These precautions will prevent the dreaded soreness of the arm. [Sidenote: How people themselves infect their arms with pus germs] The person operated on is himself often responsible for the bad arm. A careful doctor will put a dressing on the arm, after he has supplied the vaccine, and will tell you to let that dressing alone, for he wishes to take it off himself. About the third or fourth day after the vaccination, your arm begins to itch. Possibly you have forgotten what the doctor told you; at any rate, you pay no attention to directions and take the dressing off to scratch the arm. When you scratch the wound, you introduce pus germs into it, and you have no reason to expect anything but a sore arm. In this case, it is not the fault of the vaccinator or of the vaccination; it is your own fault. Never touch a vaccination sore; in fact, it is dangerous to touch any sore. =Questions.= 1. How is a successful vaccination determined? 2. What are some pretended vaccinations? 3. Mention some of the things that cause bad arms after vaccination. =Remember.= 1. A successful vaccination causes a sore identical with the sores that result from smallpox. 2. A fly blister is not a vaccination in any sense of the word. 3. A very sore arm does not result from a properly performed vaccination, but from carelessness on the part of the vaccinator or the person vaccinated. CHAPTER XXXI CONSUMPTION, THE GREAT WHITE PLAGUE Tuberculosis, or consumption, has been known for many centuries. It was known long before Rome was ever heard of. Hippocrates, a Greek physician, studied it, and said that if it were treated in its early stages, it could be cured. [Sidenote: Why consumption is called the Great White Plague] Tuberculosis is called the Great White Plague. It is called the Great Plague, because it kills more people than does any other one disease; the White Plague, because people who suffer from it become so pale and white. [Sidenote: Consumption more destructive than war] It is estimated that nearly 200,000 people die from tuberculosis every year in the United States. This means that in this country there is one death from consumption every two minutes and thirty-six seconds. Is it not fearful to think of nearly 200,000 people dying every year, in the United States alone, from a disease that we know can be prevented? Do you not think that we ought to do everything we can to prevent this disease from spreading? During the Civil War 205,070 soldiers were killed in both armies. This war lasted four years. During the same length of time there were 640,000 deaths from tuberculosis in the United States. This means that consumption killed over three times as many people as were killed during the same length of time in the Civil War. In some parts of the country one out of every seven deaths is caused by this disease, but the average throughout the country is one death out of every ten. [Illustration: FIG. 64. Comparing 640,000 deaths from tuberculosis the United States during four years with the 205,070 deaths in the Civil War.] [Sidenote: Prevalence of tuberculosis] There are more than 700,000 people sick from tuberculosis every year in the United States alone. Of this number nearly 200,000 die every year. Tuberculosis is a disease that can be prevented. It may take a long time to get rid of it, but it can be abolished. When you think of all the people that are sick from tuberculosis, and of all those who die from it every year, you will surely want to do all you can to help prevent this suffering and death. [Sidenote: Tuberculosis a disease of various parts of the body:] When people speak of consumption they usually mean tuberculosis of the lungs; but tuberculosis is not confined to the lungs. The germs that cause tuberculosis may attack any part of the body, and from one part may go to other parts, setting up a growth wherever they go. [Sidenote: (_1_) Of the throat] Tuberculosis of the throat is a common form of the disease. When the germs of tuberculosis settle in the throat, they destroy the tissues very rapidly and, as a rule, kill the patient much more quickly than they do when they start in the lungs. [Sidenote: (_2_) Of the joints] Another frequent form of tuberculosis in occurs in the knee; this is popularly called "white swelling." It quickly destroys the knee joint and results in a stiff leg. The growth may stop there, but more often it extends from the knee to other parts of the body. Often we see a little boy or girl wearing one shoe with a sole much thicker than the other. This is because one leg is shorter than the other, and we notice that the shortened leg is deformed as well. This condition sometimes results from an injury, but it is far more likely to be caused by tuberculosis of the hip joint. [Sidenote: (_3_) Of the spine] Again we see boys and girls with diseases of the spine, so that they have "hunch backs" or are twisted to one side. These conditions result from tuberculosis of the bones of the spine. [Illustration: FIG. 65. One of the effects of tuberculosis.] [Sidenote: (_4_) Of the glands] Sometimes we see children and grown people with swellings on their necks. These swellings may look smooth, but they feel as if they were made up of little bunches of grapes or plums under the skin. They are almost always due to the growth of the germs that cause tuberculosis of the little glands of the neck. [Sidenote: (_5_) Of the stomach] Any one of the other glands of the body is just as liable to become affected by tuberculosis as are the glands of the neck. Tuberculosis of the stomach or bowels is not at all uncommon. The germs of tuberculosis are likely to attack any of the tissues of the body, especially if the cells composing these tissues are for any reason weakened so that they cannot do the work required of them. When the tuberculosis germs grow in tissues, the tissues finally break down and an abscess forms. A tubercular abscess is sometimes called a "cold abscess." All such abscesses finally break and an open sore results. The matter that comes from the open sore and from the abscess when it is first opened is full of the germs that cause tuberculosis. If this matter is allowed to become dry, the germs are blown about in the dust. Then other people may inhale them or take them into their bodies through the mouth or skin and thus contract consumption. [Sidenote: The old belief that consumption is inherited] Until a few years ago it was generally believed that consumption was inherited. That is, it was thought that children whose father or mother had consumption were born with the disease. Even to-day many people hold to this idea, because they have not studied or learned of the discoveries made in recent years. These people still believe that if a child's father or mother dies of tuberculosis, the child will die of tuberculosis, too, no matter how careful he may be or how much of a fight he may make against it. It is true that many people whose parents have died of consumption also die from this disease; but this does not prove that they were born with consumption. It merely shows that they had a good chance to catch the disease by being continually with some one who had it. It is also true that a great many people die from consumption whose parents did not have it. If consumption is an inherited disease, where did these people get it? [Sidenote: How the germ of tuberculosis was discovered] About thirty years ago, Dr. Robert Koch discovered that all consumptives have in their sputum a long, slender germ which he called the tubercle bacillus. Some of these germs he injected into guinea pigs, and he found that they caused the pigs to have consumption. Then he made many other experiments, and proved beyond question that it is this very germ that causes tuberculosis, and that no one has consumption unless he has this germ in his body. [Sidenote: Evidence that consumption is not inherited] Then the question arose, "Is the baby whose parents have consumption born with this germ in its body?" This question could not at first be answered; but tests were made by taking the children of consumptive parents away from their parents, and keeping them in homes where there were no consumptives. It was found that these babies did not develop the disease. From these and many other tests, it has been proved that consumption is not inherited, and that the reason the child of the consumptive so often has consumption is because he lives with people having the disease. [Sidenote: Evidence that consumption is a house disease] Consumption seems to be confined to certain families, and this has led many people to think that the disease is inherited, regardless of the proof that it is not. When we carefully study the facts in various cases, we find that the disease is not confined to a certain family, so much as it is to the _house_ in which the family lives. The record of a single house will illustrate how tuberculosis sticks to the house rather than to the family. From 1880 to 1901, a particular house was occupied by a father, mother, and six children, of whom four died of consumption. From 1902 to 1903 the house was occupied by another father and mother with eight children. They moved away because of the great amount of sickness in the family. At present this father and one of his children have tuberculosis. In 1904 the house was occupied by still another family, consisting likewise of a father, mother, and eight children. Now it is known that four of the children have tuberculosis, and it is feared that three others have also contracted the disease. In 1905 a son of the first occupant, with his wife and two children, returned to live in the house. The father of this family died of tuberculosis. Up to 1906 the total results from this house, scattered through four families, were as follows: five deaths, six cases in people still living, and three suspected cases. [Illustration: FIG. 66. The constant danger of infection in railway cars, where germs can live as well as in a house.] [Sidenote: Why consumption is a house disease] When the consumptive coughs, he sends fine droplets of moisture into the air. These droplets contain the germs that cause tuberculosis. The moisture evaporates and the germs are left sticking to the floors, the walls, the curtains, and the furniture of the room. When the room is swept or dusted, the germs are stirred up with the dust and people inhale them. The germ that causes consumption will live for a long time in a house; you cannot see it, but it is there. Wherever a consumptive has lived, he has left the germs of this disease behind him. [Sidenote: How to disinfect houses] If a house in which a consumptive has lived is thoroughly disinfected, all the germs he left there will be killed. Scattering disinfectants about a room does no good. The only proper way to disinfect is to close the house, for if the disinfectant is strong enough to kill the disease germs, no human being can stay in the house while it is being used. Disinfecting should be done by the health officer, because he knows how much disinfectant is needed to kill every germ in the house and how it should be used. [Sidenote: Fraudulent disinfectants] Sometimes you will see an advertisement saying that certain disinfectants will kill the germs of disease but will not affect the people. Always remember that any disinfectant that is strong enough to kill the disease germs will also kill human beings, and do not be fooled by such advertisements. _Never move into a house that has been previously occupied, until the house has been disinfected._ Do not take it for granted that the people who lived there before had no communicable disease. Do not take the word of the agent or of any one else that there has never been sickness in the house. People sometimes have tuberculosis without knowing it; people sometimes have tuberculosis or other communicable diseases without telling of it. It does not cost much to disinfect a house, and if the disinfection is properly done the disease germs will be killed. "An ounce of prevention is worth a pound of cure." Try to convince your father that by having the new home disinfected he may save not only doctor's fees, but perhaps the lives of himself and his family. There are a great many things that boys and girls can do to help fight this disease. This "scourge" can be wiped out; but if the boys and girls do not help in this great work, it will never be done. =Questions.= 1. Why do people call consumption the Great White Plague? 2. What is the annual death rate from consumption in the United States? 3. Compare the fatality from consumption with the number of soldiers killed during the Civil War. 4. What amount of illness in the United States is due to consumption? 5. Describe at least four forms of tuberculosis. 6. What determines the part of the body in which the germ of tuberculosis grows? =Remember.= 1. Tuberculosis and consumption are the same disease. 2. This disease kills more people than war, although it might be prevented. 3. Tuberculosis is not confined to the lungs but may attack the tissues of any part of the body. 4. Consumption is not inherited; it is a house disease rather than a family disease. 5. A house should be disinfected by the health officer before it is occupied by a new tenant. CHAPTER XXXII HOW CONSUMPTION IS SPREAD AND HOW PREVENTED [Sidenote: How tuberculosis germs leave the body:] The sputum (spit) of the consumptive and the discharges from tubercular sores contain the germs that cause tuberculosis. Sometimes these germs are so numerous that thousands of them would be found clinging to the point of a needle dipped into the sputum or discharges from a patient. When the consumptive coughs, he sends into the air many of the germs that cause tuberculosis. We cannot kill the germs while they are in the body of the consumptive; but we can kill them after they have left the body, by seeing that none of the sputum or discharge from tubercular wounds or sores is allowed to become dried and blown about as dust. [Sidenote: (_1_) In discharges from sores] When the discharge from a tubercular sore becomes dried and blows about with the dust, the germs are inhaled into the lungs of other people, or fall into other sores and cause them to become tubercular. Since this is one of the most frequent ways by which this dread disease is spread, you will say at once, "Why, every particle of matter from a tubercular sore ought to be burned, so that there would be no possibility of the germs being scattered." This of course ought to be done, but this is not enough. People sometimes have consumption and are not aware that they have it. Others may have tubercular sores and not know them to be such. Any sore, whether it is tubercular or not, contains disease germs. They may not be the germs of tuberculosis, but even the least dangerous of them is the germ that causes pus (matter). Since we are trying to get rid not only of the germs that cause tuberculosis, but also of the germs that cause all communicable diseases, it would be better to say, "All discharges from _any_ sore should be burned immediately." [Sidenote: (_2_) In the sputum] When people spit on the sidewalk or on the floor, the sputum will of course become dry. Sometimes a lady drags her dress through the sputum on the sidewalk or on the floor; it sticks to her dress and she takes the germs home with her. The sputum of the consumptive is loaded with the germs that cause tuberculosis, and if this sputum is allowed to be blown about with the dust, people will inhale it and thus get the germs into their lungs. Certainly the consumptive should never spit on the sidewalk or on the floor, or in the mine, workshop, or in any place where the sputum may become dry and form dust. Of course he should not fill the air about him with germs by coughing into it; everybody knows that. [Illustration: FIG. 67. A sputum cup of waterproof pasteboard.] [Sidenote: Why everybody should be careful about spitting and coughing] But _no_ man or woman, boy or girl, should ever spit on the floor or sidewalk. In the first place it is bad manners. No person does this who is well brought up. In the second place, we must remember that the consumptive does not like to have others know that he has consumption; this feeling is a part of the disease. If you expect the consumptive to refrain from spitting on the floor or sidewalk, you must help him by your example. You cannot expect him to be the only one to hunt up a cuspidor, when you yourself are spitting on floor or sidewalk. If you expect the consumptive to take the precaution necessary to protect you from this disease, you must take the same precaution yourself. In the matter of coughing, the same rules hold true. If you expect the consumptive to hold a handkerchief before his mouth when he coughs, you must do the same. [Sidenote: How to avoid spitting on the floor or sidewalk:] Since it is not right that the consumptive should spit on the floor or sidewalk, it will naturally be asked, "What is the consumptive to do with what he coughs up?" [Sidenote: (_1_) By using paper napkins] At a very small cost he can buy paper napkins and envelopes which have been treated with paraffin to prevent moisture going through them. If every one with a cough or with any such trouble as catarrh, which makes him want to spit frequently, would carry a supply of these paper napkins and paraffin envelopes, he would always have a suitable place in which to spit. When you cough up anything, spit into one of these little napkins, put the napkin into the envelope, and when you get home burn the whole thing. [Illustration: FIG. 68. A pocket cuspidor.] [Sidenote: (_2_) By using pocket cuspidors] There are other conveniences which can easily be carried in the pocket, called pocket cuspidors. Some are made of thin cardboard, treated with paraffin, and filled with cotton to hold all the moisture of the sputum; others are made of glass, shaped like a bottle, with a wide mouth. Those made of cardboard should be burned as soon as possible and the glass ones should be thoroughly washed with boiling water. [Sidenote: (_3_) By having public cuspidors] In some cities cuspidors have been placed at the edge of the sidewalk in an effort to lessen the spread of disease caused by spitting. These cuspidors have a stream of water running through them constantly and are connected with the sewer. They are so made that they cannot easily be kicked over or upset, and they are placed on stands just high enough to make it easy to spit into them. If properly made, they are not unsightly. Would it not be a good thing if your town would put such cuspidors on your streets, and if the merchants would put them into their stores? Every office, every workshop, every store, every railway and street car should be provided with cuspidors. [Illustration: FIG. 69. The common drinking cup--a fruitful source of infection.] [Illustration: FIG. 70. The individual drinking cup--each cup clean and free from disease germs.] [Sidenote: How consumption is spread from the lips:] We know that the substance which people cough up when they have consumption contains the germs that cause this disease. When they spit this matter out, many of the germs stick to the lips. This is true not only of consumption, but of the germs of other diseases, such as diphtheria, measles, and scarlet fever. [Sidenote: (_1_) By drinking cups] When there are disease germs on the lips, it is impossible for a person to drink and not leave some of the germs sticking to the edge of the cup or glass. If the germs of disease are in the mouth, every time that the person suffering from this disease drinks from a cup, he leaves some of the germs on the edge of it. The next person to drink from that cup may get the germs into his mouth. [Illustration: FIG. 71. A sanitary drinking fountain for public places.] Always avoid drinking from a cup or glass from which another person has been drinking. You can never tell who may have disease germs in his mouth, or when you may get them on your lips by drinking from the same cup. Each individual should have his own cup and should never let any one else drink from it. [Sidenote: (_2_) By putting pencils into the mouth] When you put the point of your pencil into your mouth, you will leave germs on it just as you do on the edge of a cup when you drink. Never put your pencil into your mouth; never use any other person's pencil; never trade pencils. [Sidenote: (_3_) By the common bite] Sometimes we see a child giving his friends a bite of his apple or candy or cake. Of course when disease germs are in the mouth of the one who takes a bite, the germs will be left on the apple, candy, or cake. By no means should a boy or girl be selfish, but if you have something to share with your friends, break it or cut it into pieces. Never take into your mouth anything from which another person has taken a bite. [Sidenote: How tubercular cows cause consumption] Milk that comes from consumptive cows may contain the germs that cause tuberculosis. When you drink the milk from such cows, you take these germs into your body. They find their way from the stomach and intestine into the blood, and there they travel about until they find a spot where the cells are dead or are not doing their work properly. When they find such a place, they settle down and begin to grow; and the first thing you know, you will have tuberculosis in that part of your body. Sometimes the germs do not have to go out of the stomach or intestines to find a favorable opportunity to take hold and grow. When this happens, we have consumption of the bowels. One cannot tell by looking at milk or by tasting it whether or not the germs of tuberculosis are present. They do not make the milk sour; neither do they make it look different from pure milk. One cannot tell by looking at a cow whether or not she has tuberculosis. Sometimes a cow will have tuberculosis and yet look very healthy. There is, however, a way by which we can tell when a cow has this disease, no matter how healthy she may look. This is what is known as the tuberculin test. [Sidenote: How to detect tuberculosis in a cow] If a little tuberculin is injected under the skin of a cow that has tuberculosis, it will make her have a fever and appear sick for a day or two. If she is free from tuberculosis, it will not make her sick at all. It would seem as if all people who sell milk would want to know whether their cows have consumption so as not to run any risk of conveying the disease to their customers. Some of them do take this precaution, but a great many of them do not want to go to this trouble. Sometimes you will hear them say, "Oh, I do not believe in this tuberculin test." They do not want to believe in it because they know that the cows, if tested and found to have tuberculosis, will have to be killed. The reason that dairymen sell us milk from tubercular cows is the same that makes the man with scarlet fever in his house fail to tell the health officer about it; the same that makes the butcher buy and sell meat from diseased cattle; the same that makes some people absolutely regardless of the welfare of others--it is selfishness. =Questions.= 1. How does a patient give off tuberculosis germs? 2. Why should even well people refrain from spitting in public? 3. Why should the sputum be taken care of? 4. Why should we avoid the common drinking cup? 5. What is the danger from putting pencils into the mouth? 6. Is it safe to use another person's pencil? 7. What is the best way of sharing food? 8. How can one be protected from tubercular milk? =Remember.= 1. The sputum and discharges from all sores should be immediately burned or disposed of in such a way that they cannot become dry and be blown about as dust. 2. Consumption may be contracted by the use of the common drinking cup, or by putting into your mouth such things as pencils and coins. 3. The milk from a cow suffering from consumption contains the germ of tuberculosis. 4. A cow may have tuberculosis and not appear to be sick. 5. The only way to determine whether a cow has tuberculosis is by using the tuberculin test. 6. Every milch cow should be tuberculin tested. CHAPTER XXXIII HOW CONSUMPTION IS CURED [Sidenote: Consumption should be recognized early] When people first get consumption, they seldom realize that they are seriously sick. Most of them think they have a bad cold, or are overworked, or that they have been staying too closely in the house. Often they will not even see a doctor until they are so sick that the doctor cannot do much for them. When you have a slight cough that "hangs on"; when you feel feverish every afternoon; when you are short of breath; when you get tired very easily; when you do not feel like eating anything except candies and cakes--then you should think of consumption. These are not all the signs, but they are enough to make you go at once to a doctor. A long time ago the doctor would have felt badly if he had been obliged to tell you that you had consumption; but now he knows that if you go to him early in the disease and follow his directions, you will get well. [Sidenote: How consumption is cured: (_1_) By rest] When the doctor finds that a person has consumption, the first thing he orders is rest. By this he means absolute _rest_. He does not mean that the patient can go to school or to the office part of the day and rest the remainder of the day. The doctor will want to watch him constantly. Then there comes a time when he must begin to take a little exercise; the doctor tells him just how much exercise to take, and just what form of exercise is best for him. [Sidenote: (_2_) By fresh air] The consumptive must have plenty of fresh air all the time; he must be out-of-doors as much as possible. You will wonder how the doctor expects him to be out-of-doors when he has been told that he must have absolute rest. Later we will show you how one can practically be out-of-doors and yet at the same time be in bed. [Sidenote: (_3_) By sunshine] Sunshine will kill the germs of any disease more quickly than almost anything we know of, and a consumptive must have all the sunshine that he can get. Of course it cannot get into the body to kill the germs, but it strengthens the cells of the body so much that they can fight with just that much more energy. [Illustration: FIGS. 72 and 73. Living outdoors in cold weather.] [Sidenote: (_4_) By nourishing food] Nothing is more important than pure food in building up the body and in making heat and power. In consumption the food that is stored up in the body burns itself up very fast. The consumptive must therefore take not only the food needed to supply the usual demands of the body, but enough to make something extra for the disease to burn up without drawing on the reserve fund stored in the body. In order to do this, he will have to eat a great deal, and what he eats must be of the kind that makes the best building material and the most nourishing material. He cannot tax his stomach by eating things that are not nourishing; all the work his stomach can do must be devoted to the foods he really needs. The weapons with which we fight consumption are rest, good food, fresh air, and sunshine. These will do more good than all the medicine in the world. Fresh air is not only one of the best things for the cure of consumption, but it is one of the best things for the prevention of consumption. You should always breathe plenty of fresh air night and day, and there is plenty of fresh air to be had if you will take it. [Illustration: FIG. 74. A window tent. (Invented by Dr. W. E. Walsh.)] [Sidenote: How to have fresh air at home:] If you have only a single window in your room, try to sleep with your head in the fresh air. It is not always easy to arrange a room in such a way that you can have fresh air without placing your bed in a draft, but even this difficulty can be overcome. [Sidenote: (_1_) By window tents] There are several devices, called window tents, which you can buy. By the use of such a tent, your head will be out-of-doors all the time; yet the draft cannot strike your body, because a part of the tent fits around your neck and cuts off the air from the rest of your body. One of these tents is shown in Figure 74. You do not put your head out of the window; your head is on your pillow just as if the tent were not there. Your bed is placed directly in front of the window and the tent comes down over your pillow, allowing your head practically to be out-of-doors, but keeping the cold air out of the room. Sleeping under a window tent is the next best thing to sleeping out-of-doors. [Illustration: FIG. 75. A sleeping porch built in a house.] [Sidenote: (_2_) By sleeping porches] Many of our modern houses are built with sleeping porches on which one can sleep outdoors summer and winter. Where there is not a special sleeping porch on the house, an ordinary porch may often be made to serve the purpose, or a very inexpensive sleeping porch can be added to the house. [Sidenote: (_3_) By tent cots] Sometimes people cannot get the use of a porch of any kind. In such cases it may be possible to put up a tent in the yard. If the yard is very small, a tent cot may be used. This is simply a cot with a tent on it, which can be closed up and put away in the daytime and set up again at night. In a large city where the houses have no yards at all, this arrangement can be used by setting it up on the roof of the house. There is almost always some way of securing fresh air at night if we will only give a little thought to the matter. [Sidenote: Fresh air in schoolrooms] Unfortunately, many of our school buildings are not provided with good ventilating plants. A proper system of ventilation furnishes at least 1200 cubic feet of fresh air per hour for each child in each room. [Illustration: FIG. 76. An open-air schoolroom for consumptive children.] [Sidenote: The necessity for playgrounds] In large cities it is often impossible to find outdoor space in which boys and girls may play during recess. Even this difficulty can be overcome by turning the roof of the school building into a playground, with a high wire netting around it. Every school yard should be provided with swings, bars, and gymnasium apparatus to encourage the children to take plenty of exercise. Children who live in crowded towns need exercise during vacation as well as during school days, and the school yards should be open to them at all times. A summer teacher who shows the children the best way to exercise, has work fully as important as that of any other teacher during the school term. A sound body is more valuable than education itself, but a good education and a sound body together are the best assets any man or woman can have. =Questions.= 1. State the four things necessary to cure consumption; show the value of each. 2. What is the value of fresh air to every one? 3. How may an abundance of fresh air be secured in the home? 4. In the school? =Remember.= 1. Rest, fresh air, sunshine, and nourishing food are the cures for consumption. 2. All these things can be secured in any climate and by every person. 3. =Tuberculosis is a communicable disease.= 4. =Tuberculosis can be prevented.= 5. =Tuberculosis can be cured.= APPENDIX[4] A SUMMARY OF ANATOMY BONES AND JOINTS [Sidenote: The framework of the body] The framework of the body is composed of bones. There are 206 bones (not including the teeth) in the body. The bones of the body are divided into four classes--long bones, short bones, flat bones, and irregular bones. [Sidenote: Construction of bones] Regardless of their shape, all bones are composed in the same way. Every bone has an outer and an inner portion. The outer portion is a dense layer called _compact bone_. The inner portion is more open, and is much weaker; this is called _cancellated bone_ (from _cancella_, a sponge). In the smaller bones, the marrow, which is quite soft, runs through the spongy bone; in the larger long bones, the marrow is distinct and is enclosed by the spongy bone. [Sidenote: The periosteum] Every bone is covered by a thick, tough layer, the _periosteum_, which has three uses. When the bone is injured by disease or accident, the periosteum makes new bone to fill in and repair the break. It also builds new bone on the surface of the old as long as the body is growing. Finally, the periosteum gives strong and firm attachment to the muscles, which send tendons into it. [Sidenote: Joints] Every bone in the body (except the hyoid bone, to which the tongue is attached) is joined with some other bone. Most of them join with two or more bones. In most instances the end of a bone which joins with another is rounded off and made very smooth, so that it can slide easily over the other bone. There are three principal kinds of joints in the body. They are called the _ball and socket_ joint, the _hinge_ joint, and the _serrated_ or _saw-tooth_ joint. [Illustration: FIG. 77. The skeleton.] [Sidenote: The ball and socket joint] The ball and socket joint is one that can move freely in all directions. We see it illustrated in the joints of the shoulder and hip. In these joints one of the bones has a deep depression in it, and this depression forms the _socket_. The other bone has a rounded head that fits into the depression. We call this rounded head the _ball_. [Illustration: FIG. 78. The structure of a bone.] [Sidenote: The hinge joint] The hinge joint is illustrated in the knee and elbow joints. These joints can move backward and forward in one plane like a hinge, but they cannot move in a circle like the ball and socket joints. You cannot swing your forearm about on a pivot at the elbow as you can your whole arm, nor will the knee joint bend in every direction as does the joint at the hip. [Sidenote: Serrated joints] Serrated joints do not move. The bones having serrated joints are fitted tightly together so that they form practically one bone. We find this kind of joint illustrated in the way the bones of the skull are put together. [Sidenote: Ligaments] The joints of the body are not held together by rivets, pins or bolts as are the joints of a machine, but by bands of very tough tissue placed about a joint in such a way as to allow it to move freely, although the bones are all the time held firmly together. These bands are called _ligaments_. Ligaments are much better than bolts or pegs would be, because they stretch a little, and thus prevent the breaking of the bones when the joint is put under a severe strain. [Illustration: FIG. 79. The muscles.] MUSCLES AND TENDONS [Sidenote: What muscle is] The lean meat of any animal is composed entirely of muscle tissue. It is the function of the muscles to move the body. [Illustration: FIG. 80. The biceps muscle contracted.] [Sidenote: How the muscles work] The muscles are nearly all attached to the bones. They are just long enough to let the joint straighten out when the muscles are at rest, but when the joint bends the muscle contracts. When a muscle contracts it becomes shorter and thicker. Sometimes it becomes very much thicker in one place. Every boy knows how much thicker the arm muscle (_biceps_) becomes when he bends his elbow hard. He calls this "showing his muscle." [Sidenote: Tendons] There is not room enough on most of the bones for all the muscles to be attached directly to them. Instead of being thus attached directly to the bone, they end in what we call _tendons_. These tendons are hard and strong, and a very small tendon will lift as much without breaking as quite a large muscle. The muscles are soft and would have to be attached over a large area in order to secure the required strength. The tendons, being so much stronger than the muscles, can be attached to a very small area and yet secure the same amount of power as would result from attaching the muscle itself. The tendons pass directly into the periosteum, the thick, strong covering of the bones. So strong is this attachment that the bone will often break before the tendon will pull loose. THE SKIN [Sidenote: The skin as an armor] The entire body is covered with skin, which regulates the heat of the body and acts as an armor against blows and cuts which would otherwise injure the delicate nerves and blood vessels beneath. It also serves to some extent to keep out the germs of disease. The skin appears to be smooth, but if you examine it through a strong magnifying glass you will see that it is divided into little areas. The dividing lines do not run straight, however, and the areas are not square like those you find on a checkerboard. [Illustration: FIG. 81. A section of the skin, highly magnified.] [Sidenote: Sweat glands] After looking at the skin with a strong magnifying glass you will think that you must have seen all its irregularities, but if you will look at it with a powerful microscope you will find out many other things. In the first place you will see many little openings in the skin. These little openings make the ridges which divide the skin into little areas. Some of the openings are _sweat glands_, and there is always some perspiration coming out of them. When you are very warm you can see, without the aid of the glass, the drops of perspiration as they come out on the surface of the skin. When you are not very warm you cannot see these drops of perspiration, but they are nevertheless coming out all the time. When the perspiration comes so slowly that you cannot see it, it is called _insensible perspiration_. [Sidenote: Hair] The whole body is covered with hair. You can see the hair on your head and some of the hair on your arms and the backs of your hands, but most of the hair on the body is so fine that you cannot see it without a microscope. Each of the fine hairs on the body has a root that goes through the skin just as the root from each hair on your head goes through it. [Sidenote: Sebaceous glands] Opening into the little pockets in which the hairs stand, are glands that secrete a kind of oily material. They are called _sebaceous glands_ or _follicles_. Sometimes these follicles become stopped up; then the material they secrete becomes thick and cheesy, and the little black points appear on the skin which we call _blackheads_. The white matter which comes out of these blackheads is merely the secretion of the glands from which the water has been absorbed, leaving the solid or cheesy portion. [Sidenote: Nails] There is a part of the skin that we do not usually think of as skin. We mean the _nails_. The finger nails and the toe nails do not look like the rest of the skin of the body, but they are made of just the same kind of cells. The cells of the nails are flat, dead, and closely packed together. There are no sweat glands, or sebaceous glands, or any hairs in the nails. THE DIGESTIVE SYSTEM [Sidenote: The alimentary canal] The digestive system is the part of our bodies in which the food we eat is so changed that it can be made use of by the little cells in the body. It is composed of a long canal with many parts and enlargements, each part necessary for a certain required work. This canal as a whole is called the _alimentary canal_. [Sidenote: Teeth] The mouth does the first part of the work for the digestive system. Here we find the teeth, which are used for grinding the food. The teeth are composed of three parts, the _head_ (or _crown_), the _neck_ and the _root_. The head, or crown, is very hard. Each tooth is hollow, and in the hollow portion there are nerves and blood vessels. [Sidenote: The salivary glands] Opening into the mouth are three pairs of glands known as _salivary glands_. One pair of glands is located just above the angle of the jaw. It is these glands that become swollen when we have mumps. Another pair of glands is placed just inside the jaw bone, near the root of the tongue, and the third pair is located under the tongue. These three pairs of glands secrete the saliva which moistens the food and aids in digesting the starch. [Illustration: FIG. 82. The alimentary canal.] [Sidenote: The esophagus] The food passes from the mouth; through a passage called the _esophagus_, or gullet, to the _stomach_. [Sidenote: The stomach] The stomach is one of the enlarged parts of the alimentary canal. Its walls are quite thick, and in these walls are thousands of little glands. These glands secrete a fluid called _gastric juice_. When the food enters the stomach it is held there for a long time, and the walls of the stomach squeeze upon it so that the food is mixed with the gastric juice until every bit of it that will be of any use to the body has become fluid in character. Not only does the gastric juice make the food liquid, but it acts on it and changes some of it so that it will be suitable for use by the little cells of the body. As fast as the food is made liquid by the juices of the stomach it is allowed to pass into the intestine through an opening called the _pyloric opening_. [Sidenote: The intestine] The intestine is a long, narrow, twisting and turning tube that is divided into two principal parts, the large and small intestine. In the walls of the intestine are many little glands that secrete a fluid that helps in digesting the food. Two fluids, one made by the liver, the other by the pancreas, are brought into the intestine by two small tubes, which come together in the wall of the intestine six or seven inches below the pyloric opening. These fluids perform a very important part in the digestion of all the different foodstuffs. [Sidenote: Villi and lymphatics] Besides the little glands in the walls of the intestine there are many thousands of little finger-like projections standing up from the walls. These are called _villi_. Each villus has in it very small vessels, into which the food passes after it has been digested. These vessels are of two sorts: blood vessels, which take up the digested starch and proteid foods, and another sort known as _lymphatics_, which take up the fats. All the lymphatics combine into a single vessel which empties into the great vein at the base of the neck. Thus the fatty foods pass into the blood and are mingled with the food materials taken up directly by the blood vessels. CIRCULATION OF THE BLOOD [Sidenote: Two kinds of blood vessels] There are two kinds of blood vessels in the body. We call them _arteries_ and _veins_. The arteries serve to carry the blood from the heart to all parts of the body, and the veins serve to carry the blood back to the heart. The heart is really a part of the blood vessels, half of each side being like the veins and half like the arteries. [Sidenote: Arteries and veins] The walls of the arteries are thicker than those of the veins. Two sets of arteries leave the heart, one from each side. The artery that starts from the right side of the heart goes to the lungs and carries _venous blood_, which has a very poor supply of oxygen and is full of impurities. We call this the _pulmonary artery_. The artery that leaves the left side of the heart goes to all parts of the body but the lungs and carries _arterial blood_, which has much more oxygen and is much more free from impurities. [Sidenote: Capillaries] If we follow the blood as it circulates we will see how it reaches all parts of the body. The big artery that leaves the left side of the heart divides into smaller and smaller arteries until there are branches going to every part of the body. These branches keep dividing until they are so small that we call them _arterioles_, and these little arterioles again divide and become so small that we call them _capillaries_. [Sidenote: Changes in the blood] While the blood is passing through the arterioles and the capillaries, something is happening to it. The little cells with which these small vessels come in contact have been taking the oxygen and the nourishing material out of the blood. At the same time they have been putting something into the blood. In place of the oxygen they have been putting in carbon dioxid and in place of the nourishing material they have been putting in the worn-out materials from the cells. As the blood passes through certain parts of the body, such as the kidneys, the worn-out materials from the cells are taken out of the blood and sent out of the body. The carbon dioxid is left in the blood until it goes to the lungs. [Illustration: FIG. 83. The white vessels represent the circulation of the arterial blood; the gray, the circulation of the venous blood.] [Sidenote: Venous blood] The blood has now been followed to the capillaries, where oxygen and nourishing material have been taken out of it, and where something else has been added to it. As we follow a little capillary, we find that instead of dividing again, it joins others and gradually grows larger. As these blood vessels grow larger the walls do not become so thick as the walls of the arteries of the same size. These larger vessels formed by the union of capillaries are called _veins_. In other words, the veins are simply continuations of the arteries that have divided into extremely small branches and have now come together again. The blood which has been changed is now called _venous blood_. It has much less oxygen in it, but has received a great deal of carbon dioxid. The veins continue to come together, until finally they form a single large vein which empties into the upper half of the right side of the heart. From there the blood is driven into the lower half of the right side of the heart and thence to the pulmonary artery, which goes to the lungs. The blood is not changed in the heart, so what goes into the pulmonary artery is still venous blood. [Sidenote: Arterial blood] The blood goes straight from the heart to the lungs and there it is changed into arterial blood. The change consists in taking oxygen from the air and giving off carbon dioxid to the air. From the lungs the blood goes through the capillaries again into the veins, the small capillaries in the lungs uniting to form the pulmonary veins. These veins finally unite into one vein that empties into the upper half of the left side of the heart, and from there the blood goes to the lower half of the same side. The blood has now reached its starting point and is ready to begin its journey again. The journey of the blood is as follows: [Sidenote: Entire circulation] From the right side of the heart to the arteries; from arteries into arterioles; from arterioles to capillaries; from capillaries into veins; from veins into the heart; from the heart to the lungs; and from the lungs back to the heart again. THE RESPIRATORY SYSTEM [Sidenote: Use of the respiratory system] That portion of the body by which we breathe is called the respiratory system. This system is composed of the _nasal passage_, the _pharynx_, the _larynx_, the _trachea_, the _bronchi_, and the _lungs_. The mouth is not a part of the respiratory system; we should never breathe through our mouths. [Sidenote: The use of the nose in breathing] As the air passes through the nasal passage it is warmed and moistened, and a great deal of dust and dirt is taken out of it. Thus the nasal passage serves to warm, to moisten, and to clean the air we breathe, and is a very important part of the respiratory system, since either cold or dry air is very irritating to the lungs. [Illustration: FIG. 84. The air passages of the head and throat.] [Sidenote: Pharynx, larynx, and trachea] There is only one tube leading from the back of the nasal passage to the lungs. Different parts of this tube are given different names. The pharynx is that part that extends from the back of the nose to the vocal chords. The larynx is the part of the throat where the vocal chords are located. We sometimes call it the "Adam's apple." It is very prominent in some men, but seldom noticeable in women. The trachea is the part of the tube leading down from the larynx. At the lower end of the trachea the tube divides into two parts that we call the bronchi, one leading to each lung. [Sidenote: The bronchi] The bronchi carry the air from the trachea to the lungs. They divide again and again until they become so small that there is a branch for each little air cell in the lungs. [Illustration: FIG. 85. The lungs.] [Sidenote: The lungs] The lungs are the most important part of the respiratory system. They are made up of lobes. There are two lobes in the left lung and three in the right. Each lobe is divided into _lobules_, which means small lobes. Each lobule is divided into air spaces. In these air spaces, or cells, the work of the lungs is performed. [Sidenote: Air cells] The capillaries run in the thin walls of the air spaces. The walls of these fine blood vessels are so very thin that the air in the air cells comes in almost direct contact with the blood in the vessels. While the blood is passing through the vessels in the walls of the air spaces, something happens to both the blood and the air. The air we take into our lungs contains a great deal of oxygen and very little carbon dioxid. The air that comes out of our lungs contains a great deal of carbon dioxid and much less oxygen. In other words, the oxygen from the air goes into the blood, and the carbon dioxid from the blood goes out into the air. [Sidenote: Necessity of pure air] If the air we breathe is not pure and does not contain enough oxygen, the blood cannot get all the oxygen we need, and the cells of the body become sick and die. If, when we breathe, we do not fill each little air cell in our lungs with air, a great deal of the blood sent to the lungs for oxygen cannot get it. If we wear very tight clothing we cannot take a full breath and hence cannot fill all the air spaces with air. If the air spaces in the lungs are not filled, the blood does not get the oxygen it needs, as there is no other place in the body to get it. THE EYE AND THE EAR [Sidenote: The eye compared to a camera] The eye is one of the most important organs in the body and also one of the most delicate. It is very much like a camera. [Sidenote: The cornea and the sclera] When you look at an eye you are likely to think that the front of it is blue or brown. The colored part is not the front of the eye. If you look at the eye from the side you will see that there is a curved part in front of the colored part and that the curved part is perfectly clear. This curved clear part of the eye we call the _cornea_. The cornea connects with the white part of the eye, and this white part extends all around the rest of the eye, except at a small point in the back where the _optic nerve_ comes through. This white part we call the _sclera_. [Sidenote: Aqueous humor] The space between the cornea and the colored part of the eye is filled with a clear fluid that is called the _aqueous humor_, which means watery fluid. The space occupied by this fluid is called the _anterior chamber_ of the eye. [Sidenote: The iris] The iris, which is the colored portion of the eye, is a curtain that is hung between the anterior and posterior chambers of the eye. It prevents any light getting into the posterior chamber except that which passes through a round hole in the iris called the _pupil_. The pupil grows larger or smaller according to the amount of light needed by the eye. If you look away from a bright light at something in the dark, the pupil grows larger; if you look back at the light, it grows smaller. You can see this in a hand mirror. [Sidenote: Lens] Behind the pupil is a clear mass shaped like a very strong magnifying glass. This is the _lens_. The lens causes to be formed on the back of the eye a clear picture of whatever you are looking at. When you focus a camera, you move the back towards or away from the lens. When you focus your eye you cannot move the back of the eye, but you can make the lens more or less convex as may be needed to make a clear picture. [Illustration: FIG. 86. A cross-section of the eye.] [Sidenote: Vitreous humor] Behind the iris and the lens, we find the posterior chamber of the eye. This occupies by far the greater portion of the ball and corresponds to the dark chamber of a camera. This chamber is filled with a clear fluid called the _vitreous humor_, which means jelly-like fluid. It is a clear, gelatinous substance. [Sidenote: The retina and the optic nerve] The optic nerve enters the eyeball from the back and spreads its fibers out in a thin membrane called the _retina_, which corresponds to the sensitive plate in a camera. The lens focuses on the retina the image of any object you look at. The impression made on the minute nerve endings in the retina is carried by the optic nerve fibers to the brain. When this impression reaches the brain we see the object. [Sidenote: Movements of the eye] Each eye has six muscles that turn it in whatever direction you want to look. These muscles are very delicate, and for true sight they must be exactly adjusted. If the muscles on one side of the eye are stronger than those on the other side, you will be cross-eyed or wall-eyed. If one of the muscles in one eye is stronger than the corresponding muscle in the other eye, it pulls the eyeball out of place and you "see double." [Sidenote: The use of the outer ear] The portion of the ear that you see on the side of your head has as much to do with hearing as the outer rim of the horn into which you speak has to do with making a record for the phonograph. You know that the record is really made at the little end of the horn, while the big end simply collects the sound. The outside portion of the ear simply collects sounds, and the real hearing is done with the portion of the ear that is not seen. [Illustration: FIG. 87. The ear, showing the outer, middle, and the inner part.] The outer ear connects with the short tube that leads to the _drum_, which is a thin membrane that separates the middle ear from the outer ear. This drum does not have so much to do with hearing as is supposed. To have a hole in the drum does not mean that you cannot hear. [Sidenote: The middle ear] The middle ear is that portion which is just inside the drum. In this we find a chain of little bones. The one attached to the drum is shaped much like a hammer, and is called the _malleus_, which means mallet or hammer. The next one is shaped like an anvil and is called _incus_, which means anvil, and the third is called _stapes_, which means stirrup. The flat part of the stapes fits into a small opening that leads to the internal ear. [Sidenote: The inner ear] The internal ear is shaped like a snail shell. It makes several turns, which are hollow like the ends of a conch shell. In these channels the nerve that receives the impressions made by the sounds is distributed. This nerve carries the impressions to the brain. [Illustration: FIG. 88. The nervous system.] THE NERVOUS SYSTEM [Sidenote: Importance of the nervous system] This system is so important in its use and so difficult to understand in its details, that a description of it should have more space than can be given in this summary. Can you imagine having no feeling and being unable to move? This would be your condition if you had no nerves. [Sidenote: Nerves compared to telegraph system] Briefly, the nerves might be called the telegraph system of the body. There is a great central station called the brain where messages are received and sent out; there are many sub-stations that make up the spinal cord. Twelve great nerves pass directly from the brain to the body; all others pass from the spinal cord. [Sidenote: Extent of nervous system] Every nerve leaving these centres divides and sub-divides into little threads as the arteries divide and sub-divide into arterioles and capillaries, until every part of the body--every muscle and part of the skin--has its nerve. [Sidenote: Voluntary and reflex action] Every time you _choose_ to move your hand, your brain sends to the necessary muscles an instantaneous order to act. This is called _voluntary action_. If you put your finger against a hot stove you jerk it away before you could have time to _choose_ to do it. This happens as an order from a sub-station and is called _reflex action_. Messages travel both ways and it is necessary that the nervous connection with every part of the body remain unbroken, and important that the nervous condition be kept healthy. NOTES TO THE TEACHER A false delicacy has often prevented the teaching of vital lessons to growing children. The day is how at hand when foolish sentiment must no longer prevent the spread of any knowledge which is necessary to exterminate the plagues that have afflicted the race. In chapters 17, 18, 19 and 32, unpleasant facts are given in plain language. They are facts that parents do not teach their children and that most teachers will not frankly treat with classes in a school. Though they are disagreeable to discuss, they are essential for children of school age to know. Now that the dependence of public health upon personal hygiene is recognized, personal habits and sanitary conditions are more frankly dealt with than formerly. It is an excellent thing occasionally, to have one or two points of an assigned lesson answered in writing. Any topic that the teacher may think advisable to treat in this manner may be discussed on paper at the beginning of the recitation, five or six minutes being allowed for that purpose. Even a whole chapter may be assigned to be studied with a view of answering in writing the questions at the end of the chapter. The written test can then take the place of the usual oral recitation. This method is suggested to the teacher who hesitates to discuss orally certain plain but essential facts. Chapter 32 on the Spread and Prevention of Consumption can be treated with best results orally, if the pupils are first made to _feel_ the great danger of consumption and to realize the possibility of preventing the vast havoc wrought by that dread disease. The attitude of teacher and pupils should be that while the discussion may be disagreeable, the disgusting habits referred to in the text are so commonly practised that unless their dangers are taught this disease can never be wiped out. INDEX Adenoids, 49, 50 Air, amount necessary for health, 45; effects of impure, 45-48; fresh air, when needed, 45-48; how secured, 46, 47; how changed in body, 45; necessity of pure air, 45-48 Air cells, 175 Alcohol, effect of, on body, 67-70; on brain work, 70; on consumptives, 69; on descendants, 69; on liver, 68; on morals, 69; on nervous system, 69; on powers of resistance, 68; on stomach, 67; false ideas about effects of, 67; what business men think of, 70 Alimentary canal, 169, 170 Amoebic dysentery, how prevented, 122; how spread, 122; where prevalent, 122 Animals free from typhoid fever, 113 Antitoxin, how it acts, 108-110; how discovered, 109; sometimes considered a poison, 111; prevents diphtheria, 110; saves lives, 110 Aqueous humor, 177 Arterial blood, 172 Arteries, 171 Articles used by the sick, dangers from, 75; how to treat, 76 Bathing, importance of, 60; frequency of, 60 Baths, hot, 61; cold, 61 Bedtime for children, 51 Blood, arterial, 172; how changed in the body, 174; venous, 171, 172 Boils, how caused, 95, 99 Bones, 163 Bronchi, 175 Building foods, 14, 15 Candy, when harmful, 54; when not harmful, 54 Canned meats, why poisonous, 32 Capillaries, 172 Cells, are alive, 6; body made of, 6; body needs new, 14; how killed, 7; must not be killed, 6; size of a, 5; what they are like, 5 Circulation of the blood, 171-174 Clothing, effect of damp, 11; promotes health, 9; proper weight of, 10 Common drinking cup, 153 Consumption. _See Tuberculosis_ Cooking, effects of improper, 34, 35; fatty foods, 34; meats, 35; starchy foods, 34 Cornea, 177 Coughing, dangers from, 147, 150-153; how to prevent dangers from, 152, 153 Cuspidors, in public buildings, 152; pocket, 152; street, 152 Dairy, sickness about a, 26, 103, 115 Decomposed foods dangerous, 30, 32 Decomposition, cause of, 30; effect of cold on, 31; of foods, 30-32 Desserts, when harmful, 40; when not harmful, 40 Dining table, effect of dirty, 37; cheerfulness at, 37 Diphtheria, cure of, 108-111; germs present after recovery, 101, 102; germs present when throat is not sore, 104; how to confine germs, 100; how poison is fought, 108-110; mild cases, how detected, 104; nature of the poison, 108; prevalence of, 100; where germs come from, 100; why some cases are not quarantined, 102-104 Dirt, a cause of sickness, 77, 78; getting into milk from cows, 23, 117; from cow barns, 23-25; from milk cans and bottles, 26, 27; from milkmen, 25; from flies, 28, 80, 81 Diseased animals, effect on meats, 19-21; effect on milk, 28; tuberculosis from, 28, 155 Drafts, evil effects of, 10; how to prevent harm from, 10 Ear, care of, 58; drum, 179; inner ear, 181; middle ear, 179; outer ear, 179 Esophagus, 170 Excreta from sick, how dispose of, 76, 118 Exercise, necessity of, 51, 161 Eye, how germs get into, 56; how overworked, 57; method of testing, 58 Far sight, 58 Flies, breeding places for, 77, 80; as germ carriers, 80, 81, 116; how to get rid of, 82, 83; how to keep out, 83 Fly screens, where needed, 83 Foods, advertised, 16; building, 14-16; decomposition of, 30-32; heat-producing, 14-16; improper cooking of, 34, 35; cost of suitable, 16; uses of foods, 14-17; uses of starches, 14; uses of fats, 15; value of meat as a, 15; value of milk as a, 14 Garbage cans, should be covered, 83 Germs, cause of poison in meats, 31, 32; carried by dogs and cats, 106; effect of, in wounds, 95-99; how, get through the skin, 95; how, get into the body, 79; how, get into foods, 79, 80; how put into the air, 147, 150; how kept out of the air, 151, 152; how to fight, 74; of lockjaw, 98; man's greatest foe, 1; nature of a, 73; not alike, 73; not killed by running water, 115 Hair, 169 Hearing, how tested, 58 Heat, how kept up in the body, 14 Hookworm disease, character of the worm, 120; how it enters the body, 121; how prevented, 122; nature of the disease, 121; where worm lives in the body, 121; where prevalent, 122 Insects that carry disease, 92-94 Intestines, 171 Iris, 177 Joints, 163 Larynx, 174, 175 Lens, the, 178 Ligaments, 165 Lungs, 175 Lymphatics, 171 Malaria, how transmitted, 92; how prevented, 93 Manure, a hatching place for flies, 80, 82; how to dispose of, 82 Meal times, frequency of, 53; regularity of, 53; should be pleasant, 37, 38 Measles, after effects of, 128; fatality of, 128; necessity of care in, 129; seriousness of, 128; why to avoid, 128 Meats, characteristics of good, 18; Clean Meat League, 19; from diseased animals, 19-21; germs cause poison in, 19, 32; how kept clean, 18; should be cooked, 35; value of, as a food, 18 Milk, as carrier of disease, 22, 117; effect of germs on, 22; effect of disease in cow on, 28; flies in, 28; how germs get into, 23-28; impure, dangerous, 22; polluted water in, 27; typhoid fever carried by, 117; value of, as a food, 14, 20 Mosquitoes, as disease carriers, 92, 93; how to get rid of, 94 Mouth, why some breathe through, 49 Mouth-breathing, effect of, 50 Muscles, attachment of, 167 Nails, how to care for, 61, 62 Near sight, 57 Nerves, compared to telegraph system, 181; distribution of, 181 Nose, importance of breathing through, 48 Overcoats, necessity of, 12 Overwork, effect of, 51, 52 Paper napkins for consumptives, 152 Parties, time for, 53 Pencils in mouth, 155 Pharynx, 175 Play a form of work, 52 Playgrounds, 161 Pocket cuspidors, 152 Ptomaines, 19 Quarantine, breaking, shows selfishness, 126; how broken by family, 105; rules of, 105; seriousness of breaking, 101; when safe to raise, 102; why necessary, 101; why some cases escape, 102-104 Reflex action, 181 Respiratory system, 174-177 Rest, proper amount of, 51 Retina, 178 Rocky Mountain Spotted (Tick) Fever, how transmitted, 94 Rubbers, necessity of wearing, 11 Saliva, effect of, on starches, 39, 41 Salivary glands, 170 Scarlet fever, a dangerous disease, 124; mild cases dangerous, 123, 124 Scarlatina, 125 Scarlet rash, why quarantine is necessary in, 125 School lunches, 37 Sclera, 177 Sebaceous glands, 169 Sewage, effect of, on water, 85-87, 115 Sickness about a dairy, 26, 103, 115; due to germs, how prevented, 3 Sick room, stay away from, 75 Skin, care of, 60, 61 Smallpox, fatality of, 131; how prevented, 135-137; during Franco-Prussian War, 132; in Sweden, 133; in Gloucester, 134; in the Philippine Islands, 134 Spitting, dangers from, 151; how avoided, 152; where to spit, 152, 153; where not to spit, 151 Springs, how polluted, 87 Street cuspidors, 152 Sunshine, effect of, on germs, 77, 78 Suppuration, how the surgeon prevents, 96; how you may prevent, 97; real cause of, 96 Sweat glands, the work of, 60 Teeth, brittle, 42; dangers from poor, 41-43; how to care for, 43; necessity of baby teeth, 41; uses of teeth, 41; why, decay, 42 Tendons, 167 Tobacco, a poison, 64; effect of, on blood, 65; on heart, 66; on nervous system, 66; on nose and throat, 65; on stomach, 66; extra work caused by, 64 Toilets, improper construction of, 86; proper construction of, 87; relation to wells, 85-87 Tonsils, 49, 50 Trachea, 175 Tuberculin test, 155, 156 Tuberculosis, can be prevented, 142, 148, 157; fatality of, 142; fresh air in, 157, 158; germ, discovery of the, 145; how to get, out of a house, 147, 148; how germs leave the body, 150, 151; how spread from cows, 28, 155; how spread from the lips, 153-155; how detected in cows, 155; a house disease, 146, 147; not inherited, 146; of the glands, 144; of the joints, 143; of the spine, 144; of the stomach, 144; of the throat, 143; prevalence of, 142; pure food in, 158; rest in, 157; should be recognized early, 157; sunshine in, 158; why called the Great White Plague, 142 Typhoid fever, animals free from, 113; carried by flies, 80, 81, 116; carried by milk, 22, 117; effect of a single case, 114; how germs leave the body, 113; how germs get into the body, 113; how germs get into water, 114; importance of cleanliness, 117, 118; life of germs in a stream, 115; recovered patient dangerous, 117 Umbrellas, necessity of, 11 Vaccination, cause of sore arms after, 140, 141; discovery of, 132; how, prevents smallpox, 135; necessity of repeating, 137; pretended vaccination, 138; when successful, 138 Ventilation, in homes, 46, 159; in public buildings, 48, 161; in workshops, 48 Veins, 171 Venous blood, 171, 172 Villi, 171 Vitreous humor, 178 Voluntary action, 181 Water, avoid polluting, 85-88, 115; effect of sewage on, 85, 115; how germs get into, 85-88; polluted, in milk, 27; safe sources of, 88 Wells, how polluted, 86, 87; relation of toilets to, 86, 87 Windows, should be kept open, 45-47; should be screened, 83 Wood-ticks, as disease carriers, 93; how abolished, 94 Wounds, importance of keeping clean, 97 Yards should be clean, 77 Yellow fever, how transmitted, 92; how prevented, 92 FOOTNOTES: [1] Bujar and Baier state that the nourishing power of bacon is represented by 2,767, while the nourishing power of butter is represented by 2,610. [2] The cleaning out of these cemented vaults is an exceedingly unpleasant task. Some prefer to have a strong, water-tight box placed under the closet seats. When this box is nearly full, it can be removed to some place where fertilizer is needed, and there emptied, the contents being plowed into the ground. In order to make this task as simple as possible, it is a good plan to put the box on skids, and have a heavy strip in one end with a bolt and ring through it, so that a horse can be hitched to the box to draw it away. If a little dry earth or lime is put into the box each day, there will be no unpleasant odor. [3] The teacher should demonstrate the action of acids and alkalies on a solution of litmus. [4] At the request of many practical teachers the author has appended this brief summary of anatomy. The material is intended to be used for reference or to be assigned as lessons in connection with the chapters of the book, at the discretion of the teacher. 
21353	----	* * * * * +-----------------------------------------------------------+ | 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. | | | +-----------------------------------------------------------+ * * * * * [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 CHAPTER V MOUTH BREATHING 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. [Illustration: MOUTH BREATHERS BEFORE "ADENOID PARTY"] The features in the following cut are familiar to teachers the world over. Parents may reconcile themselves to such lips, eyes, and mouths, but seldom do even neglectful parents fail to notice "mouth breathing." Children afflicted by such features suffer torment from playfellows whose scornful epithets are echoed by the looking-glass. No fashion plate ever portrays such faces. No athlete, thinker, or hero looks out from printed page with such clouded, listless eyes. The more wonder, therefore, that the meaning of these outward signs has not been appreciated and their causes removed; conclusive reason, also, for not being misled by recent talk of mouth breathing, adenoids, and enlarged tonsils, into the belief that the race is physically deteriorating. Three generations ago Charles Dickens in his _Uncommercial Traveller_ pointed out a relation between open mouths and backwardness and delinquency that would have saved millions of dollars and millions of life failures had the civilized world listened. He was speaking of delinquent girls from seventeen to twenty years old in Wapping Workhouse: "I have never yet ascertained why a refractory habit should affect the tonsils and the uvula; but I have always observed that refractories of both sexes and every grade, between a Ragged School and the Old Bailey, have one voice, in which the tonsils and uvula gain a diseased ascendency." To-day we are just beginning to see over again the connection between inability to breathe through the nose and inability to see clearly right from wrong and inability to want to do what teachers and parents wish. Physical examinations show now, and might just as well have shown fifty years ago, that the great majority of truants and juvenile offenders have adenoids and enlarged tonsils. A recent examination made by the New York board of health on 150 children in one school made up from the truant school, the juvenile court, and Randall's Island, showed that only three were without some physical defect and that 137 had adenoids and large tonsils. Dickens wrote his observations in 1860; in 1854 the New York Juvenile Asylum was started, and up to 1908 cared for 40,000 children; in 1860 William Meyer pointed out, so that no one need misunderstand, the harmful effects of adenoids. What would have been the story of juvenile waywardness, of sickness, of educational advancement, had examinations for defective breathing been started in 1853 or 1860 instead of 1905; if one per cent of the attention that has been given to teaching mouth breathers the ten commandments had been spent on removing the nasal obstructions to intelligence? [Illustration: A "DEGENERATE" MADE NORMAL BY REMOVAL OF ADENOIDS] William Hegel, who is pictured on page 48, before his tonsils and adenoids were removed was described by his father in this way: "When playing with other boys on the street he seems dazed, and sluggish to grasp the various situations occurring in the course of the game. When he decides to do something he runs in a heedless, senseless way, as if running away,--will bump against something, pedestrian or building, before he comes to himself; seems dazed all the time. When told something by his mother he giggles in the most exasperating way, for which he receives a whipping quite often." The father said the whipping was of no avail. The child was restless, talkative, and snored during sleep. He had an insatiable appetite. He was removed or transferred from five different schools in New York City. To get redress the father took him to the board of education, whence he was referred to the assistant chief medical inspector of the department of health, whose examination revealed immensely large fungous-looking tonsils and excessive pharyngeal granulations (adenoids). He was operated on at a clinic. The tonsils and adenoids removed are pictured on the opposite page, reduced one third. After the operation the child was visited by the assistant medical inspector. There was a marked improvement in his facial expression,--he looked intelligent, was alert and interested. When asked how he felt, he answered, "I feel fine now." It required about fifteen minutes to get his history, during all of which time he was responsive and interested, constantly correcting statements of his father and volunteering other information. Eleven days after the operation he was reported to have had no more epileptic seizures. "Doesn't talk in sleep. Doesn't snore. Doesn't toss about the bed. Has more self-control. Tries to read the paper. His immoderate appetite is not present." [Illustration: REASON ENOUGH FOR MOUTH BREATHING Adenoid and tonsils reduced one third] While the open mouth is a sure sign of defects of breathing, it is not true that the closed mouth, when awake and with other people, is proof that there are no such defects. Children breathe through the mouth not because they like to, not because they have drifted into bad habits, not because their parents did, not because the human race is deteriorating, but because their noses are stopped up,--because they must. A mouth breather is not only always taking unfiltered dirt germs into his system but is always in the condition of a person who has slept in a stuffy room. What extra effort adenoids mean can be ascertained by closing the nostrils for a forenoon. For many reasons it is perhaps unfortunate that we can breathe at all when the nose is stopped up. If we could see with our ears as well as with our eyes, we should probably not take as good care of our eyes. In this respect the whole race has experienced the misfortune of the man of whom the coroner reported, "Killed by falling too short a distance." Because we can breathe through the mouth we have neglected for centuries the nasal passages. When a cold stops the nose we necessarily breathe through the mouth. Unfortunately children make the necessary effort required to breathe through the nose long before other people notice the lines along the nose and the slow mind. Mouth breathing will show with the child asleep, before the child awake loses power to accommodate his effort to the task. Therefore the importance of a physical test at school to detect the beginnings of adenoids and large tonsils before these symptoms become obvious to others. No child should be exempted from this examination because of apocryphal theories that only the poor, the slum child, the refractory, or the unclean have defects in breathing. This very afternoon a friend has told me of her year abroad with a girl of nine, whose parents are very wealthy. The girl is anæmic. Her backwardness humiliates her parents, especially because she gave great promise until two years ago. High-priced physicians have prescribed for her. It happens that they are too eminent to give attention to such simple troubles as adenoids that can be felt and seen. They are looking for complications of the liver or inflammation of muscles at the base of the brain. One celebrated French savant found the adenoids, assured the mother that the child would outgrow them, and advised merely that she be compelled to breathe through the nose. The mother and nursemaids nag the child all day. The poor unwise mother sits up nights to hold the child's jaws tight in the hope that air coming through the nose will absorb the adenoids. The mother is made nervous. Of course this makes the child more nervous and adds to the evil effects of adenoids. If the mother had the good fortune to be very poor, she could not sit up nights, and would long ago have decided either to let the child alone or else to have the trouble removed. Adenoids are not a city specialty. Country earache is largely due to adenoids or to inflammation that quickly leads to adenoids. In 415 villages of New York state twelve per cent were found to be mouth breathers. For two summers I have known a lad named Fred. He lives at the seashore. Throughout his twelve years he has lived in a veritable El Dorado of health and nature beauty. Groves and dunes and flora vie with the blues of ocean and sky in resting the eye and in filling the soul with that harmony which is said to make for sound living. Yet to a child, Fred's schoolmates are experts on patent medicines and on the heredity that is alleged to be responsible for bad temper, running sores, tuberculosis, anæmia, and weak eyes. Freddie is particularly favored. His well-to-do parents have supplied him with ponies, games, and bicycles. Nothing prevents his breathing salt air fresh from the north pole but hermetically sealed windows. The father thinks it absurd to make a fuss over adenoids. Didn't he have them when a boy, and doesn't he weigh two hundred pounds and "make good money"? The mother never knew of operations for such trifles when she taught school; she supposes her boy needs an operation, but "just can't bear to see the dear child hurt." As for Fred, he breathes through his mouth, talks through his nose, grows indifferent to boy's fun, fails to earn promotion at school, and fears that "I won't be strong in spite of all the patent medicine I've taken." Father, mother, and Fred feel profound pity for the city child living so far from nature. Adenoids are not monopolized by children whose parents are ignorant of the importance of them and of physical examination. Last summer I was asked by a small boy to buy some chocolate. A glance at his cigar box with its two or three uninviting things for sale showed that the boy was really begging. He had thick lips, open mouth, "misty" eyes, and a nasal twang. I asked him if his teacher had not told him he had lumps back of his nose and could not breathe right. He said, "No." I explained then that he could make a great deal more money if he talked like other boys, stepped livelier, and breathed as other people breathe. He said he had "been by a doctor onct but didn't want to be op'rated." I turned to my companion and asked, "Have you never noted those same lines on your boy's face?" Although he had been lecturing on mouth breathers, he had never noticed his own boy's trouble. He hastened home and found the infallible signs. The mother declared it could not be true of her boy. About five months before, their family physician had said of the child's earache, "The same inflammation of the nasal passages that causes earache causes adenoids; you must be on the lookout." Although in the country, the boy's appetite was not good and his zest for play had flagged. They had looked for the trouble to back generations and in psychology books,--everywhere but at the boy's face, in his mouth, and in his nose. After the operation, which took less than two minutes, the appetite was ravenous, the eyes cleared, and the spirit rebounded to its old buoyancy that craved worlds to conquer. The new personal experience made a deep impression upon my friend's mind. He wanted everybody to know how easy it was to overlook a child's distress. One person after another had a story to tell him; even the janitor said: "You'd ought to have seen our John at sixteen. He spent a week by the hospital." The only people who do not seem to know more than the new convert are the mouth breathers whom he religiously stops on the street. The indexes to adenoids and large tonsils for the teacher to read at school are: 1. Inability to breathe through the nose. 2. A chronically running nose, accompanied by frequent nose-bleeds and a cough to clear the throat. 3. Stuffy speech and delayed learning to talk. "Common" is pronounced "cobbéd"; "nose," "dose"; and "song," "sogg." 4. A narrow upper jaw and irregular crowding of the teeth. 5. Deafness. 6. Chorea or nervousness. 7. Inflamed eyes and conjunctivitis. The adenoids and large tonsils discovered at school are an index: 1. To children needlessly handicapped in school work. 2. To teachers needlessly burdened. 3. To whole classes held back by afflicted children. 4. To breeding grounds for disease. 5. To homes where children's diseases and tuberculosis are most likely to break out and flourish. 6. To parents who need instruction in their duty to their children, to themselves, and to their neighbors, and who are ignorant of the way in which "catching" diseases originate and spread. The riot that occurred when the adenoids of children in a school on the "East Side" in New York City were removed without the preliminary of convincing the parents as to the advantages of the operation was merely a demand for the "right to knowledge," which is never overlooked with impunity. Reluctance to permit operation on a young child, and the natural shrinking of a parent at seeing a child under the surgeon's knife, require the teacher or school physician or nurse to answer fully the usual questions of the hesitant mother and father. 1. Is the operation necessary? Will the child not outgrow its adenoids? Usually the adenoid growths atrophy or dry up after the age of puberty. Adenoids are not uncommon in adults, however. The surgeon general of the army reports that during the year 1905, out of 3004 operations on officers and enlisted men in service, there were 225 operations on the nose, mouth, and pharynx, 103 of which were operations for adenoids and enlarged or hypertrophied tonsils. Allowing the child to "outgrow" adenoids may mean not only that he is being subjected to infection chronically but that his body is allowed to be permanently deformed and his health endangered. Beginning at the age of the second dentition, the bones of jaw, nose, throat, and chest are undergoing important changes--nasal occlusion. Adenoids left to atrophy--if large enough to cause mouth breathing--may mean atrophy of this developing process, permanent disfiguration of face, and permanent deformity of chest and lungs. 2. Will the growth recur? In a few cases it does recur; frequently either because it was not desirable to make a complete removal of the adenoid tissue or because the surgeon was careless. If the growths do recur, then they must be removed again. 3. Is the operation a dangerous one? 4. Is an anæsthetic necessary? 5. Will the operation cure the child of all its troubles? These questions are best answered by the process and results of an "adenoid party," which was given especially for the benefit of this book, every step and symptom of which were carefully studied. The seven children pictured here were discovered by their school physician to have moderately large adenoid growths,--one boy having enlarged tonsils also. [Illustration: MOUTH BREATHERS IMMEDIATELY AFTER "ADENOID PARTY"] The picture on page 46 was taken by flash light at 2.30 P.M., January 15, 1908. At 3 P.M. the principal escorted these children into the operating room at Vanderbilt Clinic. The doctor examined the throat and nose of each child, entered the name and age of each, together with his diagnosis, on a clinic card, sending each child into the next room after examination. He then called the first boy and explained that it would hurt, but that it would be over in a minute. The principal stood by and told him to be brave and remember the five cents he could have for ice cream afterwards. The clinic nurse tied a large towel about him and put him in her lap; with one hand she held his clasped hands, while the other held his head back. The doctor then took the little instrument--the curette--and pushed it up back of the soft palate, and with one twist brought out the offending spongy lump. The boy's head was immediately held over a basin of running water. He was so occupied with spitting out the blood that rushed down to choke him that he hadn't time to cry before the acute pain had ceased. The rush of cool air through his nostrils was such a pleasurable sensation that he smiled as the school nurse escorted him out into the hall to wait for his companions. At 3.30 P.M. all seven children were out in the hall, all seven mouths were closed, and all seven faces were clothed with the sleepy, peaceful expression that comes with rest from the prolonged labor of trying to get enough air. At 3.45 P.M. they had been all reëxamined by the doctor, and a few tag ends were picked out of the nasopharynx of one child. At 4 P.M. the "party" had returned to the Children's Aid Society's school and to the ice cream that follows each adenoid party. It is worth while to tell mothers stories of the "marvelous improvement in school progress of those children whose brains have been poisoned and starved by the accursed adenoid growths, and how their bodies fairly bloom when the mysterious and awful incubus is removed," to use the words of one school principal. It is worth while to show them "before" and "after" pictures, and "before" and "after" children, and "before" and "after" school marks. CHAPTER VI CATCHING DISEASES, COLDS, DISEASED GLANDS Deadly fevers, the plague, black death, cholera, malaria, smallpox, taught mankind invaluable lessons. Millions of human beings died before the mind of man devoted itself to preventing the diseases for which no sure cure had been found. Efforts to conquer these diseases were tardy because men were taught that some unseen power was punishing men and governments for their sins. The difference between the old and the new way is shown powerfully by a painting in the Liverpool Gallery entitled "The Plague." A mediæval village is strewn with the dead and dying. Bloated, spotted faces look into the eyes of ghouls as laces and jewelry are torn from bodies not yet cold. In the foreground a muscular giant, paragon of conscious virtue, clad like John the Baptist and Bible in hand, finds his way among his plague-stricken fellow-townsmen, urging them to turn from their sins. Modern efficiency learns of the first outbreak of the plague, isolates the patient, kills rats and their fleas which spread the disease, thoroughly cleanses or destroys, if necessary, all infected clothing, bedding, floors, and walls, and makes it possible for us to go on living for each other with a better chance of "bringing forth fruits worthy for repentance." Where boards of health make it compulsory to report cases of sickness due to contagion, health records are a reliable index to "catching" diseases. But now that the chief infection is the kind that afflicts children, we can read the index before the outbreak that calls in a physician to diagnose the case. School examination shows which children have defects that welcome and encourage disease germs. It points to homes that cultivate germs, and consequently menace other homes. To locate children who have enlarged tonsils may prevent a diphtheria epidemic. To detect in September those who are undernourished, who have bad teeth, and who breathe through the mouth will help forecast winter's outbreaks of scarlet fever and measles. One dollar spent at this season in examination for soil hospitable to disease germs may save fifty dollars otherwise necessary for inspection and cure of contagious diseases. It is harder at first to interest a community in medical examination than in medical inspection, because we are all afraid of "catching" diseases, while few of us know how they originate and how they can be prevented by correcting the unfavorable conditions which physical examination of school children will bring to light. Courses in germ sociology are therefore of prime necessity. How do germs act? On what do they live? Why do they move from place to place? What causes them to become extinct? With few exceptions, germs migrate for the same reason as man,--search for food, love of conquest, and love of adventure. When there is plenty of food they multiply rapidly. Full of life, overflowing with vitality, they move out for new worlds to conquer. Like human beings, they will do their best to get away from a country that provides a scanty food supply. Like men and women, they starve if they cannot eat. Like boys and girls, they avoid enemies; the weak give way to the strong, the slow to the swift, the devitalized to the vitalized. Human sociology imprisons, puts to death, deprives of opportunity to do evil, or reforms those who murder, steal, or slander. Germ sociology teaches us to do the same with injurious germs. We imprison them, we take away their food supply, we kill them outright, or we starve them slowly. They have a peculiar diet, being especially partial to decomposing vegetable and animal matter and to what human beings call dirt. By putting this diet out of their reach we make it impossible for them to propagate their kind. By placing poison within their reach or by forcing it upon them we can successfully eliminate them as enemies. As the president of Mexico restored order "by setting a thief to catch a thief," so modern science is setting germs to kill germs that harm crops and human stock. Of utmost consequence is it that the body's germ consumer--its pretorian guard--be always armed with vitality ready to vanquish every intruding hostile germ. If we are false to our guard, it will turn traitor and join invaders in attacking us. But here, as in dealing with evils that originate with human beings, an ounce of prevention is worth a ton of cure. The most effectual way to eliminate germ diseases is to remove the cause--the food supply of disease germs. The fact that many germs are plants, not animals, does not weaken the analogy, for weeds do not get a chance in well-tilled soil. Perhaps the most notable recent example of government germ extermination is the triumph over the yellow-fever and malaria mosquito in Panama. When the French started to build a canal in Panama, the first thing they did was to build a hospital. The hospital was always full and the canal was given up. At the time the United States proposed to re-attempt the work, it was thought that it could not be done without great loss of life and without great labor difficulties. Instead of taking the sickness for granted and enlarging the French hospital, the chief medical inspector, Gorgas, took for granted that there need be no unusual sickness if proper preventive measures were taken. He knew what the French had not known, that the yellow-fever scourge depends for its terrors upon mosquitoes. Accordingly, with the aid of six thousand men and five million dollars he set about to starve out the few infected and infectious kinds of mosquito,--the yellow-fever or house mosquito and the malaria or meadow mosquito. He introduced waterworks and hydrants, paved the streets, drained the swamps and pools in which they breed, and instituted a weekly house-to-house inspection to prevent even so much as a pail of stagnant water offering harbor to these enemies. The grass of the meadows where the malaria mosquito breeds was cut short and kept short within three hundred feet of dwellers,--as far as the mosquito can fly. All ditches were disinfected with paraffin, and the natives were forced to observe sanitary laws. President Roosevelt, in his special message to Congress on the Panama Canal in 1906, stated that in the weekly house-to-house visit of the inspectors at the time he was in Panama but two mosquitoes were found. These were not of the dangerous type. As a consequence of this sanitary engineering there is very little sickness in Panama, the hospital is seldom one third full, and the canal is progressing very much faster than was expected. Panama, like Havana, is now safer than many American cities, because cleaner and less hospitable to disease germs. Any place where numbers of people are accustomed to assemble favors the propagation of germs,--whether it be the meetinghouse, the townhall, the theater, or the school. Every teacher can be the sanitary engineer of her own schoolroom, school, or community by coöperating with the school doctor, the town board of health, family physicians, and mothers. Every teacher can exterminate disease by applying the very same principles to her schoolroom as Chief Medical Inspector Gorgas applied to Panama. Knowledge, disinfection, absolute cleanliness, education, and inspection are the essential steps. First she must know that "children's diseases" are not necessary. She should discountenance the old superstition that every child must run the gamut of children's diseases, that every child must sooner or later have whooping cough, measles, chicken pox, mumps, scarlet fever, just as they used to think yellow fever and cholera inevitable. The price of this terrible ignorance has been not only expense, loss of time, acquisition of permanent physical defects, and loss of vitality, but, for the majority of children, death before reaching five years of age. All these "catching" diseases are germ diseases, which disinfection can eliminate. The free use of strong yellow soap and disinfectants on the school floor, windows, benches, desks, blackboards, pencils, in the coat closets and toilets, plus the natural disinfectants, hot sun and oxygen, will prevent the schoolroom from being a source of danger. One or more of these germ-killing remedies must be constantly applied; cleansing deserves a larger part in every school budget. Often country towns are as ignorant of the existence of germs and of the means of preventing the spread of disease as the woman in a small country town who used daily to astound the neighbors by the "shower of snow" she produced by shaking the bedding of her sick child out of the window. Their astonishment was soon changed to panic when that shower of snow resulted in a deadly epidemic of scarlet fever. Medical inspection of New York City's schools was begun after an epidemic of scarlet fever was traced to a popular boy who passed around among his schoolmates long rolls of skin from his fingers. Much of the care exercised at school to prevent children's diseases is counteracted because children are exposed at home and in public places to contagion, where ignorance more often than carelessness is the cause of uncleanliness. By hygiene lessons, illustrating practically the proper methods of cleaning a room, much may be done to enlist school children in the battle against germs. Through the enthusiasm of the children as well as through visits to the homes parents may be instructed as to the danger of letting well children sleep with sick children; the wisdom of vaccination to prevent smallpox, of antitoxin to prevent serious diphtheria, of tuberculin tests to settle the question whether tuberculosis is present; why anything that gathers dust is dangerous unless cleansed and aired properly; and why bedding, furniture, floor coverings, and curtains that can be cleansed and aired are more beautiful and more safe than carpets, feather beds, upholstery, and curtains that are spoiled by water and sunshine; how to care for the tuberculous member of the family, etc. Anti-social acts may be prevented, such as carrying an infected child to the doctor in a public conveyance, thereby infecting numberless other people; sending infected linen to a common laundry; mailing a letter written by an infected person without first disinfecting it; sending a child with diphtheria to the store; returning to the dairy unscalded milk bottles from a sick room. The daily inspection of school children for contagious diseases by the school physician has, where tried, been found to reduce considerably the amount of sickness in a town. Such inspection should be universally adopted. Moreover, the teacher should be conversant with the early symptoms of these diseases so that on the slightest suspicion the child may be sent home without waiting for the physician's call. Like the little girl who never stuttered except when she talked, school children and school-teachers are rarely frightened until too late to prevent trouble. The "easy" diseases such as measles, whooping cough, etc., cost our communities more than the more terrible diseases like typhoid and smallpox. During one typical week ending May 18, 630 new cases of measles were reported to one department of health. Obviously the nineteen deaths reported give no conception of the suffering, the cost, the anxiety caused by this preventable disease. The same may be said of diphtheria and croup, of which only thirty-two deaths are reported, but 306 cases of sickness. Yet no one to-day will send a child to sleep with a playmate so as to catch diphtheria and "be done with it." The most strategic point of attack is almost universally unrecognized. That is the child's mouth. Here the germs find lodgment, here they find a culture medium--at the gateway of the human system. The mouth is never out of service and is almost never in a state of true cleanliness. Solid particles from the breath, saliva, food between the teeth, and other débris form a deposit on the teeth and decompose in a constant temperature of ninety-eight degrees Fahrenheit. In the normal mouth from eight to twenty years of age the teeth present from twenty to thirty square inches of dentate surface, constantly exposed to ever-changing, often inimical, conditions. This bacterially infected surface makes a fairly large garden plot. Every cavity adds to the germ-nourishing soil. Dental caries--tooth decay--is a disease hitherto almost universal from birth to death. Thus the air taken in through the mouth becomes a purveyor of its poisonous emanations and affects the lung tissues and the blood. Food and water carry hostile germs down into the stomach. Thence they may be carried into any organ or tissue, just as nourishment or poison is carried. Moreover, the child with an unclean mouth not only infects and reinfects himself but scatters germs in the air whenever he sneezes or coughs. In a cold apartment where there is no appreciable current of air a person can scatter germs for a distance of more than twenty-two feet. Germs are also scattered through the air by means of salivary or mucous droplets. It is this fact that makes colds so dangerous. TABLE VIII =City of Manchester Education Committee= =INFECTIOUS OR CONTAGIOUS DISEASES IN SCHOOLS INFORMATION FOR TEACHERS= Four columns are omitted: (1) Interval between Exposure to Infection and the First Signs of the Disease; (2) Day from Onset of Illness on which Rash appears; (3) Period of Exclusion from School after Exposure to Infection; (4) Period of Exclusion from School of Person suffering from the Disease -----------+------------------------------+------------+------------------ DISEASE | PRINCIPAL SIGNS AND SYMPTOMS | Method of | REMARKS | | Infection | -----------+------------------------------+------------+------------------ Measles |_Begins like cold in the | |After effects |head_, with _feverishness, | |often severe. |running nose, inflamed and | |Period of greatest |watery eyes, and sneezing_; | |risk of infection |small crescentic groups of | Breath and |first three or |_mulberry-tinted spots_ appear| discharges |four days, before |about the third day; _rash | from nose |the rash appears. |first seen on forehead and | and mouth. |May have repeated |face_. The rash varies with | |attacks. Great |heat; may almost disappear if | |variation in type |the air is cold, and come out | |of disease. |again with warmth. | | -----------+------------------------------+------------+------------------ German |Illness usually slight. Onset | | Measles |sudden. _Rash often first | | |thing noticed;_ no cold in | Breath and | |head. Usually have | discharges |After effects |_feverishness_ and _sore | from nose |slight. |throat_, and the _eyes may | and mouth | |be inflamed. Rash_ something | | |between Measles and Scarlet | | |Fever, variable. | | -----------+------------------------------+------------+------------------ Chicken |Sometimes begins with | |When children Pox |feverishness, but is _usually | |return, examine |very mild_ and without sign | |head for |of fever. _Rash_ appears on | |overlooked spots. |second day as _small pimples_,| |All spots should |which in about a day become | |have disappeared |filled with _clear fluid_. | Breath and |before child |This fluid then becomes | crust of |returns. A mild |_matter_, and then the _spot | spots. |disease and |dries up_and _the crust falls | |seldom any after |off_. | |effects. | | | |May have _successive crops of | | |of rash_ until tenth day. | | -----------+------------------------------+------------+------------------ Whooping |_Begins like cold in the | |After effects Cough |head_, with _bronchitis_ and | |often very severe |_sore throat_, and a _cough_ | |and the disease |which is _worse at night_. | Breath and |causes great |Symptoms may at first be very | discharges |debility. Relapses |mild. Characteristic | from nose |are apt to occur. |_"whooping" cough_ develops | and mouth. |Second attack |in about a fortnight, and the | |rare. Specially |spasm of coughing often ends | |infectious for |with _vomiting_. | |first week or two. | | |If a child is sick | | |after a bout of | | |coughing, it is | | |most probably | | |suffering from | | |whooping cough. | | | | | |Great variation in | | |type of disease. -----------+------------------------------+------------+------------------ Mumps |Onset may be sudden, beginning| | |with sickness and fever, and | | |_pain about the angle of the | Breath and |Seldom leaves |jaw_. The _glands become | discharges |after effects. |swollen and tender_, and the | from nose |Very infectious. |_jaws stiff_, and the _saliva | and mouth. | |sticky_. | | -----------+------------------------------+------------+------------------ Scarlet |The _onset is usually sudden_,| Breath, |Dangerous both Fever or |with _headache, languor, | discharges |during attack and Scarlatina |feverishness, sore throat_, | from nose |from after effects. |and often the child is _sick_.| and mouth, |Great variation |Usually within twenty-four | particles |in type of disease. |hours the _rash_ appears, and | of skin, |Slight attacks |is _finely spotted, evenly | and |as infectious as |diffused_, and _bright red_. | discharges |severe ones. Many |The _rash_ is seen first on | from |mild cases not |the _neck and upper part of | suppuratory|diagnosed and many |chest_, and lasts three to | glands or |concealed. The |ten days, when it fades and | ears. Milk |peeling may last |the _skin peels in scales, | specially |six to eight weeks. |flakes_, or even _large | apt to |A second attack is |pieces_. The _tongue_ becomes | convey |rare. When scarlet |whitish, with bright red | infection. |fever is occurring |spots. The eyes are not watery| |in a school, all |or congested. | |cases of sore | | |throat should be | | |sent home. -----------+------------------------------+------------+------------------- Diphtheria |Onset insidious, may be rapid | Breath and |Very dangerous |or gradual. Typically _sore | discharges |both during attack |throat_, great weakness, and | from nose, |and from after |swelling of glands in the | mouth, and |effects. When |neck, about the angle of the | ears. |diphtheria is |jaw. The back of the throat, | |occurring in a |tonsils, or palate may show | |school all children |_patches_ like pieces of | |suffering from sore |yellowish-white kid. The most | |throat should be |pronounced symptom is great | |excluded. There is |debility and lassitude, and | |great variation of |there may be little else | |type, and mild |noticeable. There may be | |cases are often not |hardly any symptoms at all. | |recognized but are | | |as infectious as | | |severe cases. There | | |is no immunity from | | |further attacks. | | |Fact of existence | | |of disease | | |sometimes | | |concealed. -----------+------------------------------+------------+------------------- Influenza |_Begins with feverishness, | Breath and |Excessively |pain in head, back_, and | discharges |infectious. After |_limbs_, and usually _cold in | from nose |effects often very |the head_. | and mouth. |serious and | | |accompanied with | | |great prostration | | |and nervous | | |debility. -----------+------------------------------+------------+-------------- Smallpox |The illness is usually well | Breath, |Peculiarly |marked and the onset rather | all |infectious. When |sudden, with _feverishness, | discharges,|smallpox occurs in |severe backache, and | and |connection with a |sickness_. About third day | particles |school or with any |a _red rash_ of _shotlike | of skin |of the children's |pimples_, felt below the skin,| or scabs. |homes, an endeavor |and seen first about the | |should be made to |_face_ and _wrists. Spots | |have all persons |develop_ in _two days_, then | |over seven years |form _little blisters_, and | |of age |in other two days become | |revaccinated. |_yellowish_ and filled with | | |matter. _Scabs_ then form, | |Cases of modified |and these fall off about | |smallpox--in |the fourteenth day. | |vaccinated | | |persons--may be, | | |and often are, so | | |slight as to | | |escape detection. | | |Fact of existence | | |of disease may be | | |concealed. Mild | | |or modified | | |smallpox as | | |infectious as | | |severe type. -----------+------------------------------+------------+----------------- =In the following diseases only the affected child is excluded= =Erysipelas.= Child should not | =Ringworm on Scalp.= Child should return till all swelling and | be excluded till cured. Very peeling of skin has disappeared. | difficult to cure and often takes | a very long time. =Ophthalmia.= Child should not | return till all traces have | =Phthisis= (=Consumption=). If in disappeared. | advanced stage and coughing much | _or spitting_, child should be =Scabies or Itch.= Child should be | excluded. (Infection from breath excluded until cured. | and dried spit floating in the air | as dust.) =Ringworm on Skin.= Child should be | excluded till cured. This takes | =Impetigo= (=Contagious Sore=). only a few days if properly | Child should be excluded until treated. | cured. A week or ten days should | suffice. =A. BROWN RITCHIE=, _Medical Officer to Education Committee_. Most people still think that colds are due to cold air or draughts rather than to a cold germ, which finds a body unequipped with resisting power, with its germ police off guard, exhausted from overwork, or disaffected and ready to turn traitor if the enemy seems stronger than our vitality. Sometimes it seems as if we contracted it from a sneezing fellow-passenger, sometimes from a draught from an open car window. An uninformed opponent of the theory that colds are a germ disease wrote the following letter last winter to a New York newspaper: In addition to the Society for the Suppression of Noises there should be in this town a Society for the Suppression of "Fresh-Air" Fiends. The newspapers report an epidemic of pneumonia, grippe, and colds. It is almost entirely due to the fact that the average New Yorker is compelled to live, move, and have his being from daylight to midnight in a succession of draughts of cold air caused by the insanity of overfed male and female hogs, who, with blood almost bursting through their skins, demand "fresh air" in order to keep from suffocating. Everywhere a man goes, day or night, he is in a draught caused by the crazy ideas about fresh air. Our wise ancestors, who as a rule lived much longer than we do, and had much better health, said: "If the wind should blow through a hole, God have mercy on your soul." After the correspondent has learned that our ancestors had more colds than we, had poorer health, and died twenty years younger, perhaps he will listen to proof that his unclean warm air weakens the body and makes it an easy prey to cold germs. Many physicians preach and practice this fallacy as to fresh air and colds, but few physicians now deny that influenza is a germ disease or that a nose so irritated and so neglected as to secrete large quantities of mucus is a better place for breeding disease germs than a nose whose membranes are clean and not thus irritated. Until medical specialists are agreed, and until they have definitely located the cold germ, we laymen must choose for ourselves a working theory. The weight of opinion at the present time declares that colds are due to germs. Strong membranes with good circulation and drainage provide poor food for germs. Congested membranes furnish proper conditions for propagation. The germ theory explains the spread of germs from the nose to the passages of the head, and from head to arteries and lungs. A cold can always be charged to some one else. How many can be laid to our account? There is one right that is universally not recognized, and that is the right of protection from the germs showered in the air we breathe, over the food we eat, by the sneezes of our unfortunate neighbor at school, in the street car, at the restaurant. The chief danger of a cold is to our neighbor, not to ourselves. A cold which a strong person may throw off in a day or two may mean death to his tuberculous neighbor. Though for our own health "lying up for a mere cold" is an unnecessary bore, the failure to do so may deprive our neighbor of a right greater than the right to protection against scarlet fever or smallpox. Though formerly this statement would not have been true, rights change with conditions, and the fact that to-day the three most deadly diseases are pneumonia, tuberculosis, and diphtheria,--all diseases of the respiratory organs,--justifies the assertion that we have a right to protection against colds. The prevalence of colds, sore throats, irritated vocal cords, bad voices, catarrh, bronchitis, laryngitis, and asthma in America to-day demands summary measures. One can learn to sneeze into a handkerchief, not into a companion's face or into a room. School children can be taught to avoid handkerchiefs on which mucus has dried. In the far distant future we may be willing to use cheesecloth, and boil it or throw it away, or, like the Japanese, use soft paper handkerchiefs and burn them after using. TABLE IX DEATH RATE PER 10,000 POPULATION, PNEUMONIA AND BRONCHITIS FIVE-YEAR PERIOD, 1896-1900 England and Wales 22.70 Scotland 27.40 Stockholm 26.70 London 31.20 Berlin 16.10 Vienna 39.70 Christiania 21.30 Boston 30.60 Chicago 24.20 Philadelphia 25.10 New York City 36.60 One child with a cold can infect a whole class or family, thus depriving the class and family of the top of their vitality and efficiency without their consent. Because a person is thought a weakling who lies up for a "mere cold," one is inclined to wish that colds were as prostrating as typhoid, in which case there would be some hope of their extermination. The exclusion of children with colds from school deserves trial as a check to children's diseases. Many of these "catching" diseases start with a cold in the head, as, for instance, measles, influenza, and whooping cough. The first symptom of mumps, diphtheria, and scarlet fever is a sore throat or swollen glands, which, because they commonly accompany a cold, are not at first distinguished from it. The first step for the teacher or mother in reading the index for colds is to look into the coat closet for evidence of warm clothing and overshoes, then to note whether the children put them on when they go out for lunch or recess. Whether "cold" settles in the nasal passages, ear, or stomach depends upon which is the weak spot. Draughts, thin soles, wet soles, exposure when perspiring, may be the immediate cause of the nutritional or respiratory disturbances that give cold germs a foothold. Adenoids, diseased teeth, inflamed ears, may furnish the food supply. "There is no use treating children and sending them on fresh-air trips as long as they have nutritional and digestive disturbances due to bad teeth, or colds due to adenoids," said a physician when examining a party of children for a summer outing. The great preventive measure to be taken for catching diseases, colds, diseased glands,--in fact all germ diseases,--is the repeated cleansing of those portions of the human body in which germs may find lodgment,--the mouth, the nose, the eyes, and the ears. In caring for young infants great pains is taken to cleanse all the orifices daily, but as soon as the child washes himself this practice is usually abandoned. Washing these gateways is far more important than washing the surface of the body through which germs could not possibly gain entrance into the system except through wounds. Oftentimes the douching of the nostrils with salt water will stop a cold at once. The mouth is the most important place of all, and the teacher should take care of her pupils' mouths first and foremost. As bad teeth, enlarged tonsils, and adenoids harbor germs and putrescent matter that vitiate every incoming and outgoing breath, these defects should be immediately corrected. Are we coming to a time when a thorough house-cleaning in the mouth of every child will take place before he enters the schoolroom, preferably in the presence of the teacher? Two other "catching" diseases cause city schools a great deal of trouble,--trachoma and pediculosis (head lice). There are probably no two diseases more quickly transmitted from one person to another. Almost before their presence is known, all children of a school or all persons of a group have contracted them. When at college twenty men of my fraternity discovered almost at the same time that they had an infectious eye trouble; yet we thought we were using different towels and otherwise taking sanitary precautions. Last summer a Vassar graduate took a party of tenement children for a country picnic. She returned with head lice that required constant attention for weeks. What then may we expect of children who live in homes where there is neither water, time, nor privacy for bathing, where one towel must serve a family of six, where mothers work for wages away from home and see their children only before seven and after six? Unfortunately for thousands of children, many parents still believe these troubles will be outgrown. Last summer a fresh-air agency in New York City arranged for several hundred school girls to go to a certain camp for ten days each. The only condition was that the heads should be free from lice and nits (eggs). From the list furnished by school-teachers--girls supposed to have been cured by school nurses--not one in five was accepted. A baby two weeks old, brought to Caroline Rest, had already begun to suffer from this easily preventable scourge. Of 1219 children examined in Edinburgh, Scotland, 909, or 69 per cent, had some skin disease, and 60 per cent had sores due to head lice. Even when neglect has caused the loss of hair and ugly sores on the head, mothers deceive themselves into believing that some other cause is responsible. Trachoma, if neglected, not only impairs the health of the eye, but may cause blindness. Tears carry the germs from the eye to the face, where they are taken up on handkerchiefs, towels, and fingers and infect other eyes. Of late, thanks to school nurses and physicians and hygiene instruction, American cities have found relatively little trachoma except among recent immigrants. So dangerous is the germ and so insidious its methods of propagation, that a physician should be summoned at once at the first sign of inflammation. Conjunctivitis is due to a germ, and will spread unless checked. Since the board of health of New York City has instituted the systematic examination of the eyes of the children in the public schools, it has found fully one third affected with some form of conjunctivitis. Many of these cases are out-and-out trachoma, others acute conjunctivitis, and a larger proportion are "mild trachoma." This last form of the disease is found to a great extent among children who have adenoids. The adenoids should be regarded as a predisposing factor rather than a direct cause. Therefore sore eyes are given as one of the indexes of adenoids. When we consider that adenoids are made up of lymphoid material, and that trachoma follicles are made up of the same sort of tissue, it is not surprising that the two conditions are found in the same child. The catarrhal inflammation produced by adenoids in the nasal mucous membrane travels up the lachrymal duct and thus infects the conjunctiva by contiguity. In preventing pediculosis and infection of the eye vigilance and cleanliness are indispensable. After the diseases are advanced, after the germ colonies have taken title, some antiseptic or germ killer more violent than water is needed,--kerosene for the hair or strong green oil soap; for the eye, only what a physician prescribes. CHAPTER VII EYE STRAIN Wherever school children's eyes have been examined, from six to nine out of thirty are found to be nearsighted, farsighted, or otherwise in need of attention. A child is dismissed from school for obstinately declaring that the letter between _c_ and _t_ in "cat" is an _o_; "a pupil in her fourth school year was recently brought to me by her teacher with the statement that she did unreasonably poor work in reading for an intelligent and willing child;" a boy is punished for being backward. These three cases are typical. Examinations showed that the first child was astigmatic and not obstinate; the boy had run a pin into one eye ten years before and destroyed its sight; while the second girl was found to be afflicted with diplopia, and in a friendly chat told the following story: "I very often see two words where there is only one. When I was a very little girl I used to write every word twice. Then I was scolded for being careless. _So I learned that I must not say two words even when I saw them._" As Miss Alida S. Williams, principal of Public School 33 in New York City, has in many articles and addresses freely illustrated from school experience, the art of seeing is acquired, not congenital, and every human being who possesses it has learned it. The large proportion of children suffering more or less seriously from eye trouble has led many persons to suggest physical deterioration as the cause. Eye specialists, however, assure us that eye troubles are probably as old as man. Our tardiness in learning the facts regarding these troubles is due in part to the lack, until recently, of instruments for examining the eye and for manufacturing glasses to correct eye defects; in part, also, to the tendency of the medical profession, which I shall repeatedly mention, to explain disorders by causes remote and hard to find rather than by those near at hand. About 1870 Dr. S. Weir Mitchell's attention was called "to the marked relief of headache, insomnia, and other reflex symptoms following the correction of optical defects by glasses." In 1874 and 1876 he wrote two articles that "impressed upon the general profession the grave significance of eye strain." Since that time, "in Philadelphia at least, no study of the rebellious cause of headache or of the obscure nervous diseases has ever been considered complete until a careful examination of the eyes has included them as a possible cause of the disturbance." The new fact, therefore, is not weak eyes or strained eyes, but rather (1) an increase in the regular misuse of eyes by school children, seamstresses, stenographers, lawyers, etc.; and (2) the incipient propaganda growing out of school tests that show the relation of eye strain to headache, nervous diseases, stomach disorder, truancy, backwardness. Every school, private and parochial as well as public, should supply itself with the Snellen card for testing eyes. Employers would do well to have these cards in evidence also, for they may greatly increase profits by decreasing inefficiency and risks. If there is no expert optician near, apply for cards to your health board or school board; failing there, write to your state health and school boards. In many states rural teachers are already supplied with these cards by state boards. In October, 1907, the New York state board of health sent out cards, with instructions for their use, to 446 incorporated towns. The state commissioner of education also sent a letter giving school reasons for using the cards. Results from 415 schools having shown that nearly half the children had optical defects, it is proposed to secure state legislation that will make eye tests obligatory in all schools. Such a test in Massachusetts recently discovered twenty-two per cent of the school children with defective vision, and from forty to fifty thousand in need of immediate care by specialists. [Illustration: POSITIONS OFTEN SUGGEST EYE STRAIN] Of course eye specialists,--oculists,--if skillful, know more about eyes and eye troubles than general medical practitioners or teachers. Preliminary eye tests, however, may be made by any accurate person who can read. The Massachusetts state board of health reports that tests made by teachers were "not less efficient" than tests made by specialists. In June, 1907, a group of eminent oculists recommended to the school board of New York City that teachers make this first test after being instructed by oculists. Persons interested in the schools nearest them can quickly interest teachers and pupils by starting tests with this card. In cities oculists can be found who will be glad to explain to teachers, individually or in groups, how the cards should be used and what dangers to avoid. Nature intended the human eye to read the last line of this card at a distance of ten feet. This conclusion is not a guess, but is based upon the examination of thousands of eyes. In making the test, the number of feet the eye ought to see is written as the denominator of the fraction; the distance the eye can see clearly is the numerator. If the child's card reads, "Right eye 10/10, left eye 10/20," it means that the right eye sees without conscious strain the distance it is intended to see, while the left eye must be within ten feet to see what it ought to see twenty feet away. The practical steps for a teacher to take in making eye tests are: 1. Scrutinize the faces for a strained or worried expression while reading or writing, for squint eyes, for unnatural positions, and for improper distances (more or less than nine inches) from eye to book. 2. Select for first tests the children who obviously need attention and will be obviously benefited. Use the eye test to help trace the cause of headaches, nervousness, inattention. 3. Let the children mark off the distances with a foot rule and chalk, going as high as twenty. Be sure to get the best light in the room. 4. Start all children on the ten-foot line. If a child cannot read at ten feet the letter which should be seen at that distance, move the child forward, have it step forward and backward, and note the result carefully. It is better to have ten separate letters of exactly the right size and the same size than a row of letters on one card, as in the Snellen test, otherwise memory will aid the eye, or, as happened recently, a whole class may agree to feign remarkable nearsightedness or farsightedness by confusing letters learned in advance from the card. If the Snellen card is used, and if it is more convenient to have both child and card stationary, satisfactory results will be obtained by having the child read from large letters down as far as he can see. 5. Have the child read from right to left, from left to right, or skip about so that memory cannot aid the eye. 6. Test each eye separately. I was twenty-five years old before I learned that my left eye did practically all of the close sight work. A grown woman discovered just a few days ago that she was almost blind in the left eye; when she rubbed the right one while reading she was shocked to find that she could see nothing with the left eye. 7. If the card is stationary and the child moved, and if only one size of the letter is used, put in the denominator the number of feet at which the normal eye should see clearly, and in the numerator the distance at which each eye and both together can easily see. If the regular Snellen card is used containing letters of different size, place in the denominator the number of the lowest line each eye and both eyes together can read easily, and in the numerator the number of feet from card to eye. 8. Explain the result to the child, to his fellows, to his parents. If the left eye reads 10/20 and the right eye 10/30, it means that neither eye is normal, and that reading small type is a constant strain, even though unnoticed. The right eye must be within ten feet to read what it should read at twenty feet. The left eye must be within ten feet to read what it should read at thirty feet. If the two eyes read at ten, it means that in working together they successfully strain for a result that is not worth what it is costing. When eyes thus unconsciously see what they are not intended to see, it is only a matter of time when stomach and nervous system will announce that the strain can no longer be borne. Indigestion, dislike of study, restlessness follow. If, however, the eyes are so near the normal that their story reads 12/10 or 8/10, the strain will be negligible _for the present_. If, on the other hand, the only difficulty is a confusion of _x_ and _z_ with _c_ and _g_, it means that there is a strain due to astigmatism, and that the child should be sent to an oculist. 9. Teach children and parents (and practice what you preach) the urgent importance of periodic reëxamination, just as you would teach them to visit a dentist twice a year. This is needed by those who wear eyeglasses, and more particularly by those who have recently put them on. Moreover, as shown below, it is needed by children able to pass satisfactorily the Snellen test. 10. Acquire the habit of reading the eye for evidence of temperate or intemperate living, sleeping, eating, dancing, drinking, and smoking. Inflamed eyes are _results_,--signals of danger. "The organ may be faultless in construction and in its work poor, because of nerve exhaustion, or, in a less and more easily recoverable degree, nerve fatigue." If unusual eye conditions are not readily explained by mode of living or by eye tests, an oculist should be consulted. The limits of the card test must be constantly kept in mind: (1) it does not register eye sickness due to dust, smoke, or disease germs; (2) it does not show unconscious eye strain due to successful accommodation. But it will discover a great part of the children who most need care. Sooner or later, too, inflammation of the eyelids, due to external causes, will affect the nerves of the eye and their power to conceal by accommodation the eye's defects. Just as we unconsciously open the mouth when a cold stops up the nose, the eye adapts itself to our needs without our realizing it. We expect it to see. It sees. If our eyes are not made alike, they do their best to work together. Like a good team of horses, the slow one hurries, the fast one holds back a little. But if one eye is 10/15 and the other 10/10, they will both be unnatural and strained if both read the same type. The effects of this strain frequently upset the stomach before the eyes rebel. I learned that I needed eyeglasses after a case of protracted indigestion, first diagnosed as "nervous" and later traced to eyes. Thousands of upper-grade children and college students are dieting for stomach trouble that will last until the eyes are relieved of the undue and unrecognized strain. To prove the influence of eye strain on indigestion, persuade some obstinate parent to wear improperly focused glasses for a day; she will then be willing to have her child's eyes attended to. It is unfortunate that the eyes will overwork without protesting. For years many persons suffer without learning that their eyes are unlike, or, as often happens, that one eye does all the close range work. Even when being tested, eyes will seem to see easily what requires a great effort of "accommodation." To prevent this self-deception skilled oculists do not trust the eye card, but put a drug in the eye that benumbs the muscles of accommodation. They cannot contract or expand if they want to. The oculist then studies the length of the eye and the muscle of accommodation. With this absolute knowledge of how each eye is made he knows what is wrong, exactly at what angle light enters the eye, whether objects are focused too soon or too late, exactly what kind of eyeglasses or what operation upon the eye is needed to enable it to do its work without undue straining or accommodation. So unconsciously do the eyes accommodate themselves to the work expected of them that not infrequently a child with seemingly perfect sight may be more in need of glasses than the child with imperfect sight. Practically, however, it is out of the question at the present time to have the majority of children given a more thorough test than that provided by the Snellen card. Where eye strains escape this test teachers will find evidence in complaints of headache, nervousness, sick stomach, chorea, or even epilepsy. The constant strain may also cause red or inflamed lids. Parents and teachers must be on the constant lookout for these symptoms of good sight persisting in spite of imperfect eyes. An epidemic of eyeglasses is usually the consequence of eye tests. So naturally do we associate eyeglasses with eye defects that some people assert that the eye tests at school originate with opticians more intent upon selling spectacles than upon helping children. In fact, even among educators who proclaim the need for eye tests there has been far more talk of eyeglasses than of removable conditions that cause eye strain. The women principals of New York City have sounded an alarm, and urge more attention to light and to reading position, more rest, more play, more hand work, less home study and less eye work at school, rather than more eyeglasses to conceal temporarily the effect of abusing children's eyes. Putting glasses on children without changing causal conditions is like giving alcohol to consumptives. The feeling of relief is deceptive. The trouble grows worse. For some time to come eye tests will find eye troubles by the wholesale in every industrial and social class, in country as well as city schools. In 415 New York villages 48.7 per cent of school children had defects of vision,--this without testing children under seven,--while 11.3 per cent had sore eyes. There are three possible ways of remedying defects: (1) changing the eye by operation; (2) changing the light as it enters the eye by eyeglasses; (3) decreasing the demands made upon the eye. To change eyes or light requires a technical skill which few physicians as yet possess. It will be remembered that it is but thirty years since the medical profession in America first began to understand the relation of eye defects to other defects. Until a generation of physicians has been trained by medical colleges to learn the facts about the eye and to apply scientific remedies, it is especially necessary that teachers and parents reduce the demands made upon children's eyes; oral can be substituted for written work, manual for optical work, relaxed and natural movement for discipline, outdoor exercise for less home study. Other requirements are suitable light and proper position, and abolition of shiny paper, shiny blackboard, and fine print. Even after it is easy to obtain the correction of eye defects it will still be necessary to adapt the demands upon children's eyes to the strength and shape of those eyes. Because we are born farsighted, nearsighted, and astigmatic, we must be watchful to eradicate conditions that aggravate these troubles. Finally, there is no excuse whatever for permitting the parent of any school child in the United States to remain ignorant of the fact that it is just as absurd to go to the druggist or jeweler for eyeglasses as to the hardware store for false teeth. The education of physician, oculist, and optician can be expedited by eye tests in school and by the follow-up work of schools in removing the prejudice of parents against glasses when needed. Because knowledge of chemistry preceded knowledge of the human body, the teaching of medicine still shows the effect of predilection for the remote, the problematical, the impossible. This predilection has influenced many specialists as well as many general practitioners, both overlooking too frequently obvious causes that even intelligent laymen can be taught to detect. Very naturally the man who makes money out of attention to simple troubles has stepped into the field not as yet occupied by the general practitioner and the specialist. Thus we have the optician, the painless tooth extractor, and quack cures for consumption. Opticians are placing before hundreds of thousands simple truths about the eye not otherwise taught as yet. Because they make their money by selling eyeglasses and because their special knowledge pertains to glasses rather than to eyes they frequently fail to recognize their limitations. Physicians feel very strongly that it is as unethical for an optician to fit eyeglasses without a physician's prescription as for a pharmacist to give drugs without a physician's prescription. The justification for this feeling should be based not upon the commercial motive of the optician but upon his ignorance. A physician uninformed as to eye troubles is just as unsafe as an optician determined to sell glasses. It must be made unethical and unprofessional for physician and optician alike to prescribe in the dark. Laymen and physicians must be taught that it is just as unethical and unprofessional for oculists and physicians to fail to bring their knowledge within the practical reach of the masses as for the optician to advertise his wares. School tests will not have been used to their utmost possibilities until optician and physician alike take the ethical position that the first consideration is the patient's welfare, not their own profits. It must soon be recognized as unethical and unprofessional for an optician who is also a skilled physician to refer patients to a medical practitioner ignorant as to optical science. Whether opticians and physicians are unprofessional or unethical may be told by reëxamination if the _examiner_ is himself competent and ethical. There is no better judge of their efficiency than the patient himself, who can tell whether the results promised have been effected. Whether the work of a country oculist is efficient and ethical can be learned: (1) by teaching country school children to recognize eye strain; (2) by comparing his results with those of other physicians. As soon as one or two states have tested eyes, we shall have an average by which to compare each class, school, and city with others of their size under similar conditions. If a particular physician finds half as many more or only half the average number, the presumption will be that his results are inaccurate and warrant an investigation. The interested teacher or parent can render an inestimable service to her local school and to the children of her state by taking steps to secure state laws compelling eye tests in all schools. Finally, it must be remembered by teachers, employers, parents, and all eye users that eyes are constantly changing; that eyes may need glasses six months after they are examined and found sound; that glasses change or develop the eye, so that they may be unnecessary and harmful six months after they are prescribed, or the eye may require a stronger glass; that eyeglasses become bent and scratched, so that they worry and strain the eye; that a periodic examination is essential to the health of the eye. In caring for the health of the eye, we should also remember that our eyes are our chief interpreters of the world that gives us problems, profits, and pleasures. Out of gratitude, if not out of enlightened self-interest, we owe our eyes protection, attention, and training, so that without straining we shall always be able to see truth and beauty. CHAPTER VIII EAR TROUBLE, MALNUTRITION, DEFORMITIES The presence of adenoids is a frequent cause of both slight and aggravated deafness. Of 156 deaf mutes examined 59 per cent had adenoids, while only 6 per cent of the general run of the children in the neighborhood had this trouble. In mouth breathing, the current of air entering the mouth draws out some of the air from the Eustachian tube which ventilates the middle ear and unequalizes the atmospheric pressure on the eardrum, causing it to sink in and to blunt the hearing. An examination of the eardrums of school children in New York who are mouth breathers showed a high percentage of deafness, incipient or pronounced, accompanying adenoids. For example, of 9 mouth breathers selected from one class (average age 7-8 years), 6 were well-marked cases of deafness. Of 8 mouth breathers (average age 8-9 years), and of 5 mouth breathers (average age 5-6 years), all had noticeable defects of hearing. Many adults that suffer from deafness maintain that they never had any trouble in childhood. Yet the evidences of nose and throat trouble in childhood persist and disprove such statements. _The foundations of deafness in later life are, in most instances, laid in childhood._ Since the majority of cases of ear trouble occurring in school children accompany diseased conditions of the nose and throat, the proper care of nose and throat will, in large measure, balance the shortcomings of the aural examinations. Since the examination of the drum itself is not practicable, especial care should be given to the examination of the nose and throat. The figures published by New York City's department of health show that of 274,641 children examined from March, 1905, to January, 1908, 3540, or 1.2 per cent, gave evidence of defective hearing. Ear specialists suggest that this small percentage results from employing the whisper test at twenty feet. The whisper test at sixty feet has been set by experts as a test of normal hearing. But preciseness with this test is well-nigh impossible when we consider that the acoustics, the quality of the examiner's voice, the weather, the vowel or consonant sounds, all are variable quantities. The watch test is frequently used, but since a young teacher in her enthusiasm used an alarm clock to make the test, specialists have decided that the volume of sound differs in watches to such a degree as to make the watch test unreliable. The examination of the eye has been reduced to mathematical precision, due altogether to the anatomy of that organ. As yet there is no instrument for the ear comparable to the ophthalmoscope. The acoumeter is largely used by aurists and can be obtained from the optician. This instrument has an advantage over the whisper or watch tests in that its tick is uniform. Each ear should be tested separately. Let the child place his finger against the flap of one ear while the other is being tested. Then compare the farthest distance from the ear at which the tick can be heard with the normal, standard distance. During the test all sound should be eliminated as far as possible and the eyes should be closed. At a demonstration of ear testing at Teachers College, one student stated that she could not hear the tick of the watch at a distance greater than twenty inches. Then the tester walked noisily toward her, leaving the watch on the desk, five feet away from the patient. She heard it now. When the class burst out laughing she opened her eyes, and, seeing the watch so far away, exclaimed, "Why, I thought I imagined it." Be careful in testing a child to distinguish between what he "thinks he imagines" and what he really hears. Because of the difficulties of this test a doubt should be sufficient to warn the teacher to send the child to be tested by an expert. Detection of slight deafness may lead to the discovery of serious defects of nose or throat. Inflammation from cold or catarrh may cause deafness, which if neglected may permanently injure the ear. Often deafness is due to an accumulation of wax. A running ear should receive immediate attention, as it is an indication of inflammation which may imperil the integrity of the eardrum, and, if neglected, may eat its way through the thin partition between the ear and the brain and cause death. It should never be assumed that deafness is incurable. Stupidity, inattention, and slowness to grasp a situation accompany difficulty of hearing and should cause the teacher to examine the ears. No ear trouble is negligible. Children and parents should be taught that the normal ear is intended to hear for us, not to divert our attention to itself. When the ear aches or "runs" or rumbles there is something wrong, and it should be examined together with the throat and nose. NERVOUSNESS In New York City one child in ninety-one already examined has had the form of nervous disease known as St. Vitus's Dance, or chorea. So prone are we to overlook moderate evils and moderate needs that the child with aggravated St. Vitus's Dance is apt to be cured sooner than the child who is just "nervous." Teachers cannot know whether twitching eyes, emotional storms, constant motion of the fingers or feet are due to chorea, to malnutrition, to eye strain, or to habits acquired in babyhood or early childhood and continued for the advantage that accrues when discipline impends. Many a child treasures as his chief asset in time of trouble the ability to lose his temper, to have a "fit," to exhibit nervousness that frightens parent, teacher, or playmate, incites their pity, and wards off punishment. The school examination will settle once for all whether the trouble can be cured. The family physician will explain what steps to take. TESTS OF MALNUTRITION We Americans were first interested in the physical examination of school children by exaggerated estimates of the number of children who are underfed. As fast as figures were obtained for eye defects, breathing defects, bad teeth, some one was ready to declare that these were results of underfeeding. Hence the conclusion: give children at least one meal a day at school. Scientific men began to set us straight and to give undernourishment a technical meaning,--soft bones, flabby tissue, under size, anæmia. While too little food might cause this condition, it was also explained that too much food of the wrong sort, or even food of the right sort eaten irregularly or hurriedly or poisoned by bad teeth, might also cause undernourishment, including the extreme type known as malnutrition. In extreme instances the symptoms enable an observant teacher who has learned to distinguish between the pretty hair ribbon and clean collar and the sunken, pale, or hectic cheek and lusterless eyes to detect the cause. But as with eyes and nose, an unhealthy condition of nourishment may exist long before outward symptoms are noticeable. Therefore the value of the periodic searching examination by the school physician. [Illustration: SAME AGE, SAME SCHOOL, DIFFERENT NUTRITION] BONE TUBERCULOSIS; ORTHOPEDIC TESTS Only recently have we laymen learned that knee trouble, clubfoot, ankle sores, spine and hip troubles, scrofula, running sores at joints, etc., are not hereditary and inevitable, but are rather the direct result of carelessness on the part of adult consumptives. These conditions in school are indices of homes and houses where tuberculosis is or has been active, and of health boards that are or have been inactive in checking the white plague. Early examination may disclose the small lump on the child's spine,--which one mother diagnosed as inherited "round shoulders,"--and save a child from being a humpback for life. Moreover, the examination of the crippled child's brothers and sisters will often show the beginnings of pulmonary tuberculosis. [Illustration: A GRIEVOUS PENALTY FOR NEGLECT BY ADULT CONSUMPTIVES] ENLARGED GLANDS--TUBERCULOSIS In almost every class are one or more children who are proud of small or big lumps under one or more jaws. Only physicians can find very small lumps. Many family doctors will say, "Oh, he will outgrow those," or "Those lumps will be absorbed." Like most other evils that we "outgrow" or that pass away, these lumps shriek not to be neglected. They mean interference with nourishment and prevent proper action of the lymphatic system, as adenoids prevent free breathing. Even when not actually infected with tubercle bacilli, they are fertile soil for the production of these germs. If detected early, they point to home conditions and personal habits that can be easily corrected. In New York one child in four has these enlarged glands. If the same proportion prevails in other parts of the United States, there are 5,400,000 children whose strength is being needlessly drained, many of whom, if neglected, will need repeated operations. [Illustration: MODEL OF AMERICA'S FIRST HOSPITAL FOR SEASHORE FRESH-AIR TREATMENT OF NONPULMONARY TUBERCULOSIS IN CHILDREN To be erected at Rockaway Beach, New York City] CHAPTER IX DENTAL SANITATION "Have their teeth attended to first, and many of the eye defects will disappear." This was an unexpected contribution to the debate upon free eyeglasses for the school children of New York City. So little do most of us realize the importance of sound, clean teeth, and the interrelation of stomach and sense nerves, that even the school principals thought the eye specialist was exaggerating when he declared that bad teeth cause indigestion and indigestion causes eye strain. "Bad" teeth mean to most people dirty teeth and offensive odors, loose, crooked, or isolated teeth, or black stumps. Even among dentists a great many, probably the majority, do not appreciate that "bad" teeth mean indigestion, lowered vitality, plague spots for contaminating sound teeth and for breeding disease germs. Until recently the only rule about the teeth of new recruits in the United States army was: "There must be two opposing molars on each side of the mouth. It doesn't matter how rotten these molars may be." The surgeon general was persuaded to change to "four opposing molars on each side"; still nothing as to the condition of the two additional molars! In the German army there is a regular morning inspection of teeth and toothbrushes. Several German insurance companies give free dental treatment to policy holders, not to bestow charity but to increase profits. Neglecting "baby teeth" and adenoids may mean crooked second teeth that will cause: (1) hundreds of dollars for straightening; (2) permanent business handicap because crooked teeth are disagreeable to others, because mastication is less perfect, and because a disfigured mouth means dis-arranged nerves; or perhaps (3) large dental bills because it is difficult to clean between cramped, crooked teeth. Unfortunately the great majority of parents rarely think of their children's teeth until too late to preserve them intact. Even among families where the rule of brushing the teeth twice daily prevails, regular dental examination is often not required. Doctors and dentists themselves have not been trained to realize that the teeth are a most dangerous source of infection when unclean. Does your dentist insist upon removing tartar and food particles beyond your reach, upon polishing and cleansing, or does he regard these as vanity touches, to be omitted if you are in a hurry? [Illustration: INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL] Physicians send tuberculosis patients to hospitals or camps without correcting the mouth conditions that make it impossible for the patient to eat or swallow without infecting himself. Tonics are given to women whose teeth are breeding and harboring disease germs that tear down vitality. Nurses watch their suffering patients and do the heavier tasks heroically, but are not trained to teach the simple truths about dental hygiene. The far-reaching results of neglect of teeth will not be understood until greater emphasis is placed on the bacteriology, the economics, the sociology, and the æsthetics of clean, sound teeth. Whether or not there is at present a tendency to exaggerate the importance of sound teeth, there is no difference of opinion as to the fact that the teeth harbor virulent germs, that the high temperature of the mouth favors germ propagation, that the twenty to thirty square inches of surface constantly open to bacterial infection offer an extensive breeding ground, and that the formation of the teeth invites the lodgment of germs and of particles of food injurious both to teeth and to other organs. By scraping the teeth with the finger nail and noticing the odor you can convince yourself of the presence of decomposing organic matter not healthful to be carried into the stomach. By applying a little iodine and then washing it off with water, your teeth may show stains. These stains are called gelatinous plaques, which are transparent and invisible to the naked eye except when colored by iodine. These plaques protect the germs, which ferment and create the acid which destroys tooth structure. Their formation can be prevented by vigorous brushing and by eating hard food. The individual with decayed teeth, even with unclean teeth, is open to infection of the lungs, tonsils, stomach, glands, ears, nose, and adenoid tissues. Every time food is taken, and at every act of swallowing, germs flow over the tonsils into the stomach. Mouth breathers with teeth in this condition cannot get one breath of uncontaminated air, for every breath becomes infected with poisonous emanations from the teeth. Bad teeth are frequently the sole cause of bad breath and dyspepsia, and can convey to the system tuberculosis of the lungs, glands, stomach, or nose, and many other transmissible diseases. They may also cause enlarged tonsils and ear trouble. Apart from decomposing food and stagnant septic matter from saliva injured by indigestion, and by sputum which collects in the healthy mouth, there are in many infected mouths pus, exudations from the irritated and inflamed gum margins, gaseous emanations from decaying teeth, putrescent pulp tissue, tartar, and chemical poisons. Every spray from such a mouth in coughing, sneezing, or even talking or reading, is laden with microbes which vitiate the air to be breathed by others. Indigestion from imperfect mastication and imperfect salivation (themselves often due solely to bad teeth) is far less serious than indigestion from germ infection. Germs taken into the stomach can so change the composition of saliva (a natural disinfectant when healthy) as to render it no longer able to kill germs. Indigestion may result in excess of uric acid and toxic material, so that the individual becomes subject to gout and rheumatism, which in turn frequently destroy the bony support of the teeth and bring about Riggs's Disease. The last named is a prevalent and disfiguring disease, whose symptom is receding gums. The irritating toxins deposited on the teeth cause inflammation of the tissues at the gum margins. The gums withdraw more and more from sections of the teeth; the poisons get underneath and work back toward the roots; the infection increases and hastens the loosening of the teeth. I know of a man who had all of his teeth extracted at twenty-one years of age, because he was told that this was the only treatment for this disease, which was formerly thought to be incurable. Yet thorough cleansing and removal of this matter from under the edges of the gums, disinfection, a few visits to the dentist, will stop the recession but cannot regain lost ground. Among those who regularly use the toothbrush, instinct, comfort, or display is the ruling motive, while a small percentage have evolved to the anti-nuisance stage, where the æsthetic standard of their group forbids any member to neglect his teeth. The anti-slum and pro-slum motives for mouth cleanliness and dental sanitation have been awakened in but one or two places. A significant pro-slum activity is the dental clinic organized by forty volunteer dentists, acting for an industrial school maintained by the New York Children's Aid Society. [Illustration: NEW YORK CHILDREN'S AID SOCIETY'S DENTAL CLINIC FOR SCHOOL CHILDREN] Here 550 children have been examined, 447 teeth extracted, 284 teeth filled, 200 teeth treated for diseased pulp (and only 24 sets cleaned), 40 dentists taking turns in giving time to this work. The equipment cost but $239; cards and stationery, $72; incidentals, $33. The principal attends the clinic, because in her presence no child is willing to confess fear or unwillingness. To supplement this work, the dentists have prepared for free distribution a leaflet which tells in short, clear sentences how to care for the teeth. [Illustration: (leaflet)] +----------------------------------------------------------------------+ | A DENTAL CATECHISM =When should they be cleansed?= | | | | =What are the teeth for?= Immediately after the morning and | | noonday meals and before going to | | To masticate food; that is, bed. | | grind it into fine particles, | | mix it with saliva, and so =By what means should they be | | begin its digestion; also to cleansed?= | | aid in speaking and singing. | | By a moderately stiff brush, | | =How long should they last?= water, and floss silk. | | | | To the very end of life. =How should these be used?= | | | | =How do we lose them?= The brush should be first used in | | a general way, high up on the | | By decay, by loosening, and by gums length-wise of the jaws, to | | accident. remove large particles and | | stimulate the gums, then the | | =What causes teeth to decay?= brush and the teeth should be | | carefully rinsed with water. The | | Particles of food decaying in brush should next be used with a | | contact with them. rolling or circular motion, so | | that the bristles will follow the | | =Where does food lodge?= lines of all the grooves and | | spaces in which the particles of | | All along the edges of the gums, food have lodged, and so brush | | in the spaces between the teeth, them out. Then again the mouth | | and in the crevices of their should be rinsed with water. | | grinding surfaces. | | =Should the gums be brushed?= | | =Can we prevent this loss?= | | Yes, moderate friction helps to | | Yes, to a large extent. keep them healthy. | | | | =How can we do it?= =How can the spaces between the | | teeth be reached?= | | By using the teeth properly and | | by keeping them clean and the By dental floss silk passed | | gums healthy. between the teeth, drawn | | carefully back and forth till it | | =What does using them properly reaches the gum, pressed firmly | | mean?= against the side of each tooth in | | turn and drawn out towards the | | 1. Using sufficient hard or grinding end of the tooth, and | | fibrous food to give the teeth this repeated several times in | | and gums full exercise. each space. | | | | 2. Taking time enough to =Should tooth powder or paste be | | masticate food thoroughly before used?= | | swallowing. | | Usually once a day. | | =How often should teeth be | | cleansed?= | | | | As often as they are used. | +----------------------------------------------------------------------+ Such a leaflet should be given out at dispensaries, hospitals, dental offices, schools, and from many Sunday schools and missions.[5] The time for the schools to begin is when the child is first registered. Examination and reëxamination must be accompanied by explanation of the serious disadvantages of neglected teeth, and the physical, social, and economic advantages of clean, sound teeth. Instruction at school must be followed by education of parents. The school or health authorities should examine the teeth of all children before issuing work certificates. Finally, the dental, medical, and nursing professions and the press must be enlisted in the school's campaign for dental hygiene. The Dental Hygiene Council of Massachusetts should be copied in all states. A preliminary examination of teeth can be made by parent or teacher. Crooked, loose, dirty, or black teeth or receding gums can be detected by a layman's naked eye. In fact, children can be interested in finding the most obvious defects in their own or their brothers' teeth. There could be no better first lesson than to ask each pupil to look in a hand mirror and to count each tooth obviously needing a cleaning or a filling. The most urgent need can thus be ascertained without expert aid. But because parent, teacher, or child cannot discover defects does not prove that dental care is not imperative; hence the importance of examination by a dentist or by a physician competent to discover dental needs. If a private, public, or parochial school has no paid visiting dentist, a zealous school officer can, at least in large towns, persuade one or more dentists or physicians to make a few first tests to confirm the teacher's findings, and to persuade the community that regular examination and reëxamination are necessary and a saving of pain, beauty, and money. Reëxamination is necessary because decay _may_ start the day after a dentist has pronounced a tooth sound. For most of us twice a year is often enough. A reëxamination should be made upon the slightest suspicion of decay, breaking, or loosening. Educational use should be made by the teacher of the results of school examination. Children cannot be made self-conscious and cleanly by telling them that their teeth will ache three or five years from now. They can be made to brush or wash their teeth every morning and every night if they once realize that cavities can be caused only by _mouth garbage_. All decay of human teeth starts from the outside through the enamel that covers the soft bone of the tooth. This enamel can be destroyed by accidentally cracking or breaking it, or by acids eating into it. These acids come from (1) particles of food allowed to remain in the teeth; (2) tartar, etc., that adheres to the teeth and can be removed only by a dentist; (3) saliva brought up from an ill-conditioned stomach. Even where the enamel is destroyed, absolute cleanliness will prevent serious decay of the tooth. A perfectly clean tooth will not decay. Generally speaking, unless particles of food or removable acids remain on or between the teeth long enough to decompose, teeth cannot decay. Decay always means, therefore, uncleanliness. To unclean teeth is due in large part the offensive odor of many schoolrooms. Uncleanliness becomes noticeable to our neighbors sooner or later. There is no offense we are so reluctant to commit as that of having uncleanliness of our bodies disagreeable to those about us. Very young children will make every effort in their power to live up to the school's standard of cleanliness. The other side to this reason for having clean teeth is vanity. Because all cleanliness is beautiful to us, clean teeth are one attribute of beauty that all of us can possess. Habits of cleanliness are easily fixed. In the most crowded, most overworked section of large cities visitors from "uptown" are surprised by the children's bright hair ribbons, clean aprons, clean faces, and smoothly combed hair. It will be easy to add clean teeth to the list of things necessary to personal and family standing. Armenian children are taught to clean their teeth after eating, even if only an apple between meals. They covet "beautiful teeth." American standards will soon prevent these Armenians from cleaning their teeth in public, but desire for beautiful teeth will stay, and will remind them to care for their teeth in private. As coarse food gives way to sugars and soft foods, stiff toothbrushes must supplement tongue and toothpicks. [Illustration: AN ARMENIAN SCHOOL GIRL] Strong as are the instinct and display motives in cleaning teeth, both parents and children need to be reached through the commerce motive. Instinct makes children afraid of the dentist, or content when the tooth stops aching. Display may be satisfied with cleaning the front teeth, as many boys comb only the front hair or as girls hide dirty scalps under pompadours and pretty ribbons. Desire to save money may give stronger reasons for not going to the dentist than instinct and comfort can urge for going. But parents can be made to see, as can children after they begin to picture themselves as wage earners, that a dentist in time saves nine, and that no regular family investment will earn more money than the price of prompt and regular dental care. A problem in arithmetic would be convincing, if, by questions such as those on page 98, we could compare the family cost of neglecting teeth with the cost of toothbrushes, bicarbonate of soda, pulverized chalk or tooth powder, early and repeated examination by a dentist, and treatment when needed. How many members in your family? What does a toothbrush cost? How many teeth have they? How many do you need in one year? How many teeth have they lost? How much does tooth powder How many false teeth have they? cost? How many teeth have been filled? How much is needed for one year? What is the total cost to date? How much would two examinations How many days have been lost a year by a dentist cost? from work because of toothache? How many teeth are now decayed? What will it cost to have them attended to? The result will show that the money spent for one good "house cleaning" of one child at fourteen or eighteen exceeds the cost of keeping clean and in repair the teeth of the entire family. How effective and economical is thorough cleaning is confessed by an eminent dentist, who taught an assistant to clean his patients' teeth. "Do you know," he said, "I had to stop it, so perceptibly did my work decrease." The total time required to examine school children for teeth needing attention is much less than the time now lost by absence from school or wasted at school on account of toothache. To remind school children regularly of dental hygiene is not more important than for the school to remind parents repeatedly of the many reasons for attending to their children's teeth. It is not enough, however, to send one message to parents. Illustrated lectures, mothers' meetings, demonstrations at hospitals and fresh-air homes are all very serviceable, but listening is a poor substitute for understanding. Schools should see that parents understand the æsthetics, the economics, the humanity of dental hygiene. The best test of whether the parent has understood is the child's tooth. Dental examination of children applying for work certificates gives the health and school authorities a means of enforcing their precepts. When no child is allowed to go to work whose teeth cause malnutrition or disgust, the news will spread, and both child and parent will see clearly the grave need for dental care. [Illustration: WON BY THE ECONOMIC ARGUMENT] Finally, local papers can be interested. They will print almost anything the teacher sends about the need for dental care. They like particularly facts about the number of cavities found, the number of children needing care, efforts made to procure care, and new facts about diseases that can be caused by bad teeth or about diseases that can injure teeth. Teachers can persuade dentists and physicians to write stories. No newspaper will refuse to print such statements as this: "A tuberculous patient in six weeks lost ground steadily. I persuaded him to go to a dentist to clean the vestibule to his digestive system, and to have a set of false teeth. He enjoys his meals, and has gained twelve pounds in six weeks." Popular magazines and newspapers mention teeth seldom, because those who best know the interesting vital things are making money, not writing articles or otherwise concerning themselves with dental education. It is said that of forty thousand American dentists not over eleven thousand are readers of dental journals, and probably not three hundred contribute to professional literature. One dentist who is working for the children's clinic described above, when asked by the board of education to lecture to the people on the care of the teeth and to recommend simple, readable books, told me that he knew no good books to suggest. Five obstacles exist to practicing what is here preached: 1. The expensiveness of proper dentistry. 2. The untrustworthiness of cheap dental service and "painless" dental parlors; the domination of the supply houses wishing to sell instruments and other supplies. 3. The ethical objection to any kind of advertising or to work by wholesale. 4. The lack of dispensaries. 5. The profit-making basis of dental education. Additional reasons these for cleanliness that will make the dentist serviceable for his knowledge rather than for his time and gold. Good dentists really "come too high" for both the poor and the comfortably situated. Families in New York City that have four or five thousand dollars a year hesitate to go to a dentist whom they thoroughly trust, because his time is worth more than they feel they can afford to pay. The "free-extraction" dental parlors undoubtedly are doing a vast amount of harm. In every city are dental quacks that injure wage-earning adults as much as soothing-sirup quacks injure babies. Instead of teaching people to preserve their teeth, they extract, and then, by dint of overpersuading by a pretty cashier hired for the purpose, make a contract for a gold crown or a false set at an exorbitant price. A reputable dentist has said that a dental parlor can do more damage to the welfare of the race in a few months than a well-intentioned man in the profession can repair in a lifetime. Its question is not, What can I do for this patient? but What is there in this mouth for me? Many "parlors" never expect to see the same person twice, because they do not make him comfortable or gain his confidence; they put a filling in on top of decayed matter or even diseased pulp; put in plates and bridges that do not fit; charge more than the examination at first leads one to expect; refuse to correct mistakes; deny having ever seen the patient before. Yet true and severe as this arraignment is, many of these parlors, with their liveried "runners in," are doing an educational service not otherwise provided; it is conceivable that in many cities they are doing less harm by their malpractice than well-intentioned men in the profession by neglect of public needs or by failure to organize facilities for meeting those needs. I realize that advertising is "unethical" among dentists as among physicians. Humbug and imposition are supposed to go inevitably with self-advertising by the methods used in selling shoes or automobiles. Therefore such advertising is prohibited. But what seems to be forgotten in this definition of ethics is that the need and the opportunity for dental care must be advertised in some way, if we are ever to control diseases and evils due to bad teeth. The rich that one dentist can help are able to pay for his good taste, his neat attendants, his automobile, his club dues, his vacations at fashionable resorts, his hours without work, his standard of living. All of these things advertise him, just as hospital appointments and social position may and do advertise successful physicians. The patients of moderate means that one dentist can treat cannot afford to pay for rent, time disengaged, and indirect advertising. Either they must have free treatment, must go without treatment, or must go to a dental parlor where dental needs are organized so that a very large number will contribute to rent and display. It is out of the question to have both dentists and patients so distributed and prices so adjusted that dentists can make a good living by charging what the patient can afford, and at the same time admit of every patient being properly treated when necessary. Judging from every other branch of work, the solution of the problem lies partly in free care for those who can pay nothing or very little, and partly in coöperative treatment through the heretofore objectionable dental parlors. If instead of inveighing against advertisers, honorable and capable dentists worked through dental and medical societies to secure adequate public supervision of dental practice, more progress would be made against dental malpractice. Dental clinics will quickly follow the publication of facts that schools should gather. In some places these should be separate; but at first the best thing is to make every hospital, every children's home, every settlement a clinic, and every school an examining center. A skilled dentist informs me: "The demand that will follow examination of school children's teeth will make it profitable for young dentists to adopt a coöperative scheme, where several young men hire a parlor in a cheap district, and, under the supervision of some experienced dentist, give good advice at reasonable rates. This is the best antidote to the dental parlor which exploits the public so shamelessly." Bellevue Hospital in New York is the first general hospital to establish regular dental examination; others will undoubtedly soon follow. Dental education for profit rather than for instruction and for health has been the rule. Even where universities have put in dental courses, they have demanded a net profit from tuition. Instead of protecting society against men incapable of caring for teeth, the schools have marketed certificates to as large numbers as slowly enlightened self-interest would permit. Much progress has been made toward uniform standards of admission and graduation, but dental colleges sadly need the light and the inspiration of school facts about teeth. Of fourteen dental journals in America, only one has the advancement of dental science as its first reason for existence. Thirteen are trade journals. Not one of these would print articles proving that the supplies advertised by their backers were inimical to dental hygiene. Many dental colleges still retain on their faculties agents or editors in the pay of supply houses, Harvard's new dental school being a notable exception. This trade motive tolerates and encourages the disreputable practices of existing dental parlors. Largely because of this prostitution of the dental profession, patients generally neglect the repairing and cleansing of the teeth and the sterilizing of the mouth from which germs are carried to all parts of the body. Dental journalism for the sale of supplies cannot outlive the dentist's reading of the school's index. Many dentists will say that they must learn dentistry before they learn the economics and sociology of clean teeth. Being a young profession, it is natural that dentistry should first devote itself to learning its own mechanics,--the tricks of the trade--how to fill teeth. But the fact that it took the medical profession centuries to begin to feel responsibility for community health is no reason why the social sense of the dentist should be dormant for centuries or decades. We need training and exercise to determine what kind of filling will be most comfortable and most serviceable; whether the pulp of the teeth needs treating or removing before the filling is inserted; whether it is worth while to fill a deciduous or baby tooth. Sociology will never take the place of dental technic. The few dentists who have studied the social significance and social responsibility of their profession declare, however, that careless workmanship and indifferent education of patients continue chiefly because dentists themselves do not see the community's interest in dental hygiene. The school can socialize or humanize the dental profession if teachers themselves possess the social sense and make known the facts about the need for dental care among school children. FOOTNOTES: [5] _The Teeth and Their Care_, by Thaddeus P. Hyatt, D.D.S., is a short, concise treatment of the principles of dental sanitation. CHAPTER X ABNORMALLY BRIGHT CHILDREN What is commonly considered abnormal brightness in a school child is often a tendency to live an abnormal physical life. Being a child bookworm means that time is spent indoors that should be spent playing games with one's fellows. Excellence in the activities of children, not ability to imitate the activities of adults, should be the test of child brightness. To be able to hit a bull's-eye, to throw a ball accurately, to calculate the swing of a curve or the bound of a "grounder," these are tests of brightness quite as indicative of mental power as the ability to win highest marks in school, while less injurious to physical power. The child who is abnormally bright requires special treatment just as much as the child who is abnormally dull. The former as well as the latter must have his abnormal condition corrected if he is to grow into a normally bright man. The college man who sacrifices health to "marks" is thus described by the director of physical training at Harvard University: A drooping head, a pale face, dull, sunken eyes, flat chest and rounded shoulders, with emaciated limbs, soft flabby muscles, and general lack of good physical, mental, and moral tone. For the protection of these physical defective grinds it is suggested to put a physical qualification upon the candidates of Phi Beta Kappa and their awards of scholarship. If scholarship men cannot be induced to take time to improve their physique for fear of lowering their college standing, then give them credit for standing in physical work. The abnormally bright, at whatever age, is as much a subject for examination and treatment as the child with adenoids and pulmonary tuberculosis. Such attention will increase the percentage of abnormally bright schoolmates who figure in active business in later life. Moreover, it will decrease the number of high school superintendents who declare that their honor pupils are physical wrecks. There are children who develop very rapidly, both physically and mentally, and whose mental superiority is not at the expense of their bodies. Protection of such children requires that their minds be permitted to progress as rapidly as bodily health justifies. It is as cruel to keep back a physically and mentally superior child, as to push the physically or mentally defective beyond his powers. Worry and fatigue can be produced by lack of interest as well as by overwork. "Normal" should not be confused with "average." To keep a bright child back with the average child--marking time till the dull ones catch up--is to make him abnormal. The tests that we have employed for grading pupils are either the tests of age in years or of mental capacity. The first takes no account of slowness or rapidity of physiological development,--of physiological age. The second encourages mental activity at the expense of physique. The entrance of a child into school, the promotion from one class to another, the entrance into college, are thus determined either by the purely artificial test of age or by the individual teacher's discretion. There is nothing to prevent the ambitious teacher or the ambitious parent from pushing a child into kindergarten at four, high school at twelve, college at fifteen. If this cannot be done at the public school, a private school is resorted to. A community of college professors once started a school for faculty children. A tremendous pressure was put upon these scions of intellectual aristocracy to enter the high school at twelve. No thought was given to the ventilation of the school. The windows were so arranged that they could not be opened without the air blowing on some child's back. "You could cut the air with a knife" was a description given by one sensible professor who had taken his sturdy girl of seven away from the school, because he feared that in this environment she would become like the other little puny, pale, undersized children of that school. The University of Pennsylvania has instituted a psychological clinic. Parents and teachers are invited to bring any deviation from the usual or the expected to the attention of this clinic. Every month a bulletin is published called the _Psychological Clinic_, which will be found of great service in dealing with the abnormally bright as well as with the abnormally dull. Naturally the well-to-do and the rich are the first to take advantage of these special facilities for ascertaining just what work should be done by a precocious child or by the mentally and morally retarded. Abnormal brightness means power to be happy and to be serviceable that is above the average. Every school can be a miniature psychological clinic. While every teacher cannot be an expert, national and state superintendents can constantly remind teachers that the abnormally bright are also abnormally apt to neglect physical welfare and to endanger future mental power. CHAPTER XI NERVOUSNESS OF TEACHER AND PUPIL Nervousness of teacher and pupil deserves special mention. So universal is this physical defect that we take it for granted, especially for teachers. Teachers themselves feel that they need not even apologize for nervousness, in fact they too frequently use it as an excuse for impatience, ugly temper, discourtesy, and unfairness. Children, slates, papers, parents, blackboards "get on their nerves." Nervousness of teacher causes nervousness of pupils and adds to the evil results of mouth breathing, bad teeth, eye strain, and malnutrition. These conditions, added to bad ventilation, bad light, and an overcrowded schoolroom, render the atmosphere thoroughly charged with electricity--nerves--toward the end of the day. Lack of oxygen to breathe as well as inability to breathe it; lack of well-printed books and good light, as well as lack of the power to use them; toothache, earache, headache, deplete the vitality of both teacher and pupil. Most of the disturbances at school are but outward signs of unwholesome physical conditions. If the teacher attempts to treat these causes by crushing the child, she makes confession of her own nervousness and inadequacy and visits her own suffering upon her pupils. A transfixing glance prolonged into an overbearing stare, a loud, sharp voice, a rough manner, are successful only so far as they work on the nervousness of her pupil. She finds that it is temporarily effective, and so by her example and practice sets the child an example in losing control of himself. The position often assumed by school children when before authority, of hands held stiffly at the side, head drooped, and roving eye, does not mean control: it means a crushed spirit, hypocrisy, or brooding anarchy. The mother or teacher who obtains obedience by clapping her hands, pointing her finger, distorting her face, is copying in her own home the attitudes of caste in India, of serfdom in Russia, the discipline of the prison the world over, a modern reminder of the power of life and death or of physical torture. A young college girl unfamiliar with the ways of the public school was substituting in the highest grammar grade. The time for civics arrived. Here, she thought, is a subject in which I can interest them. The boys showed a vast amount of press information, as well as decided opinions on the politics of the day. The candidates which they elected for the position of ideal American patriot were Rockefeller, Lincoln, and Sharkey the prize fighter. During the ensuing debate, which gave back to Lincoln his proper rank, the boys in the back of the room had moved forward and were sharing seats with the boys in the front. Every boy was engrossed in the discussion. The room was in perfect order,--not, however, according to the ideas of the principal, who entered at that moment to see how the new substitute was managing the class, famed for its bad boys. With the stern look of a Simon Legree she demanded, "How dare you leave your seats!" When one child started to explain she shouted: "How dare you speak without permission! Don't you know your teacher never permits it? Every boy take his own seat at his own desk." This principal was far more to be pitied than the boys, for they had before them the prospect of "work papers" and a grind less monotonous and more productive than the principal's discipline. She was a victim of a nerve-racking system, more sinned against than sinning. There is nothing in school life _per se_ to cause nervousness. Given a well-aired, sunny room, where every child has enough fresh air to breathe, where he can see without strain, where he has a desk fitted to his body and work fitted to his maximum abilities, a teacher who is physically strong and mentally inspiring, and plenty of play space and play time, there will be no nervousness. One who visits vacation schools is struck with the difference in the atmosphere from that of the winter day schools. Here are the same rooms, the same children, and in many cases the same teachers, but different work. Each child is busy with a bright, interested, happy expression and easy attitude. Some are at nature study, some are weaving baskets, making dresses, trimming hats, knitting bright worsted sacks and mittens for the winter. Boys are at carpentering, raffia, or wrought-iron work. In none of the rooms is the absolute unity or the methodical order of the winter schoolroom, but rather the hum of the workroom and the order that comes from a roomful of children interested in the progress of their work. This condition only illustrates what a winter schoolroom might be were physical defects corrected or segregated, windows open, light good, and work adapted to the child. [Illustration: VACATION SCHOOL INTEREST: AN ANTIDOTE TO NERVOUSNESS] Nervousness is not a monopoly of city teachers and city pupils. In country schools that I have happened to know, nervous children were the chief problem. Nervousness led in scholarship, in disorder, in absences, in truancy, and in backwardness. After reading MacDonald's _Annals of a Quiet Neighborhood_, I became interested in one or two particularly nervous children, just to see if I could overcome my strong dislike for them. To one boy I gave permission to leave the room or to go to the library whenever he began to lose his self-control. My predecessors had not been able to control him by the rod. A few weeks after Willie's emancipation from rules, the county superintendent was astonished to see that the county terror led my school in history, reading, and geography. Had I known what every teacher should be taught in preparation,--the relation of eye strain, bad teeth, adenoids, "overattention," and malnutrition to nervousness and bad behavior,--I could have restored many "incorrigibles" to nerve control. Had I been led at college to study child psychology and child physiology, I should not have expected a control that was possible only in a normal adult.[6] In its primary aspect the question of nervousness in the schoolroom is purely physiological, and the majority of principals and teachers are not trained by professional schools how to deal with it. Normal schools should teach the physical laws which govern the child's development; should show that the pupil's mental, moral, and physical nature are one and inseparable; that children cannot at one time be docile, sickly, and intelligent,--perfect mentally and imperfect physically. Until teachers are so taught, the condition cannot be changed that makes of our schools manufactories of nervous teachers and pupils. Country nervousness, like city nervousness, is of three kinds: (1) that caused by defective nervous systems; (2) that resulting from physical defects other than defects of the nervous system, but reacting upon it; (3) that due to habit or to lack of self-control. Children who suffer from a defective nervous system should, in city schools, be segregated where they can have special care under constant medical supervision. Such children in schools too small for special classes should be given special treatment. Their parents should know that they have chorea, which is the same trouble as St. Vitus's Dance, although often existing in a degree too mild to attract attention. Special treatment does not mean that such children should be permitted to interfere with the school progress of other children. In many rural schools, where special privileges cannot be given children suffering with chorea without injury to other children, it would be a kindness to the unfortunates, to their parents, and to all other children, were the parents requested to keep such children at home. Nervousness that results from removable physical defects--eye strain, adenoids, indigestion, earache--will be easily detected by physical examination, and easily corrected by removing the physical defect. Preventable nervousness due to "habit" can be quite as serious in its effects upon the mind and health as the other two forms of nervousness. Twitching the face, biting the nails, wetting the lips, blinking the eyelids, continually toying with something, being in perpetual motion and never relaxing, always changing from one thing to the next, being forever on the rush, never accomplishing anything, are common faults of both teacher and pupil. We call them mannerisms or tricks of personality. They are readily imitated by children. I once knew a young lawyer who had started life as an oyster dealer, whose power of imitation helped to make him responsive to both helpful and harmful influences. After being at the same table for two weeks with a talented man whom he admired, he acquired the latter's habit of constantly twitching his shoulder and making certain gestures. These habits in turn quickly produced a nervousness that interfered with his power to reason straight. Nervousness is often confused with aggressiveness, initiative, confidence. "Think twice before you jump, and perhaps you won't want to jump" is a very difficult rule to follow for any one whose bodily movements are not under perfect control. It is said that the confusion of city life causes habits of nervousness. Unfortunately no one knows whether the city children or the country children have the highest percentage of nervousness. There is a general feeling that city life causes an unwholesome degree of activity, yet one finds that those people in the city who least notice the elevated railway are those whose windows it passes. City noises irritate those who come from the country, or the city man on returning to the city from the country, but a similar irritation is felt by the city-bred man on coming to the country. Mr. Dooley's description of a night in the country with the crickets and the mosquitoes and the early birds shows that it is the unusual noise rather than the volume or variety of noises that wreck nerves. At the time of the opening of the New York schools in 1907 a newspaper published an editorial on "Where can the city child study?" showing that in New York the curriculum, the schoolhouse, and the tenements are so crowded and so noisy that study is practically impossible. Lack of sleep, lack of a quiet place in which to study at school and at home, are causes for nervousness, whether these conditions are in the city or in the country. What evidence is there that the country curriculum is less crowded or country work better adjusted to the psychological and physiological age of the country pupil? The index is there; it should be read. In breaking habits of nervousness the first step is to explain how easily habits are formed, why their effects may be serious, and how a little attention will correct them. When a habit loses its mystery it becomes unattractive. Children will take an interest in coöperating with each other and with the teacher in curing habits acquired either at home or at school. My pupils greatly enjoyed overcoming the habit of jumping or screaming after some sudden noise. I told them how, when a boy, my imagination had been very much impressed by one of Thackeray's characters, the last remnant of aristocratic traditions, almost a pauper, but possessing one attribute of nobility,--absolute self-control. When his house burned he stood with his ankles crossed, leaning on his cane, the only onlooker who was not excited. For months I imitated that pose, using sticks and rakes and fork handles. The result was that when I taught school, a scream, a broken desk, or unusual noise outside reminded me of my old aristocrat in time to prevent my muscles from jumping. In a very short time several fidgety and nervous girls and boys had learned to think twice and to relax before jumping. One test of thorough relaxation in a dentist's chair proves the folly of tightening one's muscles. When in school or out the remedy for nervousness is relaxation. The discipline that prohibits a pupil from stretching or changing his posture or seat is as much to be condemned as that which flourishes the rod. It has been said of our schools that children are not worked to death but bored to death. Wherever a room must be stripped of all beauty and interest to induce concentration, wherever the greater part of the teacher's time must be spent in keeping order, there is confession either of inappropriateness of the present curriculum or of the failure of teacher and text-book to present subjects attractive to the pupils. Nervous habits will be inevitable until the pupil's attention is obtained through interest. Sustained interest will be impossible until teacher and pupil alike practice relaxation, not once a morning or twice a day, not during recess or lunch hour, but whenever relaxation is needed. In overcoming nervousness of teacher and pupil, both must be interested in home causes as well as school causes of that nervousness. Time must be found to ask questions about those causes and to discuss means for removing them. Naturally it will be embarrassing for a very nervous teacher to discuss nervousness with children,--until after she has overcome her own lack of nerve stability. To help her or to compel her to learn the art of relaxation of bodily and of mental control is the duty and the privilege of the school physician, of her doctor, and of superintendent and trustees. The outside point of view is necessary, because of the peculiar fact that almost every nervous person believes that he has unusually good control over his nerves, just as a man in the midst of his anger will declare that he is cool and self-controlled. Had Robert Burns been thinking of the habit of nervousness he could not have thought of a better cure than when he wrote: Oh wad some power the giftie gie us To see oursel's as ithers see us; It wad frae mony a blunder free us, And foolish notion. FOOTNOTES: [6] _The Unconscious Mind_ by Schofield, _The Study of Children and their School Training_ by Dr. Frances Warner, and _The Development of the Child_ by Nathan Oppenheimer show clearly the physical and mental limitations and possibilities of children. CHAPTER XII HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING _A boy without play means a father without a job. A boy without physical training means a father who drinks. When people have wholesome, well-disciplined bodies there will be less demand for narcotics as well as for medicines._ On these three propositions enthusiasm has built arguments for city parks and playgrounds, for school gymnastics, and for temperance instruction. We have tried the remedies and now realize that too much was expected of them. Neither movement appreciated the mental and physical education of spontaneous games and play. Like hygiene instruction, physical training was made compulsory by law in many states, and, like hygiene instruction, physical training had to yield to the pressure of subjects in which children are examined. At the outset both were based upon distorted psychology and physiology. Of late physical training has been revived "to correct defects of the school desk and to relieve the strain of too prolonged study periods." In New York grammar schools ten minutes a day for the lower grades, and thirty minutes a week for the higher grades, are set aside for physical training. With the exception of eighteen schools where apparatus is used, the exercise has been in the class rooms. It consists of what are known as "setting-up exercises,"--deep breathing and arm movements for two minutes between each study period, often forgotten until it is time to go home, when the children are tired and need it least. Many teachers so conduct these exercises that children keenly enjoy them. [Illustration: SERVICEABLE RELIEF FROM SCHOOL STRAIN, BUT A POOR SUBSTITUTE FOR OUTDOOR PLAY] Like hygiene instruction, physical training preceded physical examination. Generally speaking, it has not yet, either in schools or in colleges, been related to physical needs of the individual pupil. In fact, there is no guarantee that it is not in many schools working a positive injury on defective children or imposing a defective environment on healthy children. Formal exercises in cramped space, in ill-ventilated rooms, with tight belts and heavy shoes, are conceded to be pernicious. Formal exercises should never be given to any child without examination and prescription by a physician. Children with heart weakness, enlarged tonsils, adenoid growths, spinal curvature, uneven shoulders, are frequently seen doing exercises for which they are physically unfit, and which but serve to deplete further their already low vitality. Attention might be called to many a class engaged in breathing exercises when by actual count over half the boys were holding their mouths open. Special exercises are needed by children who show some marked defect like flat foot, flat chest, weak abdominal muscles, habitual constipation, uneven shoulders, spinal trouble, etc. That no physical training should be provided for normal children is the belief of many leading trainers. This special training is useful to develop athletes or to correct defects. Like massage, osteopathy, or medicine, it should follow careful diagnosis. The time is coming when formal indoor gymnasium exercises for normal pupils or normal students will be considered an anomaly. There is all the difference in the world between physical development and what is called physical training. The test of physical development is not the hours spent upon a prescribed course of training, but the physical condition determined by examination. To be refused permission to substitute an hour's walk for an hour's indoor apparatus work is often an outrage upon health laws. Given a normal healthy body, plenty of space, and plenty of playtime, the spontaneous exercise which a child naturally chooses is what is really health sustaining and health giving. Mere muscular development artificially obtained through the devices of a gymnasium is inferior to the mental and moral development produced by games and play in the open air. Eustace Miles, M.D., amateur tennis player of England, says: I do not consider a mere athlete to be a really healthy man. He has no more right to be called a really healthy man than the foundations or scaffolding of a house have a right to be called a house. They become a good house, and, indeed, they are indispensable to a good house, but at present the good house exists only in potentiality. The "healthy-mindedness" and "physical morality" which play and games foster rarely result from physical training as a business, at stated times, indoors, under class direction. It is too much like taking medicine. A certain breakfast food is said to have lost much of its popularity since advertised as a health food. When the National Playground Association was organized President Roosevelt cautioned its officers against too frequent use of the word "supervision" on the ground that supervision and direction were apt to defeat the very purpose of games and to stultify the play spirit. Is the little girl on the street who springs into a hornpipe or a jig to the tune of a hurdy-gurdy, or even the boy who runs before automobiles or trolley cars or under horses' noses, getting less physical education than those who play a round game in silence under the supervision of a teacher in the school basement, or who stretch their arms up and down to the tune of one, two, three, four, five, six? Who can doubt that the much-pitied child of the tenement playing with the contents of the ash can in the clothes yard or with baby brother on the fire escape is developing more originality, more lung power, and better arteries than the child of fortune who is led by the hand of a governess up and down Fifth Avenue. Children have not forgotten how to play, but adults have forgotten to leave space in cities, and time out of school, home work, and factory work in which children may play. Again, the child--whether a city child or a country child--rarely needs to be taught how to play. Teaching him games will not produce vitality. Games are the spontaneous product of a healthy body, active mind, and a joy in living. Give the children parks and piers, roof gardens and playgrounds in which they may play, and leave the rest to them. Give them time away from school and housework, and leave the rest to them. Instead of lamenting the necessity for playing in the streets, let us reserve more streets for children's play. There are too many students of child welfare whose reasoning about play and games is like that of a lady of Cincinnati, who, upon reading the notice of a child-labor meeting, said: "Well, I am glad to see there is going to be a meeting here for child labor. It is high time some measure was taken to keep the children off the streets." Physical examinations would prove that streets are safer and better than indoor gymnasiums for growing children. Intelligent physical training will train children to go out of doors during recess; will train pupils and teachers not to use recess for study, discipline, or eating lunch. [Illustration: SPONTANEOUS PLAY ON ONE OF NEW YORK CITY'S SCHOOL ROOF PLAYGROUNDS] "After-school" conditions are quite as important as physical training and gymnastics at school. Not long ago a nurse was visiting a sick tenement mother with a young baby. She found a little girl of twelve standing on a stool over a washtub. This child did all the housework, took care of the mother and two younger children, got all the meals except supper, which her father got on his return from work. As the nurse removed the infant's clothes to give it a bath, the little girl seized them and dashed them into the tub. "Yes, I am pretty tired when night comes," she confessed. This child has prototypes in the country as well as the city, and she did not need physical training. She did not lack initiative or originality. She did need playmates, open air, a run in the park, and "fun." The educational value of games and outdoor play should be weighed against the advantages of lowering the compulsory school age, and of bridging over the period from four to seven with indoor kindergarten training. Neither physical training nor education is synonymous with confinement in school. The whole tendency of Nature's processes in children is nutritional; it is not until adolescence that she makes much effort to develop the brain. Overuse of the young mind results, therefore, in diverting natural energy from nutritive processes to hurried growth of the overstimulated brain. The result is a type of child with a puny body and an excitable brain,--the neurotic. The young eye, for example, is too flat (hypermetropic)--made to focus only on objects at a distance. Close application to print, or even to weaving mats or folding bits of paper accurately, causes an overstrain on the eye, which not only results in the chronic condition known as myopia,--short-sightedness,--so common to school children, but which acts unfavorably on the constitution and on the whole development of the child. At the recent International Congress of School Hygiene in London, Dr. Arthur Newsholme, medical officer of health of Brighton, made a plea for the exclusion of children under five years of age from schools. "During the time the child is in the infant department it has chiefly to grow. Nutrition and sleep are its chief functions. Paints, pencils, paper, pins, and needles should not be handled in school by children below six." Luther Burbank, in an article on "The Training of the Human Plant," says: The curse of modern child life in America is overeducation, overconfinement, overrestraint. The injury wrought to the race by keeping too young children in school is beyond the power of any one to estimate. The work of breaking down the nervous systems of the children of the United States is now well under way. Every child should have mud pies, grasshoppers, and tad-poles, wild strawberries, acorns, and pine cones, trees to climb and brooks to wade in, sand, snakes, huckleberries, and hornets, and any child who has been deprived of these has been deprived of the best part of his education. Not every child can have these blessings of the country, but every child can be protected from the stifling of the nature instinct of play by formal indoor "bossed" exercises, whether called games, physical training, gymnastics, or Delsarte. [Illustration: NEW YORK CITY'S SCHOOL FARM DOES NOT STIFLE NATURE INSTINCT] The answer to the protest against too early and too constant confinement in school has always been: "Where will the child be if out of school? Will its environment at home not work a worse injury to its health? Will not the street injure its morals?" Because we have not yet worked out a method of supervising the health of those children who are not in school, it does not follow that such supervision is impossible. Perhaps the time will come when there will be state supervision over the health of children from birth, parents being expected to present them once a year at school for examination by the school physician. In this way defects can be corrected and health measures devised to build up a physique that should not break down under the strain of school life. For children whose mothers work during the day, and for those whose home environment is worse than school, it might be cheaper in the long run to assign teachers to protect them from injury while they play in a park, roof garden, or out-of-door gymnasium. If parks and playgrounds come too slowly, why not adopt the plan advocated by Alida S. Williams, a New York principal, of reserving certain streets for children between the hours of three and five, and of diverting traffic to other streets less suitable for children's play? So great is the value--mentally, morally, and physically--of out-of-door play that it has even been suggested that the substitution of such play for school for all children up to the age of ten would insure better minds and sounder physiques at fifteen. It is generally admitted that the child who enters school at eight rather than at six will be the gainer at twelve. What a travesty upon education to insist upon schooling for children because they are apt to be run over on the street, or to be neglected at home, to shoot craps, or belong to a gang and develop bad morals. Educators will some day be ashamed to have made the schools the catch-all or the court-plaster for the evils of modern industry. Instead of pupils and mothers going to the school, enough hygiene teachers, and play teachers, and district physicians could be employed with the money now spent on indoor instruction to do the house-to-house visiting urged in many chapters of this book. Such a course of action would have an incalculable effect on the reduction of tuberculosis, not only in making healthier physiques but by inculcating habits of outdoor life and love of fresh air. The danger of those contagious diseases which ravish childhood would be greatly reduced. An ambition for physical integrity would make unnatural living unpopular. Competition in games with children _of the same physical class_ develops accuracy, concentration, dispatch, resourcefulness, as much as does instruction in arithmetic. Smoking can easily be discredited among boys trying to hit the bull's-eye. A boy would sooner give up a glass of beer than the championship in rifle shooting or a "home run." The influence of the "spirit of the game" on practical life has been described thus by New York's director of physical training, Dr. Luther H. Gulick: Play is the spontaneous enlistment of the entire personality in the pursuit of some coveted end. We do not have to pursue the goal; we wish to--it is our main desire. This is the way in which greatest discoveries, fortunes, and poems are made. It is the way in which we take the responsibilities and problems of life that makes it either a deadly bore--a mere dull round of routine and drudgery--or the most interesting and absorbing game, capable of enlisting all the energy and enthusiasm we have to put into it. The people who accomplish things are the people who play the game. They let themselves go; they are not afraid. Under the stimulus and enthusiasm of play muscles contract more powerfully and longer than under other conditions. Blood pressure is higher in play. It is far more interesting to play the game than to work at it. When you work you are being driven, when you play you are doing the driving yourself. We play not by jumping the traces of life's responsibilities, but by going so far beyond life's compulsions as to lose sight of the compulsion element. Play up, play up, and play the game. CHAPTER XIII VITALITY TESTS AND VITAL STATISTICS Two things will disclose the strength or weakness of a bank and the soundness or unsoundness of a nation's banking policy, namely, a financial crisis or an expert audit. A searching audit that analyzes each debit and each credit frequently shows that a bank is solvent only because it is not asked to pay its debts. It continues to do business so long as no obvious weaknesses appear, analogous to measles, adenoids, or paralysis. A frequent disorder of banking results from doing too big a business on too little capital, in making too many loans for the amount of cash held ready to pay depositors upon demand. This disorder always comes to light in a crisis--too late. It can be discovered if looked for in advance of a crisis. Many individuals and communities are likewise physically solvent only because their physical resources are not put to the test. Weaknesses that lie near the surface can be discovered before a crisis by physical examination for individuals and sanitary supervision for communities. Whether individuals or communities are trying to do too much business for their health capital, whether the health reserves will pay debts that arise in a crisis, whether we are ill or well prepared to stand a run on our vitality, can be learned only by carefully analyzing our health reserves. Health debits are compared with health credits for individuals by vitality tests, for communities by vital statistics. Of the many vitality tests none is practicable for use in the ordinary class room. Scientific training is just as necessary for such tests as for discovering the quality of the blood, the presence or absence of tubercle bacilli in the sputum, diphtheria germs in throat mucus, or typhoid germs in milk. But scientific truth, the results of scientific tests, can be made of everyday use in all class rooms. State and national headquarters for educators, and all large cities, can afford to engage scientists to apply vitality tests to school children for the sake of discovering, in advance of physical breakdown and before outward symptoms are obvious, what curriculum, what exercise, what study, recreation, and play periods are best suited to child development. It will cost infinitely less to proceed this way than to neglect children or to fit school methods to the loudest, most persistent theory. The ergograph is an interesting strength tester. It takes a picture (1) of the energy exerted, and (2) of the regularity or fitfulness of the manner in which energy is exerted. Perhaps the time will come when science and commerce will supply every tintype photographer with an ergograph and the knowledge to use it. Then we shall hear at summer resorts and fairs, "Your ergograph on a postal card, three for a quarter." We can step inside, harness our middle finger to the ergograph, lift it up and down forty-five times in ninety seconds, and lo! a photograph of our vitality! If we have strong muscles or good control, the picture will be like this: [Illustration: FIG. 1. Ergogram of T.R., a strong, healthy girl, before taking 40 minutes' work in the gymnasium. Weight used, 3.5 kg. Distance lifted, 151 cm. Work done, 528.5 kg.-cm.] If weak and nervous, we shall look like this before taking exercise: [Illustration: FIG. 2. Ergogram of C.E., a weak and somewhat nervous girl, before taking 40 minutes' work in the gymnasium. Weight used, 3.5 kg. Distance lifted, 89 cm. Work done, 311.5 kg.-cm.] And like this after gymnasium exercise: [Illustration: FIG. 3. Ergogram of C.E. after taking 40 minutes' work in the gymnasium, showing that the exercise proved very exhausting. Weight used, 3.5 kg. Distance lifted, 55 cm.] In Chicago, two of whose girls are above photographed, the physician was surprised to have four pupils show more strength late in the day than in the morning. "Upon investigation it was found that the teacher of the four pupils had been called from school, and that they had no regular work, but had been sent to another room and employed themselves, as they said, in having a good time." The chart on page 127 shows the effect of the noon recess and of the good time after three o'clock. Chicago's child-study experts concluded after examining a large number of children: 1. In general there is a distinct relationship in children between physical condition and intellectual capacity, the latter varying directly as the former. 2. The endurance (ergographic work) of boys is greater than that of girls at all ages, and the difference seems to increase after the age of nine. 3. There are certain anthropometric (body measurements) indications which warrant a careful and thorough investigation into the subject of coeducation in the upper grammar grades. 4. Physical condition should be made a factor in the grading of children for school work, and especially for entrance into the first grade. 5. The great extremes in the physical condition of pupils in the upper grammar grades make it desirable to introduce great elasticity into the work of these grades. 6. The classes in physical culture should be graded on a physical instead of an intellectual basis. [Illustration: FIG. 4] To these conclusions certain others should be added, not as settled beyond any possibility of modification, but as being fairly indicated by these tests. 1. The pubescent period is characterized by great and rapid changes in height, weight, strength of grip, vital capacity, and endurance. There seems to accompany this physical activity a corresponding intellectual and emotional activity. It therefore is a period when broad educational influences are most needed. From the pedagogic standpoint it is preëminently a time for character building. 2. The pubescent period is characterized by extensive range of all physical features of the individuals in it. Hence, although a period fit for great activity of the mass of children, it is also one of numerous individual exceptions to this general law. During this period a greater per cent of individuals than usual pass beyond the range of normal limits set by the mass. It is a time, therefore, when the weak fail and the able forge to the front, and hence calls for a higher degree than usual of individualization of educational work and influence. 3. Unidexterity is a normal condition. Rapid and marked accentuation of unidexterity is a pubescent change. On the whole, there is a direct relationship between the degree of unidexterity and the intellectual progress of the pupil. At any given age of school life bright or advanced pupils tend toward accentuated unidexterity, and dull or backward pupils tend toward ambidexterity.... Training in ambidexterity is training contrary to a law of child life. 4. Boys of school age at the Bridewell (reform school) are inferior in all physical measurements to boys in the ordinary schools, and this inferiority seems to increase with age. 5. Defects of sight and hearing are more numerous among the dull and backward pupils. These defects should be taken into consideration in the seating of pupils. Only by removing the defects can the best advancement be secured. 6. The number of eye and ear defects increases during the first years of school life. The causes of this increase should be investigated, and, as far as possible, removed. 7. There are certain parts of the school day when pupils, on the average, have a higher storage of energy than at other periods. These periods should be utilized for the highest forms of educational work. 8. The stature of boys is greater than that of girls up to the age of eleven, when the girls surpass the boys and remain greater in stature up to the age of fourteen. After fourteen, girls increase in stature very slowly and very slightly, while boys continue to increase rapidly until eighteen. 9. The weight of the girl surpasses that of the boy about a year later than her stature surpasses his, and she maintains her superiority in weight to a later period of time than she maintains her superiority in height. 10. In height, sitting, girls surpass boys at the same age as in stature, namely, eleven years, but they maintain their superiority in this measurement for one year longer than they do in stature, which indicates that the more rapid growth of the boy at this age is in the lower extremities rather than in the trunk. 11. Commencing at the age of thirteen, strength of grip in boys shows a marked accentuation in its rate of increase, and this increase continues as far as our observations extend, namely, to the age of twenty. In girls no such great acceleration in muscular strength at puberty occurs, and after sixteen there is little increase in strength of grip. The well-known muscular differentiation of the sexes practically begins at thirteen. 12. As with strength of grip, so with endurance as measured by the ergograph; boys surpass girls at all ages, and this differentiation becomes very marked after the age of fourteen, after which age girls increase in strength and endurance but very slightly, while after fourteen boys acquire almost exactly half of the total power in these two features which they acquire in the first twenty years of life. 13. The development of vital capacity bears a striking resemblance to that of endurance, the curves representing the two being almost identical. Physiological age, according to studies made in New York City, should be considered in grading, not only for physical culture classes but for all high school or continuation classes. Dr. C. Ward Crampton, assistant physical director, while examining boys in the first grade of the High School of Commerce, noticed a greater variation in physical advancement than in years. He kept careful watch of the educational progress and discovered three clear divisions: (1) boys arrived at puberty,--postpubescent; (2) boys approaching maturity,--pubescent; (3) boys not yet approaching maturity,--prepubescent. The work in lower grades they had all passed satisfactorily, but in high school only the most advanced class did well. Practically none of the not-yet-maturing boys survived and few of the almost mature. In other words, the high school course was fitted to only one of the three classes of boys turned out of the grammar schools. The others succumbed like hothouse azaleas at Christmas time, forced beyond their season. Physiological age, not calendar years or grammar school months, should determine the studies and the companions of children after the tenth year. Physiological strength and vitality, not ability to spell or to remember dates, should be the basis of grading for play and study and companionship among younger children. Vitality, power to endure physically, should be the test of work and recreation for adults. Physicians may be so trained to follow directions issued by experts that physical examinations will disclose the chief enemies of vitality and the approximate limits of endurance. Teachers may train themselves to recognize signs of fatigue in school children and to adapt each day's, each hour's work to the endurance of each pupil. One woman principal has written: School programmes, after they have been based upon the laws of a child's development, should provide for frequent change of subject, alternating studies requiring mental concentration with studies permitting motor activity, and arranging for very short periods of the former. Anæmic children should be relieved of all anxiety as to the results of their efforts, and only short hours of daylight work required of them. The disastrous consequences of eye strain should be understood by all in charge of children who are naturally hypermetropic. The ventilation of a class room is far more important than its decoration or even than a high average percentage in mathematics, and the lack of pure air is one of the auxiliary causes of nervous exhaustion in both pupils and teachers. Deficient motor control is a most trustworthy indication of fatigue in children, and teachers may safely use it as a rough index of the amount of effort to be reasonably expected of their pupils. Facial pallor or feverish flushes are both evidences of overtasking, and either hints that fatigue has already begun. As to unfavorable atmospheric conditions, the teacher herself will undoubtedly realize them as soon as the children, but she should remember that effort carried to the point of exhaustion, injurious as it is in an adult, is yet less harmful than it is to the developing nerve centers of the child. Because adults at work and at play reluctantly submit themselves to vitality tests, because few scientists are beseeching individuals to be tested, because almost no one yearns to be tested, the promotion of adult vitality and of community vitality can best be hastened by demanding complete vital statistics. Industrial insurance companies and mutual benefit societies are doing much to educate laborers regarding the effect upon vitality of certain dangerous and unsanitary trades, and of certain unhygienic habits, such as alcoholism and nicotinism. Progress is slower than it need be because state boards of health are not gathering sufficiently complete information about causes of sickness and death. American health and factory inspection is not even profiting, as it should, from British, German, and French statistics. Statistics are in ill repute because the truth is not generally known that our boasted sanitary improvements are due chiefly to the efficient use of vital statistics by statesmen sanitarians.[7] The vital statistics of greatest consequence are not the number of deaths or the number of births, not even the number of deaths from preventable diseases, but rather the number of cases of sickness from transmissible diseases. The cost and danger to society from preventable diseases, such as typhoid, diphtheria, scarlet fever, measles, are imperfectly represented by the number of deaths. Medical skill could gradually reduce death rates in the face of increasing prevalence of infectious disease. With few exceptions, only those patients who refuse to follow instructions will die of measles, diphtheria, or smallpox. The scarlet-fever patient who recovers and goes to church or school while "peeling" can cause vastly more sickness from scarlet fever than a patient who dies. Dr. W. Leslie Mackenzie, who has recently written _The Health of the School Child_, said ten years ago, while health officer of Leith: Death is the ultimate and most severe injury that any disease can inflict, but short of death there may be disablement, permanent or temporary, loss of wages, loss of employment, loss of education, increase of home labor, increase of sickness outlays, increase of worry, anxiety and annoyance, disorganization of the household, general impairment of social efficiency. The best guarantee against such loss, the best protection of health, and the most essential element of vital statistics is prompt, complete record of cases of sickness. Statistics of sickness are confined to sickness from transmissible diseases, because we have not yet arrived at the point where we recognize the state's right to require information, except when the sick person is a menace to the health of other persons. The annual report of a board of health should give as clear a picture of a community's health during the past week or past quarter as the ergograph gives of the pupils mentioned on page 126. As ragged, rapidly shortening lines show nervousness and depleted vitality, so charts and diagrams can be made to show the needless waste of infant life during the summer months, the price paid for bad ventilation in winter time, when closed windows cause the sickness-and-death line from diphtheria and scarlet fever to shoot up from the summer level. In cities it is now customary for health boards to report weekly the number of deaths from transmissible diseases. Health officers will gladly furnish facts as to cases of sickness, if citizens request them. Newspapers will gladly publish such information if any one will take the pains to supply it. Wherever newspapers have published this information, it quickly takes its place with the weather reports among the news necessities. Marked changes are commented on editorially. Children can easily be interested, as can adults, in filling out week by week a table that will show increases and decreases in preventable sickness due to transmissible diseases. TABLE X CASES OF INFECTIOUS AND CONTAGIOUS DISEASES REPORTED =================+================================================ | WEEK ENDING +------+------+------+------+------+------+------ | Oct. | Nov. | Nov. | Nov. | Nov. | Nov. | Dec. | 26 | 2 | 9 | 16 | 23 | 30 | 7 -----------------+------+------+------+------+------+------+------ Tuberculosis | | | | | | | pulmonalis | 350 | 350 | 317 | 364 | 345 | 337 | 422 Diphtheria and | | | | | | | croup | 313 | 264 | 283 | 331 | 282 | 343 | 326 Measles | 142 | 212 | 203 | 261 | 293 | 323 | 472 Scarlet fever | 208 | 228 | 231 | 252 | 278 | 323 | 372 Smallpox | -- | 1 | -- | 1 | -- | -- | 2 Varicella | 40 | 83 | 91 | 162 | 136 | 115 | 167 Typhoid fever | 106 | 105 | 107 | 123 | 86 | 77 | 71 Whooping cough | 6 | 13 | 15 | 14 | 27 | 9 | 8 Cerebro-spinal | | | | | | | meningitis | 6 | 11 | 3 | 4 | 4 | 8 | 15 -----------------+------+------+------+------+------+------+------ Total | 1171 | 1267 | 1250 | 1512 | 1451 | 1535 | 1855 =================+======+======+======+======+======+======+====== =================+========================================= | WEEK ENDING +------+------+------+------+------+------ | Dec. | Dec. | Dec. | Jan. | Jan. | Jan. | 14 | 21 | 28 | 4 | 11 | 18 -----------------+------+------+------+------+------+------ Tuberculosis | | | | | | pulmonalis | 360 | 354 | 308 | 344 | 432 | 402 Diphtheria and | | | | | | croup | 369 | 338 | 347 | 308 | 370 | 406 Measles | 471 | 517 | 346 | 581 | 691 | 803 Scarlet fever | 397 | 417 | 426 | 478 | 562 | 585 Smallpox | 4 | 3 | 2 | -- | 2 | -- Varicella | 160 | 198 | 123 | 98 | 199 | 169 Typhoid fever | 62 | 35 | 42 | 37 | 55 | 36 Whooping cough | 12 | 19 | 3 | 25 | 24 | 14 Cerebro-spinal | | | | | | meningitis | 13 | 7 | 6 | 11 | 16 | 13 -----------------+------+------+------+------+------+------ Total | 1844 | 1888 | 1603 | 1882 | 2351 | 2428 =================+======+======+======+======+======+====== In cities where physicians are not compelled to notify the health board of danger centers,--that is, of patients sick from measles, smallpox, or diphtheria,--and in smaller communities where notices are sent only to state boards of health, parents will find it difficult to take a keen interest in vital statistics. But if teachers would start at the beginning of the year to record in such a table the days of absence from school because of transmissible disease, both they and their pupils would discover a new interest in efficient health administration. After a national board of health is organized we may reasonably expect that either state boards of education or state boards of health will regularly supply teachers with reports that will lead them to compare the vitality photographs of their own schools and communities with the vitality photographs of other schools and other communities working under similar conditions. Then children old enough to study physiology and hygiene will be made to see the happiness-giving possibilities of vitality tests and vital statistics. [Illustration: VITAL STATISTICS CAN MAKE DISEASE CENTERS AS OBVIOUS AND AS OFFENSIVE AS THE SMOKE NUISANCE] Instead of discussing the theory of vital statistics, or the extent to which statistics are now satisfactory, it would be better for us at this point to make clear the significance of the movement for a national fact center for matters pertaining to personal, industrial, and community vitality. Five economic reasons are assigned for establishing a national department of health: 1. To enable society to increase the percentage of exceptional men of each degree, many of whom are now lost through preventable accidents, and also to increase the total population. 2. To lessen the burden of unproductive years by increasing the average age at death. 3. To decrease the burden of death on the productive years by increasing the age at death. 4. To lessen the cost of sickness. It is estimated that if illness in the United States could be reduced one third, nearly $500,000,000 would be saved annually. 5. To decrease the amounts spent on criminality that can be traced to overcrowded, unwholesome, and unhygienic environment. In addition to the economic gain, the establishment of a national department of health would gradually but surely diminish much of the misery and suffering that cannot be measured by statistics. Sickness is a radiating center of anxiety; and often death in the prime of life closes the gates of happiness on more than one life. Let us not forget that the "bitter cry of the children" still goes up to heaven, and that civilization must hear, until at last it heeds, the imprecations of forever wasted years of millions of lives. If progress is to be real and lasting, it must provide whatever bulwarks it can against death, sickness, misery, and ignorance; and in an organization such as a national department of health, adequately equipped,--a vast preventive machine working ceaselessly,--an attempt at least would be made to stanch those prodigal wastes of an old yet wastrel world. Among the branches of the work proposed for the national bureau are the following: infant hygiene; health education in schools; sanitation; pure food; registration of physicians and surgeons; registration of drugs, druggists, and drug manufacturers; registration of institutions of public and private relief, correction, detention and residence; organic diseases; quarantine; immigration; labor conditions; disseminating health information; research libraries and equipment; statistical clearing house for information. Given such a national center for health facts or vital statistics, there will be a continuing pressure upon state, county, and city health officers, upon physicians, hospitals, schools, and industries to report promptly facts of birth, sickness, and death to national and state centers able and eager to interpret the meaning of these facts in such simple language, and with such convincing illustrations, that the reading public will demand the prompt correction of preventable evils. Our tardiness in establishing a national board of health that shall do this great educational work is due in part to the fact that American sanitarians have frequently chosen to _do things_ when they should have chosen to _get things done_. Almost every state has its board of health, with authority to require registration of births, deaths, and sickness due to transmissible disease; with few exceptions the heads of these state boards have spent their energies in abating nuisances. In a short time they have degenerated into local scavengers, because they have shown the public neither the meaning of the vital statistics gathered nor its duty to support efficient health administration. The state reports of vital statistics have not been accurate; therefore in many states we have the anomalous situation of an aggressive veterinary board arousing the farmer and the consumer of milk to the necessity of protecting the health of cattle, and an inactive, uninformed state board of health failing to protect the health of the farmer and the consumer. Vital statistics presume efficient health administration. An inefficient health officer will not take the initiative in gathering health statistics. If some one else compels him to collect vital statistics, or furnishes him with statistics, they are as a lantern to a blind man. Unless some one also compels him to make use of them, unless we remove the causes of transmissible or infectious diseases and check an epidemic when we first hear of it, the collection of information is of little social value. "Statistics" is of the same derivation as "states" and "statesmen." Statistics have always been distinguished from mere facts, in that statistics are instruments in the hands of the statesman. Wherever the term "statistics" is applied to social facts it suggests action, social control of future contingencies, mastery of the facts whose action they chronicle. The object of gathering social facts for analysis is not to furnish material for future historians. They are to be used in shaping future history. They are facts collected with a view to improving social vitality, to raising the standard of life, and to eliminating permanently those forces known to be destructive to health. Unless they are to be used this way, they are of interest only to the historical grub. No city or state can afford to erect a statistical office to serve as a curiosity shop. Unless something is to be done to prevent the recurrence of preventable diseases annually experienced by your community or your school, it is not reasonable to ask the public printer to make tables which indicate the great cost of this preventable sickness. A tax collector cannot discharge his duties unless he knows the address of every debtor. The police bureau cannot protect society unless it knows the character and haunts of offenders. A health officer cannot execute the law for the protection of society's health unless he knows the haunts and habits of diseases. For this he must look to vital statistics. But the greatest service of vital statistics is the educational influence. Health administration cannot rise far above the hygienic standards of those who provide the means for administering sanitary law. The taxpaying public must believe in the economy, utility, and necessity of efficient health administration. Power and funds come from town councils and state legislatures. To convince and move these keepers of the purse, trustworthy vital statistics are indispensable. Information will be used for the benefit of all as soon as it is possessed by all. Fortunately the gathering of vital statistics is not beyond the power of the kind of health officer that is found in small cities and in rural communities. If years of study of mathematics and of the statistical method were required, we should despair of obtaining light within a century. But the facts we want are, for the most part, common, everyday facts, easily recognizable even by laymen; for example, births, deaths, age at death, causes of death, cases of transmissible diseases, conditions found upon examination of children applying for work certificates, etc. Where expert skill is required, as at state and national headquarters, it can be found. Every layman can train himself to use skillfully the seven ingredients of the statistical method which it is his duty to employ, and to know when to pay for expert analysis and advice. We can all learn to base judgment of health needs upon the seven pillars,--desire to know, unit of inquiry, count, comparison, percentages, classification, and summary. FOOTNOTES: [7] Dr. Arthur Newsholme's _Vital Statistics_ should be in public libraries and on the shelves of health officers, public-spirited physicians, and school superintendents. CHAPTER XIV IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS? Last year a conference on the physical welfare of school children was told by a woman principal: "Of course we need physicians to examine our children and to teach the parents, but many of us principals believe that our school curriculum and our school environment manufacture more physical defects in a month than all your physicians and nurses will correct in a year." At the same meeting the physical director of schools of New York City appealed eloquently for "biological engineers" at school, who would test the child's strength as building engineers are employed to test the strength of beams and foundations.[8] As explanation for the need of the then recently organized National School Hygiene Association, he elaborated the proposition that school requirements and school environment damage child health. "Ocular defects are in direct ratio to the length of time the pupil has attended school.... A desk that is too high may easily be the indirect agent for causing scoliosis, producing myopia or astigmatism.... Physically examine school children by all means, but do not fail to examine school desks." Fifty schools in different parts of New York City were examined last year with especial reference to the factors likely to cause or to aggravate physical defects.[9] The results, tabulated and analyzed, prove that the woman principal was right; many schools are so built or so conducted, many school courses are so devised or so executed, that children are inevitably injured by the environment in which the compulsory education law forces them to spend their formative years. [Illustration: ONE OF NEW YORK CITY'S ROOF PLAYGROUNDS] Recently I noticed that our little office girl, so anæmic and nervous when she left school that we hesitated to employ her, was becoming rosy and spirited. The child herself explained the change: "I like it better. I have more money to spend. I get more outdoor exercise, and then, oh, the room is so much sunnier and there is more air and the people are all so nice!" And these were just the necessities which were lacking in the school from which she came. Moreover, it is a fair commentary on the school work and the school hygiene in too many of our towns and cities to-day. "I like it better" means that school work is not adapted to the dominant interests of the child, that the curriculum includes subjects remote from the needs and ambitions of the modern school child, and fails to include certain other subjects which it recognizes as useful and necessary, and therefore finds interesting. "I have more money to spend" means that this little girl was able to have certain things, like a warm, pretty dress, rubbers, or an occasional trolley ride, which she longed for and needed. "I get more outdoor exercise" means that there was no open-air playground for her school, that "setting up" exercises were forgotten, that recess was taken up in rushing home, eating lunch, and rushing back again, and that "after school" was filled up with "helping mother with the housework." "The office is so much sunnier and I get more air" accounts for the increase in vitality; and "the people are all so nice," for the happy expression and initiative which the undiscriminating discipline at school had crushed out. [Illustration: BONE TUBERCULOSIS IS ONE OF THE PENALTIES FOR DRY SWEEPING AND FEATHER DUSTERS] For such unsanitary conditions crowded sections of great cities have no apologies to make to rural districts. A wealthy suburb recently learned that there was overcrowding in every class room, and that one school building was so unsanitary as to be a menace to the community. Unadjustable desks, dry sweeping, feather dusters, shiny blackboards, harassing discipline that wrecks nerves, excessive home study and subjects that bore, are not peculiar to great cities. In a little western town a competition between two self-governing brigades for merit points was determined by the amount of home study; looking back fifteen years, I can see that I was encouraging anæmic and overambitious children to rob themselves of play, sleep, and vitality. Many a rural school violates with impunity more laws of health than city factories are now permitted to transgress. After child labor is stopped, national and state child labor committees will learn that their real interest all the time has been child welfare, not child age, and will be able to use much of the old literature, simply substituting for "factory" the word "school" when condemning "hazardous occupations likely to sap [children's] nervous energy, stunt their physical growth, blight their minds, destroy their moral fiber, and fit them for the moral scrap heap." Many of the evils of school environment the teacher can avert, others the school trustee should be expected to correct. So far as unsanitary conditions are permitted, the school accentuates home evils, whereas it should counteract them by instilling proper health habits that will be taken home and practiced. Questions such as were asked in Miss North's study will prove serviceable to any one desiring to know the probable effect of a particular school environment upon children subject to it. Especially should principals, superintendents, directors, and volunteer committeemen apply such tests to the public, parochial, or private school, orphanage or reformatory for which they may be responsible. I. NEIGHBORHOOD HEALTH RESOURCES 1. Is the district congested? 2. Is congestion growing? 3. How far away is the nearest public park? a. Is it large enough? b. Has it a playground or beauty spot? c. Has it swings and games? d. Is play supervised? e. Have children of different ages equal opportunities, or do the large children monopolize the ground? f. Are children encouraged by teachers and parents to use this park? 4. Are the streets suitable for play? a. Does the sun reach them? b. Are they broad? c. Are they crowded with traffic? 5. How far away is the nearest public bath? a. Has it a swimming pool? b. Has it showers? c. Is it used as an annex to the school? [Illustration: VACATION-SCHOOL PLAY CLINIC ON A "VACANT" CITY LOT OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH] II. EFFECT OF SCHOOL EQUIPMENT UPON HEALTH 1. Is there an indoor yard? a. Is the area adequate or inadequate? b. Is the floor wood, cement, or dirt? c. Is the heat adequate or deficient? d. Is the ventilation adequate or deficient? e. Is the daylight adequate, deficient, or almost lacking? f. Is there equipment for light gymnastics and games? g. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally? 2. Is there an outdoor yard? a. Is the area ample or inadequate? b. Is the area mainly occupied by toilets? c. Is the daylight sufficient or deficient? d. For how many hours does the sun reach it? e. Is it equipped for games? f. How much larger ought it to be? g. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally? 3. Is there a gymnasium? a. Is it large enough? b. Is it used for a gymnasium? c. Is it cut up into class rooms? d. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally? 4. Is there a roof playground? a. Is there open ventilation? b. Is it used in the daytime? c. Is it used at night? d. Is it used during the summer? e. Is it monopolized by the larger children? f. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally? 5. Are washing facilities adequate? a. How many pupils per washbasin? b. Are there individual towels? c. Have eye troubles been spread by roller towels? d. Are only clean towels permitted? e. Are there bathing facilities; are these adequate? f. Are swimming pools used for games, contests, etc.? g. Are bathing facilities used out of school hours? h. Who is responsible for cleanliness of towels, washbasins, and swimming pools? i. How often is water changed in swimming pool, or is it constantly changing? 6. Is adequate provision made for clean drinking water? a. Are sanitary fountains used that prevent contamination of faucet or water? b. How often are cups or faucets cleaned? 7. Is provision made for airing outer clothing? a. Are children permitted to pile their clothing in the class room? b. Are there hooks for each child? c. Are lockers provided with wire netting to permit ventilation? d. Are lockers or hooks in the halls or in the basement? e. Have you ever thought of the disciplinary and social value of cheap coat hangers to prevent wrinkling and tearing? [Illustration: AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF CONGESTION--A BOYS' HIGH SCHOOL, NEW YORK CITY] III. THE CLASS ROOM AS A PLACE OF CONFINEMENT 1. How many sittings are provided? a. How many pupils are there? 2. What is the total floor area? a. What proportion is not occupied by desks? 3. Are the seats adjustable? a. Are the seats adjusted to pupils? b. Where desks are adjustable, are short children seated in low desks, or are children seated according to class or according to discipline exigencies without regard to size of desk? c. Are seats placed properly with reference to light? 4. Is the light ample and proper? a. For how many hours must artificial light be used in the daytime? b. Is artificial light adequate for night work? c. Does the reflection of light from blackboard and walls injure the eye? d. Are the blackboards black enough? e. Are the walls too dark? f. Is the woodwork too dark? g. Are window panes kept clean? 5. Is the air always fresh? a. Is ventilation by open windows? b. Is ventilation artificial? c. Does the ventilating apparatus work satisfactorily? d. Are the windows thrown open during recess, and after and before school? e. Do unclean clothes vitiate the atmosphere? f. Do unclean persons vitiate the atmosphere? g. Does bad breath vitiate the atmosphere? h. Are pupils and parents taught that unclean clothes, unclean persons, and bad breath may decrease the benefits of otherwise adequate ventilation and seriously aggravate the evils of inadequate ventilation? 6. Is the temperature properly regulated? a. Has every class room a thermometer? b. Are teachers required to record the thermometer's story three or more times daily? c. Is excess or deficiency at once reported to the janitor? 7. Are the floors, walls, desks, and windows always clean? a. How often are they washed? b. Is twice a year often enough? c. Do the floors and walls contain the dust of years? d. Is dry sweeping prohibited? e. Has wet sawdust or even wet sand been tried? f. Has oil ever been used to keep down surface dust on floors? g. Are feather dusters prohibited? h. Are dust rags moist or dry? i. Is an odorless disinfectant used? 8. Does overheating prevail? a. Do you know teachers and principals who protest against insufficient ventilation, particularly against mechanical ventilation, while they themselves are "in heavy winter clothing in a small room closely sealed, the thermometer at 80 degrees"? IV. EXERCISE AND RECREATION 1. How much time and at what periods is exercise provided for in the school schedule? a. Indoors? b. Outdoors? 2. How much exercise indoors and outdoors is actually given? 3. Are the windows open during exercise? 4. Is exercise suited to each child by the school physician after physical examination, or are all children compelled to take the same exercise? 5. Whose business is it to see that rules regarding exercise are strictly enforced? 6. Do clouds of dust rise from the floor during exercise and play? 7. Are children deprived of exercise as a penalty? 8. Should hygiene talks be considered as exercise? [Illustration: HOME WORKSHOPS NEED FRESH AIR] V. THE SCHOOL JANITOR AND CLEANERS 1. Do they understand the relation of cleanliness to vitality? 2. Is their aim to do the least possible amount of work, or to attain the highest possible standard of cleanliness? 3. Will the teacher's complaint of uncleanliness be heeded by trustees? If so, is the teacher not responsible for uncleanliness? 4. Have you ever tried to stimulate the pride of janitors and cleaners for social service? a. Have you ever tried to show them how much work they save themselves by thorough cleansing? b. Have you ever shown them the danger, to their own health, of dust and dirt that may harbor infection and reduce their own vitality? 5. What effort is made to instruct janitors and cleaners by your school trustees or by your community? 6. Have you explained to pupils the important responsibility of janitors for the health of those in the tenements, office buildings, or schools? a. Do you see in this an opportunity to emphasize indirectly the mother's responsibility for cleanliness of home? [Illustration: SCHOOL WORKSHOPS ALSO NEED FRESH AIR] VI. REQUIREMENTS OF CURRICULUM 1. How much home study is there? a. How much is required? b. What steps are taken to prevent excessive home study? c. Are light and ventilation conditions at home considered when deciding upon amount of home study? 2. Is the child fitted to the curriculum, or is the curriculum fitted to the child? a. Does failure or backwardness in studies lead to additional study hours or to regrading? b. Are there too many subjects? c. Are the recitation periods too long? d. Are the exercise periods too short and too few? e. Is there too much close-range work? f. Is it possible to give individual attention to individual needs so as to awaken individual interest? 3. Is follow-up work organized to enlist interest of parents, or, if necessary, of outside agencies in fitting a child to do that for which, if normal, he would be physically adapted? By reducing the harm done by old buildings and by the traditions of curriculum and discipline, teachers can do a great deal. Perhaps they cannot move the windows or the desks, but they can move the children. If they cannot insure sanitary conditions for home study, they can cut down the home study. If the directors do not provide proper blackboards, they can do less blackboard work. They can make children as conscious, as afraid, and as resentful of dirty air as of dirty teeth. They can make janitors believe that "dry sweeping" or "feather dusting" may give them consumption, and leave most of the dirt in the room to make work for the next day; that adjustable desks are made to fit the child's legs and back, not the monkey wrench; that the thermometer in the schoolroom is a safer guide to heat needed than a boiler gauge in the basement; that fresh air heated by coal is cheaper for the school fund than stale air heated by bodies and by bad breath. Finally, they can make known to pupils, to parents, to principals and superintendents, to health officials and to the public, the extent to which school environment violates the precepts of school hygiene. If the state requires the attendance of all children between the ages of five and fourteen at school for five hours a day, for five days in the week, for ten months in the year, then it should undertake to see that the machinery it provides for the education of those children for the greater part of the time for nine years of their lives--the formative years of their lives--is neither injuring their health nor retarding their full development. If the amount of "close-range" work is rapidly manufacturing myopic eyes; if bad ventilation, whether due to faulty construction or to faulty management, is preparing soil for the tubercle bacillus; if children with contagious diseases are not found and segregated; if desks are so ill adapted to children's sizes and physical needs that they are forming crooked spines; if too many children are crowded into one room; if lack of air and light is producing strained eyes and malnutrition; if neither open air, space, nor time is provided for exercise, games, and physical training; if school discipline is adapted neither to the psychology nor the physiology of child or teacher, then the state is depriving the child of a greater right than the compulsory education law forces it to endure. Not only is the right to health sacrificed to the right to education, but education and health are both sacrificed. In undertaking to enforce the compulsory education law, to put all truants and child laborers in school, the state should be very sure for its own sake that it is not depriving the child of the health on which depends his future usefulness to the state as well as to himself. TABLE XI EFFECTS OF A CHILD LABOR LAW Increase in Chicago Attendance Grades 4-9 ######## 1901-1902 ############# 1902-1903 ###################################################### 1903-1904 Grades 9-15 ####################### 1901-1902 #################### 1902-1903 ###################################################### 1903-1904 FOOTNOTES: [8] _The Sanitation of Public Buildings_, by William Paul Gerhard, contains a valuable discussion of how the school may avoid manufacturing physical defects. [9] By Professor Lila V. North, Baltimore College for Women, for the New York Committee on the Physical Welfare of School Children, 105 East 22d Street, New York City. CHAPTER XV THE TEACHER'S HEALTH "Teachers, gentlemen, no less than pupils, have a heaven-ordained right to work so adjusted that the highest possible physical condition shall be maintained automatically." This declaration thundered out by an indignant physician startled a well-meaning board of school directors. The teacher's right to health was, of course, obvious when once mentioned, and the directors concluded: 1. School conditions that injure child health also injure teacher health. 2. Poor health of teacher causes poor health of pupil. 3. Poor health of pupil often causes poor health of teacher. 4. Adequate protection of children requires adequate protection of their teachers. 5. Teachers have a right to health protection for their own sake as well as for their children's sake. Too little concern has hitherto been shown for the vitality of teachers in private or public schools and colleges. Without protest, and without notice until too late, teachers often neglect their own health at home and at school,--recklessly overwork, undersleep, and undernourish; ruin their eyes, their digestion, and their nerves. School-teachers are frequently "sweated" as mercilessly as factory operatives. The time has come to admit that a school environment which destroys the health of the teacher is as unnecessary and reprehensible as an army camp that spreads typhoid among a nation's defenders. A school curriculum or a college tradition that breaks down teachers is as inexcusable as a gun that kills the gunner when discharged. Experience everywhere else proves that periodic physical examinations and health precautions, not essays about "happy teachers--happy pupils," are indispensable if teachers' health rights are to be protected. Physical tests are imposed upon applicants for teachers' licenses by many boards of education. In New York City about three per cent of those examined are excluded for defects of vision, of hearing, of probable endurance. Once a teacher, however, there is no further physical examination,--no way of discovering physical incapacity, nothing to prevent a teacher from exposing class after class to pulmonary tuberculosis contracted because of overwork and underventilation. The certainty of salary increase year by year and of a pension after the twentieth year will bribe many a teacher to overtax her own strength and to jeopardize her pupils' health. Seldom do training schools apply physical tests to students who intend to become teachers. One young girl says that before starting her normal course she is going to the physician of the board of education for examination, so as to avoid the experience of one of her friends, who, after preparing to be a teacher, was rejected because of pulmonary tuberculosis. During her normal course no examination will be necessary. Overwork during the first year may cause pulmonary tuberculosis, and in spite of her foresight she, too, may be rejected four years hence. The advantages of physical examination upon beginning and during the courses that prepare one for a teacher are so obvious that but little opposition will be given by prospective teachers. The disadvantages to teacher and pupil alike of suffering from physical defects are so obvious that every school which prepares men and women for teachers should make registration and certification dependent upon passing a satisfactory physical test. No school should engage a teacher who has not good proof that she can do the required work without injury to her own or her pupils' health. Long before physicians can discover pulmonary tuberculosis they can find depleted vitality which invites this disease. Headaches due to eye trouble, undernourishment due to mouth breathing, preventable indigestion, are insidious enemies that cannot escape the physical test. Three objections to physical tests for teachers will be urged, but each loses its force when considered in the light of general experience. 1. _A sickly teacher is often the most efficient teacher in a school or a county._ It is true that some sickly teachers exert a powerful influence over their pupils, but in most instances their influence and their efficiency are due to powers that exist in spite of devitalizing elements. Rarely does sickness itself bring power. It must be admitted that many a man is teaching who would be practicing law had his health permitted it. Many a woman's soul is shorn of its self-consciousness by suffering. But even in these exceptional instances it is probable that children are paying too dearly for benefits directly or indirectly traceable to defects that physical tests would exclude. 2. _There are not enough healthy candidates to supply our schools._ This is begging the question. In fact, no one knows it is true. On the contrary, it is probable that the teacher's opportunity will make even a stronger appeal to competent men and women after physical soundness and vitality are made conditions of teaching,--after we all believe what leading educators now believe, that the highest fulfillment of human possibilities requires a normal, sound body, abounding in vitality. 3. _Examination by a physician, especially if a social acquaintance, is an unnecessary embarrassment._ The false modesty that makes physical examination unwelcome to many adults, men as well as women, is easily overcome when the advantages of such examination are understood. It is likewise easy to prove to a teacher that the loss of time required in having the examination is infinitesimal compared with the loss of time due to ignoring physical needs. The programme for school hygiene outlined in Chapter XXVII, Part IV, assumes that state and county superintendents will provide for the examination of teachers as well as of pupils. [Illustration: TEACHERS WILL PREFER PHYSICAL EXAMINATIONS TO FORCED VACATIONS Boston Society for Relief and Study of Tuberculosis] Because the health of others furnishes a stronger motive for preventive hygiene than our own health, it is probable that the general examination of teachers will come first as the result of a general conviction that unhealthy teachers positively injure the health of pupils and retard their mental development. Children at school age are so susceptible and imitative that their future habits of body and mind, their dispositions, their very voices and expressions, are influenced by those of their teachers. Experts in child study say that a child's vocal chords respond to the voices and noise about him before he is able to speak, so that the tones of his voice are determined before he is able to express them. This influence is also marked when the child begins to talk. Babies and young children instinctively do what adults learn not to do only by study,--follow the pitch of others' voices. Can we then overestimate the effect upon pupils' character of teachers who radiate vitality? The character and fitness, aside from scholarship, of applicants for teachers' licenses are now subjected by the board of examiners of New York City to the following tests: 1. Moral character as indicated in the record of the applicant as a student or teacher or in other occupation, or as a participant in an examination. 2. Physical fitness for the position sought, reference being had here to all questions of physical fitness other than those covered in a physician's report as to "sound health." 3. Satisfactory quality and use of voice. 4. Personal bearing, cleanliness, appearance, manners. 5. Self-command and power to win and hold the respect of teachers, school authorities, and the community. 6. Capacity for school discipline, power to maintain order and to secure the willing obedience and the friendship of pupils. 7. Business or executive ability,--power to comprehend and carry out and to accomplish prescribed work, school management as relating to adjustment of desks, lighting, heating, ventilation, cleanliness, and attractiveness of schoolroom. 8. Capacity for supervision, for organization and administration of a school, and for the instructing, assisting, and inspiring of teachers. These tests probably exclude few applicants who should be admitted. Experience proves that they include many who, for their own sake and for children's sake, should be rejected. The moral character, physical fitness, quality of voice, personal bearing, self-command, executive ability, capacity for supervision, are qualities that are modified by conditions. The voice that is satisfactory in conference with an examiner may be strident and irritating when the teacher is impatient or is trying to overcome street noises. On parade applicants are equally cleanly; this cannot be said of teachers in the service, coming from different home environments. Self-command is much easier in one school than in another. Physical fitness in a girl of twenty may, during one short year of teaching, give way to physical unfitness. Therefore the need for _periodic tests_ by principal, superintendent, and school board, _to determine the continuing fitness_ of a teacher to do the special task assigned to her, based upon physical evidence of her own vitality and of her favorable influence upon her pupils' health and enjoyment of school life. Shattered nerves due to overwork may explain a teacher's shouting: "You are a dirty boy. Your mother is a dirty woman and keeps a dirty store where no decent people will go to buy." A physical examination of that unfortunate teacher would probably show that she ought to be on leave of absence, rather than, by her overwork and loss of control, to cause the boys of her class to feel what one of them expressed: "Grandmother, if she spoke so of my mother I would strike her." Just as there should be a central bureau to count and correct the open mouths and closed minds that clog the little old red schoolhouse of the country, so a central bureau should discover in the city teacher as well as in the country teacher the ailments more serious than tuberculosis that pass from teacher to pupil; slovenliness, ugly temper, frowning, crossness, lack of ambition, cynicism,--these should be blackballed as well as consumption, contagious morphine habit, and contagious skin disease. Crooked thinking by teacher leads to crooked thinking by pupil. Disregard of health laws by teacher encourages unhygienic living by pupils. A man whose fingers are yellow, nerves shaky, eyes unsteady, and mind alternately sleepy and hilarious from cigarettes, cannot convey pictures of normal, healthy physical living, nor can he successfully teach the moral and social evils of nicotinism. Both teacher and pupil have a right to the periodic physical examination of teachers that will give timely warning of attention needed. Until there is some system for giving this right to all teachers in private, parochial, charitable, and public schools, we shall produce many nervous, acrid, and physically threadbare teachers, where we should have only teachers who inspire their pupils with a passion for health by the example of a good complexion, sprightly step, bounding vitality, and forceful personality born of hygienic living. PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS CHAPTER XVI EUROPEAN REMEDIES: DOING THINGS AT SCHOOL Recently I traveled five hundred miles to address an audience on methods of fitting health remedies to local health needs. I told of certain dangers to be avoided, of results that had always followed certain remedies, of motives to be sought and used, of community ends to seek. Not knowing the local situation, I could not tell them exactly what to do next, or how or with whom to do it; not seeing the patient or his symptoms, I did not diagnose the disease or prescribe medicine. Several members of the audience who were particularly anxious to start a new organization on a metropolitan model were disappointed because they were told, not just how to organize, but rather how to find out what sort of organization their town needed. They were right in believing that it was easier to copy on paper a plan tried somewhere else, than to think out a plan for themselves. They had forgotten for the time being their many previous disappointments due to copying without question some plan of social work, just as they copy Paris or New York fashions. They had not expected to leave this meeting with the conviction that while the _ends_ of sanitary administration may be the same in ten communities, health _machinery_ should fit a particular community like a tailor-made suit. American-like, they had a mania for organization. I once heard an aged kindergartner--the savant of an isolated German village--describe my fellow-Americans as follows: "Every American belongs to some organization. The total abstainers are organized, the brewers are organized, the teachers are organized, the parents are organized, the young people and even the juniors are organized. Finally, those who belong to no organization go off by themselves and organize a society of the unorganized." Love of organization and love of copying have given us Americans a feverish desire for what we see or read about in Europe. When we talk about our European remedies we try to make ourselves believe that we are broad-minded and want to learn from others' experience. In a large number of cases our impatient demand for European remedies is similar to the schoolboy's desire to show off the manners, the slang, or the clothes picked up on his first visit away from home. With many travelers and readers European remedies or European ways are souvenirs of a pleasant visit, to be described like a collection of postal cards, a curious umbrella, a cane associated with Alpine climbing, or a stolen hymnal from an historic cathedral. Experience proves, however, that just as Roman walls and Norman castles look out of place in New York and Kansas, so European laws and European remedies are too frequently misfits when tried by American schools, hospitals, or city governments. Yesterday a Canadian clergyman, after preaching an eloquent sermon, met a professional beggar on the street in New York City and emptied his purse--of Canadian money! Quite like this is the enthusiastic demand of the tourist who has seen or read about "the way it's done in Germany." The trouble is that European remedies are valued like ruins, by their power to interest, by their antiquity or picturesqueness, or, like the beggar, by their power to stimulate temporary emotion. But we do not sleep in ruins, go to church regularly in thirteenth-century abbeys, or live under the remedies that fire our imagination. We do not therefore see their everyday, practical-result side. The souvenir value of European remedies is due to the assumption that no better way was open to the European, and that the remedy actually does what it is intended to do. Because free meals are given at school to cure and prevent undernourishment, it is taken for granted that undernourishment stops when free meals are introduced; therefore America must have free meals. Because it is made compulsory in a charming Italian village for every child to eat the free school meal, it is taken for granted that the children of that village have no physical defects; therefore let Kansas City, Seattle, and Boston introduce compulsory free meals. But when one goes to Europe to see exactly how those much-advertised, eulogized remedies operate from day to day, it is often necessary to write, as did a great American sanitarian recently, of health administration in foreign cities continually held up as models to American cities: "In spite of the rules and theories over here, the patient has better care in New York City." We have been asked of late to copy several very attractive European remedies for the physiological ills of school children, and for the physical deficiencies of the next generation of adults: breakfasts or lunches, or both, at school for all children, rich as well as poor, whether they want school nourishment or not; school meals for the poor only; school meals to be given the poor, but to be bought by those who can afford the small sum required; free eyeglasses for the poor, for poor and well-to-do, for those who wish them, for those who need them whether they want to wear eyeglasses or not; free dental care; free surgical treatment; free rides and outings during summer and winter; country children to visit the metropolis, city children to visit country and village; free treatment in the country of all children whose parents are consumptives; free rides on street cars to and from school; city-owned street railways that will prevent congestion by making the country accessible; city-built tenements to prevent overcrowding, dark rooms, insufficient air and light; free coal, free clothes, free rent for those whose parents are unable to protect them properly against hunger and cold. Every one of these remedies is attractive. Every one is being tried somewhere, and can be justified on emotional, economic, and educational grounds, if we think only of its purpose. Let us view them with the eyes of their advocates. Would it not be nice for country children to know that toward the end of the school year they would be given an excursion to the largest city of their state, to its slums, its factories, parks, and art galleries? They would grow up more intelligent about geography. They would read history, politics, sociology, and civil government with greater interest. They would have less contracted sympathies. They might even decide that they would rather live their life in the spacious country than in the crowded, rushing city. City children, on the other hand, would reap worlds of physical benefit and untold inspiration from periods of recreation and study in the country, with its quiet, its greens and bronzes and yellows, its birds and animals, its sky that sits like a dome on the earth, its hopefulness. Winter sleigh rides and coasting would give new vigor and ambition. Why spend so much on teaching physiology, geography, and nature study, if in the end we fail to send the child where alone nature and hygiene tell their story? Why tax ourselves to teach history and sociology and commercial geography out of books when excursions to the city and country will paint pictures on the mind that can never be erased? What more attractive or more reasonable than appetizing, warm meals, or cool salads and drinks for the boys and girls who carry their little dinner pails and baskets down the long road where everything runs together in summer and everything freezes in winter? One needs little imagination to see the "smile that won't come off," health, punctuality, and school interest resulting from the school meal. Again, if children must have teeth filled and pulled, eyes tested and fitted for glasses, adenoids and enlarged tonsils removed, surely the school environment offers the least affrighting spot for the tragedy. Thence goblins long ago fled. There courage, real or feigned, is brought to the surface by the anxious, critical, competitive interest of one's peers. [Illustration: A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"] The economic defense of these remedies is many-sided. An English drummer once instructed me during a railroad journey from southern to northern Ireland. As we entered the fertile fields of Lord Dunraven's estate near Athlone, I expressed sympathy for other countries impoverished of soil, of wealth, and of thrift. My instructor replied: "It would pay the government to bring them all to this land free once a year, just to show them what they are missing." That his idea of an investment is sound has been proved by railroads and land companies and even by states, who give away excursions to entice settlers and buyers. Ambition at almost any cost is cheaper than indifference to opportunity. It would be cheaper for our American taxpayer to send school children to city and country than to pay the penalty for having a large number of citizens with narrow interests, unconscious of the struggles and joys of their co-citizens. Free meals, free books, free rides, free eyeglasses, are cheaper than free instruction for the second, third, and sixth terms in studies not passed because of physical defects,--infinitely cheaper than jails and almshouses, truant officers and courthouses. The demoralizing results of giving "something for nothing" did not follow free schooling or free text-books. Perhaps they would not follow the free remedies that we are asked to copy from Europe. In fact, the word "free" is the wrong word. These remedies rather require coöperation of parent with parent. It has demoralized nobody because the streets are cleaned by all of us, country roads made by the township, police paid for by taxes and not by volunteer subscription. The man whose children do not need glasses or nourishment or operation for adenoids would find it cheaper to pay for European remedies than for the useless schooling of boys unable to get along in school because of removable defects. An unruly, uninterested boy sitting beside your boy in public school, a pampered, overfed, undisciplined child sitting beside yours at private school, is taxing you without your consent and doing your child injury that may prove irreparable. It costs $2.50 to furnish a child with eyeglasses. It costs $25 to $50 to give that child a year's schooling. If the child cannot see right and fails in his studies, we have lost a good investment and, after one year so lost, we are out $22.50. In two years we have lost $47.50. But, what is more serious, we have discouraged that boy. Used to failure in school, his mind turns to other things. He is made to think that it is useless for him to try for first place. Perhaps he can play ball, and excels. He chooses a career of ball playing. Valuable years are lost. Initiative and competition are not interrupted any more by free eyeglasses and free operation for adenoids than by free schooling. There is only one place in the world where there is less competition or less struggle than among the ignorant, and that is among the ignorant and unwell. The boy who can't see the blackboard, who can't learn to spell, who can't breathe through his nose, and can't be interested, doesn't compete at all with the bright, healthy boy. Remove the adenoids, give glasses, make interest possible, and fitness to survive takes a higher level because larger numbers become fit to survive. Professor Patten says that it is easier to support in the almshouse than in competitive industry a man who cannot earn more than $1.50 a day. The question, therefore, regarding European remedies is not, To what general theory do they belong? but, What will they accomplish? How do they compare with other remedies of which we know? CHAPTER XVII AMERICAN REMEDIES: GETTING THINGS DONE In New York City there is a committee called the Committee on the Physical Welfare of School Children. The word "welfare" was used rather than "condition" because the committee proposed to use whatever facts it could gather for the improvement of home and school conditions prejudicial to child welfare. The following programme was adopted: 1. _Study of the physical welfare of school children._ a. Examination of board of health records of children needing medical, dental, or ocular care, and better nourishment. b. Home visitation of such children, in order to ascertain whether their need arises from deficient income or from other causes. c. Effort to secure proper treatment, either from parents or from free clinics or other established agencies. d. Effort to secure proper physical surroundings of children while at school--playgrounds, baths, etc. 2. _Effort to secure establishment of such a system of school records and reports_ as will disclose automatically significant school facts,--e.g. regarding backward pupils, truancy, regularity of attendance, registered children not attending, sickness, physical defects, etc. 3. _Effort to utilize available information regarding school needs_ so as to stimulate public interest and thus aid in securing adequate appropriations to meet school needs. The committee grew out of the discussion, in the year 1905, of the following proposition: _To insure a race physically able to receive our vaunted free education, we must provide at school free meals, free eyeglasses, free medical and dental care._ Thanks to the superintendent of schools of New York City, to Robert Hunter's _Poverty_, to John Spargo's _Bitter Cry of the Children_, hundreds of thousands of American citizens were made to realize for the first time that a large proportion of our school children are in serious need of medical, dental, or ocular attention, or of better nourishment. Because physicians, dentists, oculists, hospitals, dispensaries, relief agencies, had seemingly been unconscious of this serious state of affairs, they had no definite, constructive remedy to propose. Their unpreparedness served to strengthen the arguments for the European method of _doing things_. France, Germany, Italy, England, had found it necessary to do things at school. Arguing from their experience, it was only a matter of time when American cities must follow their example. Why not, therefore, begin at once to deal radically with the situation and give school meals, school eyeglasses, etc.? Those who organized the Committee on the Physical Welfare of School Children realized the danger of trying to settle so great a question with the little definite information then available. If _doing things at school_ were to be adopted as a principle and logically carried out, vast sums must be added to the present cost of the public school system. Complications would arise with private and parochial schools, whose children might have quite as serious physical defects, even though not educated by public funds. It would be difficult to obtain proper rooms for medical and dental treatment and meals, and perhaps still more difficult to insure proper food, skilled oculists, dentists, surgeons, and physicians. No one was clear as to how the problem was to be solved by small cities and rural districts, whose needy children are no less entitled to public aid simply because their numbers are smaller. Great as were the difficulties, however, the committee saw that difficulties are in themselves no reason for not doing the right thing. On the other hand, if doing things at school is wrong, if school meals fail to correct and remove physical defects, great social and educational wrong would result from New York's setting an example that would not only misdirect funds and attention in that city, but would undoubtedly lead other cities to move in the wrong direction. Right could be hastened, wrong could be prevented more effectually by facts than by any amount of theory. School meals had been made a political issue in England. The arguments supporting them were stronger than any possible arguments against them, except proof that they would be less effective in helping children than other means that might be proposed. If the American people must choose between sickly, unteachable, dull children without school meals, on the one hand, and bright, teachable, healthy children plus school meals, on the other hand, they will not hesitate because of expense or eighteenth-century objections to "socialism." During one year of investigation and of _getting things done_ the committee has prepared three studies for publication: (1) a report on the home conditions of fourteen hundred school children of different nationalities, found by school physicians to have defects of vision, breathing, hearing, teeth, and nourishment; (2) an examination of fifty schools--curriculum, buildings, home-study requirements, play space and playtime, physical culture--in an attempt to answer the question, How far does school environment directly cause or aggravate physical defects of school children; (3) a comparative study of methods now employed in a hundred cities to record, classify, and make public significant school facts. The results of the first year's work prove conclusively that physical defects are not caused solely by the inability of parents to pay for proper food. Among the twenty significant facts reported by the committee are the following: 1. Physical defects found in public schools are, for the most part, such as frequently occur in wealthy families and do not of themselves presume as the cause insufficient income. Of 145 reported for malnutrition, 44 were from families having over $20 weekly. 2. Few of the defects can be corrected by nourishment alone; plenty of fresh air, outside nourishment at school, or extra nourishment at home will not entirely counteract the influences of bad ventilation and bad light in school buildings. Country children have adenoids, bad teeth, and malnutrition. Plenty of food will not prevent bad teeth and bad ventilation from causing adenoids, enlarged tonsils, and malnutrition. 3. Children whose parents have long lived in the United States need attention quite as much as the recent immigrant. 4. A large part of the defects reported could be produced by conditions due directly to neglect of teeth. From twenty such statements of fact and from its experience in _getting things done_ for one year, the committee drew fifteen practical conclusions, among which the following deserve emphasis here: 1. The only new thing about the physical defects of school children is not their existence, but our recent awakening to their existence, their prevalence, their seriousness if neglected, and their cost to individual children, to school progress, to industry, and to social welfare. 2. _Physical deterioration_, applied to America's school children, is a misnomer. No evidence whatever has been given that the percentage of children suffering from physical defects in 1907 is greater than the percentage of children suffering from such defects in 1857. On the contrary, the small proportion of defects that are not easily removable, as well as a vast amount of evidence from medical experience and vital statistics, indicates that, if a comparison were possible, the children of 1907 would be found to have sounder bodies and fewer defects than their predecessors of fifty years ago. If there is an exception to this statement, it is probably defects of vision, with regard to which school authorities and oculists seem to agree that confinement in school for longer hours and more constant application under unfavorable lighting conditions have caused a marked increase. Positive evidence as to tendencies will be easily obtained after thorough physical examination has been carried on for a generation. 3. The effect of massing facts as to physical defects of school children should not be to cause alarm, but to stimulate remedial and preventive measures, to invoke congratulations and aggressive optimism, not doleful pessimism and palliative measures born of despair. 4. The causes of physical defects are not confined to "marginal" incomes, but, while more apt to be present in families having small incomes, are found among all incomes wherever there exist bad ventilation, insufficient outdoor exercise, improper light, irregular eating, overeating, improper as well as insufficient food, lack of medical, dental, and ocular attention. 5. Whatever may be said of free meals at school as a means of insuring punctual attendance or better attention, they are inadequate to correct physical conditions that home and street environment produce. 6. _To remove physical defects, causal conditions among all income classes should be treated, and not merely symptoms revealed at school by children of the so-called poor._ 7. Parents can and will correct the greater part of the defects discovered by the physical examination of school children, if shown what steps to take. Where parents refuse to do what can be proved to be within their power, and where existing laws are nonenforced or inadequate, the segregation of children having physical defects in special classes might prove an effective stimulus to obstinate parents. 8. Where parents are unable to pay for medical, dental, and ocular care and proper nourishment, private philanthropy must either provide adequately or expect the state to step in and assume the duty. 9. Private dispensaries and hospitals must either arrange themselves to treat cases and to educate communities as to the importance of detecting and correcting physical defects, or must expect the state to provide hospital and dispensary care. Until private hospitals and dispensaries take steps to prevent people with adequate incomes from imposing upon them for free treatment, it is difficult to make out a case against free eyeglasses and free meals for school children. 10. Either private philanthropy or the state must take steps to procure more dental clinics and an educational policy on the part of the dental profession that will prevent the exploitation of the poor when dental care is needed. 11. The United States Bureau of Education is the only agency with authority and equipment adequate to secure from all sections of the country proper attention to the subject. Nothing in the world can prevent free meals, free eyeglasses, free medical care, free material relief at school, unless educational use is made by each community of the facts learned through physical examination to correct home, school, and street conditions that produce and aggravate physical defects. The national bureau can mass information in such a way as to convince budget makers in city, county, and state to vote gladly the funds necessary to promote the physical welfare of school children. [Illustration: THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.] How the committee got things done is often referred to. There is something about a request for coöperation, whether by schools or by any other agency, that enlists the interest of those whose help is asked. The reason is not that people are flattered by requests to serve on committees, or that human nature finds it difficult to be unfriendly or unkind. On the contrary, men and women are by nature social; there is more joy in giving than in withholding, in working with others than in working alone. Men and women, official and volunteer agencies, will coöperate with school-teachers when invited, for the same reason and with the same readiness that ninety-nine farmers out of a hundred, on the prairie or in the mountain, will welcome a request for food and lodging. [Illustration: WHERE "GETTING THINGS DONE" IS POSSIBLE BUT "DOING THINGS" INEFFECTIVE] Mothers will naturally take a greater interest in the welfare of their children if held responsible for proper food and proper home surroundings than if not reminded of their responsibility. In New York City a woman district superintendent of schools, Miss Julia Richman, has organized a unique "social settlement." She and several school-teachers occupy a house, known as "The Teachers' House." This is their residence. Here they are subject to neither intrusion nor importunity; no clubs or classes are held here; visitors are treated as guests, not as beneficiaries. The purpose these teachers have in living together is to work out the methods of interesting private and official leaders in community needs disclosed at school. Where clubs and social gatherings are held in school buildings, it is not unusual for a thousand mothers, recent immigrants, to meet together in one hall to hear talks on the care of children. Thus, instead of principals, teachers, and physicians taking the place of mothers (which they nowhere have succeeded in doing), they do succeed in harnessing mothers to the school programme. It may take two, three, or ten visits to get a particular mother to do the necessary thing for her child, but when once convinced and once inspired to do that thing, she will go on day in and day out doing the right thing for that child and for all others in her home. It may take a year to convert a police magistrate whose sympathy for delinquent parents and truant children is an active promoter of disorder; but a magistrate convinced, efficient, and interested is worth a hundred volunteer visitors. To get things done in this way for a hundred thousand children costs less in time and money than to do the necessary things for one thousand children. CHAPTER XVIII COÖPERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES Scientists agree that the human brain is superior to the animal brain, not because it is heavier, but because it is finer and better supplied with nerves. As one writer has said, the human brain is better "wired," has better organized "centrals." A poor system of centrals will spoil a telephone service, no matter how many wires it provides. An independent wire is of little use, because it will not reach the person desired at the other end. The ideal system is that which almost instantly connects two persons, no matter how far away or how many other people are talking at the same time on other wires. The school that tries to do everything for its pupils without using other existing agencies for helping children[10] will be like the man who refuses to connect his telephone with a central switch board, or like a bank that will not use the central clearing house. As one telephone center can enable scores of people to talk at once, and as one clearing house can make one check pay fifty debts, so hospital and relief agencies enable a teacher who employs "central" to help several times as many children as she alone can help. [Illustration: ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE UNIT] It seems easier for a teacher to give twenty-five cents to a child in distress than to see that the cause of the misery is removed. In New York City there are over five hundred school principals, under them are over fifteen thousand teachers, and the average attendance of children is about six hundred thousand, representing one hundred and fifty thousand homes. If teachers give only to those children who ask for help, many will be neglected. In certain sections of the city principals have combined to establish a relief fund to be given out to children who need food, clothes, shoes, etc. One principal had to stop replacing stolen overcoats because, when it was known that he had a fund, an astonishingly large number of overcoats disappeared. At Poughkeepsie school children get up parties, amateur vaudeville, minstrel shows, basket picnics, to obtain food and clothing for children in distress. They are, of course, unable to help parents or children not in school. Of this method a district superintendent in New York said to his teachers and principals: "For thirty-two years I have been working in the schools of this district. I have given food and shoes to thousands of children. I know that however great our interest in a particular child when it comes to us with trouble at home, our duty as teachers prevents us from following our gift into the home and learning the cause of the child's trouble. This last winter we have made an experiment in using a central society, which makes it a business to find out what the family needs, to supply necessaries, country board, medicine, etc. We now know that we can put a slip of paper with the name and address of the child into a general hopper and it will come out eyeglasses, food, rent, vacation parties, as the need may be." Relief at home through existing agencies was brought about by the distribution of cards like those on opposite page, which offer winter and summer coöperation. [Illustration: FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID CHILDREN IN ORDER OF NEED] [Illustration: (Facsimile of flyer for the New York Association for Improving the Condition of the Poor.)] +--------------------------------------------------------------------+ | =For School Children= | | | | Compulsory education implies the ability of all families, even the | | poorest, to take advantage of school benefits. This means that | | children should be fed properly, clad comfortably, and healthfully | | housed. | | | | The New York Association for Improving the Condition of the Poor | | aims to coöperate with school-teachers in every part of Manhattan | | and The Bronx to insure comfort and prevent suffering among school | | children, their parents, and younger brothers and sisters. On one | | day last winter we received appeals from school principals and | | teachers in behalf of twenty-nine families. Within six hours every | | family was visited, emergent aid in food and coal provided for | | many, and orders given for shoes and dresses and coats required by | | the children of school age. During the winter we gave not only | | clothing, groceries, food, and rent, but found work for older boys | | and parents, taught mothers to prepare food properly, and sent a | | visiting cleaner to make sick mothers comfortable and to get the | | children ready for school. | | | | In a word, we followed that need, the surface evidence of which | | comes to the attention of the teacher, back into the home and its | | conditions, aiding throughout the period when the family was | | unable to do justice by the school child. | | | | In many instances the home income was sufficient, but the home | | management inefficient. Probably such homes could be more | | effectively benefited through educational work emanating directly | | from the school. | | | | We can be reached by telephone (348, 349, and 1873 Gramercy) from | | 9 A.M. to 12 M. Letters or postal cards should be addressed to | | Mrs. H. Ingram, Superintendent, 105 East 22d Street. Reference | | slips will be gladly furnished upon application. | | | | The New York Association for Improving | | 1843 * the Condition of the Poor * 1905 | | | | =Teachers of Manhattan and The Bronx= | | | | _Do you know of such children as these:_ | | | | 1. Convalescent children now out of school, who would be | | benefited by a stay at the seashore in May or June? | | | | 2. Children in school whose anæmic condition would be | | greatly improved by a week at Sea Breeze during July or | | August? | | | | 3. Small brothers and sisters (and tired mothers) who may | | need outings or special help? | | | | The New York Association for Improving the Condition of the | | Poor will act promptly. Write or telephone (348 Gramercy). | +--------------------------------------------------------------------+ When these cards were first distributed several teachers went from room to room, asking children who needed help to raise the hand. In many cases parents were very angry that their children should have asked for help. But help given in instances like the following soon proved to teachers that they could afford the time necessary to notice children who appeared neglected, when so much good would ensue: The father is sick and unable to work. They cannot get clothes for the children, who are not attending school on that account. Children were provided with shoes and clothes. November 30, 1907, a school principal reported that six children in one family needed underwear. A visitor discovered that one of the boys who had the reputation of being unruly and light-fingered also had adenoids. He was taken to a hospital for operation, and was later interested in his school work. A little girl was unruly and truant. No attempt was made to keep her at school, but she was reported to the Committee on the Physical Welfare of School Children. The parents could not control her. The girl was taken for examination by a specialist and found to be feeble-minded. Later she was sent to a custodial institute. Another little girl was nine years old, but could not talk. A University Extension Society worker found that she was not kept at school because it was too much trouble. The child was taken to a physician who operated and corrected the tongue-tie. A girl of twelve said she must stay home to "help mother." The mother was found to be a janitress, temporarily incapacitated by rheumatism. A substitute was provided until the mother was well, and all the children were properly clad for school. After the adenoid operations in a New York school that occasioned the East Side riots of 1906, the physicians and principals who had persuaded parents to permit the operations were fearful lest the summer in unsanitary surroundings might make the demonstration less complete. Over forty children in three parties were sent away for the summer, where they had wholesome food and all the milk they could drink and fresh air day and night. When they returned in the fall the principal wrote: "The improvement in each individual is simply marvelous. We shall try to continue this condition and shall constantly urge the parents to keep up the good work by means of proper food and fresh air." In none of these instances could the teachers have accomplished equal results for the individual children or for the families without neglecting school duties. By informing other agencies as to children's needs, teachers started movements that have since helped practically every school child in New York City. Dispensaries are setting aside separate hours for school children; fresh-air agencies are giving preference to children found by teachers or school physicians to be in physical need; relief agencies are making "rush orders" of every note from teachers; the health board is more active because volunteer agencies have added their voice to that of teacher and health officer in demanding adequate funds for physical examination of school children. [Illustration: "CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL, THE FATHER KILLED--THE CHILDREN WERE BOARDED IN THE COUNTRY UNTIL THE MOTHER RECOVERED] Coöperation is at present easier in New York than in any other city. Charitable societies, hospitals, dispensaries, are probably more keenly alive to their responsibilities and are at least more apt to have acquired the habit of coöperation when asked. Yet even here I have been told repeatedly by teachers: "If we have to wait for that hospital or that charitable society, our children will go barefoot." In small communities where hospital and relief agencies are for emergencies only and generally inactive, it seems that the first thing to do is to ask some friends to establish a small relief fund, just as it is easier to give a child a five-cent meal than to teach its mother how to prepare its food. But the school-teacher will find that it takes very much less energy to arouse the relief society than to maintain her own relief work. In fact, in many cities nothing could do more to strengthen hospitals and charitable societies than to put them in touch with the needs of school children. For a principal to make known the fact that school children are neglected will help the charitable society and hospital to get the funds necessary to do their part better than they are now doing it and better than the school could ever do it. Finally, one reason for a breakdown of charitable societies is not their own inadequacy, but rather the failure of the school and church to make use of an agency better equipped than themselves to give material relief. The teacher sees the child every day, while the relief society will never see it and has no reason to see it until some one calls attention to it. The very first step, and an indispensable one in relief policy, is for teachers to be on the lookout for children not adequately provided for, and then have the physical evidence discovered at school followed to the home for the cause of the child's distress. [Illustration: HOME-TO-HOME INSTRUCTION IN COOKING Anæmic condition of child due to bad cooking, not to lack of income] _Coöperation_ removes the cause of distress; _doing_ may aggravate it. Teachers would do well to draw up for themselves a chart which will show exactly what part of the community's work can be best done by their school. On the following page is charted the social work now being conducted at the Massachusetts General Hospital, Boston. So far as agencies exist to deal with any individual or family problem coming into the social-work square, the hospital aims to utilize that agency. Its own direct dealing with neurasthenics, with hygiene education, with sexual deviates, is primarily for the purpose of giving adequate treatment to the needy, and secondarily to demonstrate how adequate treatment should be organized for the community. Please to note that governmental agencies are not mentioned in Dr. Cabot's chart. This does not mean that he would not emphasize the importance of those agencies, but that up to the present time, for the particular cases dealt with in his clinics, governmental agencies can be reached most effectively through the private charitable agencies in the reference square. So the teacher will frequently find that the relief bureau, children's society, public education association, or church can get better results for her pupils from public health and correctional agencies than can she by writing directly. [Illustration: CHART OF SOCIAL WORK, MASSACHUSETTS GENERAL HOSPITAL] +-----------------------------------+ | _Work for the Tuberculous_ | | | | 1. Tuberculosis classes | | 2. Reference to other agencies | | 3. Examination of children | | 4. Stimulation of suburbs | +-----------------------------------+ | | | +--------------------------------+ | +--------------------------------+ | _Psychiatric Work_ | | | _Work for Hygienic Conditions_ | | | | | | | 1. For neurasthenics and | | | 1. Individual instruction | | hysterics | | | 2. Convalescent homes | | 2. For defectives | | | 3. Industrial hygiene | | 3. For stammerers | | | 4. Home hygiene | | 4. For epileptics | | | | +--------------------------------+ | +--------------------------------+ \ | / \ | / \ | / \ | / \ | / \ | / \ | / +-----|-----+ | | /SOCIAL WORK\ /| M.G.H. |\ / +---/|\-----+ \ / / | \ \ / / | \ \ / / | \ \ / / | \ \ +-------/-----|-----\-------\---+ | _References to Other Agencies_| | | /|1. Hospitals and sanatoriums | / |2. Associated charities |\ / |3. Societies for children | \ / |4. District and visiting nurses| \ / |5. Settlements | \ / |6. Homes--temporary or not | \ / /|7. Employment agencies | \ / / +-------------|-----------------+ \ +------------/-----/----+ | +--\-------\----------+ | _Ward Work_ | | | | | | | | _Work for | | 1. With cases soon to | | | Cases of | | be discharged | | | Varicose Ulcer_ | | 2. Cases needing | | | | | friendly offices | | | | +-------------/---------+ | +---------\-----------+ / | \ +-----------/-----------+ | +--------------\----------+ | _Work for | | | _Assistance to M.G.H._ | | Sexual Deviates_ | +---------|---------+ | Financial investigation | | | | _Assistance to | | | | 1. Unmarried but | | Other Agencies_ | |(a) of Cases asking free | | pregnant | | | | treatment | | 2. Diseased | | 1. Steering cases | |(b) of Cases presumably | | 3. Exposed | | 2. Coöperation | | able to pay a physician | +-----------------------+ +-------------------+ +-------------------------+ In country districts no plan has yet been worked out for adequate relief. Fortunately, however, the distress is generally of such a kind, and the teacher so well acquainted with all the parents of her district, that it will not be difficult to procure such attention as is necessary. Country schools should be furnished by county and state superintendents with clear directions for getting the treatment afforded in the immediate vicinity. Where teachers are alone in seeing the need for coöperation they can quickly interest young and old, physicians, dentists, pastors, health officers, in home visiting, street cleaning, nursing, helping truants, needed changes of curriculum, etc. _Getting things done_ is easy because it is human to love the _doing_; getting things done is _doing_ of the highest order. FOOTNOTES: [10] The importance of recognizing the family as the unit of social treatment is presented in Edward T. Devine's _Principles of Relief_, and in Homer Folks's _Care of Dependent, Defective, and Delinquent Children_. CHAPTER XIX SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE The popular arguments for free meals, free relief, free medical treatment at school, are based upon the assumption that there are but two ways to travel, one leading to a physically sound, moral, teachable child, the other to an undernourished, subnormal, backward child. They tell us we must choose either school meals or malnutrition, school eyeglasses or defective vision, free coal or freezing poor, free rent or people sleeping on the streets, free dental clinics at school or indigestion and undernourishment, free operation at school for adenoids or backward, discouraged pupils. If there is no other alternative than neglect of the child, if we must either waste fifty dollars in giving a child education that he is physically unable to take, or pay two, three, four, or even fifty dollars to fit him for that education, the American people will not hesitate. Whether there are other roads to healthy children, whether it is cheaper and better for the school to see that outside agencies prepare the child for education rather than itself to take the place of those outside agencies, is a question of fact, not of theory. Facts prove, as we have seen, that there is more than one way to prevent malnutrition. Parents can be taught to attend to their children; hospitals and dispensaries will furnish eyeglasses where parents are unable to pay for them; charitable societies will go back of the need for eyeglasses to the conditions that produce that need and will do vastly more for the child than can eyeglasses alone. If parents, hospitals, dispensaries, and charitable societies will attend to children's needs, then relief at school is unnecessary, even though it may seem desirable. The objection to school surgery should be clearly before us, so that we can judge of the two methods that are open to us,--_treatment at school_ vs. _treatment away from school_. Society is so organized that the treatment of serious physical defects and social needs at school would upset the machinery a very great deal. For the school to do for its children whatever they may need during their school years will require the setting up of a miniature society in every school building or under every school board. Unless schools are to equip themselves to take the place of all existing facilities for relief and surgery, children would not be so well taken care of as at present. It should not be forgotten that the physical welfare of the school child is the most accurate index to the physical needs of the community. After all, the child lives for six important years before coming to the school and leaves at the early age of fourteen or fifteen; even while attending school it sleeps at home and is influenced more by home and street standards of ventilation, cleanliness, and morality than by conditions at school. It would seem, therefore, the wider use of the school's influence to use the child's appeal to strengthen every agency having to do with community health, rather than to concentrate upon the child himself. If babies were properly cared for up to the sixth year, the protection of the school child's health would be infinitely easier. To take our eyes from the child not yet in school and from the child just out of school is to make the mistake that so many advocates of the child labor movement have made of going whither and only so far as our interest leads us and of not continuing until our work is accomplished. [Illustration: "DOING THINGS" THROUGH MODEL TENEMENTS] Do we want to make of our schools miniature hospitals, dispensaries, relief bureaus, parks? Or shall we use the momentum of society's interest in the school child to put within the reach of every school building adequate hospitals, dispensaries, relief centers, and parks for school child and adult? Shall every little school have its library, or shall the child be taught at school how to use the same library that is available to his parents and older brothers and sisters? If the library is to be under the school roof, if dispensary and relief hospital are to be conducted on the same site as the school, shall they be known as dispensary, library, relief bureau, each under separate management, or shall they be known as school under the management of school principal and superintendent? So complicated and many-sided is the problem of working together with one's neighbor for mutual benefit that it is a safe rule for the schools to adopt: _We shall do nothing that is unnecessary or extravagant. We shall have done our part if we do well what no one else can do. Whatever any agency can do better than we, we shall leave to that agency. Work that another agency ought to have done and has left undone, we shall try to have done by that agency._ [Illustration: IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT UNINFLUENCED "Getting things done" by the Tenement House Department their special need] I know a hospital where a welfare nurse was recently employed. Within a few blocks were three different relief agencies and two visiting-nurse's associations, having among them over one hundred visitors and nurses going to all sections of Manhattan. This nurse had the choice of telephoning to one of these agencies and asking it to call at the needy home of one of her hospital patients, or of going to the home herself. Had she chosen to use another agency, she could have been the means of furnishing the kind of help needed in every needy home discovered in her hospital rounds, but she chose to do the running about herself and thus of helping ten families where she ought to have helped five hundred. Much the same condition confronts the school that tries to do all extra work for its child instead of seeing that the work is done. Illustration is afforded by the New York tenement department. Whereas European cities have built a few model tenements, New York City secured a law declaring that everybody who built a tenement and everybody who owned a tenement should provide sanitary surroundings. At the present time a philanthropist, by spending two million dollars, could give sanitary surroundings to thirty-five families; by spending each year the interest on one tenth that sum he could insure the enforcement of the tenement laws affecting every tenement resident in New York City. If schools are to perform surgical operations, they are in danger of being sued for malpractice; discipline will be interfered with. Finally, let us not forget that we are dealing with buildings, teachers, and school institutions as they exist. Where education is made compulsory, the unpleasant and the controversial should be kept out of school. Because a democratic institution, the American school should represent at all times a maximum of general agreement. To take _palliative measures to public schools_ not only _leaves undone remedial_ work necessary for the health of public school children but _neglects entirely the still large numbers who go to parochial, private pay, and private free schools_; no one has had the temerity to suggest that the public shall force upon nonpublic schools a system of free operations, free eyeglasses, free meals. Civilization has painstakingly developed a large number of agencies for the education and protection of mankind. Of these agencies the school is but one. Its first and peculiar function is _to teach and to train_. This it can do better than any other agency or combination of agencies. In attempting to "bring all life under the school roof," we use but a small part of our resources. Instead of persuading each of the agencies for the promotion of health to do its part for school children, we set up the school in competition with them. Thus in trying to _do things_ for school children we are in danger of crippling agencies equipped to do things for both school children and their parents, for babies before they come to school, and for wage earners after they leave school. _Getting things done_ will lead schools to study underlying causes; _doing things_ has heretofore caused schools to confine themselves to symptoms. _Getting things done_ will leave the school free to concentrate its attention upon school problems; _doing things_ will lead it afield into the problem of medicine, surgery, restaurant keeping, and practical charity. CHAPTER XX PHYSICAL EXAMINATION FOR WORKING PAPERS There is no sacred right to work when our work involves injury to ourselves and to our neighbor. Work at the expense of health is an unjustifiable tax upon the state. It is the duty of society to protect itself against such depletion of national efficiency. Three classes of workmen need special attention: (1) those who are physically unfit to work; (2) those who are physically unfitted for the work they are doing; (3) those who are subjected to unhealthful surroundings while at work. Viewing these three classes from the standpoint of their neighbors, we have three social rights that should be enforced by law: (1) the right to freedom from unhealthy work; (2) the right to work fitted to the body; (3) the right to healthy surroundings at work. It is undoubtedly true that just as the sick child may be found at the head of his class, so unhealthy men and women are often good business managers, good salesmen, good typewriters, successful capitalists. They excel, however, not because of their ill health, but in spite of it, excepting of course those instances where men and women, because of ill health, have devoted to business an attention that would have been given to recreation if bad health had not deprived recreation of its pleasure. As statistics in school have proved that the majority of mentally superior children are also physically superior, so statistics will probably prove that the number of the "sick superior" among the working classes is very small, while the danger of inefficiency that comes from physical defect is very great. There is one time in the individual's working life when the state may properly step in and demand an inventory of physical resources, and that is when the child asks the state for permission to go to work. Strategically, this is probably the most important of all contact as yet provided between society and the future wage earner. Here at the threshold of his industrial career the boy may be told for what work he is physically fitted, what physical defects need to be remedied, what physical precautions he needs to take, in order to do justice to himself and his opportunity. Every year from two to three million children leave the public schools of this country to join the army of workers. The percentage of those recruits who have physical defects needing attention is undoubtedly great; how great we shall never know until the benefits of physical examination are given to all of them. What steps is your state taking to ascertain the physical fitness of the children who present themselves each year for working papers? How does it insure itself against the risk of their defective eyesight, chorea, deafness, or general debility? Does it inform children of their defects, or tell them how they may increase their earning power by correcting these defects? What effort does it make to induce children to avoid dangerous trades, or trades that are particularly dangerous for their physiques? At the close of school last spring I had my secretary look in upon the New York board of health and see what demands that city makes upon its boys and girls before allowing them to drive its machinery, to run its elevators, to match its colors, to sew on its buttons, to set its type, to carry its checks to the bank. The officer at the door of the room where the children were being examined, greeted her as follows: "You must bring your child with you; bring his birth certificate or swear that he is fourteen years old, and bring a signed statement from his teacher that he has been in school for one hundred and thirty consecutive days within twelve months." "Is there no physical examination or test?" she asked. "No, no," he answered impatiently. Yet the board of health certifies that "said child has in our opinion reached the normal development of a child of its age, and is in sound health and is physically able to perform the work which it intends to do." In addition the blank calls for place and date of birth, color of hair and of eyes, height, weight, and facial marks. Volunteer societies in practically every state in the Union have been working for years to have it made a criminal offense to employ a child who has not been in school a minimum of days after a stated age (12, 13, 14, 15). Even in New York, however, the center of this agitation, no strong demand was made upon the board of health to apply a physical-fitness test as well as an age test until 1908 when examination for working papers was added to the programme for child hygiene. Yet who does not know girls and boys of sixteen less fit for factory or shop work than other boys and girls of twelve? It is the fetich of age which has made possible the "democracy" that permits a child of fourteen to work all day on condition that he go to school at night! [Illustration: CHILDREN ENLISTING IN THE INDUSTRIAL ARMY] [Illustration: WAITING TO BE EXAMINED FOR WORKING PAPERS An excellent opportunity for physical-fitness tests] So great is the risk of defective, sickly, or intemperate employees, that in some trades employers take every precaution to exclude them. One man with defective eyesight or unsteady nerves may cost a railroad thousands of dollars. As insurance companies rank trades as first-, second-, or third-class risks, so many factories, from long experience, debar men with certain characteristics which have been found detrimental to business. The Interborough Rapid Transit Company of New York City examines all applicants for employment, as to age, weight, height, keenness of vision, hearing, color perception, lungs, hearts, arteries, alcoholism, and nicotinism. Those who fall below the standard are rejected, but in each case the physical condition is explained to the applicant. Where defects are removable or correctable, the applicant is told what to do and invited to take another test after treatment. Moreover, accepted employees are periodically reëxamined. While designed to increase company profits and to reduce company losses, this examination obviously decreases the employees' losses also, and increases the certainty of work and prospect of promotion. Our states, and many of our industries, still have the attitude of a certain manufacturer who employs several hundred boys and girls. I asked him what tests he employed. "I look over a long line of the applicants and say," pointing his finger, "I want you, and you, and you; the rest may go." I asked him if he made a point of picking out those who looked strong. "No. The work is easy, sitting down all day long and picking over things. I select those whose faces I like. Yes, there is one question we now ask of all the girls. One day a girl in the workroom had an epileptic fit and it frightened everybody and upset the work so that the foreman always asks, 'Do you have fits? Because if you do, you can't work here.'" He makes no attempt to determine the physical fitness and endurance of the children employed, because when the strength of one is spent there is always another to step into her place. Because the apprentice's future is of no value to the manufacturer, the state must restrict the manufacturer's freedom to spend like water society's capital,--the health of the coming generation. Could there be a grosser mis-management of society's business than to permit trade to waste children on whose education society spends so many millions yearly? The most effective and most timely remedy is physical examination as a condition of the work certificate. A simple, easily applied, inexpensive measure that imposes only a legitimate restriction upon individual freedom, it is absolutely necessary in order to get to the bottom of the child labor problem. If thoroughly applied, children of the nation will no longer be exploited by unscrupulous or indifferent employers, nor will their health be hazarded by lack of discriminating examination that rejects the obviously sick and favors the apparently robust. Furthermore, knowledge that this test will be applied when work certificates are required, will be an incentive to the school boy and girl to keep well. Tell a boy that adenoids or weak lungs will keep him from getting a job, and you will make him a strong advocate of operation and of fresh air. Show him that his employers will not wish his services when his week is out if he is physically below par, and he will gladly submit to a board of health examination and ask to be told what his defects are and how to correct them. [Illustration: CHILDREN AT WORK BELOW BOTH AGE LIMIT AND VITALITY LIMIT National Child Labor Committee] Some there are who will object to this appeal to the child's economic instinct. This objection does not remove the instinct. The normal child is greedy for a job. His greed, as well as that of the manufacturer and parent, is responsible for much of the child labor; his greed for activity, for association, for money, and so for work. A little boy came into my office and wanted to hire as an office boy. I looked at him and said: "My little fellow, you ought to be in school. What do you want to hire out here for?" He said, "I am tired of school; nothing doing." He doesn't care about work for its own sake; he doesn't care about wealth for its own sake; he wants to get into life; to be where there is "something doing." In this lies one potent argument for vocational training. To tell a boy of his physical needs just before he has taken his first business step is to put him everlastingly in our debt. Then he is responsive, and, fortunately for the extreme cases, necessarily dependent, for he knows that his refusal would stand between himself and his ambition. When boys and girls go for work certificates to Dr. Goler, medical officer of health at Rochester, he requires not merely evidence of age and of schooling, but examines their eyes for defective vision and for disease, their teeth for cavities and unhealthy gums, and their noses and throats for adenoids and enlarged tonsils. If a boy has sixteen decayed teeth, Dr. Goler explains to him that teeth are meant to be not only ornaments and conveniences, but money getters as well. The boy learns that decayed teeth breed disease, contaminate food, interfere with digestion, make him a disagreeable companion and a less efficient worker. If he will go and have them put into proper condition he will enjoy life better and earn good wages sooner. After the teeth are attended to the boy secures his work certificate. If the boy's mother protests in tears or in anger that her boy does not work with his teeth, she learns what she never learned at school, that sound teeth help pay the rent. If a girl applicant for working papers has adenoids, she is asked to look in the mirror and to notice how her lips fail to meet, how the lower jaw drops, how much better she looks with her jaws and lips together. She is told that other people breathe through the nose, and that perhaps the reason she dislikes school and does not feel as she used to about play is that she cannot breathe through her nose as she used to. She is shown that her nose is stopped up by a spongy substance, as big as the end of her little finger, which obstruction can be easily removed. She is shown adenoids and enlarged tonsils that have been removed from some other girl, and is so impressed with the before-operation and after-operation contrast and by the story of the other girl's rapid increase in wages, that she and her mother both decide not to wait for the adenoids to disappear by absorption. After the operation they come back with proof that the trouble is gone, and get the "papers." Similar instruction is given when defects of vision seriously interfere with a child's prospects of getting ahead in his work, or when evidence of incipient tuberculosis makes it criminal to put a child in a store or factory. [Illustration: THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT WORK IN LABRADOR] No law as yet authorizes the health officer of Rochester to refuse work certificates to children physically unfit to become wage earners. A higher law than that which any legislature can pass or revoke, has given Dr. Goler power over children and parents, namely, interest in children and knowledge of the industrial handicap that results from physical defects. This higher law authorizes every health officer in the United States to examine the school child before issuing a work certificate, to tell the child and his parents what defects need to be removed, for what trades he is physically unfitted, what trades will not increase his physical weakness, and to what trade he is physically adapted. We should not forget that a large proportion of our children never apply for work certificates; some because they never intend to work; some because they expect to remain in school until sixteen or later; some because they live on farms, in small towns, or in cities and states where prohibition of child labor is not enforced. Because there is no reason for this large proportion of children to visit a board of health, some substitute must be found. This substitute has been already suggested by principals and district superintendents in New York City, who claim that the natural place for the examination of children is the school and not health headquarters. Developing the idea that the school should pronounce the child's fitness to leave school and to engage in work, we are led to the suggestion that the state, which compels evidence that every child, rich or poor, is being taught during the compulsory school age, shall also at the age of fourteen or sixteen require evidence that the child is physically fit to use his education, and that it shall not, because of preventable ill health, prove a losing investment. Parochial and private schools, the ultra-religious and ultra-rich, may resent for a time public supervision of the physical condition of children who do not ask for work certificates. This position will be short-lived, because however much we may disagree about society's right to control a child's act after his physical defects are discovered, few of us will question the state's duty to tell that child and his parents the truth about his physical needs before it accepts his labor or permits him to go to college, to "come out," to "enter society," or to live on an income provided by others. Thus an invaluable commencement present can be given by the state to children in country schools and to those compelled to drop out of fourth or fifth grades of city schools. [Illustration: THE HEALTH DEPARTMENT'S CLINICAL CARE AND HOME INSTRUCTION COME AFTER WAGE LOSSES, WHILE WORK CERTIFICATES PRECEDE BREAKDOWNS FROM TUBERCULOSIS] A brief test of this method of helping children, such as is now being made by several boards of health at the instance of the National Bureau of Labor, will prove conclusively that parents are grateful for the timely discovery of these defects which handicap because of their existence, not because of their discovery. Of the cadets preparing for war at West Point, it has recently been decided that those "who in the physical examinations are found to have deteriorated below the prescribed physical standard will be dropped from the rolls of the academy." Shall not cadets preparing for an industrial life and citizenship be given at least a knowledge of an adequate physical standard? To allow the school child to deteriorate whether before or after going to work is only to waste potential citizenship. Citizens who use themselves up in the mere getting of a living have no surplus strength or interest for overcoming incompetence in civic business, or for achieving the highest aim of citizenship,--the art of self-government for the benefit of all the governed. CHAPTER XXI PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE Governor Hughes, in his address to the students in Gettysburg College, pleaded for such lives that strength would be left for the years of achievement. How many men and women can you count who are squandering their health bank account? How many do you know who are now physically bankrupt? The man who is prodigal of his health may work along all right for years, never realizing until the test comes that he is running behind in his vitality. The test may be hard times, promotion, exposure to cold, heat, fever, or a sudden call for all his control in avoiding accident. If his vitality fails to stand the test, his career may be ruined, "all for the want of a horseshoe nail": because of no health bank account to draw upon in time of need,--failure; because of vitality depleted by alcohol, tobacco, overeating, underexercise, or too little sleep,--no power to resist contagious diseases; because of ignorance of existing lung trouble,--a year or more of idleness, perhaps poverty for his family; or there is neglected ear or eye trouble,--and thousands of lives may be lost because the engineer failed to read the signals. Adults are now examined when applying for insurance or accident policies, for work on railroads, for service in the army and on the police and fire forces of cities that provide pensions. It is somewhat surprising that the hundreds of thousands who carry life insurance policies have not realized that a test which is rigorously imposed for business reasons by insurance companies can be applied by individuals for business reasons. Generations hence the state will probably require of every person periodic physical examination after school age. Decades hence business enterprises will undoubtedly require evidence of health and vitality from employees before and during employment, just as schools will require such evidence from teachers. It is, after all, but a step from the police passport to the health passport. Why should we not protect ourselves against enemies to health and efficiency as well as against enemies to order? But for the present we must rely upon the intelligence of individuals to recognize the advantage to themselves, their families, and their employers, of knowing that their bodies do not harbor hidden enemies of vitality and efficiency. From a semi-annual examination of teeth to a semi-annual physical examination is but a short step when once its effectiveness is seen by a few in each community. [Illustration: THE OLD SOUTHFIELD, NOW ANCHORED AT BELLEVUE HOSPITAL'S DOCK, NEW YORK CITY, GIVES DAILY LESSONS IN THE PREVENTABLE TAX LEVIED BY TUBERCULOSIS] Ignorance of one's physical condition is a luxury no one can afford. No society is rich enough to afford members ignorant of physical weaknesses prejudicial to others' health and efficiency. Every one of us, even though to all appearances physically normal, needs the biological engineer. New conditions come upon us with terrific rapidity. The rush of work, noise, dust, heat, and overcrowding of modern industry make it important to have positive evidence that we have successfully adapted ourselves to these new conditions. Only by measuring the effects of these environmental forces upon our bodies can we prevent some trifling physical flaw from developing into a chronic or acute condition. As labor becomes more and more highly specialized, the body of the laborer is forced to readapt itself. The kind of work a man does determines which organs shall claim more than their share of blood and energy. The man who sets type develops keenness of vision and manual dexterity. The stoker develops the muscles of his arms and back, the engineer alertness of eye and ear. All sorts of devices have been invented to aid this specialization of particular organs, as well as to correct their imperfections: the magnifying glass, the telescope, the microscope, extend the powers of the eye; the spectacle or an operation on the eye muscles enables the defective eye to do normal work. A man with astigmatism might be a policeman all his life, win promotion, and die ignorant of his defect; whereas if the same man had become a chauffeur, he might have killed himself and his employer the first year, or, if an accountant, he might have been a chronic dyspeptic from long-continued eye strain. It is a soul tragedy for a man to attempt a career for which he is physically unadapted.[11] It is a social tragedy when men and women squander their health. A great deal of the success attributed to luck and opportunity, or unusual mental endowment, is in reality due to a chance compatibility of work with physique. To secure such compatibility is the purpose of physical examination after school age. If the periodic visit to the doctor is the first law of adult health, still more imperative is the law that competent physicians should be seen at the first indication of ill health. Even when competent physicians are at hand, parents and teachers should be taught what warning signs may mean and what steps should be taken. In Germany insurance companies find that it saves money to provide free medical and dental care for the insured. Department stores, many factories and railroads, have learned from experience that they save money by inducing their employees to consult skilled physicians at the first sign of physical disorder. Many colleges, schools, and "homes" have a resident physician. Wherever any large number of people are assembled together,--in a hotel, factory, store, ship, college, or school,--there should be an efficient consulting physician at hand. If people are needlessly alarmed, it is of the utmost importance to show them that there is nothing seriously wrong. Therefore visits to the consulting physician should be encouraged. The reader's observation will suggest numerous illustrations of pain, prolonged sickness, loss of life, that could have been prevented had the physician been semi-annually visited. A strong man, well educated, with large income, personally acquainted with several of the foremost physicians of New York City, after suffering two weeks from pains "that would pass away," was hurriedly taken to a hospital at three o'clock in the morning, operated upon immediately, and died at nine. A business man of means put off going to a physician for fifteen years, for fear he would be told that his throat trouble was tobacco cancer, or incipient tuberculosis, or asthma; a physical examination showed that a difficulty of breathing and chronic throat trouble were due to a growth in the nose, corrected in a few minutes by operation. A celebrated economist was forced to give up academic work, and consecrated his life to painful and chronic dyspepsia because of eye trouble detected upon the first physical examination. A woman secretary suffered from alleged heart trouble; paralysis threatened, continuous headache and blurred vision forced her to give up work and income; a physical examination found the cause in nasal growths, whose removal restored normal conditions. A woman lecturer on children's health heard described last summer a friend's experience with receding gums: "'Why, I never heard of that disease.' she said. 'Don't you know you have it yourself'? I asked. She had never noticed that her gums were growing away in little points on her front teeth. I touched the uncovered portion and she winced. That ignorance has meant intense pain and ugly fillings. If it had gone longer, it might have meant the loss of her front teeth." A teacher lost a month from nervous prostration; physical examination would have discovered the eye trouble that deranged the stomach and produced the nerve-racking shingles which forced him to take a month's vacation. A journalist lost weeks each year because of strained ankles; since being told that he had flat foot, and that the arch of his foot could be strengthened by braces and specially made shoes, he has not lost a minute. A relief visitor, ardent advocate of the fresh-air, pure-milk treatment for tuberculosis, had a "little cough" and an occasional "cold sweat"; medical friends knew this, but humored her aversion to examination; when too late, she submitted to an examination and to the treatment which, if taken earlier, would most certainly have cured her. A mother's sickness cost a wage-earning daughter nearly $3000; softening of the brain was feared; after six years of suffering and unnecessary expense, physical examination disclosed an easily removable cause, and for two years she has contributed to the family income instead of exhausting it. Untold suffering is saved many a mother by knowledge of her special physical need in advance of her baby's birth. Untold suffering might be saved many a woman in business if she could be told in what respects she was transgressing Nature's law. [Illustration: NEW YORK CITY'S TUBERCULOSIS SANATORIUM AT OTISVILLE IS SENDING HOME APOSTLES OF SEMI-ANNUAL EXAMINATIONS] [Illustration: BOSTON'S PICTURESQUE DAY CAMP FOR TUBERCULOSIS PATIENTS IS TEACHING THE NEED FOR A PERIODIC INVENTORY OF PHYSICAL RESOURCES] To encourage periodic physical examination is not to encourage morbid thinking of disease. One reason for our tardiness in recognizing the need for thorough physical examination is the doctor's tradition of treating symptoms. After men and women are intelligent enough to demand an inventory of their physical resources,--a balance sheet of their physical assets and liabilities,--physicians will study the whole man and not the fraction of a man in which they happen to be specializing or about which the patient worries. By removing the mystery of bodily ailments and by familiarizing ourselves with the essentials to healthy living, we find protection against charlatans, quacks, faddists, and experimenters. By taking a periodic inventory of our physical resources we discharge a sacred obligation of citizenship. FOOTNOTES: [11] See _Dangerous Trades_, compiled by Thomas Oliver; also list of reports by the United States Bureau of Labor. CHAPTER XXII HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY Education's highest aim is to train us to do the right thing at the right moment without having to think. The technic of musician, stenographer, artist, electrician, surgeon, orator, is gained only from patient training of the body's reflex muscles to do brain work.[12] The lower nerve centers are storehouses for the brain energy, just as central power houses are used for storing electric energy to be spent upon demand. From habit, not from mental effort, we turn to the right, say "I beg pardon" when we step on another's foot, give our seats to ladies or to elderly persons, use acceptable table manners. No person seems "to the manner born" who has to think out each act necessary to "company manners." How numerous are the mental and physical processes essential to good manners no one ever recognizes but the very bashful or the uncouth person trying to cultivate habits of unconsciousness in polite society. The habit of living ethically enables us to go through life without being tempted to steal or lie or do physical violence. No person's morals can be relied upon who is tempted constantly to do immoral acts; ethical training seeks to incapacitate us for committing unethical deeds and to habituate us to ethical acts alone. Eight different elements of industrial efficiency are concerned with the individual's health habits,--the industrial worker, his industrial product, his employer, his employer's profit, his trade or profession, its product, his nation, national product. Obviously few men have so little to do that they have time to think out in detail how this act or that indulgence will affect each of these eight factors of industrial efficiency. Once convinced, however, that all of these elements are either helped or injured by the individual's method of living, each one of us has a strong reason for imposing habits of health upon all industries, upon employees and operatives, upon all who are a part of industrial efficiency. When these eight relations are seen, parents and teachers have particularly strong reasons for inculcating habits of health in their children. That industrial inefficiency results from chronic habits of unhealthy living is generally recognized. The alcoholic furnishes the most vivid illustration. The penalties suffered by him and his family are grave enough, but because he has not full possession of his faculties he is unpunctual, wastes material, disobeys instructions, endangers others' lives, decreases the product of his trade and of his employer, lessens the profits of both, depresses wages, increases insurance and business risks. Because no one can foresee when the "drop too much" will be taken, industry finds it important to know that the habit of drinking alcoholics moderately has not been acquired by train dispatcher, engineer, switchman, chauffeur. Because the habit of drinking moderately is apt, among lower incomes, to go hand in hand with other habits injurious to business and fatal to integrity, positions of trust in industry seek men and women who have the habit of declining drink. In the aggregate, milder forms of unhealthy living interfere with industrial efficiency even more than alcoholism. Many capable men and women, even those who have had thorough technical training, fail to win promotion because their persons are not clean, their breath offensive, their clothes suggestive of disorderly, uncleanly habits. Persons of extraordinary capacity not infrequently achieve only mediocre results because they fail to cultivate habits of cleanliness and health. An employer can easily protect his business from loss due to alcoholism among his own employees; but loss through employees' constipation, headache, bad ventilation at home, irregular meals, improper diet, too many night parties, nicotinism, personal uncleanliness, is loss much harder to anticipate and avoid. Because evil results are less vivid, it is also hard to convince a clerk that intemperance in eating, sleeping, and playing will interfere with his earning capacity and his enjoyment capacity quite as surely as intemperance in the use of alcohol and nicotine. Where employees are paid by the piece, instead of by the hour, day, or week, the employer partially protects himself against uneven, sluggish, slipshod workmen; but, other things being equal, he awards promotion to those who are most regular and who are most often at their best, for he finds that the man who does not "slump" earns best profits and deserves highest pay. [Illustration: THESE PATIENTS ON THE OLD SOUTHFIELD ARE TAXING THEIR UNIONS AND THEIR TRADES AS WELL AS THEIR FAMILIES AND THE TUBERCULOSIS COMMITTEE] There are exceptions, it is true, where both industrial promotion and industrial efficiency are won by people who violate laws of health,--but at what cost to their efficiency? Your efficiency should be measured not by some other person's advancement, but by what you yourself ought to accomplish; while the effect of abusing your physical strength is shown not only in the shortening of your industrial life and in the diminishing returns from your labor, but by the decrease of national and trade efficiency. "Sweating" injures those who buy and those in the same trade who are not "sweated" just as truly as it injures the "sweated." [Illustration: HABITS OF HEALTH AMONG DAIRYMEN MEAN SAFE MILK FOR BABIES] What are the health habits that should become instinctive and effortless for every worker? What acts can we make our lower nerve centers--our subconscious selves--do for us or remind us to do? The following constitutes a daily routine that should be as involuntary as the process of digestion: 1. Throw the bedding over the foot of the bed. 2. Close the window that has been open during the night. 3. Drink a glass of water. 4. Bathe the face, neck, crotch, chest, armpits (finishing if not beginning with cold water), and particularly the eyes, ears, and nose. If time and conveniences permit, bathe all over. 5. Cleanse the finger nails. 6. Cleanse the teeth, especially the places that are out of sight and hard to reach. 7. Breakfast punctually at a regular hour. Eat lightly and only what agrees with you. If you read a morning paper, be interested in news items that have to do with personal and community vitality. 8. Visit the toilet; if impracticable at home, have a regular time at business. 9. Have several minutes in the open air, preferably walking. 10. Be punctual at work. 11. As your right by contract, insist upon a supply of fresh air for your workroom with the same emphasis you use in demanding sufficient heat in zero weather. 12. Eat punctually at noon intermission; enjoy your meal and its after effects. 13. Breathe air out of doors a few minutes, preferably walking. 14. Resume business punctually. 15. Stop work regularly. 16. Take out-of-door exercise--indoor only when fresh air is possible--that you enjoy and that agrees with you. 17. Be regular, temperate, and leisurely in eating the evening meal; eat nothing that disagrees with you. 18. Spend the evening profitably and pleasantly and in ways compatible with the foregoing habits. 19. Retire regularly at a fixed hour, making up for irregularity by an earlier hour next night. 20, 21, 22. Repeat 4, 6, 8. 23. Turn underclothes wrong side out for ventilation. 24. Open windows. 25. Relax mind and body and go to sleep. No man chronically neglects any one of the above rules without reducing his industrial efficiency. No man chronically neglects all of them without becoming, sooner or later, a health bankrupt. In addition to this daily routine, there are certain other acts that should become habitual: 1. Bathing less frequently than once a week is almost as dangerous to health as it is to attractiveness. 2. Distaste for unclean linen or undergarments and for acts or foods that interfere with vitality should become instinctive. 3. Excesses in eating or playing should be automatically corrected the next day and the next. Parties we shall continue to have. It will be some time before reasonable hours and reasonable refreshments will prevail. Meanwhile it is probably better for an individual to sacrifice somewhat his own vitality for the sake of the union, the class, or the church. While trying to improve group habits, one can acquire the habit of not eating three meals in one, of eating less next day, of sleeping longer next night, of being particularly careful to have plenty of outdoor air. 4. Visits to the dentist twice a year at least, and whenever a cavity appears, even if only a week after the dentist has failed to find one; whenever the gums begin to recede; and whenever anything seems to be wrong with the teeth. 5. Periodic physical examination by a physician. 6. Examination by a competent physician whenever any disorder cannot be satisfactorily explained by violation of the daily routine or by interruption of business or domestic routine. Health habits do not become instinctive until a continued, conscious effort is made to accustom the body to them. When this is once done, however, the body not only attends to its primary health needs automatically, but it rebels at their omission, as surely as does the stomach at the omission of dinner. Witness the discomfort of the consumptive, trained to fresh air at a sanatorium, when he returns to his overheated and underventilated home, or the actual pain experienced in readjusting our own healthy bodies to the stuffy workroom or schoolroom after a summer vacation out of doors. I heard a consumptive say that he left a sanatorium for a day class after trying for three nights to sleep in an unventilated ward. For many people the regular morning bath is at first a trial, then a pleasure, and finally a need; if omitted, the body feels thirsty and dissatisfied, the eyes sleepy, and the spirit flags early in the day. [Illustration: IMPROVISED SEASIDE HOSPITAL FOR NONPULMONARY TUBERCULOSIS AT SEA BREEZE TEACHES PASSERS-BY THE FRESH-AIR GOSPEL] Cold baths are not essential or even good for everybody. The same diet or the same amount of food or time for eating is not of equal value for all. The temperature of bath water, the kind and quality of food, are influenced by one's work and one's cook. Set rules about these things do more harm than good. Such questions must be decided for each individual,--by his experience or by the advice of a physician,--but they must be decided and the decisions converted into health habits if he would attain the highest efficiency of which he is capable. Here again our old contrast between "doing things" and "getting things done" applies. Get your body to attend to the essential needs for you, and get it to remind you when you let the exigencies of life interfere. Don't burden your mind every day with work that your body will do for you if properly trained. [Illustration: CRIPPLED CHILDREN LEAVING SEA BREEZE HOSPITAL FOR BONE TUBERCULOSIS FIND STALE AIR OFFENSIVE BY NIGHT OR BY DAY] Obstacles to habits of health are numerous; therefore the importance of correcting those habits of factory, family, trade, city, or nation that make health habits impracticable. We must change others' prejudices before we can breathe clean air on street cars without riding outside. When one's co-workers are afraid of fresh air, ventilation of shop, store, and office is impossible. So long as parents fear night air, children cannot follow advice to sleep with windows open. Unless the family coöperates in making definite plans for the use of toilet and bath for each member, constipation and bad circulation are sure to result. Indigestion is inevitable if employees are not given lunch periods and closing hours that permit of regular, unhurried meals. Cleanliness of person costs more than it seems to be worth where cities fail either to compel bath tubs in rented apartments or to erect public baths. A temperate subsistence on adulterated, poisonous, or drugged foods might be better for one's health than gormandizing on pure foods. No recipe has ever been found for bringing up a healthy baby on unclean, infected milk; for avoiding tuberculosis among people who are compelled to work with careless consumptives in unclean air; or for making a five-story leap as safe as a fire escape. Perfect habits of health on the part of an individual will not protect him against enervation or infection resulting from inefficient enforcement of sanitary codes by city, county, state, and national authorities. [Illustration: AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH ROUTINE FOR BABIES] The "municipalization" or "public subsidy" of health habits is indispensable to protecting industrial efficiency. Public lavatories, above or below ground, have done much to reduce inefficiency due to alcoholism, constipation of the bowels, and congestion of the kidneys. Theaters, churches, and assembly rooms could be built so as to drill audiences in habits of health instead of fixing habits of uncleanly breathing. Street flushing, drinking fountains, parks and breathing spaces, playgrounds and outdoor gymnasiums, milk, food, and drug inspection, tenement, factory, and shop supervision, enforcement of anti-spitting penalties, restriction of hours of labor, prohibition of child labor,--these inculcate community habits of health that promote community efficiency. It is the duty of health boards to compel all citizens under their jurisdiction to cultivate habits of health and to punish all who persistently refuse to acquire these habits, so far as the evils of neglect become apparent to health authorities. The unlimited educational opportunity of health boards consists in their privilege to point out repeatedly and cumulatively the industrial and community benefits that result from habits of health, and the industrial and community losses that result from habits of unhealthy living. FOOTNOTES: [12] Serviceable guides to personal habits of health are _Aristocracy of Health_ by Mary Foote Henderson, and _Efficient Life_ by Dr. Luther H. Gulick. CHAPTER XXIII INDUSTRIAL HYGIENE To call the movement for better factory conditions the "humanizing of industry" implies that modern industry not influenced by that movement is brutalized. The brutalizing of industry was due chiefly to a general ignorance of health laws,--an ignorance that registers itself clearly and promptly in factory and mine. It is not that a man is expected to do too much, but that too little is expected of the human body. The present recognition of the body's right to vitality is not because the employer's heart is growing warmer, or because competition is less vicious, but because the precepts of hygiene are found to be practical. Where better ventilation used to mean more windows and repair bills, it now means greater output. Where formerly a comfortable place in which to eat lunch meant giving up a workroom and its profits, it now means 25 per cent more work done in all workrooms during the afternoon. The general enlightenment as to industrial hygiene has been accelerated by the awakening that always follows industrial catastrophes, by the splendid crusade against tuberculosis, and by compulsory notification and treatment of communicable diseases. Catastrophes, however, have dominated the vocabulary that describes factory "welfare work." Because accidents such as gas in mines, fire in factories, fever in towns, and epidemics of diseases incident to certain trades were beyond the power of the workers themselves to control or prevent, wage earners have come to be looked upon as helpless victims of the cupidity and inhumanity of their employers. This attitude has weakened the usefulness of many bodies organized to promote industrial hygiene. Although the term "industrial hygiene" is broad enough to include all sanitary and hygienic conditions that surround the worker while at work, it is restricted by some to the efforts made by altruistic or farsighted employers in the interest of employees; others think of prohibitions and mandates, in the name of the state, that either prevent certain evils or compel certain benefits; for too few it refers to what the wage earner does for himself. Pity for the employee has caused the motive power of the employee to be wastefully allowed to atrophy. Yet when a man becomes an employee, he does not forfeit any right of citizenship, nor does being an employee relieve him from the duties of citizenship. In too many cases it has been overlooked that a worker's carelessness about habits of health, as well as about his machinery, causes accidents and increases industrial diseases. Too often the worker himself is responsible for uncleanliness and lack of ventilation and his own consequent lack of vitality. A study into the conditions of ventilation and cleanliness of workers' homes will prove this. Knowing that a light, well-aired, clean, safe factory would not of itself insure healthy men, many employers have built and supplied houses for their workmen at low rents. Just as these employers failed to see that they could reach more people and secure more permanent results if they demanded that tenement laws and the sanitary code be enforced as well as the laws for the instruction of children in hygiene, so the employee has failed to see that he is a part of the public that passes laws and determines the efficiency of factory inspection. The enforcement of state legislation for working hours, proper water and milk supply, proper teaching of children, proper tenement conditions, efficient health administration, is dependent upon the interest and activity of the public, of which the working class is no small or uninfluential part. [Illustration: COUNTRY CLUB HOUSE FOR NEW YORK SOCIAL WORKERS Given by the founder of Caroline Rest Educational Fund] The first and most important step in securing hygienic rights for workingmen is to make sure that they know the rights that the law already gives them. Men still throw out their chests when talking of their rights. The posting of the game laws in a club last summer, and the instruction of all the natives of the countryside in regard to their rights as against those of outsiders, meant that for the first time in their history the game laws were enforced. All the natives, instead of poaching as has been their wont, joined together in protecting club property from intruding outside sportsmen. Poachers were caught and served with the full penalties of the law. Over winter fires these people's heroism will grow, but their respect for law will grow also, and it is doubtful if the game laws can be violated in that section so long as the tradition of this summer's work lives. And so it would be in a factory, if employees once realized that by uniting they could, as citizens, enforce health rights in the factory. The hygiene of the workshop is not the same problem as the hygiene of the home and schoolhouse, because there are by-products of factory work that contaminate the air, overheat the room, and complicate the ordinary problems of ventilation. Certain trades are recognized as "dangerous trades." The problem of adequate government control of factories is one for a sanitary engineer. It has to do with disease-bearing raw material that comes to a factory, disease-producing processes of manufacture. There is need for revision of the dangerous-trade list. Many of the industries not so classed should be; many of the so-called dangerous trades can be made comparatively harmless by devices for exhausting harmful by-products. Industrial diseases should be made "notifiable," so that they can be controlled by the factory or health department. It is those trades that are dangerous because of remediable unsanitary and unhygienic conditions which demand the employer's attention. Complaints should be made by individuals when carelessness or danger becomes commonplace. The manner in which many organizations have tried to better working conditions is similar to the manner in which Europeans are trying to help defective school children. Here, as there, is the difference between _doing things_ and _getting things done_. Here more than there is the tendency to exaggerate legislation and to neglect enforcement of law. Instead of harnessing the whole army of workingmen to the crusade and strengthening civic agencies such as factory, health, and tenement departments, houses are built and given to men, clubs are formed to amuse factory girls, amateur theatricals are organized. All this is called "welfare work." "What is welfare work?" reads the pamphlet of a large national association. "It is especial consideration on the part of the employer for the welfare of his employees." In the words of this pamphlet, the aim of this association "is to organize the best brains of the nation in an educational movement toward the solution of some of the great problems related to social and industrial progress." The membership is drawn from "practical men of affairs, whose acknowledged leadership in thought and business makes them typical representatives of business elements that voluntarily work together for the general good." As defined by this organization, welfare work is something given to the employee by the employer for the welfare of both. It is not something the employee himself does to improve his own working conditions. We are told that employees should assume the management of welfare work. Should they install sanitary conveniences? Of course not. Would they know the need of a wash room in a factory if they never had had one? No. Should they manage lunch rooms? A few employers have attempted unsuccessfully to turn over the management of the lunch rooms to the employees, the result being that one self-sacrificing subofficial in each concern would find the burden entirely on his shoulders before working hours, during working hours, and after working hours. Employees cannot attend committee meetings during working hours, and they are unwilling to do so afterwards, for they generally have outside engagements. Furthermore, the employees know nothing about the restaurant business. If they did, they would probably be engaged in it instead of in their different trades. All experiments along this line of which we have heard have failed. The so-called "democratic idea," purely a fad, never has been successfully operated. Many employers would introduce welfare work into their establishments were it not for the time and trouble needed for its organization. The employment of a welfare director removes this obstacle. Successful prosecution of welfare work requires concentration of responsibility. All of its branches must be under the supervision of one person, or efforts in different directions may conflict, or special and perhaps pressing needs may escape attention. Pressure of daily business routine usually relegates welfare work to the last consideration, but the average employer is interested in his men and is willing to improve their condition if only their needs are brought to his attention. [Illustration: FIRST LESSONS IN INDUSTRIAL HYGIENE] +--------------------------------------------------------------------+ | =Consumption= | | | | Is chiefly caused by the Filthy Habit of | | | | =SPITTING= | | | | TAKE THIS CARD HOME | | | | And show it to your family, friends, and neighbors | | | | Consumption is a disease of the lungs, which is taken from others, | | and is not simply caused by colds, although a cold may make it | | easier to take the disease. | | | | The matter coughed up and sneezed out by consumptives is full of | | living germs or "tubercle bacilli" too small to be seen. These | | germs are the cause of consumption, and when they are breathed | | into the lungs they set up the disease. | | | | DON'T GET CONSUMPTION YOURSELF | | | | Keep as well as possible, for the healthier your body, the harder | | for the germs of consumption to gain a foothold. Every person | | should observe the following rules: | | | | | | =DON'T= live, study, or sleep in rooms where there is no | | fresh air. Fresh air and sunlight kill the consumption | | germs and other germs causing other diseases; therefore | | have as much of both in your room as possible. | | | | =DON'T= live in dusty air; keep rooms clean; get rid of dust | | by cleaning with damp cloths and mops. =DON'T= sweep with | | a dry broom. | | | | =KEEP= one window partly open in your bedroom at night, and | | air the room two or three times a day. | | | | =DON'T= eat with soiled hands. Wash them first. | | | | =DON'T= put hands or pencils in the mouth, or any candy or | | chewing gum other persons have used. | | | | =DON'T= keep soiled handkerchiefs in your pockets. | | | | =TAKE= a warm bath at least once a week. | | | | =DON'T= neglect a cold or a cough, but go to a doctor or | | dispensary. | +--------------------------------------------------------------------+ [Illustration: WELFARE WORK THAT COUNTS] +-------------------------------------------------------------------+ | =HOW TO GET WELL IF YOU HAVE CONSUMPTION= | | | | If you or any one in your family have consumption, you must obey | | the following rules if you wish to get well: | | | | =DON'T= waste your money on patent medicines or advertised | | cures for consumption, but go to a doctor or dispensary | | (see last page). If you go in time, you can be cured; if | | you wait, it may be too late. | | | | =DON'T= drink whisky or other forms of liquor. | | | | =DON'T= sleep in the same bed with any one else, and, if | | possible, not in the same room. | | | | =Good food, fresh air, and rest are the best cures. Keep out | | in the fresh air and in the sunlight as much as possible.= | | | | =KEEP= your windows open winter and summer, day and night. | | | | =IF= properly wrapped up you will not catch cold. | | | | =GO= to a sanatorium while you can and before it is too | | late. | | | | =The careful and clean consumptive is not dangerous to those | | with whom he lives and works.= | | | | =Don't give consumption to others.= | | | | Many grown people and children have consumption without knowing | | it, and can give it to others. Therefore every person, even if | | healthy, should observe the following rules: | | | | =DON'T SPIT= on the sidewalks, playgrounds, or on the | | floors or hallways of your home or school. It spreads | | disease, and is dangerous, indecent, and unlawful. | | | | =WHEN YOU MUST SPIT=, spit in the gutters or into a spittoon | | half filled with water. | | | | =DON'T COUGH OR SNEEZE= without holding a handkerchief or | | your hand over your mouth or nose. | +-------------------------------------------------------------------+ $/ This method of promoting the welfare of the worker may have been a necessary step in the development of industrial hygiene. Undoubtedly it has succeeded, in many cases, in bringing to an employer's consciousness the needs of his workmen, in accustoming employees to higher sanitary standards, and in teaching them to demand health rights from their employers. In many cases, however, "welfare work" has miseducated both employer and employee. The fact that "the so-called democratic idea, purely a fad, has never been successfully operated," is due to the interpretation given to "democratic idea." The two alternatives in the paragraph above quoted are lunch rooms, wash rooms, as gifts from employers to employees, or lunch rooms and wash rooms to be furnished by employees at their own expense. The true democratic idea, however, is that factory conditions detrimental to health shall be prohibited by factory legislation, and this legislation enforced by efficient factory inspectors, regardless of what may be given to employees above the requirement of hygiene. Until employees are more active as citizens and more sensitive to hygienic rights, it is desirable that welfare directors be employed in factories to arbitrate between employer and employee, to raise the moral standard of a factory settlement, to organize amusements. Welfare work at its best is a method of dividing business profits among all who participate in making these profits. Too often welfare secretaries teach employees how to be happy in the director's way, rather than in their own way. This adventitious position increases suspicion on both sides, disturbs the discipline of the foreman, weakens rather than strengthens the worker's efficiency, because it depends upon other things than work well done and the relation of health to efficiency. In a small factory town the owner of a large cotton mill has recognized the financial benefit of physically strong workers, and is trying the experiment of a welfare director. The man himself works "with his sleeves up." The social worker has an office in the factory. A clubhouse is fitted up for the mill hands to make merry in. A room in the factory is reserved for a lunch room, with plants, tables, and chairs for the comfort of the women. Parties are given by the employer to the employees, which he himself attends. He has thrown himself into whatever schemes his director has suggested. The director complained that the reason the new lunch room was not more popular was because a piano was needed. A second-hand one would not do, for that would cultivate bad taste in music. This showed the employer that soon everything would be expected from the "big house on the hill." An event which happened at the time when the pressure was greatest on him for the piano, convinced him that his employees could supply their real needs without any trouble or delay. The assistant manager was about to leave, and in less than a week five hundred dollars was raised among the workers for his farewell gift. Walking home that night late from his office the owner was attracted by the sound of jollity, and saw a little room jammed full of mill people enjoying the improvised music of a mouth organ played to the accompaniment of heels. He resolved henceforth to train his employees to do his work well and to earn more pay,--and to let them amuse themselves. From that time on he refused to be looked upon as the _deus ex machina_ of the town. He decided that the best way to give English lessons to foreigners was to improve the school. His beneficence in supplying them with pure water at the mill did not prevent a ravaging typhoid epidemic because the town water was not watched. He saw that the best way to improve health was to strengthen the health board and to make his co-workers realize that they were citizens responsible for their own privileges and rights. Emergency hospitals and Y.M.C.A. buildings are sad substitutes for safety devices and automatic couplers. Christmas shopping in November is less kind than prevention of overwork in December. Night school and gymnastic classes are a poor penance for child labor and for work unsuited to the body. The left hand cannot dole favors enough to offset the evils of underpay, of unsanitary conditions, of inefficient enforcement of health laws tolerated by the right hand. Just because a man is taking wages for work done, is no reason why he should forfeit his rights as a citizen, or allow his children, sisters, neighbors, to work in conditions which decrease their efficiency and earning power. What the employee can do for himself as a citizen, having equal health rights with employers, he has never been taught to see. Factory legislation is state direction of industries so far as relates to the safety, health, and moral condition of the people,--and which embraces to-day, more than in any other epoch, the opinion of the workers themselves. No government, however strong, can hope successfully to introduce social legislation largely affecting personal interests until public opinion has been educated to the belief that the remedies proposed are really necessary. Until schools insist upon a better ventilation than the worst factories, how can we expect to find children of working age sensitive to impure air? Where work benches are more comfortable than school desks, where drinking water is cleaner and towels more sanitary, however unsanitary they may be, than those found in the schoolhouse, the worker does not realize that they menace his right to earn a living wage as much as does a temporary shut-down. Employers are by no means solely to blame for unhealthy working conditions. A shortsighted employee is as anxious to work overtime for double pay as a shortsighted employer is to have him. Among those who are agitating for an eight-hour day are many who, from self-interest or interest in the cause, work regularly from ten to sixteen hours. Would it help to punish employees for working in unhealthy places? The highest service that can be rendered industrial hygiene is to educate the industrial classes to recognize hygienic evils and to coöperate with other citizens in securing the enforcement of health rights. CHAPTER XXIV THE LAST DAYS OF TUBERCULOSIS If the historian Lecky was right in saying that the greatest triumphs of the nineteenth century were its sanitary achievements, the Lecky of the twenty-first century will probably honor our generation not for its electricity, its trusts, and its scientific research, but for its crusade against the white plague and for its recognition of health rights. Thanks to committees for the prevention of tuberculosis,--local, state, national, international,--we are fast approaching the time when every parent, teacher, employer, landlord, worker, will see in tuberculosis a personal enemy,--a menace to his fireside, his income, and his freedom. Just as this nation could not exist half slave, half free, we of one mind now affirm that equal opportunity cannot exist where one death in ten is from a single preventable disease.[13] Of no obstacle to efficient living is it more true than of tuberculosis, that the remedy depends upon enforcing rather than upon making law, upon practice rather than upon precept, upon health habits rather than upon medical remedies, upon coöperation of lay citizens rather than upon medical science or isolated individual effort. Without learning another fact about tuberculosis, we can stamp it out if we will but apply, and see that officers of health apply, lessons of cleanliness and natural living already known to us. [Illustration: DR. TRUDEAU'S "LITTLE RED COTTAGE" AT SARANAC--BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA] Perhaps the most striking results yet obtained in combating tuberculosis are those of the Massachusetts General Hospital in Boston. To visit its tuberculosis classes reminds one more of the sociable than the clinic. In fact, one wonders whether the milk diet and the rest cure or the effervescing optimism and good cheer of the physicians and nurses should be credited with the marvelous cures. The first part of the hour is given to writing on the blackboard the number of hours that the class members spent out of doors the preceding week. So great was the rivalry for first place that the nurse protested that a certain boy in the front row gave himself indigestion by trying to eat his meals in ten or fifteen minutes. It was then suggested that twenty hours a day would be enough for any one to stay out of doors, and that plenty of time should be taken for meals with the family and for cold baths, keeping clean, etc. Interesting facts gathered by personal interviews of two physicians with individual patients are explained to the whole class. Next to the number of hours out of doors, the most interesting fact is the number of hours of exercise permitted. A man of forty, the head of a family, beamed like a school child when told that, after nearly a year of absolute rest, he might during the next week exercise ten minutes a day. A graduate drops in, the very picture of health, weighing two hundred pounds. An apparently hopeless case would brighten up and have confidence when told that this strong, handsome man has gained fifty pounds by rest, good cheer, fresh air, all on his own porch. One young man, just back from a California sanatorium where he progressively lost strength in spite of change of climate, is now returning to work and is back at normal weight. [Illustration: OUTDOOR LIFE CHART.] [Illustration: FIGHTING TUBERCULOSIS IN THE MOUNTAINS--SARANAC] Every patient keeps a daily record, called for by the following instructions: Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock, daily; movements of bowels; hours in open air; all food taken; total amount of milk; total amount of oil and butter; appetite; digestion; spirits; cough (amount, chief time); expectoration (amount in 24 hours, color, nature); exercise (if allowed), with temperature and pulse 15 minutes after exercise; sweats; visitors. The following simple instructions can be followed in any home, even where open windows must take the place of porches: Rest out of doors is the medicine that cures consumption. Absolute rest for mind and body brings speedy improvement. It stops the cough and promotes the appetite. The lungs heal more quickly when the body is at rest. Lie with the chest low, so the blood flow in the lungs will aid to the uttermost the work of healing. The rest habit is soon acquired. Each day of rest makes the next day of rest easier, and shortens the time necessary to regain health. The more time spent in bed out of doors the better. Do not dress if the temperature is above 99 degrees, or if there is blood in the sputum. It is life in the open air, not exercise, that brings health and strength. Just a few minutes daily exercise during the active stage of the disease may delay recovery weeks or months. Rest favors digestion, exercise frequently disturbs digestion. When possible have meals served in bed. Never think the rest treatment can be taken in a rocking-chair. If tired of the cot, shift to the reclining chair, but sit with head low and feet elevated. Do not write letters. Dictate to a friend. Do not read much and do not hold heavy books. While reading remain in the recumbent posture. [Illustration: FIGHTING TUBERCULOSIS IN DAY CAMPS--BOSTON] Once having learned the simple facts that must be noted and the simple laws that must be followed, once having placed oneself in a position to secure the rest, the fresh air, and the health diet, no better next steps can be taken than to observe the closing injunction in the rules for rest: There are few medicines better than clouds, and you have not to swallow them or wear them as plasters,--only to watch them. Keeping your eyes aloft, your thoughts will shortly clamber after them, or, if they don't do that, the sun gets into them, and the bad ones go a-dozing like bats and owls. [Illustration: THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW YORK CITY] +--------------------------------------------------------------------+ | CONSUMPTION IN EARLY STAGES CAN BE CURED | | | | Take your case in time to a good physician or to a dispensary and | | you may be cured--DO NOT WAIT. | | | | Consumption is "caught" mainly through the spit of consumptives. | | | | Friends of Consumption--Dampness, Dirt, Darkness, Drink. | | | | Enemies of Consumption--Sun, Air, Good Food, Cleanliness. | | | | If you have tuberculosis do not give it to others by spitting; | | even if you have not, set a good example by refraining from a | | habit always dirty and often dangerous. | | | | _The Committee on the Prevention of Tuberculosis_ | | _Of the Charity Organization Society_ | | | | (By Courtesy of Siegel Cooper Co.) | +--------------------------------------------------------------------+ Important as are sanatoriums in mountain and desert, day or night camps within and near cities, milk and egg clinics, home visiting, change of air and rest for those who are known to be tuberculous, their importance is infinitesimal compared with the protection that comes from clean, healthy environment and natural living for those not known to be tuberculous. This great fact has been recognized by the various bodies now engaged in popularizing the truth about tuberculosis by means of stationary and traveling exhibits, illustrated lectures, street-car transfers, advertisements, farmers' institutes, anti-spitting signs in public vehicles and public buildings, board of health instructions in many languages, magazine stories, and press reports of conferences. This brilliant campaign of education shows what can be done by national, state, and county superintendents of schools, if they will make the most of school hygiene and civics. [Illustration: AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS CRUSADERS SHOULD FOLLOW] +-------------------------------------------------------------------+ | CIRCULAR ISSUED BY | | | | The Committee of Sanitation of the Central Federated Union of | | New York | | | | The Committee on the Prevention of Tuberculosis of the Charity | | Organization Society | | | | 105 East 22d Street, New York City | | | | * * * * * | | | | Don't Give Consumption to Others | | | | Don't Let Others Give It to You | | | | * * * * * | | | | =How to Prevent Consumption= | | | | =The spit and the small particles coughed up and sneezed out by | | consumptives, and by many who do not know that they have | | consumption, are full of living germs too small to be seen. THESE | | GERMS ARE THE CAUSE OF CONSUMPTION.= | | | | | | =DON'T SPIT on the sidewalks--it spreads disease, and it is | | against the law.= | | | | =DON'T SPIT on the floors of your rooms or hallways.= | | | | =DON'T SPIT on the floors of your shop.= | | | | =WHEN YOU SPIT, spit in the gutters or into a spittoon.= | | | | =Have your own spittoons half full of water, and clean them | | out at least once a day with hot water.= | | | | =DON'T cough without holding a handkerchief or your hand | | over your mouth.= | | | | =DON'T live in rooms where there is no fresh air.= | | | | =DON'T work in rooms where there is no fresh air.= | | | | =DON'T sleep in rooms where there is no fresh air.= | | | | =Keep at least one window open in your bedroom day and | | night.= | | | | =Fresh air helps to kill the consumption germ.= | | | | =Fresh air helps to keep you strong and healthy.= | | | | =DON'T eat with soiled hands--wash them first.= | | | | =DON'T NEGLECT A COLD or a cough.= | | | | | | =How to Cure Consumption= | | | | =DON'T WASTE YOUR MONEY on patent medicines or advertised | | cures for consumption, but go to a doctor or a | | dispensary. If you go in time YOU CAN BE CURED; if you | | wait until you are so sick that you cannot work any | | longer, or until you are very weak, it may be too late; | | at any rate it will in the end mean more time out of work | | and more wages lost than if you had taken care of | | yourself at the start.= | | | | =DON'T DRINK WHISKY, beer, or other intoxicating drinks; | | they will do you no good, but will make it harder for you | | to get well.= | | | | =DON'T SLEEP IN THE SAME BED with any one else, and, if | | possible, not in the same room.= | | | | =GOOD FOOD, FRESH AIR, AND REST are the best cures. Keep in | | the sunshine as much as possible, and KEEP YOUR WINDOWS | | OPEN, winter and summer, night and day. Fresh air, night | | and day, is good for you.= | | | | =GO TO A HOSPITAL WHILE YOU CAN AND BEFORE IT IS TOO LATE. | | There you can get the best treatment, all the rest, all | | the fresh air, and all the food which you need.= | | | | =THE CAREFUL AND CLEAN CONSUMPTIVE IS NOT DANGEROUS TO THOSE | | WITH WHOM HE LIVES AND WORKS= | +-------------------------------------------------------------------+ Is it not significant that America's national movement is due primarily to the organizing capacity of laymen in the New York Charity Organization Society rather than to schools or hospitals? Most of the local secretaries are men whose inspiration came from contact with the non-medical relief of the poor in city tenements. The secretary of the national association is a university professor of anthropology, who has also a medical degree. The child victim's plea--Little Jo's Smile--was nationalized by an association of laymen, aided by the advertising managers of forty magazines. The smaller cities of New York state are being aroused by a state voluntary association that for years has visited almshouses, insane asylums, and hospitals. These facts I emphasize, for they illustrate the opportunity and the duty of the lay educator, whether parent, teacher, labor leader, or trustee of hospital, orphanage, or relief society. Three fundamental rules of action should be established as firmly as religious principles: 1. The public health authorities should be told of every known and every suspected case of tuberculosis. 2. For each case proved by examination of sputum to be tuberculous, the public-health officers should know that the germs are destroyed before being allowed to contaminate air or food. 3. Sick and not yet sick should practice habits of health that build up vitality to resist the tubercle bacilli and that abhor uncleanliness as nature abhors a vacuum. [Illustration: FIGHTING TUBERCULOSIS WITH A NATIONAL ORGANIZATION] All laws, customs, and environmental conditions opposed to the enforcement of these three principles must be modified or abolished. If the teachers of America will list for educational use in their own communities the local obstacles to these rules of action, they will see exactly where their local problem lies. The illustrations that are given in this book show in how many ways these rules of action are now being universalized. Three or four important steps deserve especial comment: 1. Compulsory notification of all tuberculous cases. 2. Compulsory removal to hospital of those not able at home to destroy the bacilli, or compulsory supervision of home care. 3. Examination of all members of a family where one member is discovered to be tuberculous. 4. Special provision for tuberculous teachers. 5. Protection of children about to enter industry but predisposed to tuberculosis. 6. Prohibition of dry cleaning of schools, offices, and streets. 7. Tax provision for educational and preventive work. Compulsory notification was introduced first in New York City by Hermann M. Biggs, M.D., chief medical officer: 1893, partially voluntary, partially compulsory; 1897, compulsory for all. Physicians who now hail Dr. Biggs as a statesman called him persecutor, autocrat, and violator of personal freedom fifteen years ago. Foreign sanitarians vied with American colleagues in upbraiding him for his exaggeration of the transmissibility of consumption and for his injustice to its victims. As late as 1899 one British expert particularly resented the rejection of tuberculous immigrants at Ellis Island, and said to me, "Perhaps if you should open a man's mouth and pour in tubercle bacilli he might get phthisis, but compulsory notification is preposterous." In 1906 the International Congress on Tuberculosis met in Paris and congratulated New York upon its leadership in securing at health headquarters a list of the known disease centers within its borders; in 1906 more than twenty thousand individual cases were reported, ten thousand of these being reported more than once. To know the nature and location of twenty thousand germ factories is a long step toward judging their strength and their probable product. To compulsory notification in New York City is largely due the educational movements of the last decade against the white plague, more particularly the growing ability among physicians to recognize and to treat conditions predisposing to the disease. As in New York City, the public should provide free of cost bacteriological analysis of sputum to learn positively whether tuberculosis is present. Simpler still is the tuberculin test of the eyes, with which experiments are now being made on a large scale in New York City, and which bids fair to become cheap enough to be generally used wherever physical examinations are made. This test is known as Calmette's Eye Test. Inside the eyelid is placed a drop of a solution--95 per cent alcohol and tuberculin. If conjunctivitis develops in twenty-four hours, the patient is proved to have tuberculosis. Some physicians still fear to use this test. Others question its proof. The "skin test" is also being thoroughly tried in several American cities and, if finally found trustworthy, will greatly simplify examination for tuberculosis. Dr. John W. Brannan, president of Bellevue and Allied Hospitals, New York City, is to report on skin and eye tuberculin tests for children at the International Congress on Tuberculosis, mentioned later. [Illustration: FIGHTING TUBERCULOSIS BY ORGANIZED COÖPERATIVE DISPENSARY WORK] [Illustration: FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE] Compulsory removal of careless consumptives is yet rare. One obstacle is the lack of hospitals. In New York ten thousand die annually from tuberculosis and fifty thousand are known to have it, yet there are only about two thousand beds available. So long as the patients anxious for hospital care exceed the number of beds, it does not seem fair to give a bed to some one who does not want it. On the other hand, it should not be forgotten that patients are taken forcibly to smallpox and scarlet-fever hospitals, not for their own good, but for the protection of others. The last person who should be permitted to stay at home is the tuberculous person who is unable, unwilling, or too ignorant to take the necessary precautions for others' protection. A rigid educational test should be applied as a condition of remaining at home without supervision. The objections to compulsory removal are two: (1) it is desired to make sanatorium care so attractive that patients will go at the earliest stage of the disease; (2) an unwilling patient can defeat the sanitarian's effort to help him and others. The alternative for compulsory removal is gratuitous, and, if need be, compulsory, supervision of home care, such as is now given in New York City. In Brighton, England, Dr. Newsholme treats his municipal sanatorium as a vacation school, giving each patient one month only. Thus one bed helps twelve patients each year. Almost any worker can spare one month and in that time can be made into a missionary of healthy living. Family examining parties were begun in New York by Dr. Linsly R. Williams, for the relief agency that started the seaside treatment of bone tuberculosis. Many of the crippled children at Sea Breeze were found to have consumptive fathers or mothers. In one instance the father had died before Charlie had "hip trouble." Long after we had known Charlie his mother began to fail. She too had consumption. Family parties were planned for 290 families. Weights were taken and careful examination made, the physician explaining that predisposition means defective lung capacity or deficient vitality. Of 379 members, supposedly free from tuberculosis, sixteen were found to have well-marked cases. (Of twenty Boston children whose parents were in a tuberculosis class, four had tuberculosis.) In one instance the father was astonished to learn not only that he was tuberculous, but that he had probably given the disease to the mother, for whom he was tenderly concerned. Of special benefit were the talks about teeth and nourishment, and about fresh air and water as germ killers. One examination of this kind will organize a family crusade against carelessness. [Illustration: FIGHTING TUBERCULOSIS IN SMALL CITIES New York State Charities Aid Association] Tuberculous teachers ought to be excluded from schoolrooms not merely because they may spread tuberculosis, but because they cannot do justice to school work without sacrifices that society ought not to accept. A tuberculous teacher ought to be generous enough to permit public hospitals to restore her strength or enterprising enough to join tuberculosis classes. It is selfish to demand independence at the price which is paid by schools that employ tuberculous teachers. [Illustration: FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND SALT AIR] Predisposition to tuberculosis should be understood by every child before he is accepted as an industrial soldier. Many trades now dangerous would be made safe if workers knew the risk they run, and if society forbade such trades needlessly to exhaust their employees. A perfectly sound man is predisposed to tuberculosis if he elects to work in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack of exercise in the open air, prepare lungs to give a cordial reception to tubercle bacilli. Rooms as well as persons become infected. Fortunately, opportunities to work are so varied in most localities that workers predisposed to tuberculosis may be sure of a livelihood in an occupation suited to their vitality. Destruction of germs in the air, in carpets, on walls, on streets, is quite as important as destruction of germs in lungs. Why should not tenants and workers require health certificates stating that neither house nor working place is infected with tubercle bacilli? Some cities now compel the disinfection of premises occupied by tuberculous persons _after_ their removal. Landlords, employers, tenants, and employees can easily be taught to see the advantage of disinfecting premises occupied by tuberculous cases _before_ detection. [Illustration: FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR HOSPITALS FOR BONE TUBERCULOSIS] Dry cleaning, feather dusters, dust-laden air, will disappear from schoolrooms within twenty-four hours after school-teachers declare that they shall disappear. We have no right to expect street cleaners, tenement and shop janitors, or overworked mothers to be more careful than school-teachers. Last year I said to a janitress, "Don't you realize that you may get consumption if you use that feather duster?" Her reply caused us to realize our carelessness: "I don't want any more than I've got now." Shall we some day have compulsory examination and instruction of all cleaners, starting with school cleaners? [Illustration: FIGHTING TUBERCULOSIS IN OPEN TENTS] Taxing is swift to follow teaching in matters of health. Teachers can easily compute what their community loses from tuberculosis. The totals will for some time prove a convincing argument for cleanliness of air, of body, and of building wherever the community is responsible for air, building, and body. The annual cost of tuberculosis to New York City is estimated at $23,000,000 and to the United States at $330,000,000. The cost of exterminating it will be but a drop in the bucket if school-teachers do their part this next generation with the twenty million children whose day environment they control for three fourths of the year, and whose habits they can determine. The first meeting in America of the International Congress on Tuberculosis was held at Washington, D.C., September 21 to October 12, 1908. For many years the proceedings of this congress will undoubtedly be the chief reference book on the conquest of tuberculosis.[14] How many aspects there are to this problem, and how many kinds of people may be enlisted, may be seen from the seven section names: I. Pathology and Bacteriology; II. Sanatoriums, Hospitals, and Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in Children--Etiology, Prevention, and Treatment; V. Hygienic, Social, Industrial, and Economic Aspects; VI. State and Municipal Control of Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man. [Illustration: FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER BED, OTISVILLE, NEW YORK] How many-sided is the responsibility of each of us for stamping out tuberculosis is shown by the preliminary programme of the eight sessions of Section V. These topics suggest an interesting and instructive year's study for clubs of women, mothers, or teachers, or for advanced pupils. I. ECONOMIC ASPECTS OF TUBERCULOSIS 1. The burdens entailed by tuberculosis: a. On individuals and families. b. On the medical profession. c. On industry. d. On relief agencies. e. On the community. f. On social progress. 2. The cost of securing effective control of tuberculosis: a. In large cities. b. In smaller towns. c. In rural communities. II. ADVERSE INDUSTRIAL CONDITIONS 1. Incidence of tuberculosis according to occupation. 2. Overwork and nervous strain as factors in tuberculosis. 3. Effect of improvements in factory conditions on the health of employees. 4. Legitimate exercise of police power in protecting the life and health of employees. III. THE SOCIAL CONTROL OF TUBERCULOSIS 1. Outline of a comprehensive programme for: a. National, state, and municipal governments. b. Departments of health and departments of public relief. c. Private endowments. d. Voluntary associations for educational propaganda. e. Institutions, such as schools and relief agencies, which exist primarily for other purposes. 2. A symposium on the relative value of each of the features in an aggressive campaign against tuberculosis: a. Compulsory registration. b. Free sputum examination. c. Compulsory removal of unteachable and dangerous cases. d. Laboratory research. e. Hospital. f. Sanatorium. g. Dispensary. h. The tuberculosis class. i. Day camp. j. Private physician. k. Visiting nurse. l. After-care of arrested cases. m. Relief fund. n. Climate. o. Hygienic instruction,--personal and in class. p. Inspection of schools and factories. q. Educational propaganda. IV. EARLY RECOGNITION AND PREVENTION 1. Importance of discovering the persons who have tuberculosis before the disease has passed the incipient stage. 2. Examination of persons known to have been exposed or presumably predisposed. 3. Systematic examination of school children during their course and on leaving school to go to work. 4. Professional advice as to choice of occupation in cases where there is apparent predisposition to disease. V. AFTER-CARE OF ARRESTED CASES 1. Instruction in healthful trades in the sanatorium. 2. Training for professional nursing in institutions for the care of tuberculous patients. 3. Farm colonies. 4. Convalescent homes or cottages. 5. Aid in securing suitable employment on leaving the sanatorium. 6. How to deal with the danger of a return to unfavorable home conditions. VI. EDUCATIONAL METHODS AND AGENCIES 1. Special literature for general distribution. 2. Exhibits and lectures. 3. The press. 4. Educational work of the nurse. 5. Labor organizations. 6. Instruction in schools of all grades. 7. Presentation and discussion of leaflets awarded prizes by the congress. VII. PROMOTION OF IMMUNITY 1. Development of the conception of physical well-being. 2. Measures for increasing resistance to disease: a. Parks and playgrounds. b. Outdoor sports. c. Physical education. d. Raising the standards of living: housing, diet, cleanliness. 3. Individual immunity and social conditions favorable to general immunity. VIII. RESPONSIBILITY OF SOCIETY FOR TUBERCULOSIS 1. A symposium of representative a. Citizens. b. Social workers. c. Employers. d. Employees. e. Physicians. f. Nurses. g. Educators. h. Others. Cash prizes of one thousand dollars each are offered: (1) for the best evidence of effective work in the prevention or relief of tuberculosis by any voluntary association since 1905; (2) for the best exhibit of a sanatorium for working classes; (3) for the best exhibit of a furnished home for the poor, designed primarily to prevent, but also to permit the cure of tuberculosis. [Illustration: BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN _A-D, F, H-J_, private hospitals and agencies reporting cases to the official center; _E_, home care; _K, L, M_, day camp and hospitals for incipient and advanced cases] A white-plague scrapbook containing news items, articles, and photographs will prove an interesting aid to self-education or to instruction of children, working girls' clubs, or mothers' meetings. Everybody ought to enlist in this war, for the fight against tuberculosis is a fight for cleanliness and for vitality, for a fair chance against environmental conditions prejudicial to efficient citizenship. So sure is the result and so immediate the duty of every citizen that Dr. Biggs wrote in 1907: _In no other direction can such large results be achieved so certainly and at such relatively small cost. The time is not far distant when those states and municipalities which have not adopted a comprehensive plan for dealing with tuberculosis will be regarded as almost criminally negligent in their administration of sanitary affairs and inexcusably blind to their own best economic interests._ FOOTNOTES: [13] The best literature on tuberculosis is in current magazines and reports of anti-tuberculosis crusaders. For a scientific, comprehensive treatment, libraries and students should have _The Prevention of Tuberculosis_ (1908) by Arthur Newsholme, M.D. A popular book is _The Crusade against Tuberculosis_, by Lawrence F. Flick, of the Henry Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis. [14] Those desiring copies this year or hereafter will do well to write to The National Association for the Study and Prevention of Tuberculosis, 105 East 22d St., New York City. The congress is under the control of the National Association and is managed by a special committee appointed by it. Even after a national board of health is established, the National Association for the Study and Prevention of Tuberculosis will continue to be a center for private interest in public protection against tuberculosis. One of its chief functions is the preparation and distribution of literature to those who desire it. CHAPTER XXV THE FIGHT FOR CLEAN MILK "With the approval of the President and with the coöperation of the Department of Agriculture,[15] the [national quarantine] service has undertaken to prepare a complete report upon the milk industry from farm to the consumer in its relation to the public health." This promise of the United States Treasury insures national attention to the evils of unclean milk and to the sanitary standards of farmer and consumer. Nothing less than a national campaign can make the vivid impression necessary to wean dairymen of uncleanly habits and mothers of the ignorant superstition that babies die in summer just because they are babies. When two national bureaus study, learn, and report, newspapers will print their stories on the first page, magazines will herald the conclusions, physicians will open their minds to new truths, state health secretaries will carry on the propaganda, demagogues and quacks will become less certain of their short-cut remedies, and _everybody will be made to think_. The evolution of this newly awakened national interest in clean milk follows the seven stages and illustrates the seven health motives presented in Chapter II. I give the story of Robert M. Hartley because he began and prosecuted his pure-milk crusade in a way that can be duplicated in any country town or small city. Robert M. Hartley was a strong-bodied, strong-minded, country-bred man, who started church work in New York City almost as soon as he arrived. He distributed religious tracts among the alleys and hovels that characterized lower New York in 1825. Meeting drunken men and women one after another, he first wondered whether they were helped by tracts, and then decided that the mind befogged with alcohol was unfit to receive the gospel message. Then for fifteen years he threw himself into a total-abstinence crusade, distributing thousands of pamphlets, calling in one year at over four thousand homes to teach the industrial and moral reasons for total abstinence. Finally, he began to wonder whether back of alcoholism there was not still a dark closet that must be explored before men could receive the message of religion and self-control. So in 1843 he organized the New York Association for Improving the Condition of the Poor, which ever since has remembered how Hartley found alcoholism back of irreligion, and how back of alcoholism and poverty and ignorant indifference he found indecent housing, unsanitary streets, unwholesome working conditions, and impure food. [Illustration: FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS IN THE HEART OF NEW YORK CITY,--JUNIOR SEA BREEZE] [Illustration: PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK TO THE INDIVIDUAL BABY'S NEED,--ROCHESTER'S MODEL DAIRY] Hartley's instinct started the first great pure-milk agitation in this country. While visiting a distillery for the purpose of trying to persuade the owner to invest his money in another business, he noticed that "slops smoking hot from the stills" were being carried to cow stables. He followed and was nauseated by the sights and odors. Several hundred uncleaned cows in low, suffocating, filthy stables were being fed on "this disgusting, unnatural food." Similar disgust has in many other American cities caused the first effort to better dairy conditions. Hartley could never again enjoy milk from distillery cows. Furthermore, his story of 1841 made it impossible for any readers of newspapers in New York to enjoy milk until assured that it was not produced by distillery slops. The instinctive loathing and the discomfort of buyers awakened the commerce motives of milk dealers, who covered their wagons with signs declaring that they "no longer" or "never" fed cows on distillery refuse. But Hartley could not stop when the anti-nuisance stage was reached. He did not let up on his fight against impure or adulterated milk until the state legislature declared in 1864 that _every baby, city born or country born, no matter how humble its home, has the right to pure milk_. +-------------------------------------------------------------------+ | =Clean Milk for New York City= | | | | =CONFERENCE= | | | | =ROOM 44, N.Y. ACADEMY OF MEDICINE= | | =No. 17 WEST 43D STREET= | | | | =November 20th, 1906, Tuesday 3 p.m. and 8 p.m.= | | | | | | =ESSENTIAL FACTS AS TO NEW YORK CITY= | | | | =Manhattan's Infant Mortality= | | (=UNDER 5 YRS.=) | | | | June to September, 1904, 4428 | | June to September, 1905, 4687 | | June to September, 1906, 4428 | | | | =Daily Consumption of Milk= | | | | 1,600,000 qts. | | ¼ in quart bottles | | ¾ in 40-quart cans | | "Certified," 10,000 quarts | | "Inspected," 3,000 quarts | | 24 to 48 hours old on arrival | | | | =Comes from= | | | | 30,000 dairies, 40 to 400 miles distant | | 600 creameries--105 proprietors | | 10 city railroad depots | | | | =Sold in= | | | | 12,000 places, mostly from cans | | Sale of skim milk prohibited | | | | =Milk Law Violations, 1905= | | | | Destroyed, 39,618 quarts | | Arrests, 806 | | Fines, $16,435 | | | | =New York City Inspectors= | | | | 14 in country since July; might make rounds not oftener than | | once a year | | (For 3 yrs. before, only 2; previously none) | | 16 in city, might make rounds in 30 to 40 days | | (Before July, 14) | | | | | | =POINTS OF AGREEMENT= | | | | =Cleanliness is the supreme requisite, from cow to consumer= | | | | Cows must be healthy, persons free from contagious diseases, | | premises clean, water pure, utensils clean, cans and bottles | | sterile, shops sanitary | | | | =Temperature is second essential= | | | | 50° F. or lower at dairy | | 45° F. at creamery | | 45° F. or less during transportation | | Not above 50° when sold to the consumer | | | | =As to Pasteurization= | | | | Not necessary for absolutely clean milk | | Destroys benign as well as harmful germs | | Disease germs develop more rapidly than in pure raw milk | | True, 155° for 30 minutes to 167° for 20 minutes | | Cost per quart, estimated, ¼ to ½ ct. | | Commercial, 165° for 15 seconds | | Cost per quart, negligible | | | | =As to Inspection= | | | | _Some_ inspection needed within the city | | _Some_ inspection needed of dairy and creamery | | | | | | =WHAT NEXT STEPS SHOULD NEW YORK TAKE?= | | | | =Skim Milk= | | | | Should its sale be permitted? | | Under what conditions? | | How would this affect price of whole milk? | | | | =Pasteurization= | | | | Should pasteurization be made compulsory? | | For what portion of the supply? | | At whose expense? | | Would it increase price of milk? | | Does it render inspection unnecessary? | | Does it reduce need for inspection? | | Should sale of repasteurized milk or cream be permitted? | | Should bottles show whether true or commercial pasteurization | | is used? | | | | =Infants' Milk Depots= | | | | Should they use pasteurized or clean milk? | | Are municipal depots desirable? | | Should private philanthropy support depots? | | How many depots would be required in New York City? | | Is Rochester experience applicable to New York City? | | What educational work is possible in connection with milk | | depots? | | | | | | =Model Milk Shops= | | | | What may safely be sold in connection with milk? | | Should law discourage other than model shops? | | Are present sanitary laws rigid enough? | | Should private capital be encouraged to establish shops? | | Is it practicable to prohibit use of cans? | | What provision can be demanded for proper refrigeration? | | What for receiving milk before business hours when delivered | | from stations? | | What for sterilization of utensils and bottles? | | What for attendants' dress and care of person? | | Would such restrictions increase price? | | | | =Inspection= | | | | Is it practicable by inspection alone to secure a clean milk | | supply? | | Will it protect against more dangerous forms of infection? | | How many inspectors does New York City need? | | Within the city? | | Among country dairies and creameries? | | How many inspectors should the state employ? | | | | =Legislation= | | | | What needed as to diseased cattle? | | What as to diseases of persons producing or handling milk? | | Is present sanitary code sufficient? | | Shall law require sterilization of all milk cans and bottles | | by milk company or creamery before returned to farms or | | refilled? | | Shall sealing cans at creameries be required? | | Shall transferring from one can to another or from can to | | bottle in open street be made a misdemeanor? | | Shall pollution of milk cans and bottles be made a | | misdemeanor? | | Shall bacterial standard be established? | | Is state supervision now adequate? | | What further legislation is needed? | | Does present law prescribe adequate penalties? | | | | =Education= | | | | Should state system of lectures before agricultural institutes | | be extended? | | Should Maryland plan of traveling school be adopted as means | | of reaching producer? | | What can be done to assist Teachers College in its plan for | | milk exhibit? | | What can be done to teach mothers to detect unclean milk and | | to care properly for milk purchased? | | How can tenement mothers keep milk at proper temperature? | | Can nothing be done to increase the supply and cheapen the | | price of ice? | | Is it desirable that a local committee be formed to coöperate | | with the Department of Health and County Medical Society? | +-------------------------------------------------------------------+ Unfortunately Hartley and his contemporaries had never heard of disease germs that are carried by unclean milk into the human stomach. Science had not yet proved that many forms of barnyard filth could do quite as much harm as distillery refuse. Commerce had not invented milk bottles of glass or paper. The law of 1864 failed in two particulars: (1) it did not demand cleanliness from cow to consumer; (2) it did not provide means for its own enforcement, for learning whether everything and everybody that had to do with milk was clean. Not knowing of germs and their love for a warm climate and warm food, they naturally did not prohibit a temperature above fifty degrees from the time of milking to the time of sale. How much has been left for our generation to do to secure pure milk is illustrated by the opening sentence of this chapter, and more specifically by the programme of a milk conference held in New York in November, 1906, the board of health joining in the call. The four-page folder is reproduced in facsimile (excepting the names on the fourth page), because it states the universal problem, and also because it suggests an effective way to stimulate relevant discussion and to discourage the long speeches that spoil many conferences. This conference led to the formation of a milk committee under the auspices of the association founded by Hartley. Business men, children's specialists, journalists, clergymen, consented to serve because they realized the need for a continuing public interest and a persisting watchfulness. Such committees are needed in other cities and in states, either as independent committees or as subcommittees of general organizations, such as women's clubs, sanitary leagues, county and state medical societies. Teachers' associations might well be added, especially for rural and suburban districts where they are more apt than any other organized body to see the evils that result from unclean milk. The New York Milk Committee set a good example in paying a secretary to give his entire time to its educational programme,--a paid secretary can keep more volunteers and consultants busy than could a dozen volunteers giving "what time they can spare." Thanks chiefly to the conference and the Milk Committee's work, several important results have been effected. The general public has realized as never before that two indispensable adjectives belong to safe milk,--_clean_ and _cool_. Additional inspectors have been sent to country dairies; refrigeration, cans, and milk have been inspected upon arrival at night; score cards have been introduced, thanks to the convincing explanations of their effectiveness by the representatives of the Bureau of Animal Industry of the national Department of Agriculture; 8640 milch cows were inspected by veterinary practitioners (1905-1907), to learn the prevalence of bovine tuberculosis (of these thirty-six per cent reacted to the tuberculin test); state societies and state departments have been aroused to demand an efficient live-stock sanitary board; magistrates have fined and imprisoned offenders against the milk laws, where formerly they "warned"; popular illustrated milk lectures were added to the public school courses; illustrated cards were distributed by the thousand, telling how to keep the baby well; finally, private educational and relief societies, dispensaries, settlements, have been increasingly active in teaching mothers at home how to prepare baby's milk. In 1908 a Conference on Summer Care of Babies was organized representing the departments of health and education, and fifty private agencies for the care of sick babies and the instruction of mothers. The superintendent of schools instructed teachers to begin the campaign by talks to children and by giving out illustrated cards. Similar instructions were sent to parochial schools by the archbishop. [Illustration: NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN NEW YORK CITY] As elsewhere, there are two schools of pure-milk crusaders: (1) those who want cities to _do things_, to pasteurize all milk, start milk farms, milk shops, or pure-milk dispensaries; and (2) those who want cities and states to _get things done_. So far the New York Milk Committee has led the second school and has opposed efforts to municipalize the milk business. The leader of the other school is the noted philanthropist, Nathan Strauss, who has established pasteurization plants in several American and European cities. The discussion of the two schools, similar in aim but different in method, is made more difficult, because to question philanthropy's method always seems to philanthropy itself and to most bystanders an ungracious, ungrateful act. As the issue, however, is clean milk, not personal motive, it is important that educators and parents in all communities benefit from the effective propaganda of both schools, using what is agreed upon as the basis for local pure-milk crusades, reserving that which is controversial for final settlement by research over large fields that involve hundreds of thousands of tests. [Illustration: A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND SCHOOL FOR MOTHERS] Pasteurization, municipal dairies, municipal milk shops, municipal infant-milk depots, are the four chief remedies of the _doing things_ school. European experience is cited in support of each. We are told that cow's milk, intended by nature for an infant cow with four stomachs, is not suited, even when absolutely pure, to the human infant's single stomach. Cow's milk should be modified, weakened, diluted, to fit the digestive powers of the individual infant; hence the municipal depot or milk dispensary that provides exactly the right milk for each baby, prescribed by municipal physicians and nurses who know. That the well-to-do and the just-past-infancy may have milk as safe as babies receive at the depot, municipalization of farm and milk shop is advocated. Some want the city to run only enough farms and milk shops to set a standard for private farmers, as has been done in Rochester. This is city ownership and operation for educational purposes only. Finally, because raw milk even from clean dairies may contain germs of typhoid, scarlet fever, or tuberculosis, pasteurization is demanded to kill every germ. There are advocates of pasteurization that deprecate the practice and deny that raw milk is necessarily dangerous; they favor it for the time being until farms and shops have acquired habits of cleanliness. Likewise many would prefer private pasteurization or laws compelling pasteurization of all milk offered for sale; but they despair of obtaining safe milk unless city officials are held responsible for safety. Why wait to discuss political theories about the proper sphere for government, when, by acting, hundreds of thousands of lives can be saved annually? These methods of _doing things_ will not add to the price of milk; it is, in fact, probable that the reduction in the cost of caring for the sick and for inspecting farms and shops will offset the net cost of depots, farms, and dairies. [Illustration: ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS] [Illustration: ROCHESTER'S MODEL DAIRY FARM] As to pasteurization, its cost is negligible, while the cost of cleanliness is two, four, or ten cents a quart. Whether ideally clean milk is safe or not, raw milk that is not clean is unfit for human consumption. All cities should compel evidence of pasteurization as a condition of sale. Large cities should have their own pasteurizing plants, just as many cities now have their own vaccine farms and antitoxin laboratories. Parents in small towns and in the country should be taught to pasteurize all milk. The _getting things done_ school admits the need for modified milk of strength suited to the infant's stomach; affirms the danger of milk that contains harmful germs; demands educational work by city, state, and nation; confesses that talk about cleanliness will not make milk safe. On the other hand, it denies that raw milk is necessarily dangerous; that properly modified, clean, raw milk is any safer when pasteurized; that talking about germ-proof milk insures germ extinction. It maintains that pasteurization kills benign germs essential to the life of milk, and that after benign germs are killed, pasteurized milk, if exposed to infection, is more dangerous than raw milk, for the rapid growth of harmful germs is no longer contested by benign germs fighting for supremacy. While it is admitted that raw milk produced under ideal conditions may become infected by some person ignorant of his condition, and before detection may cause typhoid, scarlet fever, or consumption, it has not been proved that such instances are frequent or that the aggregate of harm done equals that which pasteurized milk may do. Pasteurization does not remove chemical impurities; boiling dirt does not render it harmless. The remedy for germ-infected milk is to keep germs out of milk. The remedy for unclean milk is cleanliness of cow, cow barn, cowyard, milker, milk can, creamery, milk shop, bottle, nipple. If the sale of unclean milk is prevented, farmers will, as a matter of course, supply clean milk. By teaching farmers and milk retailers the economic advantages of cleanliness they will cultivate habits that guarantee a clean milk supply. By punishing railroads and milk companies that transport milk at a temperature which encourages germ growth, and by dumping in the gutter milk that is offered for sale above 50 degrees, the refrigerating of milk will be made the rule. Purging magistrates' courts of their leniency toward dealers in impure, dangerous milk is better than purging milk of germs. Boiling milk receptacles will save more babies than boiling milk. Teaching mothers about the care of babies will bring better results than giving them a false sense of safety, because only one of many dangers has been removed by pasteurization. Educating consumers to demand clean milk and to support aggressive work by health departments leaves fewer evils unchecked than covering up uncleanliness by pasteurization. [Illustration: NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF SHOWING BABIES' PROGRESS] [Illustration: PRODUCING WINTER CONDITIONS IN MIDSUMMER BY PROPER REFRIGERATION FOR MILK IN FREIGHT CARS] When doctors disagree what are we laymen to do? We can take an intelligent interest in the inquiries that are now being made by city, state, and national governments. Because everybody believes that clean milk is safer than unclean milk, that milk at 50 degrees will not breed harmful germs, we can demand milk inspection that will tell our health officers and ourselves which dealers sell only clean milk at 50 degrees and never more than 60 degrees, that never shows over 100,000 colonies to the cubic centimeter. We can get our health departments to publish the results of their scoring of dairies and milk shops in the papers, as has been done in Montclair. We can tell our health officers that the best results in fighting infant mortality are at Rochester, which city, winter and summer, by inspection, correspondence, and punishment, educates farmers and dealers in cleanliness, not only censuring when dirty or careless, but explaining how to make more money by being clean. Finally, mothers can be taught at home how to cleanse the bottles, the nipples, all milk receptacles, and all things in rooms where milk is kept. Absolutely clean milk of proper temperature _at the shop_ may not safely be given to a baby in a dirty bottle. Infant milk depots, pasteurization, the best medical and hospital care, breast feeding itself, cannot prevent high baby mortality if mothers are not clean. The most effective volunteer effort for pure milk is that which first makes the health machinery do its part and then teaches, teaches, teaches mothers and all who have to do with babies. [Illustration: NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS] "Clean air, clean babies, clean milk," has been the slogan of Junior Sea Breeze,--a school for mothers right in the heart of New York's upper East Side. In the summer of 1907 twenty nurses went from house to house telling 102,000 mothers how to keep the baby well. This was the only district that had fewer baby deaths than for 1906. Had other parts of the city shown the same gain, there would have been a saving of 1100 babies. The following winter a similar work was conducted by nurses from the recently founded Caroline Rest, which has an educational fund for instruction of mothers in the care of babies, especially babies not yet born and just born. Heretofore the baby has been expected to cry and to have summer complaint before anybody worried about the treatment it received. If the baby lived through its second summer, it was considered great good fortune. Junior Sea Breeze and Caroline Rest start their educational work before the baby is sick, in fact, before it is born. Their results have been so notable that several well-to-do mothers declare that they wish they too might have a school. Dispensaries and diet kitchens and more particularly maternity wards of hospitals, family physicians, nurses, and midwives, should be required to know how to teach mothers to feed babies regularly, the right quantities, under conditions that insure cleanliness whether the breast or the bottle is used. Perhaps some day no girl will be given a graduating certificate, or a license for work, teaching, or marriage, until she has demonstrated her ability to give some mother's baby "clean air, clean body, clean milk." FOOTNOTES: [15] Libraries should obtain all reports on milk, Bureau of Animal Industry, Washington, D.C. CHAPTER XXVI PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER No profession, excepting possibly the ministry, is regarded with greater deference than the medical profession. Our ancestors listened with awe and obedience to the warnings and behests of the medicine man, bloodletter, bonesetter, family doctor. In modern times doctors have disagreed with each other often enough to warrant laymen in questioning the infallibility of any individual healer or any sect, whether homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day most of us surround the medical profession or the healing art with an atmosphere of necromancy. Even after we have given up faith in drugs or after belief is denied in the reality of disease and pain, we revere the calling that concerns itself, whether gratuitously or for pay, with conquering bodily ills. Self-laudation continues this hold of the medical profession upon the lay imagination. One physician may challenge another's faults, ridicule his remedies, call his antitoxin dangerous poison, but their common profession he proudly styles "the most exalted form of altruism." Young men and women beginning the study or the practice of medicine are exhorted to continue its traditions of self-denial, and in their very souls to place human welfare before personal or pecuniary advancement. Newspapers repeat exhortation and laudation. We laymen pass on the story that we know is not universally true,--physicians know, physicians apply what they know without consciousness of error, physicians must be implicitly trusted. For a physician to give poison when he means to give food is worse, not better, than for a layman to make the same mistake. Neither the moral code nor the law of self-preservation enjoins a tuberculous mother to take alcohol or to sleep in an unventilated room, even if an uninformed physician prescribes it. Instruction in physiology and hygiene would be futile if those who are educated as to the elementary facts of hygiene and physiology must blindly follow blind physicians. A family doctor who gives cod-liver oil for anæmia due to adenoids may do a child as much harm as a nurse who drugs the baby to make it sleep. The physician who refuses to tell the board of health when smallpox or typhoid fever first breaks out takes human life just as truly as if he tore up the tracks in front of an express train. This is another way of saying that parents and teachers must fit themselves to know whether the family physician and their community's physicians are efficient practitioners and teachers. Every one can learn enough about the preventable causes of sickness and depleted vitality to insist upon the ounce of education and prevention that is better than a pound of cure. For its sins of omission, as for its sins of commission, the medical profession shares responsibility with laymen. For years leading educators, business men, hospital directors, public officials, have known that communicable diseases could be stamped out. The methods have been demonstrated. There is absolutely no excuse to-day for epidemics of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet fever in the small towns of Minnesota, for uninterrupted epidemics of tuberculosis everywhere. Had either laymen, physicians, or school-teachers made proper use of the knowledge that has been in text-books for a generation, this country would be saving thousands of lives and millions of dollars every year. Our _doing_ and _getting done_ have lagged behind our _knowing_. The failure of physicians to "socialize" or "humanize" their knowledge is due to two causes: (1) no one has been applying _result tests_ to the profession as a whole and to the state in its capacity as doctor, testing carefully the sickness rate, the death rate, and the expense rate of preventable diseases; (2) physicians themselves have not needed to know, either at college or in practice, the tax levied upon their communities by preventable sickness. Public schools can do much to secure result tests for individual physicians, for the profession as a whole, and for boards of health. Schooling in preventive medicine, or, better named, schooling in preventive hygiene, will fit physicians to do their part in eradicating preventable disease. Preventive hygiene is not an essential part of the training of American physicians or nurses to-day. Not only are there no colleges of preventive hygiene, but medical schools have not provided individual courses. It is possible for a man to graduate with honors from our leading medical colleges without knowing what "vital statistics" means. Even boards of health, their duties and their educational opportunities, are not understood by graduates; it is an accident if the "social and economic aspects of medical practice," "statistical fallacies," "hospital administration," "infant mortality," are familiar terms. It is for this reason, rather than because physicians are selfish, that indispensable and beneficent legislation is so generally opposed by them when the prerogatives of their profession seem in danger. Practically every important sanitary advance of the past century has been fought at the outset by those whose life work should have made them see the need. Physicians bitterly attacked compulsory vaccination, medical inspection of schools, compulsory notification of communicable diseases. What is perhaps more significant of the physician's indifference to preventive hygiene is the fact that most of the sanitary movements that have revolutionized hygienic conditions in America owe their inception and their success to laymen, for example, tenement-house reform, anti-child labor and anti-tuberculosis crusades, welfare work in factories, campaigns for safety appliances, movement for a national board of health, prison, almshouse, and insane-asylum reform, schools for mothers, and milk committees. The first hospital for infectious diseases, the first board of health, the first out-of-door sea-air treatment of bone tuberculosis in the United States, were the result of lay initiative. Dr. Hermann M. Biggs says that in America the greatest need of the medical profession and of health administration is training that will enable physicians and lay inspectors to use their knowledge of preventive hygiene for the removal of living and working conditions that cause preventable sickness. A physician without knowledge of preventive hygiene is simply doing a "general repair" business. For a few months in 1907 New York City had a highly efficient commissioner of street cleaning, who, in spite of the unanimous protests and appeals of the press, refused to give up the practice of medicine. Hitherto the board of health of that city has been unable to obtain the full time of its physicians because professional standards give greater credit to the retail application of remedies than to the wholesale application of preventives. Statesmanship as well as professional ability is expected of physicians in the leading European cities, more particularly of those connected with health departments. There it is not felt that a medical degree is of itself a qualification for sanitary or health work. After the professional course, physicians must take courses in preventive hygiene and in health administration. Medical courses include such subjects as vital statistics, duties of medical officers of health, sanitary legislation, state medicine. The needless cost for one year of "catching" diseases in New York City would endow in perpetuity all the schools and lectureships and journals necessary to teach preventive hygiene in every section of this great country. That city alone sacrifices twenty-eight thousand lives annually to diseases that are officially called preventable. The yearly burial cost of these victims of professional and community neglect is more than a million dollars. When to the doctor bills, wages lost, burial cost of those who die are added the total doctor bills, wages lost, and other expenses of the sick who do not die, we find that one city loses in dollars and cents more every year from communicable diseases than is spent by the whole United States for hospitals and boards of health. Many diseases and much sickness are preventable that are not communicable. Indigestion due to bad teeth is not itself communicable, but it can be prevented. One's vitality may be sapped by irregular eating or too little sleep; others will not catch the trouble, although too often they imitate the harmful habits. Adenoids and defective vision are preventable, but not contagious. Spinal curvature and flat foot are unnecessary, but others cannot catch them. Preventive hygiene, however, should teach the physician's duty to educate his patient and his community regarding all controllable conditions that injure or promote the health. In the absence of special attention to preventive medicine new truth is forced to fight its way, sometimes for generations, before it is accepted by the medical profession. So strong are the traditions of that profession and so difficult is it for the unconventional or heterodox individual to retain the confidence of conservative patients, that the forces of honorable medical practice tend to discourage research and invention. The man who discovers a surgical appliance is forced by the ethics of his profession either to commercialize it and lose his professional standing, or to abide the convenience of his colleagues and their learned organizations in testing it. Rather than be branded a quack, charlatan, or crank, the physician keeps silent as to convictions which do not conform to the text-books. Many a life-saving, health-promoting discovery which ought to be taken up and incorporated into general practice from one end of the country to the other, and which should be made a part of the minimum standard of medical practice and medical agreement, must wait twenty-five or fifty years for recognition. [Illustration: THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS STILL AN OUTCAST IN SCORES OF HOSPITALS] For want of a school of preventive medicine to emphasize universally every new truth, the medical colleges are permitted to remain twenty-five or fifty years behind absolutely demonstrated facts as to medical truth and medical practice. In 1761 a German physician, Avenbruger, after discovering that different sounds revealed diseased tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815 Lëannec discovered that sound from the chest was more distinct through a paper horn. On that principle the modern stethoscope is built. He made an accurate diagnosis of tuberculosis, and while suffering from that disease treated himself as a living clinical study. In 1857 Pasteur proved the presence of germs "without which no putrefaction, no fermentation, no decay of tissue takes place." In 1884 Trudeau started the first out-of-door care of pulmonary tuberculosis in America. In 1892 Biggs secured the compulsory notification of pulmonary tuberculosis. In 1904 began our first out-of-door sea-air treatment for bone tuberculosis. Yet there are thousands of physicians to-day who sincerely believe that they are earning their fees, who, from houses shut up like ovens, give advice to patients for treatment of tuberculosis, who prescribe alcohol and drugs, who diagnose the disease as malaria for fear patients will be scared, who oppose compulsory registration, and who never look for the tuberculous origin of crippled children. Just think of its being possible, in 1908, for a tuberculous young man of thirty to pay five dollars a day to a sanatorium whose chief reliance is six doses of drugs a day! In 1766 America's first dentist came to the United States. By 1785 itinerant dentists had built up a lucrative practice. In 1825 a course of lectures on dentistry was delivered before the medical class at the University of Maryland. As early as 1742 treatises were written "Upon Dentition and the Breeding of Teeth in Children." In 1803 the possibility of correcting irregularities was pointed out, as was the pernicious effect of tartar on the teeth in 1827. In 1838 attempts were made to abolish, "in all common cases, the pernicious habit of tooth drawing." In 1841 treatises were written on the importance of regulating the teeth of children before the fourteenth year and on the importance of preserving the first teeth. Yet in 1908 it is necessary to write the chapter on Dental Sanitation. Few physicians, whether in private practice or hospitals or just out of medical college, consider it necessary to know the conditions of the mouth before prescribing drugs for physical illness. Osteopathy furnishes an up-to-date illustration. Discredited by the medical profession, by medical journals and medical schools, it has in fifteen years built up a practice of eight thousand men, having from one to three years' training, including over one hundred physicians with full medical training plus a course in osteopathy. There were means of learning fifteen years ago what was truth and what was quackery about the practice of osteopathy. By refusing to look for its truth and by concentrating attention upon its quackery the medical profession has lost fifteen years. Whereas the truth of osteopathy should have been adopted by the medical colleges and a knowledge of its possibilities and limitations required of every practicing physician, a position has been reached where alleged quackery seems in several important points to be discrediting the sincerity, the intelligence, and the efficiency of orthodox medicine. No appeal to the natural can be stronger, no justification of schools of preventive medicine more complete, than the following paragraph from an osteopathic physician who is among the small number who, having both the medical and osteopathic degrees, see both the possibilities and limitations of manual surgery and demand the inclusion of this new science in the medical curriculum. The physical method of treating disease presents a tremendous and significant departure from the empiricism of medicine and the experimentation of dietetics, the restricted fields of electricity, suggestion, water cures, and massage. The patient as an individual is not treated; the disease as a disease is not treated; the symptoms are not treated; but the entire physical organism, with its many parts and diverse functions, is exhaustively examined until each and every abnormal condition, whether of structure or of function, causing disease and maintaining symptoms, is found and administered to with the skill of a definite art, based upon the data of an exact science. Likewise the truths underlying Christian Science have been disdained by medical schools and medical experts, just as its spiritual truth has been disdained by religious leaders, until it has grown to such strength that laymen are almost forced to question the sincerity and the efficacy of the conventional in religion as well as medicine. In May, 1907, the Emmanuel Church in Boston organized a clinic for the purpose of utilizing for neurasthenics particularly both the spiritual and the physical truths underlying religion and the various branches of medical science. Daily papers and magazines are giving a great deal of space to this experiment in "psychotherapy," which is discussed in the chapter on Mental Hygiene. Schools and chairs in preventive hygiene would soon give to the medical profession a point of view that would welcome every new truth, such as the alliance of religion and medicine, and estimate its full worth promptly. Truth seeking would be not only encouraged but made a condition of professional standing. Just what attitude any particular physician takes can be learned by the teacher or parents whose children he treats. If he pooh-poohs or resents board of health regulations as to isolation of scarlet-fever patients, he is a dangerous man, no matter how noble his personal character. If he says cross-eyes will straighten, weak eyes will strengthen, or nose-stopping adenoids "absorb," he is bound to do harm. If he says tuberculosis is incurable, noncommunicable, hereditary, or curable by drugs, or if he tries to cure cancer by osteopathy, he can do more injury than an insane criminal. If he fails to teach a mother how to bathe, feed, and clothe the baby, how to ventilate a room for the sick or the well, he is an expensive luxury for family or for school, and belongs to an age that knew neither school nor preventive hygiene. If he takes no interest in health administration; if he overlooks unclean milk or unclean streets, open sewers, and unsanitary school buildings, street cars, churches, and theaters; if he does not help the health board, the public hospitals, the schools, the factory, and tenement departments enforce sanitary laws, he is derelict as a citizen and as a member of an "exalted profession." If he sees only the patients he himself treats or one particular malady, he is derelict as a teacher, no matter how charming his personality or how skilled in his specialty. If a school physician is slovenly in his work, if he spends fifteen minutes when he is paid for an hour, should the efficient school-teacher conceal the fact from her superiors because he is a physician? If private hospitals misrepresent facts or compromise with political evils for the sake of a gift of public money, their offense is more heinous because of their exalted purpose. The test of a physician's worth to his patients and to his community is not what he is or what he has learned, and not what his profession might be, but what happens to patient and to community. Human welfare demands that the medical profession be judged by what it does, not by what it might do if it made the best possible use of its knowledge or its opportunity. [Illustration: TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN Caroline Rest Educational Fund was given to show the value of such teaching] A dispensary that treats more patients than it can care for properly is no better than a street-car company that chronically provides too few seats and too many straps. Unless physicians test themselves and their profession by results, we shall be compelled to "municipalize the medical man." Preventable sickness costs too much, causes too much wretchedness, and hampers too many modern educational and industrial activities to be neglected. If the medical profession does not fit itself to serve general interests, then cities, counties, and states will take to themselves the cure as well as the prevention of communicable and other preventable sickness. Human life and public health are more precious than the medical profession, more important even than theories and traditions against public interference in private matters. The unreasoning opposition of medical men to government protection of health, their concentration on cure, and their tardy emphasis on prevention have forced many communities to stumble into the evil practices mentioned in Chapter XVI. Incidentally, the best physicians have learned that the prosperity of their profession increases with every increase in the general standard of living. It is the man in the ten-room house not the man in one room who supports physicians in luxury. It is the healthy man and the healthy community that value efficient medical service. Many American cities maintain dispensaries and hospitals for the poor. Whether they will go to the logical conclusion of engaging physicians to give free treatment to all regardless of income depends largely upon what the next generation of private physicians do. The state already says when a physician's training fits him to practice. It will soon expect him to pass rigid examinations in the social and economic aspects of his profession,--its educational opportunity, vital statistics, sick and death rates. Will it need to municipalize him in order to protect itself? Obviously the teacher or parent should not begin cooperation with physicians by lecturing them or by assuming that they are selfish and unwilling to teach. The best first step is to ask questions that they should be able to answer: What causes cholera morbus or summer complaint? When does milk harm the baby? How can unclean milk be made safe? Whose fault is it that the milk is sold unclean and too warm? What agencies help sick babies? What is the health board doing to teach mothers? Or, if a school physician, the teacher can ask: Why not remove these adenoids? What causes them? When will they disappear by absorption? What harm can they do in the meantime? How long would an operation take? Would it hurt very much? What would be the immediate effects? Why not act at once? What provisions are there in town for such operations? Why have the physicians paid so little attention to breathing troubles? What could your state do to interest physicians in school hygiene? Will the school physician talk to a mothers' meeting? What agencies will give outings to sick children? What dispensaries are accessible? Who is the proper person to organize a public health league? Physicians love to teach. If teachers and parents will love to learn and will ask the right questions, all physicians can be converted into hygiene missionaries, heralds of a statesmanship that guarantees health rights to all. LICENSING THE PRACTITIONER Three parties are interested in setting a high standard for physicians, dentists, druggists, nurses, and veterinary surgeons--the profession itself, the schools that educate, and the general public on whom the arts are practiced. The schools and the practitioners are, for the most part, primarily interested in protecting a monopoly of skill. Their interest in restrictive legislation is analogous to that of the labor union which limits the number of apprentices. This trade unionism among professional colleges and professional graduates of these colleges has gradually developed a higher and higher standard that results in greater protection to the public. The first step is generally to demand that all persons entering a profession after a given date shall prove to the state their ability to "practice" without injury to clients. It is almost impossible to get such laws through unless the original law exempts all persons by whatever name, who are practicing the art in question at the time the law is passed. Whether we are speaking of medicine, law, dentistry, accountancy, osteopathy, or barbering, this has been the history of compulsory restriction and of state examinations. As with regard to most other legislation, the enforcement of the law lags behind its definition. Moreover nothing is done after a man has passed a certain examination to see that he remains fit and safe to treat the public. Because no supervision is provided except on the day of examination, it is possible for men and women to fill their brains for a week or two weeks with the information necessary to pass what coaches and tutors have learned will, in all probability, be asked. Forever after, the public is left to protect itself. Out of this condition have arisen the evil, unethical, and unprofessional practices represented particularly by painless dentists, by ignorant or dishonest physicians, and by osteopaths and careless nurses. The machinery for preventing these evils is discussed in Chapter XXIX. Suffice it here to present to parents and teachers the need for examination in advance of certification that will show whether or not those who make a livelihood by caring for others' health are equipped to mitigate rather than aggravate evils, and for further tests by which the public can learn from time to time which, among those professional men who are protected by the public against competition, continue to be safe. Finally, if, as will be clearly seen, it is desirable that what we call professional ethics persist and that self-advertisement be discouraged, society must, for its own protection, adopt some other means than epithets to correct the evils of self-advertisement and quackery. Even though we admit the responsibility of each citizen when he goes to the house of a private practitioner who has made no other effort to lure him thither than to place a card in the window, it must be seen that we cannot hold responsible for their choice men and women who receive through newspapers, magazines, or circulars convincing notices that Dr. So-and-So or the Integrity Company or the Peerless Dental Parlor will place at their disposal, at prices within their reach, skill and devotion absolutely beyond their reach at the office of an efficient private practitioner. Some way must be found by which departments of health will currently impose tests of methods and results upon physicians, opticians, pharmacists, manufacturers of medicine, and dentists. As laymen become more intelligent regarding their own bodies and healthy living, it grows harder and harder for quacks and incompetents to mislead and exploit them. Better than any possible outside safeguard is hygienic living. Fortunately, we can all learn the simple tests of environment and of living necessary to the selection of physicians, dentists, and opticians, or other "architects of health" whose efficiency and integrity are beyond question. PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS CHAPTER XXVII DEPARTMENTS OF SCHOOL HYGIENE The term "school hygiene" generally suggests no other school than the public school. State laws say nothing about compulsory hygiene in military academies, ladies' seminaries, or other preparatory and finishing schools. Yet when one thinks of it, one must conclude that the right to health and to healthful school environment cannot equitably be confined to the children whose tuition is given at public expense. There is a better way to check "swollen" fortunes than by ruining the health of "fortune's children." The waste and danger of slow-minded, noticeably inefficient children are no less when parents are rich than when parents are poor. There is no justification for neglecting the health of children in parochial schools, in private schools for the well-to-do or rich, or in commercial schools for the ambitious youth of lower income strata. Nor has the commercial, parochial, private school, or college, any clearer right than the public school to injure or to fail to promote pupils' health. So far as school hygiene is advisable, so far as it is right to make hygiene compulsory, its personal and social benefits should be shared by children of school age without regard to income, and its laws should be enforced by all teachers, principals, and officers that have to do with school. In presenting a programme for school hygiene this chapter refers to the hygiene taught, the hygiene practiced, the hygiene not taught, and the hygiene not practiced in buildings and on grounds where children and youth are at school, whether these children are in kindergarten or high school, in reformatory or military academy, in charitable school, or in finishing and preparing center for society's juniors. The question of the local, state, and national machinery by which proper standards of school hygiene shall be made effective will be taken up after we have considered individual steps in a comprehensive programme for school hygiene. 1. _Thorough physical examination of all candidates for teachers' positions and periodic reëxamination of accepted teachers._ Teachers would be grateful to be told in time their own physical needs and the relations of their vitality to the vitality of their pupils. Are your teachers examined? Do they know the laws of health and the signs of child health? Are they permitted to continue in schoolrooms after tuberculosis is discovered? Are normal graduates given physical tests before being permitted to teach and before being permitted to give four years to preparation for teaching? 2. _Thorough physical examination of every single child in every single school upon entering and periodically during school life._ We believe a vast number of things that "ain't so" about the health of country children as compared with city children, of private-school children as compared with public-school children. Where do we find more degenerate men, physically and morally, than in so-called "American settlements," where, for generations, children have had all outdoors to play in, except when in homes and schoolhouses that are seldom cleansed and seldom ventilated? Open mouths and closed minds clog the "little red schoolhouse"; there headaches do not suggest eye strain; there deafness and running ears are frankly attributed to scarlet fever which everybody must have with all the other "catching" diseases, the earlier the better; there colds begin in December and run until March, to the serious injury of attendance and promotion records; there bone tuberculosis is called "knee trouble" or "spine trouble in the family"; there boys like my little friend Fred count the bottles of cod-liver oil they take to cure adenoids that could be removed in two minutes. The index to community life and community living conditions should be read in the country, not only for the country's sake, but also for the sake of the city whose milk and water, poisoned in the country, cause thousands of deaths annually, besides annual sick bills exceeding many times over the Russell Sage and Carnegie Foundations, which we rightly call munificent. Reading the index of private schools and colleges is important for their children and youth, but still more important for the community upon which unbridled passion, inability to work or to spend properly, inconsequential thinking, mediæval ideals of caste, etc., can inflict greater injuries than can typhoid fever or cholera. The physical record of each child should be kept from date of entrance to date of leaving school, showing condition at successive examinations, absence because of illness, etc. 3. _Thorough physical examination of children when leaving school, or when passing compulsory school age, as a condition to "working papers" and to "coming out."_ To give working papers to children seriously handicapped by physical defects is to buy future industrial trouble, hospital and poorhouse bills. A boy with adenoids, a girl with eye trouble, should not be permitted to begin the fight for self-support without at least being clearly shown that the correction of these defects will increase their earning power. At present a schoolgirl with incipient tuberculosis, or predisposed to that disease, can get working papers, go to a hammock or tobacco factory, work long hours, breathe bushels of dust, deplete her vitality, spread tuberculosis among her co-workers and home associates, infect a tenement,--and all this without any help or advice or any protection from society until she is too sick to work and her physician notifies the health department that she is a danger center. We may disagree about society's right to control a child's act after the defects are discovered, but who will question society's duty to tell that child and her parents the truth about her physical needs before it accepts her labor or permits her to "enter society"? 4. _Supervision by physicians of hygiene practiced in schoolrooms and on playgrounds._ Superintendent Maxwell, of New York City, and other educational leaders urge teachers to do their utmost to learn the physical conditions and home environment of the individual child, and to fit school treatment to the individual possibilities and handicaps. But experience proves conclusively that try as they will, teachers and principals have neither the special knowledge nor the time to acquire the special knowledge requisite to use the facts disclosed by the physical examination of school children. Physicians and nurses are needed, not so much for treating children, as for teaching children, parents, teachers, family and dispensary physicians. Private schools have visiting physicians who may be consulted; they need physicians to supervise, with power to examine or to require certificates of examination. The Committee on the Physical Welfare of School Children found that when a visitor was detailed for that purpose it was easy to secure the coöperation of parents, teachers, family physicians, dispensaries, school boards, and charitable societies. The Hawthorne Club's school secretary has been similarly successful in Boston, as have those of Hartley House, Greenwich House, and the Public Education Association in New York. 5. _Restriction of study hours at school and at home to limits compatible with health._ Whether the hours of study at school and at home are excessive cannot be learned from treatises on pedagogics or physiology. Because children differ in vitality as in ability to learn, the maximum limit for study hours should be determined by the individual child's physical condition. When the Japanese went to war with Russia the highest authority in the field was the army surgeon. To this fact was largely due the astonishingly small amount of sickness and the high fighting capacity and endurance of the Japanese, working under unfavorable conditions. No board of school superintendents or board of directors, no state superintendent of schools or college professor, has the right to compel or to allow study hours beyond the maximum compatible with the individual student's physical condition and endurance. The physician responsible for school hygiene should have an absolute veto upon any educational policy, method, or environment demonstrably detrimental to children's vitality. 6. _Establishment of a "follow-up" plan to insure action by parents to correct physical defects and to attend to physical needs._ The advantages of _getting things done_ over _doing things_ have been repeatedly emphasized. In smaller cities and in rural districts it is particularly important for schools to get things done better by existing local agencies, such as churches, health and street-cleaning departments, hospitals, clinics, medical and sanitary societies, trade unions, young people's societies, and women's clubs. Where parents who have been followed up and taught, obstinately or ignorantly refuse to attend to their children's needs, the segregation of the physically defective or needy will encourage the coöperation of children themselves in persuading parents to act intelligently for the child's sake. No child wants to remain "queer" or "dopey" or behind his peers. The city superintendent of schools for New York City has asked for laws compelling parents to permit operations and punishing them for neglecting to take steps, within their power, to remove physical defects discovered at school. [Illustration: TEACHING A MOTHER TO CARE FOR ONE CHILD INSURES BETTER CARE FOR ALL HER CHILDREN] 7. _Physiological age should influence school classification and school curriculum._ On this subject the studies of Dr. C. Ward Crampton, referred to in the chapter on Vitality Tests, are invaluable and as convincing as they are revolutionary. Scientists accept his proof that our present high school curriculum is ill adapted to a large proportion of children; the "physiologically too young" drop out; only the physiologically mature succeed. The two physiological ages should be given different work. Children whose bodies yearn for pictures, muscular and sense expression, should be given a chance in school for normal development. Analysis should wait for action. Organized play and physical training antedated physical examination in our schools. Like the curriculum they often disregard physiological age, doing harm instead of good. Facts as to physical condition and physiological development would enable us to utilize the momentum of these two to broaden school hygiene and to insure proper physical supervision. Only good would result from adopting Leipsic's plan of having school children examined without clothing, in the presence of parents if parents desire. Expensive? Not so expensive as high school "mortality" due to maladjusted curriculums that force the great majority of boys and girls to drop out before graduation and ruin the health of a large fraction of those who remain. 8. _Construction of school building and of curriculum so that, when properly conducted, they shall neither produce nor aggravate physical defects._ When the state for its own protection compels a child to go to school, it pledges itself not to injure itself by injuring the child. Thousands of children are now being subjected to conditions in school far more injurious than the factory and shop conditions against which the national and state child labor committees have aroused universal indignation. Two illuminating studies of school buildings in New York City were made last year by the Committee on the Physical Welfare of School Children, and later by the Board of Education. Similar studies should be made of every schoolroom. Whereas our discussions of buildings and curriculum have hitherto proceeded largely from abstract principles of light, ventilation, heating, and pedagogics, these two reports deal with rooms, equipment, courses of study, and school habits as they are, with obvious detrimental effects on child victims. Numerous questions that it is practicable to answer are given in Chapter XIV. What and when to build can be better determined after we have learned the what and the where of present equipment. In passing it is worth while to note that in large cities teachers are frequently forced to choose between bad ventilation and street noises. From Boston comes the suggestion that we avoid noises and evils of congestion by building schoolhouses for city children on the outskirts in the midst of fields, transporting, and, if necessary, feeding children at public expense. While it is true that the public funds now spent in attempting to cure physical and moral ills would purchase ample country reservations, the practical next step seems to be to provide ample play space and breathing space within the city for every school building already erected, and without fail for all buildings to be erected hereafter. 9. _Hygiene should be so taught that children will cultivate habits of health and see clearly the relation of health and vitality to present happiness and future efficiency._ Social rather than personal, public rather than private, health needs emphasis. Children can be shown how their health affects their neighbor; why money spent for health boards is a better investment than money given to corrupt politicians; that the cost of accepting Thanksgiving turkey or a park picnic from a political leader who encourages inefficient government is sickness, misery, deficient schooling, lifelong handicap; that children and adults have health rights in school and factory, on street and playground, which the law will protect if only they know when these rights are infringed. 10. _Central supervision of school hygiene._ In private and public, boarding and day, country and city, reformatory and military, commercial and high schools, the index--physical welfare of school children--should be read and interpreted. Headquarters should learn whether or not physical examinations are made and whether harmful conditions are corrected. So far as public schools are concerned, "headquarters" means for cities the fact center that informs city superintendent or school board; for rural schools, it means the county superintendent's office. Whether city or county headquarters have the facts and act accordingly should be known by state superintendents. Whether state superintendents are demanding the facts and educating the county and city headquarters of their states should be known to the national commissioner of education and by him published for all the world. Some people think the state health board should be responsible, others the state educational authority. The important thing is to make some one officer responsible. Methods can be easily worked out if the need is conceded. Legislatures will gladly confer the powers necessary to reading the index of all public schools. As for parochial and private schools, they may resent for a time public supervision of their hygiene teaching and practice. However, the case could be so presented that they would ask for it, because it would help not only their pupils and society but the schools themselves. No religious belief or private investment can afford to admit that it disregards child health; state supervision would require nothing more than evidence of adequate school hygiene. 11. _Information gained at school regarding conditions prejudicial to community health should be published and made the basis of an aggressive campaign for the enforcement of sanitary laws._ Ten thousand uses can be made of the information gained at school, ten thousand forces can be made to do educational work, but only a few kinds of work can be done effectively at school. Franklin Ford has said: "You can relate school to all life, but you cannot bring all life under the school roof." As Chapters XVI-XVIII make clear, to socialize the point of view of dispensaries and hospitals is more effective than to put clinics in school buildings. To _do for_ or _give to_ people who can help themselves is to _give up_ and _do up_ power of self-help. Machinery that must some day exist for the execution of this programme will be approximately the following: I. NATIONAL MACHINERY 1. Clearing house for facts regarding school hygiene as taught and practiced in all schools under the Stars and Stripes; this to be a part of the National Bureau of Education. 2. Scientific research to be conducted by the National Bureau of Education or by the future National Board of Health. II. STATE MACHINERY 1. Clearing house for facts regarding school hygiene taught and practiced in all schools within state limits; this to be maintained by the state educational authorities. 2. Agents to make special inquiries as to practice and teaching of school hygiene. 3. Agents to inspect and to instruct county superintendents, county physicians, teachers, normal schools, etc. 4. A bureau of experts--architect, sanitarian, teacher--whose approval must be obtained before any school building can be erected. (A plan which brought excellent results when applied by state boards to charitable institutions, hospitals for the insane, etc.) 5. Standard making by normal schools, state universities, hospitals, or other educational and correctional institutes under direct state management. III. COUNTY MACHINERY 1. Clearing house for facts regarding school hygiene taught and practiced in all schools within county limits; this to be maintained by the county superintendent of schools. 2. Physician and nurse to organize inspection and instruction for rural schools, to give lessons and make demonstrations at county institutes, to show teachers how to interest physicians, dentists, health officers, and parents in the physical welfare of school children. IV. TOWN AND TOWNSHIP MACHINERY 1. Teachers intelligent as to physical needs, as to sanitation of buildings, etc. 2. An examining physician, to be salaried where the population justifies; elsewhere to work as a volunteer in coöperation with teacher and with county physician. 3. Physical history of each child from date of entrance to date of leaving school, to be kept up to date by teacher. V. CITY MACHINERY 1. A division to be known as the Department of School Hygiene, headed by an officer who gives his entire time to that department. 2. A subcommittee of the Board of Education. 3. Clearing house for facts regarding school hygiene taught and practiced in all schools within city limits. 4. Specialists to examine applicants for teaching positions, and to reëxamine teachers to determine fitness for continuance, for promotion, and for special assignments. 5. A bureau for inspection and control of all hygiene of school buildings, old and new, with power to compel repairs or to reject plans that do not make adequate sanitary provision. 6. Similar supervision of curriculum and of study hours prescribed. 7. A bureau for the inspection and control of curriculum, required home study, exercise, physical training, etc., so far as relates to the health of pupils, and to the physical ability of children to be in certain grades or to be promoted. This will decide the duration of lessons, frequency of intermissions, sequence of subjects, time and method of recess throughout the various grades. 8. Supervision of indoor and outdoor playgrounds, roof gardens, indoor and outdoor gymnasiums, swimming pools, etc. 9. Supervision of instruction in school hygiene. 10. A staff of inspectors for communicable diseases of pupils and teachers, to be subject to the board of education or the board of health. 11. A staff of examiners adequate to examine all children and teachers at least once a year for defects of eye, ear, teeth, nose, throat, lungs, spine, bones, glands, etc., and for weight and height to be under the control of the board of education or the board of health. The expense would not be as great as the penalty paid for omitting such examination. 12. A staff of nurses to assist medical examiners to give children practical demonstrations in cleanliness, to teach mothers the care of children both at their homes and in mothers' meetings, to enlist the coöperation of family physician and neighborhood facilities, such as hospitals, dispensaries and relief agencies, magistrates' courts and probation officers,--all to be under the control of the board of education or the board of health. Whether inspectors, examiners, and nurses shall be directed by the board of education or the board of health is a question that it is impossible to decide without knowledge of local conditions. So far as state and county organizations are concerned, it is clear that whatever the boards of health may do, it will be necessary for state and county superintendents of education to equip themselves with the machinery above recommended. In cities it is quite clear that a board of education should be responsible for all of the machinery suggested, excepting the three divisions that have to do with work hitherto considered as protection against transmissible diseases, namely, inspection, examination, district visiting. In Cleveland these are school duties. In New York they are duties of the health department. Boston has school nurses and health department physicians. The state law of Massachusetts provides that where health boards do not examine school children, school boards may spend money for the purpose. As to inspection for transmissible diseases, it seems quite clear that health boards should not delegate their authority or responsibility to any other body, for they alone are accountable to their communities for protection against contagion. It is clear, too, that in the interest of community health, departments of health are justified in pointing out in advance of contagion those children most likely to become a menace. Similar grounds of public interest justify the health boards in sending nurses and physicians to the home as a means of getting things done. Dr. Biggs feels that responsibility for the physical welfare of school children will strengthen health work in all cities, and, given proper interest on the part of school officials, should make possible universal coöperation in a constructive programme. On the other hand, he believes that division of responsibility between school and health boards will weaken both in their appeals for funds and for support of a constructive programme. I have heard principals and superintendents maintain also that the moral effect of a visit to the school by a representative of the health board vested with powers of that board was much greater than a visit by a representative of the school board. They further allege that a physician coming from the outside is more apt to see things that need correction and less apt to accept excuses than an inspector who feels that he belongs to the same working group as the school-teacher. Because the follow-up work in the homes incident to successful use of knowledge gained at school involves so many sanitary remedies, it is theoretically better organization to hold the health authority responsible. CHAPTER XXVIII PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY Many of the elements of the machinery outlined in the preceding chapter already exist in New York City. All of them brought together, either by amalgamation or by proper coördination, would present a very strong front. Unfortunately, however, there is not only unsatisfactory team work, but the efficiency of individual parts is seriously questioned by the heads of the health and school departments. The inspection for contagious diseases, the examination for physical defects, the follow-up work by nurses and physicians, are in charge of the department of health. Physical training and athletics for elementary and high schools, winter recreation centers, and vacation playgrounds are under directors and assistants employed by the board of education. Heretofore inadequate powers and inadequate assistance for training or for research have been given to the physical director. The city superintendent of schools, in his report for the year 1907, presented to the board of education in January, 1908, declares that the "present arrangements have been inadequate.... In only 248 schools--less than half the total number--were any examinations for possible diseases made. In these 248 schools not more than one third of the pupils were examined. It is only a few months since any examinations for physical defects were made outside of the boroughs of Manhattan and The Bronx, and then only on account of the New York Committee on the Physical Welfare of School Children." As is so often the case, it is difficult to decide the merits of a method that has not been efficiently executed. The department of health has not hitherto done its best in its school relations. The commissioner of health, in a public interview, expresses resentment at the strictures by the school authorities. Yet in 1907 he permitted to accumulate an unexpended balance of $33,000 specifically voted for school inspectors, and repeatedly tried to have this amount transferred to other purposes. The interest of the Bureau of Municipal Research in municipal budgets that tell for what purposes money is voted and then prevent transfers without full publicity, preserved this particular fund. Moreover, the discussion that prevented its diversion from physical examinations strengthened the health department's interest in this important responsibility. Neither physicians nor nurses have been adequately supervised. Instead of seeing that defects were removed, the department of health sent out postal cards like the following: [Illustration: (Notice Example)] +-----------------------------------------------------------------------+ | "This Notice Does NOT Exclude This Child From School" | | | | DEPARTMENT OF HEALTH | | THE CITY OF NEW YORK | | | | _Oct. 2, 190_6_ | | | | The parent or guardian of ___________________________________________ | | of____________________________________attending P.S.__51___________ | | is hereby informed that a physical examination of this child seems to | | show an abnormal condition of the ___________________________________ | | ___Eyes, Nose, Throat and Teeth______________________________________ | | _____________________________________________________________________ | | Remarks__Is Anaemic__________________________________________________ | | _____________________________________________________________________ | | | | Take this child to your family physician for treatment and advice. | | Take this card with you to the family physician. | | | | THOMAS DARLINGTON, M.D., | | Commissioner of Health. | | | | HERMANN M. BIGGS, M.D., | | General Medical Officer | +-----------------------------------------------------------------------+ From 118,000 such notices sent out only 9600 replies were received, of which only one in twenty stated that attention had actually been given the needy child. The department had been satisfied with evidence that family physicians had advised parents properly, as in the case of the child above reported: [Illustration: (Card example)] +----------------------------------------------------------------------+ | TAKE THIS CARD TO YOUR PHYSICIAN | | | | The Physician in charge is requested to fill out and | | forward this postal after he has examined this child. | | | | I have this day examined ___________________________________________ | | of P.S. __51______________ and find the following condition: | | | | __As reported, Also enlarged (unclear) glands_______________________ | | and advised as follows:__operation for adenoids and tonsils_________ | | _____Dental treatment at Cornell. Fresh air ________________________ | | _____outing at Sea Breeze Eyes wait.________________________________ | | | | Respectfully yours, | | _______P.L. OB___________ | | Date __Oct. 9, 1906______ _________________________ | | | +----------------------------------------------------------------------+ For a candid, complete criticism of the medical examination work up to June, 1908, consult the report of the Bureau of Municipal Research, presented to the Washington Congress of Public Education Associations in October, 1908, by Commissioner of Health, Dr. Darlington. The bureau's study is entitled _A Bureau of Child Hygiene_, and, in addition to the story of medical examination in New York City schools, gives the blank forms adopted for use in September, 1908. Important as are the facts given in this study, its greatest value, its authors declare, is in its account of "the method of intelligent self-criticism and experiment which alone enables a public department to keep its service abreast of public needs." The Bureau of Municipal Research made its study for the purpose of learning whether the disappointing results emphasized by the school authorities were due to "dual responsibility in the school--that of the board of education and that of the department of health"--and to "lack of power or inclination to compel parents to remedy defects," or to _deficient administration_ of power and inclination by health officials. Coöperating with school physicians and nurses in three schools, 1442 children were examined, of whom 1345, or 93.2 per cent, had 3458 defects that needed treatment. The postal-card notice was followed by an interview with the parent either at school or at home. Only 4.2 per cent of the total number of parents refused to act, 81 per cent secured or permitted treatment for one or more defects, while 15 per cent promised to take the proper steps at the earliest possible date. Three fourths of the parents acted after one personal interview. "The net average result of a day's work by a nurse was the actual treatment of over five children, three of them completely, and two of them for one or more defects,"--sixty cents per child! [Illustration: A PHOTOGRAPH OF MOUTH BREATHING MAY MAKE COMPULSION UNNECESSARY] Having established the willingness--even eagerness--of parents to do all in their power to remove defects that handicapped their children, it was obviously the duty of the health department so to organize its work that it could insure the education of parents. The new Bureau of Child Hygiene gives foremost place to instruction of parents in care of babies, in needs of school children, and in the importance of physical examination when enlisting in the industrial army. Whether this work is well done is learned by result tests applied at headquarters, where work done and results are reported daily and summarized weekly. No longer will it be possible, without detection, for one physician to find only eye trouble and to neglect all other defects; for two inspectors examining different children in the same school to report results differing by 100 per cent; for physicians in different schools to find one 18 per cent, another 100 per cent with defects; for two inspectors examining identical children to agree on 51 out of 101 cases of vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases of skin disease. So conclusive were the results of follow-up work efficiently supervised by the department of health, that school officials are, for the present, inclined to waive the demand for the transfer of physicians and nurses to the board of education, and to substitute education for compulsion with parents who obstinately refuse to take proper remedial measures for their children when reported defective. This present plan requires the entire working time of inspectors and nurses for school work. Thus New York has for the present definitely abandoned the plan of having the district inspection for contagious diseases done by school physicians. The purpose of the change is not to reduce danger of infection, which was negligible, but to increase the probability of scientific attention to school children. Before a final settlement is made for New York City there should be tests showing what the school authorities would do if physicians and nurses were subordinate to them. It is conceivable that one physician working from nine to five would accomplish more than six physicians working the alleged three hours a day. So imperative are the demands of school hygiene that it seems probable that in New York and in other large cities school physicians, whether paid by the board of health or the board of education, must be expected to be at the service of school children, subject to the call of school officers, during as many hours of the day as teachers themselves must give. It is even conceivable that effective use of the knowledge gained by physical examinations of school children, and by those responsible for school hygiene, will require evening office hours or evening visits to homes, and regular Saturday office hours and Saturday visits by school physicians and nurses. Finally, it must be expected that the programme for school hygiene will need the special attention of physicians and nurses during the summer months, and other vacation periods when children and parents alike have time to receive and to carry out their instructions. One danger in New York City is that the board of education, like the board of health, when compelled to choose between so-called standard, necessary, traditional duty and school hygiene, will sacrifice the latter. The school authorities, without any more funds and without physicians and nurses, could already have made, had they desired, eye tests and breathing tests sufficiently accurate to detect the majority of children needing attention. The outcome of the discussion as to the jurisdiction of the two boards will undoubtedly be to interest both in their joint responsibility for children's welfare, and to increase the attention given by both to the physical condition of the child when he presents himself for registration as a wage earner. CHAPTER XXIX OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS The argument for _getting things done_ presumes adequate active machinery, official and private, for _doing things_ that schools are being urged to do. The chapter on Departments of School Hygiene suggests local, county, state, and national machinery necessary (1) to protect the child from injuries due to school environment, school methods, and school curriculum; (2) to getting those things done for the child at home and on the street, need for which is disclosed by physical and vitality tests at school. It is unreasonable to confine the school to the activities above outlined unless health machinery, adequate to the demands placed upon it by school and other community needs, is devised and kept in order. Generally speaking, adequate health machinery is already provided for by city charters and by the state laws under which villages, townships, and counties are organized. Quite as generally, however, machinery and methods of adequate administration are undeveloped. How much machinery has already been set to work by New York City is shown by the accompanying chart. A useful exercise for individuals or school classes wishing to study health administration would be to chart in this way the machinery actually at work in their locality, county, and state. Even for New York it should be remembered that this chart does not include national quarantine, the state protection of the port, the state dairy and health commissions, or the state and national food inspection. To get an idea of the vast amount of attention given to health in New York City there should be added to this chart the work of many departments other than the department of health. The building bureau, tenement-house department, board of water supply, sewage commission, street cleaning, public baths and comfort stations, the department of water, gas, and electricity, and finally the department of hygiene and physical training in the public schools. [Illustration: CHART SHOWING HOW NEW YORK CITY'S DEPARTMENT OF HEALTH EXERCISES IT'S AUTHORITY Courtesy of Bureau of Municipal Research] Five elements of adequate machinery are generally lost sight of: 1. The voter. 2. The nonvoter, subject to health laws and often apt to violate them. 3. The mayor, governor, or president who appoints health officers. 4. The council, board of aldermen, legislature, or congress that enacts health laws. 5. The police courts and the judiciary--police, circuit and supreme--that decide whether society has suffered from violation of law and what penalties should be inflicted for such violation. Legislative bodies have hitherto slighted their responsibilities toward public health. The chairman of a committee on public health of a state legislature was heard to remark, "I asked for that committee because there isn't a blooming thing to do." If voters, nonvoters, and health officials will follow the suggestion of this book to secure school and health reports that will disclose community and health needs, it will be increasingly difficult for legislators to refuse funds necessary to efficient health administration. To the courts tradition has required such deference that one hesitates to find out in how far they have been responsible in the past for the nonenforcement of health laws. Yet nothing is more obstructive of sanitary progress than the failure of magistrates to enforce adequate penalties for truancy, adulteration of milk, maintaining a public nuisance, defiling the air with black smoke, offering putrid meats for sale, running an unclean lodging house, defying tenement-house or factory regulations, working children under age and overtime, spitting in public places, or failing to register transmissible diseases.[16] The appointing officer cannot, of course, be held responsible unless voters and nonvoters know in how far his appointees are inefficient, and in how far he himself has failed to do his utmost to secure funds necessary to efficiency. Too frequently appointments to health positions have been made on political grounds, and catastrophes have been met by blundering incapacity. The political appointee has been made the scapegoat, and the appointing officer, whether mayor, governor, or president, has regained public confidence by replacing an old with a new incompetent. In order to have health machinery work properly, the appointing officer should not be allowed to shift responsibility for failure to his subordinates. For example, it was recently found in New York City that while the tenement-house commissioner was being condemned for failing to enforce the law, he had turned over to the corporation counsel, also appointed by the mayor, for prosecution ten thousand "violations" to which no attention whatever had been paid! The voter, nonvoter, appointing officer, legislative officer, and judicial officer determine the character and purpose of machinery and are analogous to the surveyors, stock-holders, directors, and constructors who provide railroads with tracks and with running stock. The actual running force of health department or railroad is what is meant by its official machinery. What this machinery should be depends, of course, upon the amount of business to be done, and differs with the size of the district and the character of population to be served. [Illustration: FOR PUSH-CART FOOD, INSPECTION IS PARTICULARLY NEEDFUL] Local health machinery should guarantee protection against the evils mentioned in preceding chapters. In general, one man is better than three to execute, although three may be better than one to legislate. Where small communities do not wish to have the entire state sanitary code rigidly administered, they can adopt New York's method of a legislative board of three members, headed by an executive, whose business it is to act, not talk; to watch subordinates, and to enforce rigidly and continuously ordinances passed by the board. The National Bureau of Census places under the general heading Health and Sanitation the following activities: health administration, street cleaning and refuse disposal, sewers and sewage disposal. Sanitarians generally emphasize also the health significance of efficient water service. A community's health programme should be clearly outlined in the annual budget. Where health work is given funds without specification of the kinds of work to be done, serious evils may be overlooked and lesser evils permitted to monopolize the energies of health officers. Again, after money has been voted to prevent an evil, records should be made of work done when done, and of money spent when spent, so that any diversion will be promptly made known. The best present guides to budget making, to educational health reports, and to records that show efficiency or inefficiency of health administrators are the budget and report of the department of health for New York City, and the story of their evolution told in _Making a Municipal Budget_, by the Bureau of Municipal Research. To find out whether local machinery is adequate, the reader must enumerate the things that need to be done in his community, remembering that in all parts of the United States to-day there are sanitary laws offering protection against dangers to health, excepting some dangers not understood until recently, such as child labor, dangerous trades, lack of safety devices. Adequate local protection, however, will not become permanent until adequate state machinery is secured. State health machinery should be of two kinds,--fact-gathering and executive supervision through inspection. The greatest service of state boards of health is to educate localities as to their own needs, using the experience of all communities to teach each community in how far its health administration menaces itself and its neighbors. In addition to registration of contagious diseases, facts as to deaths and births should be registered. State health boards should "score" communities as dairies and milk shops are now being scored by the National Bureau of Animal Industries and several boards of health. When communities persist in maintaining a public nuisance and in failing to enforce health laws, state health machinery should be made to accomplish by force what it has failed to accomplish by education. [Illustration: NATIONAL MACHINERY HAS STIMULATED LOCAL MILK INSPECTION AND STATE DAIRY INSPECTION] States alone can cope adequately with dangers to milk and water sources and to food. The economic motive of farmers has developed strong veterinary boards for the protection of cattle. Similar executive precaution must soon be taken by cities for the protection of babies and adults of the human species. It is far more economical to insure clean dairies, clean water sources, and wholesome manufactured foods by state inspectors than by local inspectors. At present the task of obtaining clean milk and clean water falls upon the few cities enlightened enough and rich enough to finance the inspection of community foods. Once tested, it would be very easy to prove that properly supported state health authorities will save many times the cost of their health work in addition to thousands of lives. County or district machinery is little known in America. For that reason rural sanitary administration is neglected and rural hospitals are lacking. In the British Isles rural districts are given almost as careful inspection as are cities. Houses may not be built below a certain standard of lighting, ventilation, and conveniences. Outbuildings must be a safe distance from wells. Dairies must be kept clean. Patients suffering from transmissible diseases may be removed by force to hospitals. What is more to the point, rural hospitals have proved that patients cared for by them are far more apt to recover than patients cared for much more expensively and less satisfactorily at home, while less likely to pollute water and milk sources or otherwise to endanger health. With national machinery the chapter on Vital Statistics has already dealt. We shall undoubtedly soon have a national board of health. Like the state boards, its first function should be educative. In addition, however, there are certain administrative functions where inefficiency may result in serious losses to nation, state, and locality. National quarantine, national inspection of meats, foods, and drugs are administrative functions of vital consequence to every citizen. Authorities are acquainted at the present time with the fact that the sanitary administration of the army and navy is unnecessarily and without excuse wasteful of human energy and human life. In the Spanish American War 14 soldiers died of disease for 1 killed in battle; in the Civil War 2 died of disease to 1 killed in battle; during the wars of the last 200 years 4 have died of disease for 1 killed in battle. Yet Japan in her war with Russia, by using means known to the United States Army in 1860, gave health precedence over everything else and lost but 1 man to disease for 4 killed in battle. Diseases are still permitted to make havoc with American commerce because the national government does not apply to its own limits the standards which it has successfully applied to Cuba and Panama. "The Japanese invented nothing and had no peculiar knowledge or skill; they merely took occidental science and used it. The remarkable thing is not what they did, but that they were allowed to do it. It is a terrible thing that Congress should choose to make one of its rare displays of economy in a matter where a few thousand dollars saved means, in case our army should have anything to do, not only the utterly needless and useless loss of thousands of lives, but an enormous decrease of military efficiency, and might, conceivably, make all the difference between victory and defeat." FOOTNOTES: [16] The technic and principles of municipal engineering have been treated in detail in _Principles of Sanitary Science and the Public Health_, by William T. Sedgwick, and in _Municipal Sanitation in the United States_, by Charles N. Chapin, M.D. CHAPTER XXX SCHOOL AND HEALTH REPORTS For every school-teacher or school physician responsible for the welfare of children at school, there are fifty or more parents responsible for the physical welfare of children at home. Therefore it is all important for parents to know how to read the index for their own children, for their children's associates, and for their community. School reports and health reports should tell clearly and completely the story of the school child's physical needs. [Illustration: NECESSARY TO EFFICIENT DEMOCRACY] It is impracticable at the present time to expect a large number of men and women to be interested in the reports published by school and health boards, for, with few exceptions, little effort is made to write these reports so that they will interest the parent. Fortunately, a small number of persons wishing to be intelligent can compel public officials to ascertain the necessary facts and to give them to the public. So backward is the reporting of public business that at the present time there is probably no service that a citizen can render his community which would prove of greater importance than to secure proper publicity from health and school boards. Generally speaking, these published reports fail to interest the citizen, not because officials wish to conceal, but because officials do not believe that the public is interested. A mayor of Philadelphia once furnished a notable exception. He called at the department of health and complained against publishing the number of cases of typhoid and smallpox lest stories in the newspapers "frighten the city and injure business." A sanitary inspector who was in the room asked if Philadelphia's business was more important than the health of Philadelphia's citizens. As a result of her "impertinence" the inspector was removed. That same year an epidemic of smallpox spread through all the rural districts and cities of Pennsylvania, because physicians thought it would be kinder to the patients not to make known to their neighbors the presence of so disagreeable a disease. Almost all health and school authorities, however, can be made to see the advantage of taking the public into their confidence, because public confidence means both public recognition and greater success in obtaining funds. With more funds comes the power to do more work. Other details with regard to health reports will be found in the chapter on Vital Statistics. As to school reports, little thought has been given in the past to their educational possibilities. A book was recently published--_School Reports and School Efficiency_--by the Committee on the Physical Welfare of School Children, which tells the origins of school reports; contains samples of reports from one hundred cities; gives lists of questions frequently answered, occasionally answered, and never answered; and shows how to study a particular report so as to learn whether or not important questions are answered. The United States commissioner of education has organized among state and city superintendents special committees on uniform and adequate reporting. His aggressive leadership is welcomed by school men generally, and promises vast benefits. Just because the physical welfare of the school child is an index to health needs, the school report can put into one statement for a city or a state the story told by the index. The accompanying card tells facts that the individual teacher and individual parent want to know about a child, what a superintendent wants to know about all children, and what a community wants to know about all children. A modification of this card will soon be adopted in New York City. It is both a card index and a card biography of the individual boy or girl. It is expected to follow the child from class to class, each teacher telling the story of his physical welfare and his progress. When the boy goes to a new school or new grade, his new teacher can see at a glance not only what subjects have given him trouble, but what diseases or physical defects have kept him out of school or otherwise retarded his progress. With this card it is easy to take a hundred children of the same age and the same grade, to put down in one column those who have eye defects, and in another those who have no eye defects, for every school, every district, and for the schools as a whole. Schools that use these record cards are enabled, by thus classifying the total, to learn where the defects of children are, how serious the problem is, how many days children lose from school because of preventable defects, and in what section of the city the defects are most prevalent. The mere reporting of facts will stimulate teachers, principals, and parents to give attention. For example, assume a table: FIELD OF INSPECTION Total number of public schools 7 Public schools under inspection 3 Public schools not under inspection 4 The reader wonders why four schools are neglected and which particular schools they are. Let the next table read: EXAMINATION Total registration in all schools 1500 Number of children examined 500 Number of children not examined 1000 Parents begin to wonder whether or not their children were examined, and why the taxes spent for school examination of all children go to one third of the children. The next table arrests attention: TREATMENT Number needing treatment 200 Number known to have been treated 50 Number not known to have been treated 150 We ask, at once, if examination is worth while, and if treatment really corrects the defects, saves the pupil's time and teacher's time, discovers many defects; and we want to find out whether the one hundred and fifty reported not treated have since been attended to. [Illustration: PUPIL'S RECORD] [Illustration: DEPARTMENT OF HEALTH CITY OF NEW YORK REPORT] Again, if three out of five of those examined need treatment, people will wonder whether among the thousand not examined there is the same proportion--three out of five, or six hundred--who have some trouble that needs attention. Having begun to wonder, they will ask questions, and will expect the board of health or the school physicians to see that the questions are answered. As has been proved in New York, taxpayers and the press will go farther and will demand that the annual budget provide for making general next year the benefits found to result last year from a test of health policies. The story of the prevalence of contagious diseases in school children could be told by a table such as is now in use by New York's department of health: TABLE XII PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN (Case rate schools) KEY: A: In School B: Among Absentee =========+========================================+====================== | | COMMUNICABLE | GENERAL COMMUNICABLE DISEASES[1] | DISEASES OF EYE SCHOOL | | AND SKIN[2] +----------------------------------------+----------+----------- | NUMBER | | | +----------+-----------+-----+ Number per| |Number |Found by | Reported | | 1000 |Number |per 1000 |Inspectors| by | | Registered|found by |Registered +-----+----+ Attending + + in Schools+Inspectors|in Schools | A | B | Physician |Total| Inspected |and Nurses|Inspected ---------+-----+----+-----------+-----+-----------+----------+----------- A | | | | | | | B | | | | | | | C | | | | | | | =========+=====+====+===========+=====+===========+==========+=========== [1] Smallpox, diphtheria, scarlet fever, measles, chicken pox, mumps, and whooping cough; excluded when found. [2] Trachoma and other contagious eye diseases, ringworm, impetigo, scabies, favus, and pediculosis; excluded only for persistent nontreatment. Another table shows the following facts for each disease: TABLE XIII CONTAGIOUS DISEASES FOUND IN SCHOOLS BY INSPECTORS AND NURSES (Number and disposition of cases) KEY: A: Diphtheria J: Other B: Scarlet fever K: Ringworm C: Measles L: Impetigo D: Smallpox M: Scabies E: Chicken pox N: Favus F: Whooping cough O: Pediculosis G: Mumps P: Miscellaneous H: Total Q: Total I: Trachoma ===================+=======================+=========================== | GENERAL | COMMUNICABLE DISEASES | COMMUNICABLE | OF EYE AND SKIN | DISEASES |-----+--------------------- | | EYE | SKIN +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--- | A| B| C| D| E| F| G| H| I| J| K| L| M| N| O| P| Q -------------------+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--- Cases found in | | | | | | | | | | | | | | | | | school | | | | | | | | | | | | | | | | | Cases excluded | | | | | | | | | | | | | | | | | from school | | | | | | | | | | | | | | | | | Cases treated in | | | | | | | | | | | | | | | | | school | | | | | | | | | | | | | | | | | Cases instructed | | | | | | | | | | | | | | | | | in school or | | | | | | | | | | | | | | | | | evidence of | | | | | | | | | | | | | | | | | treatment | | | | | | | | | | | | | | | | | furnished | | | | | | | | | | | | | | | | | Number of | | | | | | | | | | | | | | | | | treatments | | | | | | | | | | | | | | | | | Number of | | | | | | | | | | | | | | | | | instructions | | | | | | | | | | | | | | | | | ===================+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+=== The story of noncontagious physical defects found and treated is set forth in the following table: TABLE XIV MEDICAL EXAMINATION OF SCHOOL CHILDREN: NONCONTAGIOUS PHYSICAL DEFECTS FOUND AND TREATED, 1906 ==============+=============================+=============================+ | SCHOOL A | SCHOOL B | |--------------+--------------+--------------+--------------| | Found | Reported | Found | Reported | | | Treated | | Treated | |-----+--------+-----+--------+-----+--------+-----+--------| DEFECTS | No. | % of | No. | % of | No. | % of | No. | % of | | | Total | |Defects | | Total | |Defects | | |Defects | | Found | |Defects | | Found | | | Found | | | | Found | | | --------------+-----+--------+-----+--------+-----+--------+-----+--------+ Adenoids | | | | | | | | | | | | | | | | | | Nasal | | | | | | | | | breathing | | | | | | | | | Hyper-trophied| | | | | | | | | tonsils | | | | | | | | | Defective | | | | | | | | | palate | | | | | | | | | Defective | | | | | | | | | hearing | | | | | | | | | Defective | | | | | | | | | vision | | | | | | | | | Defective | | | | | | | | | teeth | | | | | | | | | Bad nutrition | | | | | | | | | Diseased | | | | | | | | | anterior | | | | | | | | | cervical | | | | | | | | | glands | | | | | | | | | Diseased | | | | | | | | | posterior | | | | | | | | | cervical | | | | | | | | | glands | | | | | | | | | Heart disease | | | | | | | | | Chorea | | | | | | | | | Pulmonary | | | | | | | | | disease | | | | | | | | | Skin disease | | | | | | | | | Deformity | | | | | | | | | of spine | | | | | | | | | Deformity | | | | | | | | | of chest | | | | | | | | | Deformity of | | | | | | | | | extremities | | | | | | | | | Defective | | | | | | | | | mentality | | | | | | | | | Total | | | | | | | | | ==============+=====+========+=====+========+=====+========+=====+========+ ==============+=============================+ | SCHOOL C | |--------------+--------------| | Found | Reported | | | Treated | |-----+--------+-----+--------| DEFECTS | No. | % of | No. | % of | | | Total | |Defects | | |Defects | | Found | | | Found | | | --------------+-----+--------+-----+--------+ Adenoids | | | | | | | | | | Nasal | | | | | breathing | | | | | Hyper-trophied| | | | | tonsils | | | | | Defective | | | | | palate | | | | | Defective | | | | | hearing | | | | | Defective | | | | | vision | | | | | Defective | | | | | teeth | | | | | Bad nutrition | | | | | Diseased | | | | | anterior | | | | | cervical | | | | | glands | | | | | Diseased | | | | | posterior | | | | | cervical | | | | | glands | | | | | Heart disease | | | | | Chorea | | | | | Pulmonary | | | | | disease | | | | | Skin disease | | | | | Deformity | | | | | of spine | | | | | Deformity | | | | | of chest | | | | | Deformity of | | | | | extremities | | | | | Defective | | | | | mentality | | | | | Total | | | | | ==============+=====+========+=====+========+ The effect of a report telling what schools have enough seats, proper ventilation, adequate medical inspection, safe drinking water, ample play space, and what schools are without these necessities is to cause the reader to rank the particular school that he happens to know; i.e. he says, "School A is better equipped than School B; or, School C is neglected." County and state superintendents in many states have acquired the habit of ranking schools according to the number of children who pass in arithmetic, algebra, etc. It would greatly further the cause of public health and, at the same time, advance the interest of education if state superintendents would rank individual schools, and if county superintendents would rank individual schools, _according to the number of children found to have physical defects, the number afflicted with contagious diseases, and the number properly treated_. It is difficult to compare one school with another, because it is necessary to make subtractions and divisions and to reduce to percentages. It would not be so serious for a school of a thousand pupils as for a school of two hundred, to report 100 for adenoids. To make it possible to compare school with school without judging either unfairly, the state superintendent of schools for Connecticut has made tables in which cities are ranked according to the number of pupils, average attendance, per capita cost, etc. As to each of these headings, cities are grouped in a manner corresponding to the line up of a battalion, "according to height." A general table is then shown, which gives the ranking of each city with respect to each important item. Applied to schools, this would work out as follows: TABLE XV TABLE OF RANKING-SCHOOLS ARRANGED ALPHABETICALLY ============================================================= | SCHOOL | RANK IN -------+----------+----------+----------+----------+--------- | Register | Defects | Children | Children | Children | | Found | Needing | Treated | not | | | Treatment| | Treated -------+----------+----------+----------+----------+--------- A | 10 | 11 | 11 | 12 | 6 B | 20 | 22 | 22 | 24 | 12 C | 30 | 33 | 30 | 36 | 18 =======+==========+==========+==========+==========+========= Such a table fails to convey its significance unless the reader is reminded that rank 18 in children not treated is as good a record for a school that ranks 30 in register as is rank 6 for a school that ranks 10 in register. The Connecticut report makes a serious mistake in failing to arrange schools according to population. If this were done, schools of a size would be side by side and comparison would be fair. When, as in the above table, schools are arranged alphabetically, a school with four thousand pupils may follow or precede a school with four hundred pupils, and comparison will be unfair and futile. Where, on the other hand, schools are arranged in order of register, a table will show whether schools confronted with practically the same problems, the same number of defects, the same number of children needing treatment, are equally successful, or perhaps equally inactive, in correcting these defects. The following table brings out clearly marked unequal achievement in the face of relatively equal need. TABLE XVI TABLE OF RANKING-SCHOOLS ARRANGED ACCORDING TO REGISTER, NOT ALPHABETICALLY ============================================================= | | RANK IN SCHOOL +----------+----------+----------+----------+--------- | Register | Defects | Children | Children | Children | | Found | Needing | Treated | not | | | Treatment| | Treated -------+----------+----------+----------+----------+--------- A | 9 | 9 | 9 | 9 | 9 X | 10 | 10 | 10 | 14 | 6 H | 11 | 11 | 11 | 17 | 3 =======+==========+==========+==========+==========+========= If the number of schools in a state is so large that it is unlikely that people will read the table of ranking because of the difficulty of finding their own school, an alphabetical table might be given that would show where to look in the general ranking table for the school or schools in which the reader is interested. Experience will demonstrate to public school superintendents the strategic advantage of putting together all the things they need and of telling the community over and over again just what needs there are, what penalties are paid for want of them, and what benefits would result from obtaining them. If health needs of school children were placed side by side with mental results, the relation would come out so clearly that parents, school boards, and taxpayers would realize how inextricably they are bound together and would see that health needs are satisfied. To this end superintendents should require teachers to keep daily reports of school conditions. TABLE XVII WEEKLY CLASS-ROOM SCHEDULE ===========+================+========================+============== | Temperature | Cleaning | Exercise +-----+-----+-----+-----+-----+------------+------+------- | | | | | | | In |Out of |10.30|12.00| 2.00| Dry | Wet |Disinfecting| Room | Room ----------+-----+-----+-----+-----+-----+------------+------+------- Monday | | | | | | | | Tuesday | | | | | | | | Wednesday | | | | | | | | Thursday | | | | | | | | Friday | | | | | | | | ==========+=====+=====+=====+=====+=====+============+======+======= The teacher's daily report of the temperature of a schoolroom, taken three times a day, tells the parent exactly what is the efficiency of the ventilating and heating apparatus in the particular school in which he is interested; whereas the report of the department of buildings gives only the number of schools which have an approved system of ventilation and steam heat. School authorities may or may not know that this system of ventilation is out of order, that the thermometer in the indoor playground of School A stood at forty degrees for many days in winter. But they must know it when the principal of School A sends in a daily record; the school board, the parents, or the press will then see that the condition is remedied. If the condition is due to lack of funds, funds will never be forthcoming so long as the condition is concealed. Similar results will follow publicity of overcrowding, too little play space, dry cleaning of school buildings, etc. The intent of such reporting is not to "keep tabs" on the school-teacher, the school child, the janitor, the principal, superintendent, or board, but to insure favorable conditions and to correct bad conditions. This is done best by giving everybody the facts. The objective test of the efficiency of a method throws emphasis on the method, not on the motive of those operating it. The blackboard method of publishing facts concentrates attention upon the importance of those facts and enlists aid in the attainment of the end sought. CHAPTER XXXI THE PRESS The president of Princeton University declares that for several decades we have given education that does not instruct and instruction that does not educate. Others tell us that because we read daily papers and magazines our minds become superficial, that our power to concentrate or memorize is weakened,--that we read so much of everything that we learn little of anything. As the habit of reading magazines and newspapers is constantly increasing, I think we must assume that it has come to stay. If we cannot check it, we can at least turn it to good advantage, systematize it, and discipline ourselves. Among the subjects continually described in newspapers and magazines, and even on billboards and in street-car advertising, is the subject of hygiene. No greater service can be rendered the community than for those who are conducting discussions of health to teach people how to read correctly this mass of information regarding health, to separate misinformation from information, and to apply the lessons learned to personal and public hygiene. There is no better way of doing this than to teach a class or a child to clip out of magazines and newspapers all important references to health, and then to classify these under the subject-matter treated. A teacher, parent, or club leader might practice by using the classification of subjects outlined in the Contents of this book. It is surprising how rapidly one builds up a valuable collection serviceable for talks or papers, but more particularly for giving one a vital and intelligent interest in practical health topics. Interested in comparing the emphasis placed on health topics in a three-cent paper having a small circulation with a penny paper having twenty times the circulation, I made during one week thirty-eight clippings from the three-cent paper and ninety-five from the penny paper. The high-priced paper had no editorial comment within the field of health, whereas the penny paper had three columns, in which were discussed among other things: _The Economics of Bad Teeth_; _Need for Individual Efficiency_; _"Good Fellows" Lower Standard of Living by Neglecting their Families_. The penny paper advertised fifty-two foods, garments, whiskies, patent medicines, or beautifiers urged upon health grounds. In the three-cent paper twenty-six out of thirty-eight items advertised food, clothing, patent medicine, or whisky. One issue of a monthly magazine devoted to woman's interests contained twenty-eight articles and editorials and fifty-five advertisements that concern health,--thirty-seven per cent of total reading matter and thirty-seven per cent of total advertisement. Excellent discipline is afforded by this clipping work. It is astonishing how few men and women, even from our better colleges, know how to organize notes, clippings, or other data, so that they can be used a few weeks later. There is a satisfaction in seeing one's material grow, as is remembered by all of us, in making picture scrapbooks or collections of picture postal cards and stamps. "Collections" have generally failed for want of classification,--putting things of a kind together. Chronological arrangement is uninteresting because unprofitable. One never knows where to find a picture, or a stamp, or a health clipping. Clippings, like libraries, will be little used if not properly catalogued so that use is easy. If a health-clipping collection is attempted, there are four essentials: (1) arrangement by topic; (2) inclusion of advertisements; (3) inclusion of items from magazines; (4) cross references. For classification, envelopes can be used or manila cards 10×12 inches. The teacher, parent, or advanced student will probably think the envelope most useful because most easily carried and filed,--most likely to be used. But clippings should be bound together in orderly appearance, or else it will be disagreeable working with them. Children, however, will like the pasting on sheets, which show clearly the growth of each topic. Envelopes or cards should not have clippings that deal with only one health topic. Unless a test is made to see how many health references there are in a given period, it should be made a rule not to clip any item that does not contain something new,--some addition to the knowledge already collected. Advertisements will prove interesting and educative. When newspapers and magazines announce some new truth, the commercial motive of manufacturer or dealer sees profit in telling over and over again how certain goods will meet the new need. Children will soon notice that the worst advertisements appear in the papers that talk most of "popular rights," "justice," and "morality." They will be shocked to see that the popular papers accept money to tell falsehoods about fake cures. They will be pleased that the best monthly magazines contain no such advertisements. They will challenge paper or magazine, and thus will be enlisted while young in the fight against health advertisements that injure health. To clip articles from magazines will seem almost irreverent at first. But the reverence for magazines and books is less valuable to education than the knowledge concealed in them. Except where families preserve all magazines, clippings will add greatly to their serviceability. The art of cross-referencing is invaluable to the organized mind. The purpose of classifying one's information is not to show how much there is, but to answer questions quickly and to guide constructive thinking. A clipping that deals with _alcoholism_, _patent medicine_, and _tuberculosis_ must be posted in three places, or cross-referenced; otherwise it will be used to answer but one question when it might answer three. If magazines may not be cut, it will be easy to record the fact of a useful article by writing the title, page, and date on the appropriate index card, or inclosing a slip so marked in the proper envelope. While it is true that the most important bibliography one can have in his private library is a classification of the material of which he himself has become a part while reading it, there are a number of health journals that one can profitably subscribe for. In fact, it is often true that the significant discoveries in scientific fields, or the latest public improvements, such as parks, bridges, model tenements, will not be appreciated until one has read in health journals how these improvements affect the sickness rate and the enjoyment rate of those least able to control their living conditions. The physician and nurse in their educational work for hospitals are distributors of health propaganda. Wherever there is a local journal devoted to health, parents, teachers, educators, and club leaders would do well to subscribe and to hold this journal up to a high standard by quoting, thanking, criticising it. In New Jersey, for example, is a monthly called the _New Jersey Review of Charities and Corrections_ that deals with every manner of subject having to do with public health as well as with private and public morality and education. A similar journal, intended for national instruction, is _The Survey_, whose topical index for last year enumerates two hundred and thirty-two articles dealing with subjects directly connected with public hygiene, e.g.: Schools, 6; school inspection, 3; eyes,--school children, 1; sex instruction in the schools, 2; psychiatric clinic, special children, 2; industrial education, 5; child labor, 18; playgrounds, 26; alley, crap, playing in streets, 3; labor conditions, 18; industrial accidents, 10; wage-earner's insurance, 4; factory inspection, 1; consumer's league, 3; women's work, 6; tuberculosis, 23; hospitals, dispensaries (social), 5; tenement reform, 10; living conditions, 2; baths, 1; public comfort stations, 2; lodging houses, 1; clean streets, 6; clean milk, 6; smoke, 1; noises, 1; parks, 1; patent medicines, 2; sanitary code, 1; mortality statistics, 2; social settlements and public health, 1; midwives, 1; children's bureau, 1; juvenile and adult delinquent, 25; dependent, defective, and insane, 7; blind, 5; cripples, 1; homes for aged, 1; inebriates, 3; Traveler's Aid Committee, 1; infant mortality, 2; social diseases, 2. * * * * * _The National Hospital Record_, the _Dietetic and Hygienic Gazette_, the _Journal of Nursing_, are three other magazines primarily intended for nurses and physicians, but full of suggestive material for unprofessional readers. National magazines concerned with health, but seeking popular circulation, are _Good Health_ and _Physical Culture_. In England there is a special magazine called _Children's Diseases_, which could be of great help to a school library for special reference. The same can be said of the _Psychological Clinic_, _Pediatrics_, and other technical journals published in this country. For many persons, to make the best use of any one copy of these magazines, clipping is of course impossible, but noting on a card or envelope is practicable. Of late many of the national popular magazines have several columns devoted to health. We have not appreciated the educational possibilities of these columns. In most large cities there are monthly book reviews which may be profitably consulted in learning the new thought in the health field. If teachers would either write their experience or ask questions, if children knew that in a certain magazine or newspaper questions as to ventilation, bathing, exercise, would be answered, they would take a keen interest in the progress of discussions. The large daily papers make a great feature of their health hints. It is not their fault if questioners care more about cosmetics and hair bleaches than about the fresh-air cure of headaches. They will coöperate with teachers and parents in securing more general discussion of other problems than beauty doctoring. Finally, persons wanting not only to have intelligence as to matters promoting health, but actually to exert a helpful influence in their community, ought to want the published reports of the mayor, health department, the public schools, and other institutions, noting carefully all that is said about conditions relating to health and about efforts made to correct all unfavorable conditions. The best literature of our day, with regard to social needs, appears in the reports of our public and private institutions and societies. Of increasing value are the publications of the national government printing office. Because it is no one's business to find out what valuable material is contained in such reports, and because no educational museum is comparing report with report, those who live nearest to our health problems and who see most clearly the health remedies, are not stimulated to give to the public their special knowledge in an interesting, convincing way. Teaching children how to find health lessons in public documents will advance the cause of public ethics as well as of public health. At the New York State Conference of Charities, of 1907, one official complained that the physicians made no educational use of their valuable experience for public education. He stated that a study of medical journals and health articles in popular magazines revealed the fact that the number of papers prepared by physicians in state hospitals averaged one to a doctor for every five or six years of service. This state of affairs is even more exaggerated in strictly educational institutions. Columbia University has recently instituted a series of lectures to be given by its professors to its professors, so that they may have a general knowledge of the work being done in other fields besides their own at their own university. This is equally important for teachers and heads of departments in elementary schools. It is now admitted by most educators that elementary schools and young children present more pedagogical difficulties and pressing biological problems than higher schools. If teachers and parents would realize that their method of solving the health problems that arise daily in the schoolroom and in the home would interest other mothers and teachers, their spirit of coöperation would soon be reflected in school journals, popular magazines, and daily newspapers. PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION CHAPTER XXXII DO-NOTHING AILMENTS "Men have died, from time to time, and worms have eaten them, but not for love"--_nor for work_. Work of itself never killed anybody nor made anybody sick. Work has caused worry, mental strain, and physical breakdown, only when men while working have been deprived of air, sun, light, exercise, sleep, proper food at the proper time, opportunity to live and work hygienically. Fortunately for human progress, doing nothing brings ailments of its own and has none of the compensations of work. As the stomach deprived of substantial food craves unnatural food,--sweets, stimulants,--so the mind deprived of substantial, regular diet of wholesome work turns to unwholesome, petty, fantastic, suspicious, unhappy thoughts. This state of mind, combined with the lack of bodily exercise that generally accompanies it, reacts unfavorably on physical health. An editor has aptly termed the do-nothing condition as a self-inflicted confinement: A great deal of the misery and wretchedness among young men that inherit great fortunes is caused by the fact that they are practically in jail. They have nothing to do but eat, drink, and enjoy themselves, and they cannot understand why their lives are dull. We have had the owner of a great railroad system pathetically telling the public that he is unhappy. That is undoubtedly true, because with all his race horses, and his yachts, and all the things that he imagines to be pleasures, he is not really doing anything. If he were running one little railroad station up the road, handling the freight, fussing about dispatches, living above the railroad station in two rooms, and buying shoes in a neighboring village for fifteen children he would be busy and happy. But he cannot be happy because he is in prison,--in a prison of money, a prison that is honorable because it gives him everything that he wants, and he wants nothing. A New York newspaper that circulates among the working classes where young men and women are inclined to associate health and happiness with doing nothing recently gave two columns to "Dandy Jim," the richest dog in the world. Dandy Jim's mistress left him a ten-thousand-dollar legacy. During his lifetime he wore diamonds. Every day he ate candy that cost eighty cents a pound. The coachman took him driving in the park sunny afternoons. He had no cares and nothing to work for. His food came without effort. He had fatty degeneration of the vital organs. He was pampered, coddled, and killed thereby. Thousands of men and women drag out lives of unhappiness for themselves and others because, like Dandy Jim, they have nothing to work for, are pampered, coddled victims of fatty degeneration. When President Butler of Columbia University finds it necessary to censure "the folly and indifference of the fathers, vanity and thoughtless pride of the mothers" who encourage do-nothing ailments; and when the editor of the _Psychological Clinic_ protests that the fashionable private schools and the private tutor share with rich fathers and mothers responsibility for life failures,--it is time that educators teach children themselves the physical and moral ailments and disillusions that come from doing nothing. Ten years ago a stenographer inherited two hundred and fifty thousand dollars. Her dream of nothing to do was realized. She gave up her strenuous business life. Possessions formerly coveted soon clogged her powers of enjoyment. She imagined herself suffering from various diseases, shut herself up in her house, and refused to see any one. She grew morbid and was sure that every person who approached her had some sneaking, personal, hostile motive. Though always busy, she accomplished little. Desultory work, procrastination, and self-indulgence destroyed her power of concentration. She could not think long enough on one subject to think it out straight, therefore she was constantly deceived in her friends and interests. She first trusted everybody, then mistrusted everybody. Infatuation with every new acquaintance was quickly followed by suspicion. For years she was a very sick woman, a victim of do-nothing ailments. Doing nothing has of late been seriously recommended to American business men. They are advised to retire from active work as soon as their savings produce reasonable income. It is true, this suggestion has been made as an antidote to greed rather than for the happiness of the business man. What retiring from business is apt to mean, is indicated by a gentleman who at the age of sixty decided to sell his seat on the New York Stock Exchange and to enjoy life. He became restless and very miserable. He threw himself violently into one thing after another; in less than a year he became an ill, broken old man, after trying vainly to buy back his business. Both mind and body were made to work. The function of the brain is to think to a purpose, just as the function of the heart is to pump blood. The habit of doing nothing is very easily formed. The "out-of-work" soon become "the work-shy." Having too little to do is worse for the body and mind than having too little to eat. Social reformers emphasize the bad effect on society of vagrancy. Evils of indiscriminate relief to the poor are vividly described year after year. The philanthropist is condemned, who, by his gifts, encourages an employee's family to spend what they do not earn, and to shun work. Yet the idleness of the tramp, street loafer, and professional mendicant is a negligible evil compared with the hindrance to human progress caused by the idleness of the well-to-do, the rich, the educated, the refined, the "best" people. It is as much a wrong to bring up children in an atmosphere of do-nothingism, as to refuse to have their teeth attended to or to have glasses fitted to weak eyes. From the point of view of community welfare it is far more serious for the rich child to be brought up in idleness or without a purpose than for the poor child to become a public charge. Not only has society a right to expect more from rich children in return for the greater benefits they enjoy, but so long as rich children control the expenditure of money, they control also the health and happiness of other human beings. Unless taught the value and joy of wholesome work they cannot themselves think straight, nor are they likely to want to understand how they can use their wealth for the benefit of mankind. To quote President Butler again: The rich boy who receives a good education and is trained to be a self-respecting member of the body politic might in time share on equal terms the chance of the poor boy to become a man of genuine influence and importance on his own account, just as now by the neglect, or worse, of his parents the very rich boy is apt to be relegated to the limbo of curiosities, and too often of decadence. Nervous invalids make life miserable for themselves and for others, when often their sole malady is lack of the right kind of work to do. Suiting work to interest and interest to work is an economy that should not be overlooked. The energy spent in forcing oneself to do a distasteful task can be turned to productive channels when work is made pleasurable. The fact is frequently deplored that whereas formerly a man became a full-fledged craftsman, able to perform any branch of his trade, he is now confined to doing special acts because neither his interest nor his mind is called into play. Work seems to react unfavorably on his health. He has not the pride of the artisan in the finished product, for he seldom sees it. He does a task. His employer is a taskmaster. He decides that work is not good for him as easily as when a school-boy he grasped the meaning of escape from his lessons. By failing to fit studies to a student's interest, or by failing to insure a student's interest in his studies, schools and colleges miseducate young men and young women to look upon all work as tasks, as discipline, necessary but irksome, and to be avoided if possible. Just as there is a way of turning all the energy of the play instinct into school work, so there is a way of interesting the factory and office worker in his job. However mechanical work may be, there is always the interest in becoming the most efficient worker in a room or a trade. Routine--accurate and detailed work--does not mean the stultification of the imagination. It takes more imagination to see the interesting things in statistical or record work than to write a novel. Therefore employers should make it a point to help their employees to realize the significance of the perfection of each detail and the importance of each man's part. The other day a father said to me, "I want my boys to be as ashamed to do work in which they are not interested as to accept graft." When interest in work and efficiency in work are regarded as of more importance than the immediate returns for work, when it is as natural for boys and girls to demand enjoyment and complete living in work as it is to thrill at the sight of the Stars and Stripes, do-nothing ailments will be less frequent and less costly. Work--that one enjoys--is an invaluable unpatented medicine. It can make the sick well and keep the well from getting sick. It is the chief reliance of mental hygiene. "I should have the grippe if I had time," said a business woman to me the other day; but she did not have time, hence she did not have the grippe. If you're sick with something chronic, And you think you need a tonic, Do something. There is life and health in doing, There is pleasure in pursuing; Doing, then, is health accruing-- Do something. And if you're seeking pleasure, Or enjoyment in full measure, Do something. Idleness, there's nothing in it; 'Twill not pay you for a minute-- Do something. CHAPTER XXXIII HEREDITY BUGABOOS AND HEREDITY TRUTHS One of the red-letter days of my life was that on which I learned that I could not have inherited tuberculosis from two uncles who died of consumption. For years I had known that I was a marked victim. Silently I carried my tragedy, suspecting each cold and headache to be the telltale messenger that should let others into my secret. He was a veritable emancipator who informed me that heredity did not work from uncle to nephew; that not more than a predisposition to consumption could pass even from parent to child; that a predisposition to consumption would come to nothing without the germ of the disease and the environmental conditions which favor its development; and that if those so predisposed avoid gross infection, lead a healthy life, and breathe fresh air they are as safe as though no tuberculous lungs had ever existed in the world. Some years later I learned to understand the other side of the case; I realized how I had been in real danger of contracting consumption in the darkened, ill-ventilated sick room of the uncle who taught me my letters and gave me my ideal of God's purpose in sending uncles to small boys. There are two distinct things which make each individual life: the living stuff, the physical basis of life, handed down from parent to child; and the environmental conditions which surround it and play upon it and rouse its reactions and its latent possibilities. It is like the seed and the cultivation. You cannot grow corn from wheat, but you can grow the best wheat, or you may let your crop fail through careless handling. It is well that we should think seriously about the part played by heredity, for the living stuff of the future depends upon our sense of responsibility in this regard. The intelligent citizen would do well to read such a book as J. Arthur Thompson's _Heredity_ (1908), in which the latest conclusions of science are clearly and soundly set forth. The main problem of to-day, however, is to use well the talents that we have. Here two things should always be kept in mind: First, the inherited elements which make up our minds and bodies are complex and diverse. Health and strength are inherited as well as disease and weakness; they have indeed a better chance of survival. In the most unpromising ancestry there are latent potentialities which may be made fruitful by effort. No limit whatever can be set to the possibilities of improvement in any individual. In the second place, if science has shown anything more clearly than the importance of heredity, it is the importance of environment. This influence upon human lives is within our control, and it is a grave error to neglect what lies clearly within our power and to bemoan what does not. Science has wrought no benefits greater than those which result from drawing a clear line between heredity bugaboos and heredity truths. An overemphasis on the hereditary factor in development at the expense of the environmental factor, I call a heredity bugaboo; and it is a tendency which cannot be too strongly condemned. To fight against the sins and penalties of one's grandfather is a forlorn task that quickly discourages. To overcome diseases of environment, of shop and street, of house and school, seems, on the contrary, an easy task. Heredity bugaboos dishearten, enervate, encourage excesses and neglect. Heredity truths stimulate remedial and preventive measures. We may well watch with interest the progress of eugenics, that new science which biologists and sociologists hope will some day remake the very living stuff of the human race. But meanwhile let us take up with hope and courage and enthusiasm the great hemisphere of human fate which lies within our grasp. Good food and fresh air, well-built cities, enlightened schools and well-ordered industries, stable and free and expert government,--given these things, we can transform the world with the means now at our disposal. We can reap, if we will, splendid possibilities now going to waste, and by intelligent biological and sociological engineering we can hand on to the next generation an environmental inheritance which will make their task far easier than ours. "Physical deterioration" is a bugaboo that is discovered by some in heredity and by others in modern industrial evils. The British director general called attention a few years ago to the fact that from forty to sixty per cent of the men who were being examined for military service were physically unfit. A Commission on Physical Deterioration was appointed to investigate the cause, and to learn whether the low physical standard of the would-be Tommy Atkins was due to inherited defects. The results of this study were published in a large volume called _Report on Physical Deterioration, 1904_, in which is set forth a positive programme for obtaining periodically facts as to the physique of the nation. In the course of the commission's exhaustive investigation there was found no evidence that any progressive deterioration was going on in any function of the body except the teeth. "There are happily no grounds for associating dental degeneracy with progressive physical deterioration." The increase in optical defects is attributed not to the deterioration of the eye, but to greater knowledge, more treatment, and better understanding of the connection between optical defects and headache. [Illustration: Testing Environment--House Score] +--------------------------------------------------------------------+ | DEFINITIONS OF TERMS USED IN HOUSE SCORE CARD | | | | LIGHT--Light enough to read easily in every part. | | | | GLOOMY--Not light enough to read easily in every part, but enough | | readily to see one's way about when doors are closed. | | | | DARK--Too dark to see one's way about easily when doors are | | closed. | | | | WELL VENTILATED--With window on street or fair-sized yard (not | | less than 12 ft. deep for a five-story tenement house not on a | | corner), or on a "large," "well-ventilated" court open to the sky | | at the top: "large" being for a court entirely open on one side to | | the street or yard in a five-story tenement, not less than 6 ft. | | wide from the wall of the building to the lot line; for a court | | inclosed on three sides and the other on the lot line in a | | five-story tenement, not less than 12×24 ft., "well ventilated" | | meaning either entirely open on one side to the street or yard, or | | else having a tunnel at the bottom connecting with the street or | | yard. | | | | FAIRLY VENTILATED--With window opening on a shallow yard or on a | | narrow court, open to the sky at the top, or else with 5×3 inside | | window (15 ft. square) opening on a well-ventilated room in same | | apartment. | | | | BADLY VENTILATED--With no window on the street, or on a yard, or | | on a court open to the sky, and with no window, or a very small | | window, opening on an adjoining room. | | | | IN GOOD REPAIR--No torn wall paper, broken plaster, broken | | woodwork or flooring, nor badly shrunk or warped floor boards or | | wainscoting, leaving large cracks. | | | | IN FAIR REPAIR--Slightly torn or loose wall paper, slightly broken | | plaster, warped floor boards and wainscoting. | | | | IN BAD REPAIR--Very badly torn wall paper or broken plaster over a | | considerable area, or badly broken woodwork or flooring. | | | | (Rooms not exactly coinciding with any of the three classes are to | | be included in the one the description of which comes nearest to | | the condition.) | | | | SINKS: GOOD--Iron, on iron supports with iron back above to | | prevent splashing of water on wall surface, in light location, | | used for one family. Water direct from city water mains or from a | | CLEAN roof tank. | | | | BAD--Surrounded by wood rims with or without metal flushings, | | space beneath inclosed with wood risers; dark location, used by | | more than one family; water from dirty roof tank. | | | | FAIR--Midway between above two extremes. (Sinks not exactly | | coinciding with any of the three classes are to be included in the | | one the description of which comes nearest to the condition.) | | | | WATER-CLOSET: GOOD--Indoor closet. In well lighted and ventilated | | location, closet fixture entirely open underneath, abundant water | | flush. | | | | FAIR--Indoor closet, poor condition--badly lighted and ventilated | | location, fixture inclosed with wood risers, or poor flush. | | | | POOR--Yard closet--separate water-closet in individual compartment | | in the yard. | | | | BAD--School sink--sewer-connected privy, having one continuous | | vault beneath the row of individual toilet compartments. | +--------------------------------------------------------------------+ The commission hoped "that the facts and opinions they have collected will have some effect in allaying the apprehensions of those who, as it appears, on insufficient grounds, have made up their minds that progressive deterioration is to be found among people generally." In regard to the facts which started the fear, the report says: (1) the evidence adduced in the director general's memorandum was inadequate to prove that physical deterioration had affected the classes referred to; (2) no sufficient material (statistical or other) is at present available to warrant any definite conclusions on the question of the physique of the people by comparison with data obtained in past times. [Illustration: THE BEST INHERITANCE IS A MOTHER WHO KNOWS HOW TO KEEP HER BABY WELL] The topics dealt with in the report refer to only a partial list of conditions that need to be carefully studied before we can know what environment heredity we are preparing for those who follow us: I. AS TO BABIES Training of mothers, provident societies and maternity funds, feeding of infants, milk supply, milk depots, sterilization and refrigeration of milk, effect of mother's employment upon infant mortality, still births, cookery, hygiene and domestic economy, public nurseries, crèches. II. AS TO CHILDREN Anthropometric measurements, sickness and open spaces, medical examination of school children, teeth, eyes, and ears, games and exercises for school children, open spaces and gymnastic apparatus, physical exercise for growing girls and growing boys, clubs and cadet corps, feeding of elementary school children, partial exemption from school, special schools for "retarded" children, special magistrate for juvenile cases, juvenile smoking, organization of existing agencies for the welfare of lads and girls, education, school attendance in rural districts, defective children. III. AS TO LIVING AND WORKING CONDITIONS Register of sickness, medical certificates as to causes of death, overcrowding, building and open spaces, register of owners of buildings, unsanitary and overcrowded house property, rural housing, workshops, coal mines, etc., medical inspection of factories, employment of women in factories, labor colonies, overfatigue, food and cooking, cooking grates, adulteration, smoke pollution, alcohol, syphilis, insanity. IV. AS TO HEALTH MACHINERY Medical officers of health, local, district, and national boards, health associations. Scientists of the next generation will continue to differ as to heredity truths and heredity bugaboos unless records are kept now, showing the physical condition of school children and of applicants for work certificates and for civil service and army positions. The British investigators declared that "anthropometric records are the only accredited tests available, and, if collected on a sufficient scale, they would constitute the supreme criterion of physical deterioration, or the reverse.... The school population and the classes coming under the administration of the Factory Acts offer ready material for the immediate application of such tests." In addition to the physical tests proposed in other chapters, there is great educational opportunity in the records of private and public hospitals. Every nation, every state, and every city should enlist all its educational and scientific forces to ascertain in what respects social efficiency is endangered by physical deficiencies that can be avoided only by restricting parenthood, and the environmental deficiencies that can be avoided by efficient health machinery. The greatest of all heredity truths are these: (1) the deficiencies of infants are infinitesimal compared with the deficiencies of the world with which we surround them; (2) each of us can have a part in begetting for posterity an environment of health and of opportunity. CHAPTER XXXIV INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM Wherever the Stars and Stripes fly over school buildings it is made compulsory to teach the evils of alcoholism. For nearly a generation the great majority of school children of the United States have been taught that alcohol, in however small quantities, is a poison and a menace to personal and national health and prosperity. Yet during this very period the per capita consumption of every kind of alcoholic beverage has increased. Whereas 16.49 gallons of spirituous liquors were consumed per capita of population in 1896, 22.27 gallons were used in 1906. Obviously the results of methods hitherto in vogue for combating alcoholism are disappointing. Why this paradoxical relation of precept to practice? Why is this, the most hygiene-instructed country in the world, the Elysium of the patent-medicine and cocaine traffic? If we have only the expected divergence of achievement from ideal, then there is nothing for us to do but to congratulate ourselves and posterity upon the part played by compulsory legislation in committing all states and territories to hygiene instruction in all public schools. If, on the other hand, our disappointment is due to ineffective method, then the next step is to change our method. The chief purpose of school hygiene has hitherto been not to promote personal and community health, but to lessen the use of alcohol and tobacco. Arguments were required against whisky, beer, cigars, and cigarettes. As the strongest arguments would probably make the most lasting impression upon the school child and the best profits for author and bookseller, writers vied with one another in the rhetoric and hyperbole of platform agitation. What effect would it have upon you if you were exhorted frequently during the next eight years to avoid tobacco because a mother once killed a child by washing its head in tobacco water? What is the effect on the mind of a boy or a girl who sees that the family doctor, the minister, the teacher, the judge, the governor, the President, and the philanthropist use tobacco and alcoholic beverages, when taught that "boys who use tobacco and alcoholic beverages will find closed in their faces the doors to strength, good health, skill in athletics, good scholarship, long life, best companions, many business positions, highest success"? It is probably true that "a boy once drank some whisky from a flask and died within a few hours." But that story is about as typical of boys and of whisky as that a boy once drank whisky from a flask and did not die for ninety years afterwards, or that George Washington drank whisky and became the Father of his Country. How special pleading has dominated the teaching of school hygiene is illustrated by a recent book which, for the most part, successfully breaks away from the narrow point of view and the crude methods hitherto prevailing. It presents the following facts concerning New York City: Saloons 10,821 Arrests 133,749 Expense of police department $10,199,206 Police courts, jails, workhouses, reformatories 1,310,411 Hospitals, asylums, and other charities 4,754,380 It is fair to the author to state that she does not declare in so many words that the shutting up of the saloons would obviate all the arrests and all the hospital, jail, and charity bills. Instead of _wipe out_ she says _shrivel_. No truth would have been lost by avoiding all misrepresentation. The author probably felt as I did when I took my total abstainer's protest to a celebrated scientist who had exposed certain misstatements regarding the effect of small quantities of alcohol: "Is not the untruth of these exaggerated statements less dangerous than the untruth of dispassionate, scientific statement? So long as the child mind takes in only an impression, is it not better to write this impression indelibly?" He sadly but indulgently replied, "And in what other studies would you substitute exaggeration for truth?" The reaction has already begun against exaggeration in hygiene text-books, against drawing lessons from accidental or exceptional cases of excessive use of alcohol, against classing moderate drinking and smoking with drunkenness as sins of equal magnitude, and against overlooking grave social and industrial evils that threaten children far earlier and more frequently than do tobacco and alcohol. Instead of adding an ell to the truth, text-book writers are now adding only an inch or two at a time. No longer do we favor highly colored charts that picture in purple, green, and black the effect of stimulants and narcotics upon the heart and brain, the stomach, the liver, the knee, and the eardrum, _assuming that all resultant evils are concentrated in one organ_. Menacing habits, such as overeating and indulgence in self-pity, are beginning to receive attention. It is also true that physiology and anatomy are progressively made more interesting. Publishers are looking for the utmost originality compatible with the purpose of the present laws and with the only effective public sentiment that has hitherto been interested in the interpretation of those laws. A score of improvements in the method of carrying out a small ideal will not take the place of enlarging that ideal. If existing laws stand in the way of broadening the purpose of school hygiene, let the laws be changed. If text-book publishers stand in the way, let us induce or compel them to get out of the way. If we fear rumsellers, their money, and the insidious political methods that they might employ to bring in undertruth if overtruth is once sacrificed, let us go to our communities and locate the rumseller's guns, draw their fire, tell the truth about their opposition, and educate the public to overcome it. If, on the other hand, misguided teetotalism stands in the way, then, as one teetotaler, I suggest that we prove, as we can, in our respective communities that there is a better way of inculcating habits of temperance and self-restraint than by telling untruths, overtruths, or half truths about alcohol and tobacco. Let us prove, as we can, that a subject vital to every individual, to every industry, and to every government is now prevented from fulfilling its mission not by its enemies but by its friends. We can learn the character of hygiene instruction in our schools and the interest taken in it by teachers, principals, and superintendents. We can learn how teachers practice hygiene at school, and how the children of our communities are affected by the hygiene instruction now given. Finally, we can compel a public discussion of the facts, and action in accordance with facts. Without questioning anybody's avowed motive, we can learn how big that motive is and how adequate or inadequate is the method of executing it. Alcohol and tobacco really occupy but a very small share of the interest and attention of even those men and women by whom they are habitually used. Hygiene, on the other hand, is of constant, uninterrupted concern. Why, therefore, should it be planned to have alcohol and tobacco displace the broader subject of personal and public hygiene in the attention and interest of children throughout the school life? Beyond the text-book and schoolroom a thousand influences are at work to teach the social evils, the waste of energy, and the unhappiness that always accompany the excessive use--and frequently result from a moderate use--of stimulants and narcotics. Of the many reasons for not drinking and smoking, physiology gives those that least interest and impress the child. The secondary effects, rather than the immediate effects, are those that determine a child's action. Most of the direct physiological effects are, in the majority of instances, less serious in themselves than the effects of overeating, of combining milk with acids, of eating irregularly, of neglecting constipation. Were it not for the social and industrial consequences of drunkenness and nicotinism, it is doubtful if the most lurid picture of fatty degeneration, alcoholic consumption, hardened liver, inactive stomach lining, would outweigh the pleasing--and deceiving--sensations of alcoholic beverages and cigarettes. The strong appeal to the child or man is the effect these habits have upon his mother, his employer, his wife, his children. The vast majority of us will avoid or stop using anything that makes us offensive to those with whom we are most intimately associated, and to those upon whom our professional and industrial promotion depends. Children will profit from drill in and out of school in the science of avoiding offense and of giving happiness, but unless the categories--_acts that give offense_ and _acts that give happiness_--are wide enough to include the main acts committed in the normal relations of son, companion, employer, husband, father, and citizen, those who set out to avoid alcohol and tobacco find themselves ill equipped to carry the obligations of a temperate, law-abiding citizen. Things do not happen as described in the early text-book. Other things not mentioned hinder progress and happiness. The child at work resents the mis-education received at school and suspects that he has been following false gods. The enemies that cause him trouble come from unexpected sources. He finds it infinitely easier to eschew alcohol and tobacco than to avoid living conditions that insidiously undermine his aversion to stimulants and narcotics. The reasons for avoiding stimulants in the interest of others are more numerous and more cogent than the reasons for avoiding stimulants and narcotics for one's own sake. The altruistic reasons for shunning stimulants and narcotics cannot be implanted in the child unless he sees the evil of excess _per se_ in anything and everything, and unless he becomes thoroughly grounded in the life relations and health relations to which he must adapt himself. Unclean streets, unclean milk, congested tenements, can do more harm than alcohol and tobacco, because they breed a physique that craves stimulants and drugs. Adenoids and defective vision will injure a larger proportion of the afflicted than will alcohol and tobacco, because they earlier and more certainly substitute discouragement for hope, handicap for equal chance. Failure to enforce health laws is a more serious menace to health and morals than drunkenness or tobacco cancer. If it is true that we must attack the problem of alcohol from the standpoint of its social and industrial effects, we are forced at once to consider the machinery by which cities and governments control the manufacture and sale of alcohol. It is not an exaggeration to say that courses in regulating the traffic in alcohol are more necessary than courses in the effects of alcohol upon digestion and respiration. If Sunday closing of saloons, local option, high license, and prohibition have failed, there is no evidence that the failure is due to the principles underlying any one of these methods. Until more earnest effort is made to study the effects of these methods, the results of their enforcement and the causes of their nonenforcement, no one is justified in declaring that either policy is successful or unsuccessful. It is very easy to select from the meager facts now available convincing proofs both that prohibition does not prohibit and that high license leads to increased drunkenness. The consequence is that the movements to control, restrict, or prohibit the use of alcohol are emotional, not rational. It is impossible to keep emotion, sensation, sentiment, at white heat. Most extremists worship legislation and do not try to keep interest alive by telling every week or every month new facts about the week or the month before. No new fuel is added to the anti-saloon fire, which gradually cools and dies down. Not so, however, with those who make money by the sale of intoxicants. The greater the opposition, the more brains, the more effort, the more money they put into overcoming or circumventing that opposition. Fuel is piled on and the bonfire is fed freely. Every day the anti-restriction bonfire becomes larger and larger, and the anti-saloon bonfire becomes smaller and smaller. By carefully selecting their facts, by counting the number of arrests for drunkenness and the number of saloons open on Sunday, by reiteration of their story the pro-saloonists gradually win recruits from the opposition, and, when the next election comes, their friends outnumber their enemies and the "dry" policy of a city, county, or state is reversed. The failures attributed to prohibitive or restrictive measures are probably no more numerous than the failures of government in other respects. The present ambassador from England, James Bryce, writing his _American Commonwealth_, declared that municipal government was America's "most conspicuous failure." The mayor of Toledo, writing in 1907, says, "There has been a pessimism, almost enthusiastic, about the city." These failures are due not to any lack of desire for good government, not to any fundamental evils of cities, but to the fact that municipal reform, like the crusade against alcohol, has been based upon emotionalism, not upon definite proof. Reformers have been unable to lead in the right direction, because they have looked at their lantern instead of their road. Not having cumulative information as to government acts, they have been unable to keep their fires burning. To illustrate: in November, 1907, the governor of New York state, the mayor of New York City, and reformers of national reputation eulogized the tenement-house department; yet this department, whose founding was regarded as a national benefaction, was the only department of the city government that did not receive an increase for 1908. It is in the position of temperance legislation, the facts of whose enforcement or nonenforcement are not promptly and continuously made public. Fear of the negro victim of alcoholism, social evils of intemperance, whether among white or black, industrial uncertainty and waste due to alcoholism, are the three chief motives that have swept alcohol traffic out of the greater part of the South. Knowledge of physiological evils has had little influence, except as it may have rendered more acceptable the claim that alcoholism is a disease against which there is no insurance except abolition of alcohol as a beverage. Religious revivals, street parades by day and by night, illustrated banners, personal intercession, lines of women and children at the polls, made it necessary for voters to make known their intention, and made it extremely difficult for respectable men, engaged in respectable business, to vote for saloons. Some states have gone so far as to prohibit the manufacture of alcoholic stimulants, even though not offered for sale within state limits. In Georgia wine cannot be used at the communion service, nor can druggists sell any form of liquor except pure alcohol. In Louisiana it is illegal for representatives of "wet districts" to solicit orders for liquor in any of the "dry districts." In Texas the sale of liquor in dining cars is forbidden, and the traveler may not even drink from his own flask. Congress is being urged by senators and congressmen, as well as by anti-saloon advocates, to pass laws prohibiting common carriers from delivering alcoholics to any "dry" community. The more optimistic anti-saloon workers believe it is but a matter of a short time when Congress will pass laws prohibiting the manufacture or sale of alcoholic beverages within any limits protected by the United States Constitution. Southern states have been warned that they could not afford the depreciation of real estate values, of rents, and of business that would surely follow the "confiscation of capital" and "interference with personal liberty." This warning has been met by plausible arguments that the buyers of legitimate and nonpoisonous commodities could pay better rents, better profits on business and on real estate, if freed from the uneven fight against temptation to drink. The argument that schools and streets and health must suffer if the license money was withdrawn, has been met by the plausible argument that the ultimate taxpayer--the family that wants clothing, food, and shelter--will save enough money to be able to spend still larger sums than heretofore upon education, health, and public safety. For the first time dealers in alcohol recognize the possibility of a great national movement and of national prohibition. Both the defects in methods hitherto used to oppose saloon legislation and the reasons for meeting the present situation by new methods are presented in the May issue (1907) of the _Transactions of the American Brewing Institute_. Under the title, "Social Order and the Saloon--the Measure of the Brewer's Responsibility," Mr. Hugh F. Fox, known throughout the Union as a defender of child rights, advocate of probation and children's courts, promoter of health and education, outlined a plan for research that is indispensable to the proper settling of this great question. Whether brewer or anti-saloon leaguist, total abstainer or moderate drinker, employer or trade unionist, it is necessary to the intelligent control of alcohol that each of us approach this momentous question of control or abolition of the saloon in the spirit expressed in this paper, whose thoroughness and whose social point of view would do credit to a church conference. The address is quoted and its questions copied because both show how much depends upon knowing whether laws are enforced and how much greater is the difficulty of coping with a conciliatory antagonist who professes willingness to submit to tests of evidence. The regulation of the liquor business involves fundamental questions of the function and scope of government, and there is hardly any department of organized human activity that has been the subject of so much experiment and futile tinkering.... The only people who are perfectly consistent are the prohibitionists, whose policy is abolition. Let us, however, try to detach ourselves from any personal interest that we may have in the subject, and consider it impartially as a matter of public concern. What the brewer as an individual cannot do, the brewers as an organization have done successfully in many places in spite sometimes of official negligence, corruption, or incapacity. The Texas Brewers' Association is reported as having successfully prosecuted two thousand cases against keepers of disreputable resorts during the past three years. The object of their campaign was to purify the retail liquor trade from unclean and law-defying elements. The greatest gain that has come to society, as distinguished from the individual, through the temperance movement is its effect in unconsciously informing the public that the regulation and administration of licensing is in itself a great and vital problem; and as a secondary result of such agitation, I should cite the growing sensitiveness of all persons in the business to the power of public opinion. The recognition by brewers of the force of public opinion is a recent affair. In former years they were totally indifferent to it, if indeed they did not openly flout it. Even now their appeal to public sentiment is mainly a special plea for defensive purposes, and has little or no educational value. Brewers have opposed practically every effort to effect a change in excise laws, often without any convincing reason, but simply because the proposed change involved temporary inconvenience and uncertainty, and perhaps a temporary loss. The brewing trade has utterly failed to develop a constructive programme in connection with the public regulation of its affairs. It does not seem to have any fixed principles or positive convictions as to excise methods and liquor laws. Its policy has been that of an opportunist, at the best,--or an obstructionist, at the worst. As in all other industries which affect the welfare of the people, reforms have been forced from the outside, with no help from within. Of course this is equally true of insurance and railroad corporations, of food purveyors, mine owners, cotton merchants, and a score of other interests. It is due not merely to human selfishness but to shortsightedness; in other words, to a lack of statesmanship. To call your opponents hypocrites, cranks, fakirs, and fanatics may relieve your feelings, but it doesn't convince anybody, and only hurts a just cause. It is foolish to question the motives of men who, without thought of personal gain, are trying to remedy the evils of inebriety. The church is perfectly right in urging total abstinence upon the individual. The only path of safety lies in abstinence for some individuals.... The recognition of the right of a community to establish its own licensing conditions carries with it the right of the community to determine whether there shall be any licenses at all! To make the discussion of this subject as fruitful as possible, I venture to submit the following questions for your consideration. None of them involve any direct moral issue, but there is an honest difference of opinion about each one of them, and they are certainly of vital importance in determining the course of wise and just administration. What has been the effect of high license? How much public revenue should the traffic yield? Does high license stimulate unlawful trade? How much license tax should be imposed upon local bottlers and grocers? Should they be allowed to peddle beer or to sell it in single bottles? Should the place or the individual be licensed? Should the licensing authorities be appointive or elective? By whom should they be appointed, and for what term of office? Have the courts made good or bad licensing authorities? Where the courts issue licenses, what has been the effect on the court? Should the licensing authority alone have the power to revoke a license, and discretion to withhold a license? How can the licensing authority enforce the law? Should it not be independent of the police? What should be the penalty for breach of the law? Do not severe penalties miscarry? On what plea, and under what conditions, should licenses be transferred? What has been the effect of limiting the number of saloons? Should limitation be according to area or to population? Is there any relation between the number of saloons and the volume of consumption? What should be the limit to the hours of selling? Should saloons be allowed to become places of entertainment? How can the sale of liquor by druggists be controlled? How can spurious drinking clubs be prevented or controlled? How can the operation of disreputable hotels be prevented? What should be the definition of a hotel? Who should define it? By whom should it be licensed? What special privileges should be given to it? How can the "back-room" evil be stopped? Is it legal (i.e. constitutional) to prohibit the sale or serving of liquor to women? Has the removal of screens reduced the volume of consumption? Has it improved the character of saloons? Has it solved the problem of Sunday prohibition for any length of time? What has been the general effect of it in the tenement districts? Should the state undertake to regulate the liquor business or to enforce liquor laws? Is it possible to devise any working plan which will apply with equal effectiveness and equity in communities of compact and of scattered population? Should, or should not, the principle of self-government be carefully preserved in the whole scheme of legislation to regulate the liquor business? Whether the present prohibition wave shall wash away the legalized saloon, as ocean waves have from time to time engulfed peninsulas, islands, and whole continents, depends upon the power of American educators and American officials to answer right such questions as the foregoing. The great danger is that we shall, as usual, over-emphasize lawmaking, underemphasize lawbreaking, and go to sleep during the next two or three years when we should be wide-awake and constantly active in seeing that the law is enforced. Unless exactly the same principles of law enforcement are applied in "dry districts" as we have urged for eradication of smallpox, typhoid, scarlet fever, and adenoids, local and city prohibition are doomed to failure. There must be: 1. Inspection to discover disease centers--"blind pigs," "blind tigers," etc. 2. Compulsory notification by parents and landlords, and by police and other officials. 3. Prompt investigation upon complaint from private citizens. 4. Prompt removal of the disease and disinfection of the center. 5. Segregation of individual units that disseminate disease, whether bartender, saloon keeper, owner of premises, or respectable wholesaler, none of whom should be permitted to shift to another the responsibility for violating liquor laws. 6. Persistent publicity as to the facts regarding enforcement and violation, so that no one, whether saloon leaguist or anti-saloon leaguist, shall be uninformed as to the current results of "dry" laws. It is perfectly safe to assume that none of these things will be done consistently unless funds are provided to pay one or more persons in each populous locality to give their entire time to the enforcement of laws, just as the improvement of other ills of municipal government require the constant attention of trained investigators. Cogent arguments for such funds have recently appeared in the _New York Evening Post's_ symposium on "How to Give Wisely," by Mrs. Emma Garrett Boyd, of Atlanta, and Miss Salmon, of Vassar College. If the saloon is here to stay, we must all agree that it is a frightful waste of human energy and of educational momentum to be appealing for its abolition when we might be hastening its proper control. On the other hand, if the saloon is destined to be abolished as a public nuisance and a private wrong, as a menace to industry and social order, is it not a frightful, unforgivable waste of energy to permit prohibition laws to fail, and thus to discredit the principle of prohibition? Philanthropists have provided millions for scientific research, for medical research, for the study of tuberculosis, and for the study of living conditions. It is to be hoped that a large benefaction, or that an aggregation of small benefactions, will apply to governmental attempts to regulate the sale of alcohol those methods of scientific research which have released men from the thraldom of ignorance and diseases less easily preventable than alcoholism. CHAPTER XXXV IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS OF ALCOHOLISM TO TELL THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH? If children are taught that the most effective way of combating alcoholism is to insure the enforcement of existing laws and to profit from lessons taught by such enforcement; if children are taught that the strongest reasons for total abstinence are social, economic, and industrial rather than individual and physiological,--there is much to be gained and little to lose from telling them the truth, the whole truth, and nothing but the truth about alcohol. To stimulate a child's imagination by untruths about alcohol is as vicious as to stimulate his body with alcohol. Whisky drinking does not always lead to drunkenness, to physical incapacity, to short life, or to obvious loss of vitality. Beer drinking is not always objected to by employers. Neither crime, poverty, immorality, lack of ambition, nor ignorance can always be traced to alcohol. On the contrary, it is unquestionably true that the majority of the nation's heroes have used alcoholics moderately or excessively for the greater part of their lives. It is probably true that among the hundred most eminent officials, pastors, merchants, professors, and scientists of to-day, the great majority of each class are moderate users of one or more forms of alcoholics. Overeating of potatoes or cake or meat, sleeping or working in ill-ventilated rooms, neglect of constipation, may occasion physiological and industrial injuries that are not only as grave in themselves as the evils of moderate drinking, but, in addition, actually tempt to moderate drinking. All of this can be safely admitted, because whether parents and teachers admit it or deny it, children by observation and by reading will become convinced that up to the year 1908 the noblest and the most successful men of America, as well as the most depraved and least successful, have used alcoholics. To be candid enough to admit this enables us to gain a hold upon the confidence and the intelligence of children and youth that will strengthen our arguments, based upon social and industrial as well as physiological grounds, against running the risks that are inevitably incurred by even the moderate use of alcohol. Other things being equal, the same man will do better work without alcohol than with alcohol; the same athlete will be stronger and more alert without alcohol than with alcohol; the clerk or lawyer or teacher will win promotion earlier without alcohol than with alcohol; man or woman will grow old quicker with than without alcohol. Other things being equal, a man of fifty will have greater confidence in a total abstainer than in a man of identical capacity who uses alcohol moderately; a mother will give better vitality and better care to her children without than with alcohol; a policeman or fireman or stenographer is more apt to win promotion without than with alcohol. Whatever the physical ailment, there is in every instance a better remedy for an acute trouble, and infinitely better remedies for deep-seated troubles, than alcoholics. The percentage of failure to use alcoholics moderately is so high, the uncertainty as to a particular individual's ability to drink moderately is so great, as to lead certain insurance companies, first, to give preference to men who never use alcoholics, and later, to refuse to insure moderate drinkers. Life insurance companies have the general rule that habitual drinkers are bad risks, as the alcohol habit is prejudicial to health and longevity; but they have no means of studying the risk of moderate drinkers, because, except where alcohol has already left a permanent impression upon the system, the indications are by no means such as to enable the medical examiner to trace its existence with certainty. For this reason the life insurance companies have little effect in _preventing_ alcoholism. Though they are agreed that habitual drinkers ought to be declined altogether, only a few companies have taken the decided stand of declining them. "Habitual drinkers, if not too excessive, are admitted into the general class where the expected mortality, according to the experience of the Pennsylvania Mutual Life Insurance Company, is 80 per cent, as against 56 per cent for the temperate class. Though it is only necessary to look over the death losses presented each day to see that intemperance in the use of liquors, as shown by cirrhosis of the liver, Bright's disease, diseases of the heart, brain, and nervous system, is the cause of a large proportion of the deaths, these companies prefer to grade the premiums accordingly rather than to decline habitual drinkers altogether. While this is partly due to the difficulty and expense of diagnosis, it is more probably due to an objection to take a definite stand on the temperance question." Thus the insurance companies' rules touch only the confirmed drinker, whose physique is often irreparably injured. One company writes: "Men who have been intemperate and taken the Keeley or other cures are never accepted until five years have elapsed from the date of taking the cure, and only when it can be conclusively shown that during the whole period they have refrained entirely from the use of alcoholic liquor, and that their former excesses have not in any way impaired the physical risk." Thus far American insurance companies are doing little preventive and educational work on the alcohol question, though they have the very best means at their command for so doing. According to the Metropolitan Life Insurance Company nine tenths of the school children in New York City are insured by them, and an even greater proportion of workingmen. Even though this is done "at twice the normal cost," the most cursory medical examination is given and no attempt is made to instruct them in the relation of their physical condition to their working power, or in the evils of the alcohol and the smoking habits. Naturally the moderate drinker is first rejected for positions where an occasional overindulgence would be most noticeable and most serious. The manager of a large factory tells his men: "You cannot work here unless you are sober. If you must drink at parties, stay at home if necessary until 12 o'clock the next day and sleep it off, but don't come here till you are straight. We cannot afford it." Occasionally his men stay at home and not a word is said, but the minute they are found at work in an unsteady condition they are summarily discharged. From this position it is but a step to that of an upholsterer in New York City, who prints on his order blanks, "No drinking man employed." His company recently discharged a man after twenty years of service because a customer for whom this man was working detected a whisky breath. Men reported to trade unions for frequent intoxication are blacklisted. A certain financial corporation permits no liquor on its grounds or in its lunch rooms. The head of one of its large branches was heard to say recently that he would discharge on the spot a man who showed evidences of drinking, even though he had previously worked faithfully for years. Rejection of moderate drinkers by business houses is not done on moral grounds alone, but because experience has proved the danger of employing men who have not their faculties fully under control _all_ the time they are at work. The rules are especially strict for men working for a railroad or street railway company. The Pennsylvania Railroad Company replied to my inquiry as to their custom of discriminating against drinking men in these words: "We have no printed rules in regard to this except in a general way,--that no employee is allowed to go into a saloon during his hours of work or wearing the company's uniform. Of course the men are promptly discharged or disciplined if they show the effects of liquor while on duty, and the whole tendency of the administration of the rules is to get rid of any men who are habitual drinkers, but the administration of the rules and discipline is left to the superintendent of each division." The Interborough Rapid Transit Company of New York has these printed rules for the physical standard required for applicants for employment: 1. _Examination of heart and arteries._ Rejection of candidates showing excessive or long-continued use of tobacco and alcohol, with explanation of condition, causes, and dangers of continued use. Warning to chiefs of departments regarding those accepted who show tendency to drink at times, but whose physical examination does not disclose sufficient evidence to warrant their disqualifications. Foremen and chiefs of departments to be notified and to carry out the policy of employing only men who are at all times sober and not under the influence of alcohol at all. 2. _On reëxamination of employees._ Warning to or rejection of those showing, on physical examination, indulgence to excess of alcohol, tobacco, or drugs. Warning to chief of department of evidence of such habits on part of any employee examined for any reason, but retained in service of the company with injunction to chief of department to speak with such employee and have him under proper supervision. The blacklisting of habitual drinkers by their union, and the growing tendency on the part of large corporations, factories, and business houses to take a decided stand against drinking, are having a marked effect in reducing drunkenness where it does most harm. This practice has been declared by John Bach McMasters, the noted American historian, to have exerted a stronger influence in promoting temperance and total abstinence than all the temperance crusades from Hartley's time to the prohibition wave of 1907. The school, by instructing children how the alcohol habit will affect their chances of business success, future usefulness as citizens, and enjoyment of life, will inevitably reduce the evils of alcohol. By teaching based on facts that intimately concern the life of the child, as well as by caring for his health and his environment, the schools can help supplant the desire for alcohol with other more healthy desires. No truth about alcohol is more important than that the craving for alcohol or something just as bad will exist side by side with imperfect sanitation, too long hours of work, food that fails to nourish, lack of exercise, rest, and fresh air. Conditions that produce bounding vitality and offer freedom for its expression at work and at play will supplant the craving for stimulants. Finally, the great truth contained in the last chapter must be taught, that success in coping with alcoholism is a community task requiring efficient government above all else. CHAPTER XXXVI FIGHTING TOBACCO EVILS "It is not necessarily vicious or harmful to soothe excited nerves." This editorial comment explains, even if it condemns while trying to justify, the tobacco habit. To soothe excited nerves by lying to them about their condition and by weakening where we promise to nourish, is vicious and harmful just as other lying and robbery are vicious and harmful. Yet two essential facts in dealing with tobacco evils must be considered: tobacco does soothe excited nerves, and the harm done to the majority of smokers seems to them to be negligible. For these two reasons the tobacco user, unless frightened by effects already visible, refuses to listen to physiological arguments against his amiable self-indulgence. Cheerfully he admits the theoretical possibility that by its method of soothing nerves tobacco kills nerve energy. But in all sincerity he points to men who have found the right stopping point up to which tobacco hurts less perhaps than coffee or tea, candy or lobster, overeating or undersleeping. Therefore the physician, the bishop, the school superintendent, candidly run the necessary risk for the sake of nerve soothing and sociability. Less harm would be done by tobacco if it were more harmful. Like so many other food poisons, its use in small quantities does not produce the prompt, vivid, unequivocal results that remove all doubt as to the user's injuries and intemperance. As inability to see the physiological effect upon himself encourages the tobacco user to continue smoking or chewing, so failure to identify evil physiological effects upon the smoker encourages the nonuser to begin smoking or chewing. A very few smokers give up the habit because they fear its results, but too often the man who can see the evil results would rather give up almost anything else. The one motive that most frequently stops inveterate smoking--fear--is the least effective motive in dissuading those who have not yet acquired the habit; every young man, unless already suffering from known heart trouble, thinks he will smoke moderately and without harm. Unfortunately, every boy who begins to smoke succeeds in picturing to himself the adult who shows no surface sign of injury from tobacco, rather than some other boy who has been stunted physically, mentally, and morally by cigarettes. For adult and child, therefore, it behooves us to find some other weapons against tobacco evils in addition to fear of physiological injuries. Among these weapons are: 1. Enforcement of existing laws that make it an offense against society for dealer, parent, or other person to furnish children under sixteen with tobacco in any form; and raising the age limit to twenty-one, or at least to eighteen. 2. Enforcement of restrictions as to place and time when smoking is permitted. 3. Agitation against tobacco as a private and public nuisance. 4. Explanation of commercial advantages of abstinence. Because the childish body quickly shows the injurious effects of what in adults would be called moderate smoking, the proper physical examination of school children will reveal injuries which in turn will show where and to what extent the cigarette evil exists among the children of a community. Even the scientists who claim that "in some cases tobacco aids digestion," or that "tobacco may be used without bad effects when used moderately by people who are in condition to use it," declare emphatically that tobacco "must not be used in any form by growing children or youths." Prohibitive laws can be rigidly enforced if a small amount of attention is given to organizing the strong public sentiment that exists against demoralizing children by tobacco. Thus children and youths will not need to make a decision regarding their own use of tobacco until after other arguments than physiological fear have been used for many years by parent, teacher, and society. One effective weapon is the sign on a ferryboat or street car: "No smoking allowed on this side," or "Smoking allowed on three rear seats only." Public halls and vehicles in increasing numbers either prohibit smoking altogether or put smokers to some considerable inconvenience. The trouble involved in going to places where smoking is permitted tends gradually to irritate the nerves beyond the power of tobacco to soothe. Again, many men would rather not soothe their excited nerves after five, than have their nerves excited all day waiting for freedom to smoke. Restrictions as to time or place make possible and expedite still further restrictions. Thus gradually the army of occasional smokers or nonsmokers is being recruited from the army of regular smokers. The anti-nuisance motive follows closely upon the drawing of sharp lines of time and place for the use of tobacco. Like treason, smoking in the presence of nonsmokers can be considered respectable only when the numbers who profess and practice it are numerous. If the two first-mentioned weapons are effectively used, there will be an increasing proportion of nonsmokers and not-yet-smokers who will give attentive ear to proof that nicotinism is a nuisance. The physical evidences of the cigarette habit can easily be made distasteful to all nonsmokers if frankly pointed out,--the yellow fingers, the yellow teeth, the nasty breath, the offensive excretions from the pores that saturate the garments of all who cannot afford a daily change of underwear. The anti-nuisance argument is always insidious and abiding. In the presence of nonsmokers accustomed to regard tobacco using as a nuisance, smokers become self-conscious and sensitive. Men and women alike would prefer a reputation for cleanliness to the pleasures of tobacco. The educational possibility of fighting tobacco with the name "nuisance" was recognized the other day by an editorial that protested against a law to prevent women from using cigarettes in restaurants. "The way for any man who has the desire to reform some woman addicted to the cigarette habit is insidiously and gently to point out the injurious effects on her appearance. Cigarette smoking stains a woman's fingers and discolors her teeth. It also tends to make her complexion sallow and to detract from the rubiness of her lips. It bedims the sparkle of her eyes. It makes her less attractive mornings." Chewing has practically disappeared, not because it ceased to soothe excited nerves but because it was seen to be a nasty nuisance. Finally, the selfishness of the smoker is a nuisance that continues only because it has not been called by its right name. "Do you mind if I smoke?" was a polite question two hundred years ago when tobacco was rare enough to make smoking a distinction, or fifty years ago when everybody smoked at home and in public. But it is effrontery to-day when people do mind, when smoking pollutes the air of drawing room and office, and while soothing the excited nerves of the smoker lowers the vitality of nonsmokers compelled to breathe smoke-laden air. It is selfish to intrude upon others a personal weakness or a personal appetite. It is selfish to divert from family purposes to "soothing excited nerves" even the small amounts necessary to maintain the cigar or cigarette habit. It is selfish to run the risk of shortening one's life, of reducing one's earning capacity. Because the tobacco habit is selfish it is anti-social and a nuisance, and should be fought by social as well as personal weapons, as are other recognized nuisances, such as spitting in public or offensive manners. The economic motive for avoiding and for eliminating tobacco is gaining in strength. The soothing qualities of all drugs are found to be expensive to physical and business energy if enjoyed during business hours. Strangely enough, employers who smoke are quite as apt as are nonsmokers, to forbid the use of tobacco by employees at work. Some of this seeming inconsistency is due to a dislike for cheaper tobacco or for mixed brands in one atmosphere; some of it is due to the smoker's knowledge that "soothing nerves" and sustained attention do not go hand in hand, while "pipe dreams" and unproductive meditation are fast companions; finally no little of the opposition to tobacco in business is due to fear of fire. These various motives, combining with the anti-nuisance motive among nonsmokers, have led many business enterprises to prohibit the use of tobacco in any form on their premises or during business hours, even when on the premises of others. Notable examples are railroads that permit no passenger trainman to use tobacco while on duty. (Freight trainmen are restricted more tardily because the risk of damages is less and the anti-nuisance objection is wanting.) From penalizing excessive use and prohibiting moderate use in business hours, it is a short cut to choosing men who never use tobacco and thus never suffer any of its effects and never exhibit any of its offensive evidences. No young man expects to obtain a favorable hearing if he offers himself for employment while smoking or chewing tobacco. Business men dislike to receive tobacco-scented messengers. Cars and elevators contain signs prohibiting lighted cigars or cigarettes. Insurance companies reject men who show signs of excessive use of tobacco. Why? Because they are apt to die before their time. The Interborough Rapid Transit Company of New York City rejects applicants for motormen and conductors "for excessive or long-continued use of tobacco." Why? Because, other things being equal, such men are more apt to lose their nerve in an emergency and to fail to read signals or instructions correctly. Armed with these weapons against tobacco, parents and teachers can effectively introduce physiological arguments against excessive use, against use by those who suffer from nervous or heart trouble, and against any use whatever by those who have not reached physical maturity. By avoiding physiological arguments that children will not--cannot--believe contrary to their own eyes, parents and teachers are able to speak dogmatically of that which children will believe,--injuries to children, evils of excess, restrictions as to time and place, and offensiveness to nonsmokers. But even here it is wrong, as it is inexpedient, to leave the physical strength of the next generation to the persuasive power of parents and teachers or to the faith and knowledge of minors. Society should protect all minors against their own ignorance, their own desires, the ignorance of parents and associates, and against the economic motive of tobacco sellers by machinery that enforces the law. CHAPTER XXXVII THE PATENT-MEDICINE EVIL "Dhrugs," says Dock O'Leary, "are a little iv a pizen that a little more iv wud kill ye. Ye can't stop people fr'm takin' dhrugs, an' ye might as well give thim somethin' that will look important enough to be inthrojuced to their important and fatal cold in th' head. If ye don't, they'll leap f'r th' patent medicines. Mind ye, I haven't got annything to say agin' patent medicines. If a man wud rather take them thin dhrink at a bar or go down to Hop Lung's f'r a long dhraw, he's within his rights. Manny a man have I known who was a victim iv th' tortures iv a cigareet cough who is now livin' comfortable an' happy as an opeem fiend be takin' Dr. Wheezo's Consumption Cure." The Dock says th' more he practices medicine th' more he becomes a janitor with a knowledge iv cookin'. He says if people wud on'y call him in befure they got sick he'd abolish ivry disease in th' ward except old age and pollyticks. Thus Mr. Dooley with his usual wit and insight tells the American people why they spend over two hundred million dollars annually on patent medicines. Americans consume more drugs and use more patent medicines than the people of any other country on the civilized globe. Self-medication has grown to tremendous proportions. Everywhere--in cars, on transfers, on billboards, in magazines, in newspapers, in the mails--are advertised medicines to cure disease and devices to promote health. When we consider that electric cars contain from thirty-two to fifty-two advertisements each, three fourths of which are directly or indirectly concerned with health; when we multiply these by the number of cars actually in use in American cities; when we consider the number of advertisements in magazines and daily papers, and the enormous circulation of these papers and magazines; when we consider that an increasingly large proportion of advertising space is devoted to health,--we begin to realize the cumulative power for good or for evil that health advertisements must have. To illustrate advertisements devoted to health to-day, I have kept clippings for one week of news items, editorials, and advertisements in a penny and a three-cent paper, and had them classified according to the subjects treated: ===================+=========================+======================== | PENNY PAPER | THREE-CENT PAPER +------+---------+--------+-----+---------+-------- | News |Editorial| Adver- | News|Editorial| Adver- | Item | |tisement| Item| |tisement -------------------+------+---------+--------+-----+---------+-------- Milk | 3 | -- | 2 | 3 | -- | 2 Teeth | -- | 1 | 2 | -- | -- | 1 Shoes | -- | -- | 4 | -- | -- | 1 Food | 1 | -- | -- | 1 | -- | 4 Alcohol | 1 | -- | 5 | 3 | -- | 7 Tuberculosis | -- | -- | 1 | 1 | -- | -- Patent medicine | -- | -- | 17 | -- | -- | -- Constipation cures | -- | -- | 4 | -- | -- | 5 Eyes | 3 | -- | 5 | 1 | -- | -- Beauty | 2 | 5 | 8 | -- | -- | 6 General | 8 | 3 | 3 | 5 | -- | -- -------------------+------+---------+--------+-----+---------+-------- Total | 18 | 9 | 51 | 14 | -- | 26 ===================+======+=========+========+=====+=========+======== The following list of health topics was treated in the advertisements, editorials, and articles of a popular monthly periodical devoted to women: =========================+=========+===========+=============== | ARTICLE | EDITORIAL | ADVERTISEMENT -------------------------+---------+-----------+--------------- Babies | 1 | -- | 11 Soaps and powders | -- | -- | 5 Beauty | 3 | -- | 6 Quack cures | -- | 2 | -- Tooth powders | -- | -- | 4 Household | 1 | -- | 5 Food and cooking | 1 | -- | 14 Clothes | 13 | -- | 5 Teaching sex laws | 1 | 2 | -- Medicine | 4 | 1 | -- -------------------------+---------+-----------+--------------- Total | 24 | 5 | 50 =========================+=========+===========+=============== Besides the classic patent medicines, such as Lydia Pinkham's Vegetable Compound, Castoria, Cod Liver Oil, etc., there are "Colds Cured in One Day," "Appendixine," health foods, massage vibrators, violet rays, Porosknit underwear, sanitary tooth washes, soaps, vitopathic, naturopathic, and faith cures. New ones appear every day,--enough to make a really sick person dizzy, let alone a person suffering from imaginary ailments. All seem to outline my particular symptoms. After they have flamed at me in red letters in the surface cars, pursued me in the elevated and underground, accompanied me out into the country and back again to the city, greeted me each morning in the daily paper and in my daily mail, each week or each month in the periodical, the coincidence of a familiar package on a drug-store counter seems to be providential and therefore irresistible. I know that I ought to be examined by a physician, but I am busy and not unwilling to gamble for my health; it cannot kill me and there is a chance that it will cure me. If there is nothing the matter with us, we may be cured by our faith. If we are taking a cure for consumption, the morphine in it may lull us into thinking we feel better. If we are taking a tonic for spring fever, the cheap alcohol may excite us into thinking our vitality has been heightened. Soothing sirup soothes the baby, often doping its spirit for life, or soothing it into a sleep from which it never wakes. In spite of the fact that the "Great American Fraud" has been exposed repeatedly in newspapers and magazines of wide circulation, the appeal of the quack still catches men and women of intelligence. The other night a friend went out to a dinner and conference with a lawyer in the employ of the national government. Annoyed by a nagging headache, he made for the nearest drug store and ordered a "headache powder." He admitted that it was an awful dose, but he had been told that it always "did the business." He knew the principle was bad, confessed to a scorn for friends of his whom he knew to be bromo-seltzer fiends, but he had the headache and the work to do--a sure cure and a quick one seemed imperative. The headache was due to overwork, indigestion, constipation. Plain food and quiet sleep was what he needed most. But the dinner conference plus the headache was the unanswerable argument for a dose with an immediate result. Last winter an Irish maid slowly lost her rosy cheeks and grew hollow-eyed and thin. She was taken to a specialist who discovered a rapidly advancing case of consumption. He said that owing to the girl's ignorance, stupidity, and homesickness, her only chance of recovery was to return to the "auld countrie" at once. The girl agreed to go, but insisted on a few days "to talk it over with her cousins in New York." After two weeks had elapsed she was found in a stuffy, overcrowded New York tenement. She had found a doctor who had given her a little bottle of medicine for two dollars, which would cure her in the city. It was futile to protest. Days in the unventilated tenement and nights in a "dark room" meant that she would never live to finish the bottle. For a year Miss H. took a patent preparation for chronic catarrh. It seemed to "set her up"; but it so undermined her strength, through its artificial nerve spur, that chronic catarrh was followed by consumption. It later transpired that the cure's chief ingredient was whisky, and cheap whisky. A good grandmother, herself a vigorous temperance agitator and teetotaler, offered to pay for it as long as my friend would take it faithfully. The irony of it makes one wonder how many earnest advocates of total abstinence are in reality addicted to the liquor habit. Last summer a district nurse of the summer corps who visited city babies under two years of age encountered in the hallway of a tenement a bevy of frenzied women. A baby lay on the bed gasping and "rolling its eyes up into the top of its head." The nurse asked the frightened mother what she had been giving it. "Nothing at all," said the woman. But a telltale bottle of soothing sirup showed that the child was dying from morphine poisoning. Happily the nurse came in time to save it. Is it not pitiful, this grasping for a poison in an extremity; this seizing of a defective rope to escape the fire? [Illustration: LEARNING HOW TO KEEP BABY WELL WITHOUT PATENT MEDICINES Recreation Pier, New York City, Summer, 1908] The patent-medicine evil cannot be cured by occasional exposure or by overexposure. Nor can it be cured by legislation, legislation, legislation, unless laws are rigidly enforced. Occasional exposure is no better than occasional advertising of good things. The patent-medicine business thrives on constant, not occasional, advertising. Leading advertisers expect so little from the first notice that they would not take the trouble to write out a single advertisement. That is the reason merchants charge advertising in the programmes of church, festival, and glee-club concert to charity, not to business. Warning people once does no more lasting good than sending a child to school once a month. The exposure of patent-medicine evils must be as constant as efforts to sell the medicines. Overexposure is ineffective. It is the evils of patent medicines that do harm, not their name and not their patents. The medical profession has in vain protested against proprietary medicines. Ethical barriers cannot be erected by resolution. Calling things unethical does not make them unethical. The mere patenting of medicines for profit does not make the medicine injurious any more than the mere mixing of unpatented drugs makes a physician safe. Physicians who would not themselves patent a drug will use certain patented drugs whose ingredients are known to be safe and uniform. True exposure of patent-medicine evils will enable the average physician and the average layman to distinguish the dangerous from the safe, the fraud from the genuine, lies from truths. Legislation is needed to crystallize modern knowledge and to establish in courts the right to protection against the evils of patent medicines. The national Pure Food Law, passed January 1, 1907, and now in force throughout the country, requires on the "labels of all proprietary medicines entering into interstate commerce, a statement of the quantity or proportion of any alcohol, morphine, opium, heroin, chloroform, cannabis indica, chloral hydrate, or acetanilid, or any derivative or preparation of any such substance contained therein; this information must be in type not smaller than eight-point capital letters; also _the label shall embody no statement which shall be false or misleading in any particular_." This law does not forbid patent medicines nor the use of alcohol and narcotics in patent medicines; it merely says, "Let the label tell, that all who _buy_ may read." It does not require that all who _run_ may read, for _it does not say that advertisements of a patent medicine shall tell the truth about its ingredients or its action on the human body_; only that the label on the bottle shall tell. The object of this law is to explain to the consumer the exact nature of the medicine. But to the majority of people the word "acetphenitidin" on the label of a headache medicine does not explain. The new order that requires manufacturers to substitute acetanilid for acetphenitidin does no more than replace fog with mist. Protection requires legislation that cannot be evaded by technical terms. The present law requires that packages must be properly labeled _on entering the state_. To carry out the national law, state laws should make it an offense for dealers to have in their possession proprietary medicines without explanatory labels that explain. Where state laws to this effect do not exist, the packages once in the state may be deprived of their labels and sold as secret remedies, thus nullifying the whole effect of the national law. Enforcement must be insured. Impure drugs may do as much harm as patent medicines containing harmful drugs. In New York a vigorous campaign was recently inaugurated by the department of health to drive out impure drugs. Drugs are dangerous enough at their best. When they are not what they pretend to be, whether patented or not, they may take life. One extreme case where a patient's heart was weakened when it ought to have been strengthened, led to the discovery that practically all of one particular drug offered for sale in New York City was unfit to use and calculated to kill in the emergency where alone it would be used. Yesterday four lives and several million dollars were lost in a New York fire because the hose was rotten or weak. As inspection and testing were needed to insure hose equal to emergency pressure, so inspection and testing of patent medicines and drugs are needed to make legislation effectual. Legislation and enforcement should reach the newspaper, magazine, billboard, street car, that advertises a falsehood or less than the essential truth regarding drugs, foods, and patent medicines. Public sentiment condemns the advertising of many opportunities to commit crime or to be disorderly or indecent or to injure one's neighbor. The facts about hundreds of nostrums can be absolutely determined. The advertising agency, whether secular or religious, that carries misrepresentation of drugs and foods should be forbidden circulation through the mails. The existence of such advertisements should be made evidence of complicity in a public offense and punished accordingly. Treat them as we treated the Louisiana lottery. Boards of health, instead of furnishing names to druggists and manufacturers who want to sell patent foods and medicines, should print circulars exposing frauds, and punish so far as the law permits. While trying to secure adequate legislation and efficient administration of the above-mentioned standards, there is much that can be done by individuals and clubs. We can give preference to those journals that refuse drug and food advertisements unless evidence is produced that the truth is told and that the goods are not harmful. We can refuse to have in the house a paper or journal which prints notices that lie or that conceal the truth. If this drastic measure would cut us off entirely from daily papers, we could choose the least offensive and petition it to exclude specific lying methods. When it preaches health, honesty, and philanthropy, we can cut out of one issue the noble editorial and the exploiting advertisements and send them to the editor with our protest. Knowledge of the ingredients and dangers of patent medicines should be a prerequisite for the practice of medicine or pharmacy. We can help bring about such conditions, and we can patronize physicians who send patients to drug stores that cater to intelligence rather than to ignorance. Fighting patent-medicine evils is a civic duty to be accomplished by civic coöperation, not private effort. It is impossible to organize unofficial educational agencies that can offset the cumulative, lying advertisement. Personal opposition is but the beginning. Official machinery must be set running and kept running so as to protect the public health against the commercial motive that preys upon ignorance and easily inspired faith. CHAPTER XXXVIII HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH It is usually considered futile to attempt to defeat the devil with his own methods, because he knows so much better how to use them. But abuse does not do away with use, and the success of quacks in reaching the people demands our respect. There is no reason why their methods, based on a knowledge of human nature and human psychology, should not be employed to appeal to needs rather than to weaknesses. A good thing may lie unused because of lack of advertisement. Vitality is coming to be the passion of the American people. It is on this sincere passion that fakirs have so long traded. There can be no doubt that advertisements of health-promoting goods are quite as profitable as health advertisements that injure health, when equally effective methods are used to make them reach the public. The tradition has been repeatedly mentioned in this book that the better the doctor, the less he advertises himself, except in medical and scientific journals that notoriously fail to reach the people. The same is too often true of reputable remedies and goods. The theory that these things stand or fall on their merits is not borne out by practical experience,--conspicuously in the case of "fake" remedies. Purely philanthropic undertakings for the advancement of health fail, if not placed before the people whom they aim to help in an attractive, convincing form. Failure to advertise a worthy cause limits its usefulness, and is therefore unjustifiable, whether we speak of medicine, legal aid, or dental clinics. An intensive study of the methods used to advertise patent medicines will suggest means of extending the usefulness of health-promoting goods. Aside from clever methods of suggestion that lead many people to take medicine for imaginary ailments, especially seasonal ailments, patent-remedy advertisers have employed (as an argument for the efficiency of their cures) scientific theory, bacterial origin of diseases, recent medical or physiological discoveries, and state and national movements for promoting health. In fact, they have turned to their own uses the very law that seeks to control them and the exposures that seek to exterminate them. Whatever may be the merits of Castoria, the "Don't Poison Baby" advertisement on the following page, printed just after the accompanying "Babies Killed by Patent Medicines," which appeared in a home journal, was surely a clever bit of advertising. Upon an editorial in a daily paper on the relation of eyeglasses to headache and indigestion, an optician based a promise of immediate relief for these ailments if he himself were patronized. The recent investigations of the Department of Agriculture, and of Professors Chittenden and Fisher, in regard to foodstuffs, are proving helpful to food quacks and advertisers of pills for constipation and indigestion. Since the passage of the Pure Food Law one health food is advertised in a column headed "Pure Food." When the season for pneumonia comes around numerous medicines are "sure cures" for grippe and pneumonia. "Rosy teachers look better in the schoolroom than the sallow sort," is surely a good introduction to a new food. Woman's vanity sells many a remedy advertised to counteract the "vandal hand of disease, which robs her of her beauty, yellows and muddies her complexion, lines her face, pales cheek and lip, dulls the brilliancy of her eye, which it disfigures with dark circles, aging her before her time." Who in your town is as good a friend to "owners of bad breath" as the advertiser who tells them that they "whiff out odor which makes those standing near them turn their heads away in disgust"? The climax of effective educational advertising as well as of consummate presumption and villainy is reached in the notice of an alcoholic concoction that uses the headline, "Medical Supervision Needed to Prevent the Spread of Consumption in the Schools." Thus grafting itself on the successful results of the medical examination in the Massachusetts schools, it enlists the aid of teachers, trades on the fear of tuberculosis, even indorses the fresh-air treatment. So convincing was this appeal that it was reprinted in the news columns of a daily paper in New York as official advice to school children. [Illustration: Don't Poison Baby.] So clever are these methods of advertising and so successful are they in reaching great numbers of people, that if reputable physicians would take lessons of them, they might conduct a health crusade that would exterminate tuberculosis, diminish the use of alcohol and tobacco, and save thousands of babies that die unnecessarily. The theory of patent-medicine advertising is sound. It emphasizes the joys of health, the beauty of health, the earning power of health. It adapts its message to season, event, and need. It offers testimonials of real persons cured. It is all-appealing, promising, convincing,--a fearful menace to health when the remedies offered are dishonest, a universal opportunity for promoting health if the cure is genuine. A classic example of health advertising that promotes health is Sapolio. The various hygiene lessons that have promoted Sapolio have done much to raise the standard of living in the United States. Few eminent physicians have done so much for public health as the "Poor M.D. of Spotless Town who scoured the country for miles around, but the only case he could find was a case of Sapolio." Recent press discussions about furnishing free eyeglasses to the children in the public schools have so enlightened people as to the need for expert examination of their eyes that opticians will be forced to employ competent oculists to make the preliminary examination and to see that the glasses are properly adjusted. In spite of the long mis-education by makers of corsets, the persistent advertising of "good health" and "common-sense" waists has gained an increasing number of recruits from the ranks of the self-persecuting. It is only a matter of time when the term "stylish" will be transferred to the advocates of health, because advertisers who tell the truth will, if persistent, gain a larger patronage than advertisers of falsehoods; there is profit in retaining old customers. The advertisement of a window device for "Fresh air while you sleep" will make prevention of tuberculosis more profitable than "sure cures" that lie and kill. A man deserves profit who sends this message to millions of readers: There are three kinds of cleanliness: First, the ordinary soap-and-water cleanliness. Second, the so-called "beauty" cleanliness. Third, prophylactic cleanliness, or the cleanliness that "guards against disease." But the man who sells soap ought to be the one to use this advertisement, not a man who sells toothwash that, when pure, is little better than water, that is seldom pure, and that always hurts the teeth. Many children and adults are being cured of flat foot by men who make money by selling shoes designed to strengthen the arch of the foot. Millions would never know how to discover the evil effects upon themselves of coffee and alcohol except for money-making advertisements. Little Jo's Smile taught a nation that the majority of crippled children are victims of neglect on the part of adult consumptives. Certain it is that advertising is an art promoted by the severest competition of the cleverest brains. It is a force which we cannot afford to ignore. If we can harness it to the promotion of aids to health, it will do more good than all the hygiene books ever written. To this end we must educate ourselves to distinguish between goods which do what they profess to do and those which do not. A good eye opener would be to keep for a week clippings from a high-priced daily paper, a penny daily paper, and one or two representative magazines, including a religious paper. Teachers and parents can very easily interest children in such clippings. Moreover, they can use the bulletin method, the stereopticon exhibit, the _cumulative illustration_ of a fact, which is the essence of successful advertising. Boards of health can use all the typographical aids to clear understanding,--cuts, diagrams, interesting anecdotes. In New York both the health board and the school board have issued circulars and given illustrated lectures, some of them being in school and some on public squares. Medical and sanitary societies and other educators can be induced to follow what a successful business man has called the three cardinal rules of advertising: First, put your advertisement where it will be seen. (Tell your story where it will be heard.) Second, write it so that people will read it. (Tell it so that people will understand it.) Third, tell the truth, so that people will believe it. CHAPTER XXXIX IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE? Among remedies for preventable disease and preventable poverty, the following was urged at a national conference for the betterment of social conditions: "We have been too prudish. Because we have been unwilling to teach school children the evils of violating sex hygiene, we have been unsuccessful in combating evils justly attributable to ignorance on the part of girls as to the duties and dangers of motherhood." This point of view is shared by so many men and women that a national body was organized in 1905 to promote the teaching of sex hygiene,--the Society for Sanitary and Moral Prophylaxis. This society has its headquarters in New York, and distributes at cost lectures and essays. The second of its educational pamphlets is addressed to teachers, and is entitled "Instruction in the Physiology and Hygiene of Sex." The introduction asks eleven questions of the teachers as follows: 1. Do you wish a pamphlet on sex subjects to hand to your pupils? Why? 2. Do you wish separate pamphlets for boys and girls? 3. For what age limits and social conditions do you wish them? 4. What topics do you wish the pamphlets for boys to "handle"? 5. What topic do you wish the pamphlet for girls to "handle"? 6. If you think one pamphlet sufficient for both sexes, what should it consider? 7. How far do you go in teaching sexual hygiene or reproduction? By what method? 8. What special difficulties do you find in teaching it? 9. What special need of teaching it have you found? 10. What special benefits (or otherwise) have you noticed from teaching it? 11. What criticisms (favorable or otherwise) do you encounter? The difficulty of introducing formal instruction in sex hygiene, even in the upper grades of public and private schools, is hinted at in the pamphlet. The purpose of the publishing society as given in its constitution is "to eliminate the spread of diseases which have their origin in the social evil." Although sex hygiene does not begin with sex immorality, almost every text-book on sex hygiene, and almost every pamphlet urging class instruction in sex hygiene, begins with sex immorality. Yet only the exceptional school child is in danger of violating sex morals, while every school child needs instruction in sex hygiene. Instruction in sex hygiene, whether at school or at home, should deal with sex normality, sex health, sex temperance. Instruction in sex immorality is objectionable, not merely because it offends prudists, not because it is difficult, but because it can be shown by experience to be less efficacious than training in sex health. To expect fear to prompt sex hygiene is to make a mistake that has retarded the development of sound measures in the treatment of offenders against criminal law. For centuries man failed in attempts to fit the punishment to the crime. To deter men from committing crime by holding up a threat of prolonged and dreadful punishment has been found futile. Individuals take the risk because they think they will escape detection. It is an axiom of criminal procedure that a would-be offender is deterred by the certainty, not by the severity, of punishment. The modern theory of probation is, that children and adults may be best led away from evil practices by crowding out old influences with newer and stronger interests. Occupations that are wholesome are made to rival diversions or occupations that are harmful and criminal. [Illustration: OBJECT LESSONS FOR INSTRUCTION IN SEX HEALTH Note the uncomfortable, unhealthy overdressing] Abnormal conditions of mind and body in regard to sex can almost always be traced to general physical ill health or to an unhealthy moral environment. Cure and prevention require two kinds of treatment within reach of parents and teachers: (1) build up the child's physical condition; and (2) give him other interests. Proper physical care, and work adjusted to body and mind, may be relied upon to do infinitely more to promote sex hygiene than instruction, either at home or at school, in immoral sex diseases. That sex morality is weak and untrustworthy which is based upon fear of sex diseases. Like alcoholism and nicotinism, the saddest results of sex diseases are social and economic. The strongest reasons against such diseases are economic and social, not physiological. [Illustration: THE STUDY OF INFANT HEALTH IS CONDUCIVE TO PURE-MINDEDNESS Note the simple, comfortable, hygienic dress] Once having made up our minds to concentrate the teaching of sex hygiene upon sex health rather than upon sex immorality, upon sex functions rather than upon sex diseases, the chief objection to school instruction and to instruction in class will disappear. Our school text-books in history, literature, and biology abound in references to sex distinctions, sex functions, and sex health. In enumerating the daily routine of health habits I mentioned daily bathing of the armpits and crotch. There is nothing in this injunction to offend or injure a boy or girl. If studies and physical training are to be adapted to physiological age, and if children are to know why they are graded according to physiological age as well as mental brightness, we shall soon be talking of mature, maturing and not-yet-maturing girls and boys, so that everybody will be instructed in sex hygiene without offense. Any teacher who can explain the family troubles of King Henry VIII without becoming self-conscious can easily learn to look a class of girls and boys in the face and explain how a mother's health will injure her baby before its birth, why breast-fed babies are more apt to live than bottle-fed babies, why it is as important for the mother to keep a nursing breast absolutely clean as to clean the nipple of a nursing bottle. Words whispered by children, or marked in dictionaries, to be stealthily and repeatedly looked upon and talked over with other children, lose all their glamour when pronounced by a teacher. In these days of state subsidy of school libraries the child is hard to find who has not free access to books of fiction full of voluptuous allusions that make undesirable impressions which only blunt, candid discussion of sex facts can make harmless. Children now learn, whether in fashionable private schools or crowded slums, practically all that is lascivious and unwholesome about sex. For teachers to explain that which is wholesome and pure will disinfect the minds of most children and protect them against miseducation. Class instruction in hygiene is practicable for all matters pertaining to normal sex health. Girls of thirteen should be taught in classes the fact and meaning of menstruation, and its grave importance to the health, in order that they may care for themselves not only before, during, and immediately after the menstrual period, but throughout the month, in order that menstruation itself shall not be unnecessarily painful, enervating, and harmful to efficiency. It is not yet advisable to discuss dangers peculiar to girls or dangers peculiar to boys in mixed classes. Generally speaking, it is undesirable that men teachers discuss girls' troubles with girl pupils. But why should it not become possible for women teachers to explain health dangers peculiar to girls to classes of boys? Individual instruction in sex matters should be reserved for the diseased mind, for the boy or girl who has already been morbidly instructed. Discussion of immoral sex diseases should be confined to individual talk. This field teachers have already entered. Repeated physical examination of children will detect symptoms of sex abnormality. When detected, the fact and the meaning should be explained to the individual by school physician, school nurse, or school-teacher. While much can be done through mothers' meetings and through individual instruction of parents, the most effective means of improving the general attitude towards sex health is to give the simple truth to the millions of children who have not yet left school. Armed with the A B C's of sex hygiene at school, boys and girls will be prepared to select employment, associates, and newspapers that will permit normal, healthy sex development. Men and women who are leading normal lives, who have plenty of work, sleep, fresh air, nourishing food, amusement, and exercise are unlikely to be sexually abnormal. After all, the question of instruction in sex hygiene will quickly settle itself when it is made a condition of a teacher's certificate that the applicant shall himself or herself know the personal and social reasons for sex health. The woman who does not know how to take care of her own sex health, the man who is ignorant of a woman's special needs, cannot do justice to the requirements of arithmetic, language, and discipline. Whether men and women teachers are mentally, physically, and morally equipped to be sexually normal and to teach the law of sex health will be disclosed as soon as trustees and superintendent dare to ask the necessary questions. Whether an instructor's personality will enable him to fill the minds of children with interests more wholesome, more absorbing than obscene stories or morbid sex curiosity can also be learned. When school-teachers are prepared to teach the social and economic aspects of general health they will quickly solve the problem of instruction in sex health. Just one word about country morality. It is customary to deplore the influence of large cities on the young. Of late, however, there has been a tendency to question whether, after all, sex morality is apt to be higher in the country than in the city. Parents and teachers in small towns and in rural districts will do well to take an inventory of the influences surrounding their children. It will always be impossible to give country children city diversions. One great disadvantage of country children frequently counter-acts the beneficial influence of out-of-door living; namely, isolation. The city child is practically always in or about to be in the sight of, if not in the presence of, other people. Numbers and close contact with people, though they be strangers, mean restraint and pervading social conscience. City children find it difficult to have good times in pairs. No amount of instruction of rural pupils in sex hygiene will take the place of amusements and entertainments for groups of children, forming thus a special antidote for "two's company, three's a crowd." Liberating and standardizing normal intersex relations and discouraging cramped social intersex relations are more urgent needs than instruction in sex diseases. A working environment that permits pure-mindedness will do more to inculcate a reverence for sex cleanliness and for parenthood than lectures and essays on moral prophylaxis. CHAPTER XL THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND Patent medicines and other forms of quackery could not pay such enormous dividends unless there was some truth in their claims; unless their victim found some beneficial return for his money. They win confidence because they raise hopes and combat fear. They do cure thousands of people of fear and of "ingrowing thoughts." In so doing they remove the sole cause of much disability.[17] In so doing they are merely applying by wholesale principles of mental hygiene that are legitimately used by physicians, tradesmen, teachers, and parents who deal successfully with nervousness. Quackery makes cures and makes money because of the undoubted influence of mind in causing and in removing those ailments that originate in fear, imagination, or morbid introspection. A few years ago a little out-of-the-way town in southern Minnesota was visited by train loads of the sick and crippled from miles around. Miraculous cures were heralded broadcast. Life-long cripples left wagon loads of crutches and braces to decorate the little church with the enchanted transom. People who had not walked for years returned to their homes cured. The marvels of famous shrines were fast being duplicated when the church authorities at St. Paul issued an explanation of the alleged miraculous appearance of biblical figures in the transom of the new church. The outlines of a mother carrying a baby had been vaguely impressed in the transom glass when molten. When the mystery was explained the excursions and the cures stopped. Nearly every physician and practically every medical charlatan can count scores of cures of ailments that had previously defied the skill of eminent physicians. A child's bumps actually stop aching after the mother or nurse kisses the abused spot. Invalids forget their limitations under stress of some great excitement or some intense desire for pleasures incompatible with invalidism. Many a physician of reputation owes his success in great part to the discriminating use of the _placebo_,--a bread pill designed to supplant the patient's fear with confidence. Hypnotism and "suggestion" have been successfully used to cure alcoholism and to fill patients' minds with conviction stronger than the fear that produced the sickness. A well-known writer and preacher cures insomnia by auto-suggestion, telling himself he is sleepy, is very sleepy, is going to sleep, is almost asleep, is fast asleep. Treatment by osteopathy has been followed by disappearance of diseases that cannot possibly be cured by osteopathy. Christian Science has restored to health and happy usefulness hundreds of thousands of chronic invalids. Verily is hygiene of the mind an important factor in the civics of health. Fear can originate with mind. Fear produces fear. Fear disarranges circulation of the blood and the nourishment of muscle and nerve. Fear can produce many bodily disorders which in turn feed fear. Fear cannot last unless bodily symptoms exist or arise to justify and feed it. Fear can be cured and removed in two ways: (1) by driving away fear and releasing bodily disorders from its thraldom; (2) by removing the disorders and making fear impossible to the logical mind. An enforced sea voyage begins with the disorder; a clever, buoyant physician begins with the fear. Patent-medicine proprietors, quacks, and fakes of every kind begin by displacing the fear with hope or cheer; the physical disorders frequently vanish by the same window as fear. For _fear_ write _self-pity_, _morbid self-consciousness_, _hypertrophied submission_; to _hope_ and _cheer_ add _smile_, _relaxation_, and _zest_; and we have the chief elements of mental hygiene and the reason why intelligent as well as unintelligent men like to be swindled by medical or other quacks. The social aspects of mental hygiene are particularly important. Once admitting the power of the mind to decrease vitality, we recognize the duty of seeming happy, buoyant, cheerful, vital, at least when with others, for the sake of others' minds and bodies. Secondly, we find the duty to refrain from commenting on others' appearance in a way that will start "ingrowing thoughts." A "grouchy" foreman can give blues and indigestion to a roomful of factory girls. A self-pitying teacher can check the heart beats of her class, cause arteries and lungs to contract, and deprive the brain of fresh blood. An oversympathetic neighbor can put a strong man to bed by discovering signs of nervous disintegration. Shall we gradually work out a code of mental hygiene rights and nuisances that will require compulsory notification of the "blues" and compulsory segregation of every person unable to "smile dull care away"? Is the time coming when boards of health will accompany infection leaflets with messages such as this from James Whitcomb Riley: Talk health. The dreary, never-changing tale Of mortal maladies is worn and stale. You cannot charm or interest or please By harping on that minor chord, disease. "Whatever the weather may be," says he, "Whatever the weather may be, It's the songs ye sing, and the smiles ye wear, That's a-making the sun shine everywhere." Mental hygiene has hitherto enjoyed an evil reputation and has been condemned to generally evil associations, because the rank and file have been ignorant of hygiene of every kind. Medical science has so long enveloped itself in mystery that it is in danger now of becoming discredited and of falling heir to the mantle of quackery. Quacks often get social and economic results more agreeable to the patient and more helpful to society than orthodox medicine. "When traitors become numerous enough treason becomes respectable." So when mental hygiene succeeds, it becomes science for the case in question, and for that case orthodox medicine loses its respectability. For the layman there is no safety except in having intelligence enough to know whether his trouble has defied the sincere application of mental treatment, auto-suggestion, and loyalty to the health ideal. Mental hygiene admits the existence of dental cavities, scarlet fever germs, adenoids, cross-eyes, uncleanliness, broken legs, inflamed eyes, overeating. The organic, structural defects which are to be sought by physical examination are all admitted by mental hygienists. They work for an orderly, daily routine and affirm the penalties of its violation. They would even favor going periodically to a physician, provided that we never go to him except when organic or structural disorders may safely be assumed from the fact that cheer and relaxation treatment does not give relief. Unhygienic living and mind cure cannot go together. The mind that tries to deceive itself cannot cure either mind or body. The man who violates the habits of health cannot patch his injuries or conceal the ravages of dissipation by mental hygiene. Here is the great advantage of knowing how to live hygienically, of observing habits of health, and then concerning ourselves not with ourselves, but with conditions of living for all those whose health can be affected by our health, or can affect our health and efficiency. The most recent practical application of mental hygiene for moral and physical uplifting is the "moral clinic" or "psychotherapeutic" clinic established by Emmanuel Church in Boston. This clinic represents the union of three forces,--religion, medical diagnosis, mental hygiene. As a result of this alliance it is anticipated that both religion and medicine will be humanized, socialized, vitalized, made to express more accurately and more consistently that community consciousness and that yearning for equal opportunity and equal happiness which constitute the profoundest religious impulse. No person is treated at this moral clinic whose trouble is organic or structural. In determining whether the case belongs to this clinic, expert medical diagnosis is relied upon rather than the credulity of the patient or the zeal of the clergyman. Medical scientists of highest repute can consistently coöperate, because they recognize two scientific facts: first, that many troubles are due primarily to mental disorder; and, second, the greatest asset of the human mind is that something called religion, which is no less real and potent because peculiar to each individual. Whatever may be that deepest current of thought and feeling, whatever that synthetic philosophy, that explanation of being, which guides my life, it can be of inestimable aid if enlisted in an effort to secure normal vitality of mind and body. The controlling motive of the moral clinic has proved infectious. There is reason to believe that the alliance of medicine and religion has come to stay, and that the present excitement over psychotherapeutics will settle down into a scientific utilization of religious motive and medical knowledge to prevent mental and moral disease. Unwholesome, morbid, self-centered thought is driven out. A recognition of others' claims takes its place. Hypnotism, suggestion, and group enthusiasm are used to their utmost possibilities. The success of the Boston moral clinic is due to establishing in the mind of the neurasthenic, the alcoholic, the world-weary, and the purposeless a truer conception of the pleasures that result from vitality and from altruistic effort. It is too early to classify by kind of functional disorder the patients treated. Results from one patient have been described in newspapers as follows: A school-teacher, as a result of nervous collapse, had lost control, began to fear the children under her care, and thought of relinquishing her profession. She was instructed in the art of self-control and the control of others; the notion of fear was dislodged and a sentiment of love for her little charges took its place. In the course of a few weeks this conscientious and experienced teacher regained her poise and found herself performing her duties better than ever before. Many alcoholics have for months given evidences of complete cure. Stories almost incredible are quickening pastor and physician alike throughout the country. After individual treatments are given, after religious motive is appealed to, and the soul stirred to heed the lessons of religion, medicine, and sociology, patients are given the work cure. Thus a branch of social service is established, where after-treatment is given to the patient whose thoughts have been turned from himself to others. All of a sudden the church finds itself in need of definite knowledge as to opportunities for altruistic work, as to definite community needs not met, as to people in distress who can be relieved by volunteers, as to agencies which can be called upon to coöperate both in treating the individual and in utilizing his energies for others' benefits. Because a relatively small percentage of men and women are neurasthenic, melancholy, morbid, alcoholic, the lesson of the moral clinic is most serviceable when extended for the benefit of the "not yet alcoholic" and the "not quite neurasthenic." In other words, individuals in thinking of themselves must learn the health value and soul value of purpose that centers in others' happiness. That thing which we have called tact in personality, and which in the past was discovered by induction, namely, the law of mental hygiene and the control it gives over others' health, must be taught in schools to children by wholesale, must be taught in medical and theological schools, to all physicians and all pastors. This alliance of medicine and religion, which is at present confined to one or two moral clinics, should be incorporated into education, into social work, into church work, becoming thus a part of civilization's normal point of view. Mental hygiene cannot survive conscious violation of the fundamental laws of medicine and religion. The alliance of medicine and religion will prove utterly futile unless habits of living and of thinking are inculcated that conform to nature's law of self-preservation and to God's law of brotherly love. Self-centered religion, like self-centered medicine, destroys both body and soul. FOOTNOTES: [17] The alliance of mental hygiene, medicine, and religion is discussed in the Emmanuel Church book, _Religion and Medicine; the Moral Control of Nervous Disorders_; also in its bulletins, _Religion and Medicine_. CHAPTER XLI "A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE" When a grammar-school boy I learned from the game "Quotations" that Louis Agassiz, scientist, had written the sentence with which I introduce a final appeal for living that will permit physical and civic efficiency. Agassiz has been called "America's greatest educator," and again "the finest specimen yet discovered of the genus _homo_, of the species _intelligens_." The story of his long life as teacher of teachers reads like a romance. But among his gifts to education and citizenship none can be made to mean more than the simple proposition that natural law is as sacred as a moral principle. All who remember this "beatitude" will be helped to solve many perplexing problems of dress, diet, play, education, philanthropy, morals, and civics. Reverence for the natural carries with it a distaste for the unnatural. Those who obey natural law soon come to regard its violation as a nuisance when not immoral. On the other hand, compromise with the unnatural, like compromise with vice, quickly leads first to toleration and thence to interest and practice. Therefore the importance of giving children Agassiz's conception of the sacredness of the laws that govern the human body. A passion for the natural is a strong foundation for habits of health and a priceless possession for one who wishes to know morality in its highest sense. "Natural" is less attractive to us than it would be had Agassiz first interpreted it for us rather than Rousseau or present-day exponents of "the simple life," "back to nature," and "back to the land." It is too often forgotten that no one sins against natural law more grievously than the primitive man or the isolated man in daily contact with non-human nature. Communing with nature seems not only to require communing with man but to give joys in proportion as the nature lover is concerned for the human society of which he is a part. Natural law does not become a moral principle until man is benefited or injured by man's use of nature's resources within and about him. Natural living according to natural law must be something sounder, more beautiful, and more progressive than can be read into or out of mountains, trees, brooks, and sky, or primitive society. Natural law points to a Nature Fore as well as a Nature Back, to a Nature Up and Beyond as well as a Nature Down and Behind. The Nature that was yesterday will not do for to-morrow, any more than a man is willing to give up his nature aspirations for the careless, animal ways of romping childhood. Civilization is constantly urged at each step to repeat the prayer of Holmes's old man who dreams for the Autocrat of the Breakfast Table: Oh for one hour of youthful joy! Give back my twentieth spring! I'd rather laugh a bright-haired boy Than reign a gray-beard king! Off with the wrinkled spoils of age! Away with learning's crown! Tear out life's wisdom-written page, And dash its trophies down! One moment let my life blood stream From boyhood's fount of flame! Give me one giddy, reeling dream Of life all love and fame! But every experiment in turning back exalts the present and the future. Gifts as well as problems are seen to come with complexity, and civilization flatly refuses to relinquish these gifts. Sound maturity is better than youth or age: The smiling angel dropped his pen,-- "Why, this will never do; The man would be a boy again, And be a father too!" Problems of health and of civics can never be solved by appealing to Nature Back, when only the few could be healthy, when one baby in three died in infancy, when old age was toothless and childish, when infection ravished nations, when the average life was twenty years shorter than now, and when unspeakable filth was tolerated in air, street, and house. They can all be solved by appeals to Nature Fore, which holds up an ideal of mankind physically able to enjoy all the benefits and to conquer all the dangers of civilization. It is not looking back, but looking in and forward that reveals what natural law promises to those who obey it. By using numerous tests which have been suggested in preceding chapters we can learn how far we and our communities obey natural law when working and playing. Health for health's sake has nowhere been urged. On the contrary, healthful living has been frankly valued for its aid to efficient living by individual and by community; wherefore the emphasis upon others' health and upon the civic aspects of our own health. Tests furnish us with the technic necessary to efficient living; civics, with the larger reason; natural law, with the "pillar of fire by night" to help us choose our path among habits and pleasures whose immediate results upon efficient living cannot easily be determined. Fashions, tastes, mannerisms, personal indulgences, have been left for Agassiz to deal with. Generally speaking, we all know of numerous acts committed and numerous acts omitted in our daily routine that convict us of not living up to our knowledge of physiology and hygiene,--wearing tight shoes or tight corsets, drinking strong coffee, smoking, reading while reclining, failing to insure clean air and clean bodies. Then there are other acts whose omission or commission violate no physical law so far as we can see, but whose unnaturalness we concede,--putting chalk on the eyebrows, wearing false hair or curious puffs, putting perfumery in the bath or on handkerchiefs, assuming artificial poses of body or mouth. These violations of natural law are forced upon us by "style" or "custom" or family convenience. When we come to choose between following fashions and disobeying them, we generally decide that it is better to do a foolish or slightly harmful thing than to occasion criticism, mirth, or even special notice by our dress or our abstemiousness. Last night I went to a dinner party at eight. I ate and ate a great variety of palatable foods that Nature Back never knew. After two hours of eating I imbibed for two hours the tobacco smoke of the gentlemen who made up the party. I knew that eight o'clock was too late for me to begin eating, that two hours was too long to eat, that the tobacco of others was bad for my health and for to-day's efficiency. All this I knew when I accepted the invitation to dinner. I went with no intention of preventing others from smoking or of lecturing my host or his chef or his guests for the unhygienic practices of our day. Yet the physical ills were more than offset by certain definite gains to the school children of New York that will result from last night's meeting. Natural law was abated in part. But I declined certain dishes that would not agree with me, helped myself sparingly of many dishes, avoided tobacco and wines, and by a three-mile walk in the open air, a bath, and a good long night's sleep have almost recovered my right to talk of the sacredness of natural law. Nature Back says I should not have gone to this dinner. But I was compelled to go. I know I am going to others. I cannot do my work unless I overdraw my current health account. Nature Fore tells me that effective coöperation with others will frequently require me to eat at the dinner hour of others, to retire at others' sleeping time, to wear what others will approve, to violate natural law. But Nature Fore also tells me how to build up a health reserve so that I can meet these emergencies without endangering my health credit. Nature Back demands "dress reform." Nature Fore tells me that I can march in step with my contemporaries without either attracting attention or discrediting and affronting natural law. Passion for the natural has effected numerous reforms in dress, diet, and social habits, until commerce provides a natural adaptation of practically every fashion. With regard to few things is it necessary to-day for any one who reads magazines to do violence to bodily health for fashion's sake. We may wear what we will, eat what we prefer, decline what is unnatural for us, without inviting censure. The debauches of those unfortunate people who live an unnatural, purposeless existence, affect such a small number that their laws need not be considered here. Natural law makes obedience to itself attractive; hence commerce is rapidly learning to cater to distaste for the unnatural. With few exceptions, only temporary concessions to unnatural living are required in order to dress and act conventionally. Nature Back throws little light upon conditions necessary for modern labor. It can do nothing but demand the abolition of the factory, the big store, the tenement, the school. Nature Fore says we cannot abolish the means of working out the highest forms of coöperation. But we can make them compatible with natural living. We can modify conditions so that earning a livelihood will not compel workers to violate natural law at any or all times. The greatest need of factory and tenement reform is for parents and teachers to make a religion of Nature Fore and to instill its principles in the minds of children. Parents and teachers must live the natural before they can make children love the natural. Parents and teachers cannot possibly be natural in this day, cannot live or love natural law unless they know the machinery by which their communities are combating conditions prejudicial to health, morals, and civic efficiency. INDEX Adenoids. See _Mouth breathing_ Administration, health: steps in evolution, 11-22; knowledge of needs, 220; machinery, 302-309; in combating alcoholism, 362; departments of health: (1) New York City, 26, 27, 47, 48, 61, 71, 84, 296-298, 302; (2) general, 265, 281 Advertisements: motives for, 8; for dental parlors, 100; for consumptives, 234; by physicians, 281; educational, in newspapers and magazines, 323; "no smoking" signs, 365; of patent medicines, 369; that promote health, 378-383 Agassiz, Louis, 398, 400 Air, night, 216. See _Fresh air_ Alcoholism, 343-362; compulsory instruction in, 3; insurance companies against, 7; disqualifies for railroad service, 193; depletes vitality, 201; results, 209; Hartley's fight against, 253; injures the tuberculous, 274; ineffective ways of combating, 343; incited by bad living conditions, 348; injury to negroes, 350; so-called moderate use, 358; labor unions blacklist drunkards, 361; social dangers, 386; mental hygiene, 392, 396 Animal sanitation, 252, 260, 307 Association for Improving the Condition of the Poor, New York, 177, 236, 253 Babies. See _Milk_ Bathing: motives for, 8, 13; a social requirement, 14; cold-water, 214 Beauty, reason for health, 15 Bibliography: A Bureau of Child Hygiene (Bureau of Municipal Research), 298; Annals of a Quiet Neighborhood (MacDonald), 110; Aristocracy of Health (Henderson), 208; Bitter Cry of the Children (Spargo), 33, 167; Bulletins of Emmanuel Church, 391; Bureau of Municipal Research, publications, 298; Care of Dependent, Defective, and Delinquent Children (Folks), 174; Charities and the Commons, 325; Child Growth (Newsholme), 120; Children of the Nation (Gorst), 33; Children's Diseases, 326; Clean Milk for New York City, 255; clippings, 370, 382; white-plague scrapbook, 250; Committee on Physical Welfare of School Children, programme, 166, three studies, 168; Crusade against Tuberculosis (Flick), 229; Dangerous Trades (Oliver), 203; Dental Catechism, 94; Dentistry, lectures and treatises, 274; Deterioration, Physical, report on, 339; Development of the Child (Oppenheimer), 110; Dietetic and Hygienic Gazette, 326; Efficient Life (Gulick), 208; Environment of Child at School (North), 142; Pure Food (U.S. Department of Agriculture), 379; Good Health, 326; Health of the School Child (Mackenzie), 132; Heredity (Thompson), 336; How to Give Wisely, 355; International Congress, Tuberculosis, programme, 246-249; Journal of Nursing, 326; Making a Municipal Budget (Bureau of Municipal Research), 306; Milk Industry, 252; Municipal Sanitation in the United States (Chapin), 304; National Hospital Record, 326; New Basis of Civilization (Patten), 33; New Jersey Review of Charities and Corrections, 325; Pediatrics, 326; Physical Culture, 326; Poverty (Hunter), 167; press and magazines, 322-328; Prevention of Tuberculosis (Newsholme), 229; Principles of Relief (Devine), 174; Principles of Sanitary Science and the Public Health (Sedgwick), 304; Psychological Clinic, 106, 326, 330; Real Triumph of Japan (Seaman), 23; Religion and Medicine (Emmanuel Church), 391; reports of schools, 166; reports of schools and health, 310-321; reports of institutions and societies, 327; reports of state and national conferences of charities and corrections, 327; reports of United States bureau of labor, 203; Sanitation of Public Buildings (Gerhard), 139; School Reports and School Efficiency (Snedden and Allen), 311; Social Order and the Saloon (Fox), 351; Study of Children and their School Training (Warner), 110; Study of School Buildings in New York City, 289; Teeth and their Care (Hyatt), 94; Training of the Human Plant (Burbank), 120; Typhoid Fever (Whipple), 13, 16; Uncommercial Traveller (Dickens), 46; Unconscious Mind (Schofield), 110; Vital Statistics (Newsholme), 131 Biggs, Hermann M., M.D., 237, 251, 271, 274, 295 Boston, 34, 155, 161, 241, 250, 290, 395 Boston Society for the Relief and Study of Tuberculosis, 155 Boyd, Emma Garrett, 355 Brannan, John Winters, M.D., 240 Breath, bad, 360, 379 Brightness, abnormal, 104-106 Bronchitis, 67 Brookline, 34 Budget: should provide for cleansing, 61; and tuberculosis, 237; annual health programme, 306; reforms in New York City, 350 Burbank, Luther, 120 Bureau of Municipal Research, 298, 306 Butler, Nicholas Murray, LL.D., 330, 332 Cabot, Richard C., M.D., 181 Calmette's Eye Test, 238 Carnegie Foundation, 285 Caroline Rest, 70, 267 Catching diseases: cost of, 16; unenforced laws, 30; steps in eradicating, 31; germ sociology, 57, 71; favorable soil at school, 58; instruction concerning, 62; mouth a breeding ground for, 63; information for bathers, 64; dangers of, 131; reasons for national board of health, 135; cost of, in New York City, 272; remedies urged, 384 Charity Organization Society, New York, 236, 239 Chicago, 34 Chicken-pox, 64 Child Hygiene, Bureau of: working-paper tests, 192; established, New York City, 298; programme, 299 Child labor: compulsory school attendance, 140; welfare or age test, 142; movement's limitations, 185; national and local committees, 33, 192; physical-fitness tests, 194 Children's Aid Society, New York, 56, 93 Child-saving agencies: coöperation with schools, 174-183; do-nothingism in, 332 Chorea. See _Nervousness_ Christian Science, 276, 392 Christmas shopping, 227 Cigarettes. See _Tobacco_ Cincinnati, 118 Cleanliness: acquired taste, 14; beauty of, 96; personal uncleanliness, 210; cost of, 216; dry cleaning dangerous, 244; in fighting tuberculosis, 250 Cleveland, Ohio, 294 Clippings: scrapbook, 250; envelope method, 324; advertisements, 382 Coffee, strong, 401 Colds, 63-69 College, physical tests, 39 Committee on Physical Welfare of School Children, New York, 39-41, 166, 168, 178, 286, 290, 311 Compulsory laws: school hygiene, 3; purpose of, 33; registration of catching diseases, 57; removal of tuberculosis cases, 237; notification of tuberculosis, 237, 274; hygiene, for private schools, 283; to remove physical defects, 288; restricting alcoholism, 343 Conference on Summer Care of Babies, New York, 260 Congestion: evils avoided, 290; and alcoholism, 348 Conjunctivitis, 71. See _Eyes_ Connecticut's school reports, 318 Constipation, 210, 216, 347, 357 Consumption. See _Tuberculosis_ Corsets, 381, 401 Cost: of preventable diseases, 16; of bad breath, 98; of diseases to nation, 135; of tuberculosis, 245 Crampton, C. Ward, M.D., 129, 289 Dangerous trades, 191 Darlington, Thomas, M.D., 297 Death rates: of bronchitis, 67; of pneumonia, 67; how to reduce, 131 Defects, physical: index of community needs, 33-44; removable, of children, 22; schools manufacture, 139; income distribution, 169 Delinquency, and mouth breathing, 47 Dental Hygiene Council, 95 Dental sanitation, 89-103; surface for breeding germs, 63; dentists, 93; state organizations, 95; clinics needed, 171; insurance companies treat teeth, 204; family instruction, 245; indigestion, 272; early treatises, 274; advertising parlors, 281 Devine, Professor Edward T., 174 Diet: cooking lessons at home, 180; overeating, 201, 347; improper, 210; proper and regular, 212; adapted to need, 214, 401; kitchens, 267; irregular eating, 272, 347 Diet kitchens, 267 Diphtheria, 18, 65 Dispensaries and hospitals: dental supervision, 102; coöperate with schools, 174-183, 185; welfare nurse, 188; emergency, 227; to prevent duplication, 239; lack of, 240; teach baby feeding, 261; inefficient, 278; social interest of, 292 Doing things at school, 159-165; free meals, 44, 161, 171; may hurt, 181; cripple social agencies, 185, 189; danger of malpractice, 184, 189; analogous to model tenements, 186 Do-nothing ailments, 329-334 Ear trouble, 83-85; periodic tests for, 201, 207 Edinburgh, 70 Ellis Island, 238 Environment: health problem, 9; tests, 120, 320; injurious school, 139-150; effect on physique, 203; and tuberculosis, 229-251; do-nothing ailments, 329; within our control, 336; in combating liquor, 362 Epidemics, 18, 38 Epilepsy, 47, 49 Ergograph, 125-127 Erysipelas, 65 Ethics, professional, 81, 101, 281 Eugenics, and heredity, 336 European remedies, 159-165 Eye trouble, 72-82; in high school, 40; catching diseases, 69-71; caused by bad teeth, 89; eyeglasses, free, 161, 164, 171, 184; in business, 193; examination for adults, 201; tuberculin test, 238; inefficient inspection of, 300; teachers' test, 301 Examination, physical: of school children, 33-138; best test of health needs, 33-44; individual record of, 35, 312; Snellen test, 73, 77; of teachers, 153; for work certificates, 190-200, 237, 301; by railroads, 193; at West Point, 199; periodic after school, 201-207, 218, 228; semi-annual, 202; tuberculin tests, 240; stripped, at Leipsic, 289; follow-up work, 295-300; of teachers and sex hygiene, 389 Family: unit of social treatment, 174; examining parties, 237, 241; tuberculosis histories, 241 Fear and bodily disorders, 392 Flick, Lawrence F., M.D., 229 Follow-up work, 295-301 Fox, Hugh F., 351 Fresh air: others' standards of, 9; fiends, 66; outings, 176, 178; economic value of, 195; ventilation at school, 142; ventilation at home, 210; ventilation at work, 212; ventilation at sanatoriums, 214; ventilation at churches and theaters, 217. See _Air_ Georgia, 350 Germany, 160, 204 Germs, disease: in milk bottles, 14; isolation, 31; germ sociology, 57-71; dental sanitation, 89-103; locating germ factories, 238; tuberculosis, 234 Getting things done, 166-173; doing of highest kind, 183; study underlying causes, 189; by local agencies, 287 Glands, 88 Goler, George W., M.D., 196 Gorgas, William C., M.D., 59 Government. See _Administration_ Greenwich House, 287 Grenfell Association, 197 Grippe, 379 Gulick, Luther H., M.D., 123, 208 Habits of health, 208-217; combat tobacco, 364; mental hygiene, 394; and Nature Fore, 400 Hartley House, 287 Hartley, Robert M., 252 Havana, 60 Hawthorne Club, 287 Headache, 210 Heredity, 335-342 High schools need physical tests, 39 Hip trouble. See _Tuberculosis_ Home conditions: indexed by epidemics, 32; indexed at school, 33; among different incomes, 39; cooking instructions, 180; weighing parties, 241; score card, 337; promote alcoholism, 348 Hughes, Governor Charles E., 201 Hunter, Robert, 167 Hyatt, Thaddeus P., D.D.S., 94 Impetigo, 65 Income, 34, 38, 39 India, 108 Indigestion: anti-social, 10; due to teeth, 272 Individual record card, 35, 312-314 Industrial hygiene: educates laborers, 131; factory conditions, 221, 227; factory reforms, 403; employers, 3, 210, 218, 360, 367; employees, 202, 211, 219, 228, 360 Influenza, 65-68 Ingram, Helene, 177 Insomnia, 392 Inspection: of milk, 26, 259; score cards, 27, 29, 337; of school children, 43, 61, 296; of factories, 131; of milch cows, 260; of transmissible diseases, 295; of foods, 307 Instinct, motive to health, 12, 14, 94 International Congress on tuberculosis, 238, 245 Itch, 65 Japan, 23, 287, 309 Junior Sea Breeze, 267 Kansas City, 161 Kidney trouble, 217 Labrador, 197 Lavatories, public, 217 Laws: nonenforcement demoralizing, 4; define rights, 23; when not enforced, 25; should not injure health, 151; enforcement better than character, 219; regarding milk, 258; licensing practitioners, 280; need machinery, 303, 348; to control liquor, 343, 355; test of prohibition, 353; on patent medicine, 373; on pure foods, 379 Leipsic, 289 Louisiana, 350, 376 Lung trouble. See _Tuberculosis_ Machinery, health: unsatisfactory coordination, 296; necessary, 302-309; five elements, 303 Mackenzie, W. Leslie, M.D., 132 Magistrates: promote disorder, 173; enforce health laws, 303 Malnutrition, 35; income distribution, 39; signs and tests, 86; prevention of, 184; education of family, 241 Massachusetts, 74 Maxwell, Superintendent William H., 286, 288 Measles, 64 Mental hygiene, 391-397; blues, anti-social, 10; hospital welfare work, 182; moral clinics, 276, 291, 295; and insomnia, 392 Meyer, William, M.D., 47 Milk: unclean dairies, 10; scalding receptacles of, 17; carries typhoid, 18; inspector's outfit, 24; tests of protection, 25; score cards, 26, 259, 337; public should know, 219; fight for pure, 252-267; New York conferences, 255, 260; breast feeding, 266 Milk committee, New York, 258, 260 Minnesota, 45, 269 Misgovernment causes sickness, 10 Mitchell, S. Weir, M.D., 73 Montclair, 265 Mosquitoes, 59, 307 Motives, seven health, 11-22, 377 Mouth breathing, 45-56; and delinquency, 47; adenoid parties, 55; causes deafness, 83; injures baby teeth, 89; industrial disadvantage of, 195; in Labrador, 197; preventable defect, 272; inefficient inspection of, 300 National Association for the Study and Prevention of Tuberculosis, 236, 246 National Board of Health, 133, 292, 308 National Bureau of Labor, 199 National Bureau of Census, 305 National Bureau of Animal Industry, 306 National Bureau of Education, 171, 292 National Playground Association, 118 National School Hygiene Association, 139 Nature Fore and Nature Back, 398-403 Negroes and alcoholism, 350 Nervousness, 85; and school life, 108; physical defects, 110; preventable, 111; causes of, 112; habit, 111, 113; from tobacco, 363 Neurasthenia. See _Mental Hygiene_ New Jersey, 12 Newsholme, Arthur, M.D., 120, 131, 229, 241 New York City, 16, 25, 34 New York Juvenile Asylum, 47 New York state, 12, 24 New York State Charities Aid Association, 236, 242 Nicotinism. See _Tobacco_ Normal schools, 110 North, Professor Lila V., 142 Notification of diseases, 31, 41 Nuisances, 17, 18, 23, 366 Nurses at school, 230, 286, 293, 300. See _Milk_ Oliver, Thomas, 203 Orthopedics. See _Tuberculosis_ Ophthalmia, 65 Oppenheimer, Nathan, M.D., 110 Osteopathy, 275 Panama, 59 Parents: and school hygiene, 3; interested by examinations, 41; should coöperate with physician, 279; interested in school examinations, 297; need health reports, 310; heredity, 335-342; nicotinism, 368 Parks and playgrounds, 7, 32, 118, 122, 142, 186, 290, 294 Parochial schools, 189, 198 Patent medicines: evils of, 369-377; advertisements, 380 Patten, Professor Simon N., 9, 14, 33, 165 Pediculosis, 69-71 Pennsylvania, 311 Philadelphia, 34 Phthisis. See _Tuberculosis_ Physical training, 115-117; in New York City, 296; and sex hygiene, 387 Physician: preventive medicine, 268-282; and eyes, 81; semi-annual visit to, 204; self-advertisement, 378; school, 173, 286, 293, 315 Physiological age, 105, 289, 387 Pittsburgh, 269 Plague, 15, 57 Pneumonia, 67, 379 Preventable diseases: those not communicable, 272. See _Catching Diseases_ Private schools, 189, 198, 283, 291, 330 Prohibition laws, 348, 350, 355 Pro-slum motive, 19-20 Public Education Association, New York, 287, 298 Publicity, 45, 81, 99, 292, 310-321, 382 Quarantine, first, 15; national, 308 Records: of disease centers, 31; defective, 32; individual, 35, 312-314 Reform's failure, 349 Registration: of diseases, 31 Relief, material: sound principles of, 174; at school, 175, 179, 184; indiscriminate, harmful, 332 Richman, Julia, 172 Riggs disease, 92 Rights: political, 21; not enforced, 23-32; of workmen at work, 190; machinery for enforcing, 283-322 Riis, Jacob, 18 Ringworm, 65 Rochester, N.Y., 262, 266 Rome, 15 Roosevelt, Theodore, 60, 118 Rural districts: encourage disease, 13; compared, 32; physical defects, 74; schools unsanitary, 141; hygiene in Great Britain, 308 Russia, 108 Sage Foundation, 285 St. Vitus's dance, 111 Salmon, Professor Lucy M., 355 Scabies, 65. See _Itch_ Scarlatina, 65 Scarlet fever: thrives in slums, 18; signs and method of infection, 65; "peeling," 132; compulsory removal of cases, 240; germ carried in milk, 264 School hygiene: and employers, 3; instruction compulsory, 3-10; practice of, 5, 18; biological engineering, 139, 203, 339; departments of, 283-293; in New York City, 294, 296-301 Score cards, 27, 29, 259, 337 Scranton, 269 Sea Breeze fresh-air home, 176 Sea Breeze seaside hospital, 9, 240 Seaman, L.L., M.D., 23 Seattle, 161 Sedgwick, Professor William T., 304 Sex hygiene, 384-389 Sexual deviates, 182 Shoes, tight, 401 Sickness, preventable, cost of, 278 Sleep and vitality, 201, 272 Slum, a menace, 13, 20 Smallpox: epidemics great teachers, 6; conquered by vaccination, 7; neglected in rural Pennsylvania, 18; comes rarely to cities, 31; compulsory removal of cases, 240 Snedden, Professor David S., 33, 165, 311 Snellen eye test, 73, 77 Society for Sanitary and Moral Prophylaxis, 384 Southern states, 351 Spargo, John, 33, 167 Spitting, 223, 235 State activity, 4, 73, 121, 236, 292, 306 Statistics, object of, 131, 134, 333 Strauss, Nathan, 260 Streets, 15, 122, 217, 254, 348 Study hours, too long, 287 Sweating, 152, 211 Taxes, taxpayers. See _Budget_ Teacher's health: tests of, 152-158 Teachers: social work, 172; health passport, 202; for tuberculous pupils, 237; excluded when tuberculous, 242; and physicians, 279; physical examination of, 284; use of alcohol, 358; cigarettes, 368; use clippings, 382 Teeth. See _Dental Sanitation_ Temperance. See _Alcoholism_ Tenement reforms, 20, 186, 209, 304, 403 Thompson, J. Arthur, 336 Tobacco: instruction at school, 3; economic injuries of, 201; forbidden to employees, 210; evils of nicotinism, 363-368, 386 Tonsils, hypertrophied, 44 Trachoma, 69-71 Trudeau, E.L., M.D., 274 Tuberculosis: pupils excluded from school because of, 65; aggravated by colds, 68; bone tuberculosis, 87, 88, 236; and bad teeth, 90, 99; in teachers, 153; examination for working papers, 191; periodical examination for, 201; last days of, 229-251; eye and skin tests for, 240; tests of cows, 260; carried in milk, 264; out-of-door treatment, 274; only predisposition to, inherited, 335 Typhoid: a rural disease, 13; carried in milk, 264 University Extension Society, 178 Vacation schools, playgrounds, 109, 296 Veiller, Lawrence, 9 Vitality tests and statistics, 124-138 Water, drinking: reason for works, 15; factories pollute, 17; fountains, 217; public responsibility for, 226; protecting sources, 307 Welfare work, 7, 221-225 West Point, 199 Wheeler, Herbert L., D.D.S., 93 Whipple, George C., Ph. D., 13, 16 White plague. See _Tuberculosis_ Whooping cough, 64 Williams, Alida S., 72, 122 Williams, Linsly R., M.D., 241 Work: physical examination for working papers, 190-200, 285; healthful habits, 208-217; unpatented medicine, 334. See _Industrial Hygiene_ Young Men's Christian Association, 227 * * * * * +-----------------------------------------------------------+ | Typographical errors corrected in text: | | | | Page 60: heath replaced with health | | | | Text moved to avoid splitting paragraphs with tables: | | | | First half of last paragraph on page 25, moved to page | | 29, following Table III and Table IV on pages 26 to 28. | | First half of last paragraph on page 63, moved to page | | 66, following Table VIII on pages 64 to 65. | | First half of last paragraph on page 181, moved to page | | 183, following Illustration on page 182. | | Continuation of paragraph begun on page 222, moved from | | page 225 to the end of the paragraph on page 222, to | | precede text ads/Illustrations on pages 223 and 224. | | Continuation of paragraph begun on page 254, moved from | | page 258 to the end of the paragraph on page 254, to | | precede Conference information on pages 255 to 257. | | First half of last paragraph on page 337, moved to page | | 340, following Score Cards on pages 338 and 339. | | | +-----------------------------------------------------------+ * * * * * 
47308	----	generously made available by Internet Archive (https://archive.org) Note: Project Gutenberg also has an HTML version of this file which includes the original illustration. See 47308-h.htm or 47308-h.zip: (http://www.gutenberg.org/files/47308/47308-h/47308-h.htm) or (http://www.gutenberg.org/files/47308/47308-h.zip) Images of the original pages are available through Internet Archive. See https://archive.org/details/sanitaryevolutio00jeph Transcriber's note: Text enclosed by underscores is in italics (_italics_). Small capitals have been transcribed as ALL CAPITALS. A more extensive transcriber's note can be found at the end of this text. THE SANITARY EVOLUTION OF LONDON by HENRY JEPHSON, L.C.C. Author of "The Platform: Its Rise and Progress" "The discovery of the laws of public health, the determination of the conditions of cleanliness, manners, water supply, food, exercise, isolation, medicine, most favourable to life in one city, in one country, is a boon to every city, to every country, for all can profit by the experience of one." G. GRAHAM, Registrar-General, 1871. A. Wessels Company Publishers Brooklyn, N. Y. MCMVII DEDICATED TO THE LONDON COUNTY COUNCIL BY ONE OF ITS MEMBERS THE AUTHOR 4, CORNWALL GARDENS, S.W. CONTENTS MAP _Facing page_ 1 PAGE CHAPTER I 1 CHAPTER II (1855-1860) 82 CHAPTER III (1861-1870) 155 CHAPTER IV (1871-1880) 221 CHAPTER V (1881-1890) 288 CHAPTER VI (1891-1901) 349 CHAPTER VII (1901-1906) 401 INDEX 435 [Illustration: SKETCH MAP OF LOCAL DISTRICTS IN LONDON. REFERENCE TO NAMES OF PARISHES AND DISTRICTS NUMBERED ON THE MAP. 1. Clerkenwell. 2. Holborn. 3. St. Giles'. 4. Strand. 5. St. Martin-in-the-Fields. 6. Whitechapel. 7. St. James', Westminster. 8. Westminster. 9. St. Saviour's, Southwark. 10. St. Olave's, Southwark. 11. St. George the Martyr, Southwark.] The Sanitary Evolution of London CHAPTER I THE health of the people of a country stands foremost in the rank of national considerations. Upon their health depends their physical strength and energy, upon it their mental vigour, their individual happiness, and, in a great degree, their moral character. Upon it, moreover, depends the productivity of their labour, and the material prosperity and commercial success of their country. Ultimately, upon it depends the very existence of the nation and of the Empire. The United Kingdom can claim no exemption from this general principle; rather, indeed, is it one which, in the present period of our history, affects us more vitally than it has ever done before, and in a more crucial manner than it does many other nations. The more imperative is it, therefore, that every effort should be made to raise the health of our people to the highest attainable level, and to maintain it at the loftiest possible standard. The subject is so vast and complicated that it is impossible, within reasonable limits, to treat more than a portion of it at a time. London, the great metropolis, the capital of the Empire itself, constitutes, by the number of its inhabitants, so large a portion of the United Kingdom, that the health of its people is a very material factor in that of the kingdom. It has a population greater than either Scotland or Ireland, greater than any of our Colonies, except Canada and Australasia, greater than that of many foreign States--"the greatest aggregate of human beings that has ever existed in the history of the world in the same area of space." And, in a measure too, it is typical of other of our great cities. A narrative of the sanitary history and conditions of life of the people of London, therefore, would be a material contribution to the consideration of the general subject in its national aspect, whilst it cannot but be of special interest to those more immediately concerned in the amelioration of the existing condition of the masses of the people of the great capital. Such a narrative is attempted in the following pages. It is, in the main, based upon the experiences, and inferences, and conclusions, of men who, more than any others, were in a position closely to observe the circumstances in which the people lived, their sanitary condition, and the causes leading thereto and influencing the same. It includes the principal measures from time to time passed by the Legislature to create local governing authorities in sanitary matters--the various measures designed and enacted to improve the condition of the people--and the administration of those measures by the local authorities charged with their administration. It is a narrative, in fact, of the sanitary--and, therefore, to a great extent of the social--evolution of this great city. It is doubtful how long a time would have elapsed before the condition of the people came into real prominence had it not been for the oft-recurring invasions of the country by epidemic disease of the most dreaded and fatal forms. Ever-present diseases, disastrous and devastating though they were, did not strike the imagination or appeal to the fears of the public as did the sudden onslaught of an awe-inspiring disease such as cholera. An epidemic of that dreaded disease swept over London in 1832, and there were over 10,000 cases and nearly 5,000 deaths in the districts then considered as metropolitan--the population of those districts being close upon 1,500,000. For the moment, the dread of it stimulated the people, and such governing authorities as there were, to inspection, and cleansings, and purifications, and to plans for vigorous sanitary reform; but the instant the cholera departed the good resolutions died down, and the plans disappeared likewise. There were, however, some persons upon whom this visitation made more abiding impression; and they, struck by the waste of human life, by the frequent recurrence of epidemics which swept away thousands upon thousands of victims, and distressed by the perpetual prevalence and even more deadly destructiveness of various other diseases among the people, bethought themselves of investigating the actual existing facts, and the causes of them--so far at least as London, their own city, was concerned. And then slowly the curtain began to be raised on the appalling drama of human life in London, and dimly to be revealed the circumstances in which the great masses of the working and labouring classes of the great metropolis lived, moved, and came to the inevitable end, and the conditions and surroundings of their existence. The slowness with which England as a nation awoke to the idea that the public health was a matter of any concern whatever is most strange and remarkable. It seems now so obvious a fact that one marvels that it did not at all times secure for itself recognition and acknowledgment. But men and women were growing up amidst the existing surroundings, foul and unwholesome though those were, and some, at least, were visibly living to old age; population was increasing at an unprecedented rate; wealth was multiplying and accumulating; the nation was reaching greater heights of power and fame. What, then, was there, what could there be wrong with the existing state of affairs? Real social evils, however, sooner or later, force themselves into prominence. For long they may be ignored, or treated with indifference by the governing classes; for long they may be endured by the victims in suffering and silence; but ultimately they compel recognition, and have to be investigated and grappled with, and, if possible, remedied. The real beginning of such investigations was not until near the close of the fourth decade of the nineteenth century. Information then for the first time was collected, of necessity very limited in extent, crude in form, and of moderate accuracy, but none the less illuminating in its character--information from which one can piece together in a hazy sort of way a general impression of the condition of the working and poorer classes in London at that period. Foremost among the diseases which worked unceasing and deadly havoc among the people was fever. By its wide and constant prevalence and great fatality, it was the first upon which attention became fixed. The returns which were collected as regarded it related to twenty metropolitan unions or parishes, and in them only to the pauper population, some 77,000 in number. But they showed that in the single year of 1838, out of those 77,000 persons, 14,000, or very nearly one-fifth, had been attacked by fever, and nearly 1,300 had died.[1] Being limited to the technically pauper population this information related only to one section of the community; but it nevertheless afforded the means of forming a rough estimate of the amount of fever among the community as a whole. And another fact also at once became apparent, namely, that certain parts of London were more specially and persistently haunted or infested by fever than others. In Whitechapel, Holborn, Lambeth, and numerous other parishes or districts, fever of the very worst forms was always prevalent--"typhus, and the fevers which proceed from the malaria of filth." The sanitary condition of those districts was fearful, every sanitary abomination being rampant therein, whilst certain localities in them were so bad that "it would be utterly impossible for any description to convey to the mind an adequate conception of their state." And most marvellous and deplorable of all was the fact that this fearful condition of things was allowed, not merely to continue, but to flourish without any attempt being made to remedy, or even to mitigate, some of the inevitable and most disastrous consequences. As regarded the districts in which the wealthier classes resided, systematic efforts had been made on a considerable scale to widen the streets, to remove obstructions to the circulation of free currents of air, and to improve the drainage--an acknowledgment and appreciation of the fact that these things did deleteriously affect people's health. But nothing whatever had been attempted to improve the condition of the districts inhabited by the poor. Those districts were not given a thought to, though in them annually thousands and tens of thousands of victims suffered or died from diseases which were preventable. Reports such as these attracted some degree of attention, and awakened a demand for further information, and in 1840 the House of Commons appointed a Select Committee to inquire as to the health, not only of London, but of the large towns throughout the country. Their report[2] enlarged upon the evils previously in part portrayed, and emphasised them. "Your Committee," they wrote, "would pause, from the sad statements they have been obliged to make, to observe that it is painful to contemplate in the midst of what appears an opulent, spirited, and flourishing community, such a vast multitude of our poorer fellow-subjects, the instruments by whose hands these riches were created, condemned for no fault of their own to the evils so justly complained of, and placed in situations where it is almost impracticable for them to preserve health or decency of deportment, or to keep themselves and their children from moral and physical contamination. To require them to be clean, sober, cheerful, contented under such circumstances would be a vain and unreasonable expectation. There is no building Act to enforce the dwellings of these workmen being properly constructed; no drainage Act to enforce their being properly drained; no general or local regulation to enforce the commonest provisions for cleanliness and comfort." Lurid as were the details thus made public of the condition in which the vast masses of the people in London were living, neither Parliament nor the Government took any action beyond ordering successive inquiries by Poor Law Commissioners, or Committees of the House of Commons, or Royal Commissions. Before one of these Commissions[3] the following striking evidence was given--evidence which it might reasonably be expected would have moved any Government to immediate action:-- "Every day's experience convinces me," deposed the witness,[4] "that a very large proportion of these evils is capable of being removed; that if proper attention were paid to sanitary measures, the mortality of these districts would be most materially diminished, perhaps in some places one-third, and in others even a half. * * * * * "The poorer classes in these neglected localities and dwellings are exposed to causes of disease and death which are peculiar to them; the operation of these peculiar causes is steady, unceasing, sure; and the result is the same as if twenty or thirty thousand of these people were annually taken out of their wretched dwellings and put to death--the actual fact being that they are allowed to remain in them and die. I am now speaking of what silently but surely takes place every year in the metropolis alone." But the Government took no action--beyond a Building Act which did little as regarded the housing of the people. No local bodies took action, and years were to pass before either Government or Parliament stirred in the matter. In dealing historically with matters relating to London as a whole, it is to be remembered that for a long time there had been practically two Londons--that defined and described as the "City," and the rest of London--that which had no recognised boundaries, no vestige of corporate existence, and which can best be described by the word "metropolis." The "City" was virtually the centre of London--the centre of its wealth, its industry, its geographical extent--a precisely defined area of some 720 acres, or about one square mile in extent, and originally surrounded by walls. Its boundaries had been fixed at an early period of our history, and had never been extended or enlarged. So densely was it covered with houses at the beginning of the nineteenth century, and so fully peopled, that there was practically no room for more, either of houses or people; and from then to the middle of that century its population was stationary--being close upon 128,000 at each of those periods. Apart altogether from political influences, there were in the "City" powerful economic forces at work which profoundly affected the condition and circumstances of the people, not only of the "City," but of London. These, which were by no means so evident at one time, became more and more pronounced as time went on. All through the earlier part of the nineteenth century England was attaining to world pre-eminence by her commerce, her manufactures, and her wealth. The end of the great war with France saw her with a firm grip of all the commercial markets of the world. Her merchants pushed their trade in every quarter of the globe--her ships enjoyed almost a monopoly of the carrying trade of the world. In this progress to greatness London took the foremost part, and became the greatest port and trade emporium of the kingdom, a great manufacturing city, and the financial centre of the world's trade. It was upon this commerce that the prosperity and glory of London were built: it was by this commerce that the great bulk of the people gained their livelihood, and that a broad highway was opened to comfort, to opulence, and power. And so the commercial spirit--the spirit of acquiring and accumulating wealth--got ever greater possession of London. That spirit had long been a great motive power in London; it became more and more so as the century wore on, until almost everything was subordinated to it. That indisputable fact must constantly be borne in mind as one reviews the sanitary and social condition of the people of London at and since that time. Other constant factors there were, also exercising vast influence--the constant factors of human passions and human failings--but widespread as were their effects, they were second to the all-powerful, the all-impelling motive and unceasing desire--commercial prosperity and success. Synchronous with the rise in importance of the port of London, and with its trade and business assuming ever huger volume and variety, a noteworthy transformation took place. The "City," by the very necessities of its enormous business, became gradually more and more a city of offices and marts, of warehouses and factories, of markets and exchanges, and houses long used as residences were pulled down, and larger and loftier ones erected in their place for business purposes. In some places, moreover, ground was entirely cleared of houses for the construction of docks, or for the erection of great railway termini. How marked were the effects of these changes is evidenced by the fact that from 17,190 inhabited houses in the "City" in 1801, the number had sunk to 14,575 in 1851. The explanation was the simple economic one, that land in the "City" yielded a much larger income when let for business than for residential purposes. Offices and warehouses were absolutely essential in the "City" for business. What did it matter if people had to look for a residence in some other place? London was large. They could easily find room. And the process, without control of any sort or kind, and wholly unimpeded by legislation or governmental regulation, went on quite naturally--entailing though it did consequences of the very gravest character, then quite unthought of, or, if thought of, ignored or regarded as immaterial. This then was, at that time, and still is, one of the great, if not indeed the greatest of the economic forces at work which has unceasingly dominated the housing of the people not only in the "City," but in the metropolis outside and surrounding the "City," and, in dominating their housing, powerfully affected also their sanitary and social condition. The "City" was in the enjoyment of a powerful local governing body--namely, the Lord Mayor and Corporation, or Common Council, elected annually by the ratepayers; and numerous Acts of Parliament and Royal Charters had conferred sundry municipal powers upon them. For that important branch of civic requirements--the regulation of the thoroughfares and the construction of houses and buildings--they had certain powers. The vastly more important sphere of civic welfare--namely, the matters affecting the sanitary condition of the inhabitants--was delegated by the Corporation to a body called the Commissioners of Sewers, annually elected by the Common Council out of their own body, some ninety in number. And these Commissioners had, in effect, authority in the City, directly or indirectly, over nearly every one of the physical conditions which were likely to affect the health or comfort of its inhabitants. They could also appoint a Medical Officer of Health to inform and advise them upon public health matters, and Inspectors to enforce the laws and regulations. The "City" was thus in happy possession of a powerful local authority, and a large system of local government. And it stood in stately isolated grandeur, proud of, and satisfied with, its dignity, and privileges, and wealth; glorying in its own importance and splendour; content with its own system of government, and its powers for administering its municipal affairs, and indifferent to the existence of the greater London which had grown up around it, and which was ever becoming greater. Greater indeed. The population of the "City" in 1851 was 128,000; that of the metropolis not far short of 2,500,000. The number of inhabited houses in the "City" was hundreds short of 15,000. In the metropolis it was over 300,000. The "City" was 720 acres in extent: what in 1855 was regarded as the metropolis was about 75,000 acres in extent. And here, with no visible boundary of separation between them, were what were still "Parishes," but what were in reality great towns; not merely merged or rapidly merging into each other, but already merged into one great metropolis. Some of them even had a greater population than the "City" itself. St. Pancras, for instance, with 167,000 persons; St. Marylebone with 157,000, and Lambeth with 139,000. Of that greater London--or, in effect, of London itself--there is a complicated and tangled story to tell. Long before the middle of the nineteenth century had been reached, the time had passed when the "City" could contain the trade, and commerce, and manufactures, and business, which had grown up. They had overflowed into London outside the walls, and just as in the "City" the great economic forces produced certain definite changes in the circumstances and sanitary condition of the people living therein, so, in the greater London, the commercial spirit radiating gradually outwards, produced precisely similar results, only on a far wider scale, and with more potent effect. Trade, and commerce, and wealth, and population, were increasing by leaps and bounds; and like the rings which year by year are added to the trunk of a tree, so year by year, decade by decade, London--the metropolis--spread out, and grew, and grew. From something under one million of inhabitants in 1801, the population increased to nearly two and a half millions in 1851, partly by natural increase, due to the number of those who were born being greater than of those who died, partly by immigration from the country. This was London, in the large sense of the title--London, the great metropolis which had never received recognition by the law as one great entity, and whose boundaries had never been fixed, either by enactment, charter, or custom.[5] Dependent as is the public health, or sanitary and social condition of the people, upon the circumstances in which they find themselves placed, and the economic forces which are constantly at work moulding those circumstances, it is in as great a degree dependent on the system of local government in existence at the time, upon the scope and efficacy of the laws entrusted to the local authorities to administer, and upon the administration of those laws by those authorities. As for local government--unlike the "City"--this greater London was without form and almost void. With the exception of the Poor Law Authority--the Boards of Guardians--whose sphere of duty was distinctly limited, there was, outside the boundaries of the "City," not even the framework of a system of such government; and the confusion and chaos became ever greater as years went on and London grew. There was no authority so important as to have any extended area for municipal purposes under its control and management except certain bodies, five in number, entitled "Commissioners of Sewers," charged with duties in connection with the sewerage of their districts. In some parishes some of the affairs of the parish were managed by the parishioners in open vestry assembled, at which assembly Churchwardens, Overseers of the Poor, and Surveyors of Highways were appointed to carry out certain limited classes of work. In others, the parishioners elected a select vestry to do the work of the parish. But for many of the vitally important municipal affairs there were no authorities at all. As the non-City and out-districts became more thickly peopled, and streets and houses increased in number, the inconvenience of there being practically no local government at all made itself felt. In some cases, the owners of the estates which were being so rapidly absorbed into London and being built upon, applied to Parliament for powers to regulate those estates. In other cases, persons with interests in a special locality associated themselves together and obtained a private Act of Parliament giving them authority, under the name of Commissioners or Trustees, to tax and in a very limited way to govern a particular district or group of streets forming part of a parish. Thus it happened that a large number of petty bodies of all sorts and kinds came into existence. Any district, however small, was suffered to obtain a local Act of Parliament for the purpose of managing some of its affairs, and this, too, without any reference to the interests of the immediate neighbours, or of the metropolis as a whole. Most of the limited and somewhat primitive powers possessed by them were derived from an Act passed in 1817,[6] and related to the paving of streets and the prevention of nuisances therein. Some of these bodies were authorised to appoint surveyors or inspectors; also "scavengers, rakers, or cleaners" to carry away filth from streets and houses, but the exercise of such powers was, of course, purely optional. Indeed, there were scarcely any two parishes in London governed alike. What the exact number of these various petty authorities was is unknown. Of paving boards alone, it is said that about the middle of the last century there were no less than eighty-four in the metropolis--nineteen of them being in one parish. The lighting of the parish of Lambeth was under the charge of nine local trusts. The affairs of St. Mary, Newington, were under the control of thirteen Boards or trusts, in addition to two turnpike trusts.[7] In Westminster:-- "The Court of Burgesses and the Vestry retained general jurisdiction over the whole parish for certain purposes; but the numerous local Acts so effectually subdivided the control and distributed it among boards, commissioners, trustees, committees, and other independent bodies, that uniformity, efficiency, and economy in local administration had become impossible."[8] There were authorities exclusively for paving; authorities for street improvements; authorities for lighting; even authorities for a bridge across the river. In the course of years, several hundred such bodies had been created, without any relation one to the other, and without any central controlling authority, good, bad, or indifferent, by as many Acts of Parliament. They were mostly self-elected, or elected for life, or both; and were wholly irresponsible to the ratepayers, or indeed to any one else; nor were their proceedings in any way open to the public. Many of them had large staffs of well paid officials; and there were perpetual conflicts of jurisdiction between them, and an absolute want of anything approaching to municipal administration. It has been roughly stated--roughly because there are no reliable figures--that there were about three hundred such bodies in London--"jostling, jarring, unscientific, cumbrous, and costly"--the very nature of many of them being "as little known to the rest of the community as that of the powers of darkness." Add to these numerous, clashing, and incompetent authorities, various great public companies or corporations--the water companies, and gas companies, and dock companies, each with its own special rights--which were far more favourably and generously regarded by Parliament than were the rights of the public, and one has fairly enumerated the local governing bodies then existing in London. In fact, in no parish of the great metropolis of London was there a local authority possessed of powers to deal in its own area with the multitudinous affairs affecting the health and well-being of the people. Nor was there in the metropolis any central authority--no single body, representative or even otherwise--to attend to the great branches of municipal administration which affected and concerned the metropolis as a whole, and which could only be dealt with efficiently by the metropolis being treated as a whole. The consequences to the inhabitants of London of the absence of any efficient form of local government were dire in character, terrible in extent, and unceasing in operation. The higher grades of society suffered in some degree, as disease, begotten in filth and nurtured in poverty, often invaded with disastrous consequences the homes of the well-to-do; but it was by the great mass of the industrial classes and the poorer people that the terrible burden of insanitation had to be borne, and upon them that it fell with the deadliest effect. The non-existence of a central authority, or of any capable local authorities whose function it would have been to protect them from the causes of disease, had resulted in an insanitary condition which year after year entailed the waste of thousands upon thousands of lives. And the people, in the cruel circumstances of their position, were absolutely powerless to help themselves, and had no possible means of escape from the ever-present, all-surrounding danger. The first absolute necessity of any sanitation whatever is the getting rid by deportation or destruction of all the filth daily made or left by man or beast, for such filth or refuse breeds all manner of disease, from the mildest up to the very worst types and sorts, and promptly becomes not only noxious to health, but fatal to life. The more rapidly and thoroughly, therefore, this riddance is effected, the better is it in every way for the general health of the public. So far as the metropolis was concerned, this necessity had for generation after generation been very lightly regarded; and when at last it so forced itself upon public notice that it could no longer be ignored, the measures taken were wholly inadequate and ineffective. What system there was in London as to the disposal of sewage throughout the earlier half of last century was based upon a Statute dating so far back as Henry VIII.'s reign, amended by another in William and Mary's reign. Under these Statutes certain bodies had been constituted by the Crown as Commissioners of Sewers for certain portions of London, and charged with the duty of providing sewers and drains in their respective districts, and maintaining the same in proper working order. But what might have been good enough for London in the sixteenth or seventeenth centuries was certainly not adequate in the nineteenth, when London had extended her borders in every direction, and her population had reached almost two and a half millions. Successive Parliaments had not troubled themselves about such a matter; and this neglect, which now appears almost incredible, was typical of the habitual attitude of the governing classes to the sanitary requirements of the masses of the population of the metropolis. In the eighteen hundred and forties, five such bodies of Commissioners were in existence in London, each with a separate portion of the metropolis under its charge and exercising an independent sway in its own district; and when we collect the best testimony of that time as to their work and that of their predecessors, we have the clearest demonstration of their glaring incapacity, and of the utter inadequacy and inefficiency of the sewerage in their respective districts. Many miles of sewers had, it is true, in process of time been constructed, and did exist, but much of the work had been so misdone that the cure was little better than the disease. A river is always a great temptation to persons to get rid of things they want to get rid of, particularly when the things are nasty and otherwise not easily disposed of. Londoners only followed the general practice when they constructed their sewers so that they discharged their contents direct into the Thames. The majority of these sewers emptied themselves only at the time of low water; for as the tide rose the outlets of the sewers were closed, and the sewage was dammed back and became stagnant. When the tide had receded sufficiently to afford a vent for the pent-up sewage, it flowed out and deposited itself along the banks of the river, evolving gases of a foul and offensive character. And then the sewage was not only carried up the river by the rising tide, but it was brought back again into the heart of the metropolis, there to mix with each day's fresh supply of sewage; the result being that "the portion of the river within the metropolitan district became scarcely less impure and offensive than the foulest of the sewers themselves." This was bad enough, but there were miles of sewers which, through defects of construction or disrepair, did not even carry off the sewage from the houses and streets to the river, but had become "similar to elongated cesspools," and, as such, actual sources and creators of disease. Incredible almost were the stupidities perpetrated by these Commissioners in regard to the construction of the sewers. At even so late a date as 1845 no survey had been made of the metropolis for the purposes of drainage; there was a different level in each of the districts, and no attempt was made to conform the works of the several districts to one general plan. Large sewers were made to discharge into smaller sewers. Some were higher than the cesspools which they were supposed to drain, whilst others had been so constructed that to be of any use the sewage would have had to flow uphill! It might reasonably have been expected that in the nineteenth century, at least, the twenty parishes which formed the district of the Westminster Commissioners of Sewers would have been equal to producing an enlightened and capable body as Commissioners, but the Westminster Court of Sewers was certainly not such. Even their own chief surveyor, in 1847, stigmatised it as a body "totally incompetent to manage the great and important works committed to their care and control." Upon it were builders, surveyors, architects, and district surveyors--a class of persons whose opinions "might certainly be biassed with relation to particular lines of drains and sewers." Of another of the courts--namely, the Finsbury Court of Sewers--one of the Commission had been outlawed; another was a bankrupt. It was stated at the time that "jobbery and favouritism and incompetence were rampant," and that the system was "radically wrong and rotten to the core." Certain it is that these bodies failed completely to cope with the requirements of the time. London was spreading out in all directions, and the increase of houses and population was very rapid. Practically no effort, however--certainly no adequate effort--was made by the various bodies of Commissioners to provide these new and growing districts with the means of getting rid of their sewage. And then, inasmuch as the sewage had somehow or other to be got rid of, and some substitute for sewers devised, the surface drains, and millstreams, and ditches were appropriated to use and converted into open sewers or "stagnant ponds of pestilential sewage." London was "seamed with open ditches." According to contemporary reports there were in Lambeth numerous open ditches of the most horrible description. Bermondsey was intersected by ditches of a similar character, and abounded with fever nests. Rotherhithe was the same. Hackney Brook, formerly "a pure stream," had become "a foul open sewer."[9] In St. Saviour's Union the sewers were in a dreadful condition ... "the receptacle of all kinds of refuse, such as putrid fish, dead dogs, cats, &c. Greenwich was not drained or sewered." What certainly was conclusively demonstrated was that the existence of several bodies of Commissioners, each with a district to itself, presented an insuperable obstacle to any general system of sewerage for greater London; and that one capable central authority was the first essential of an adequate and efficient system for London as a whole. Thus, then, in this first essential of all sanitation--one might say of civilisation--no adequate provision was made by Parliament for the safety of the metropolis; whilst as to other essentials of sanitation, there were no laws for the prevention of the perpetration of every sanitary iniquity; and such authorities as there were failed absolutely to use even the few powers they possessed. The defective and inefficient sewerage of the metropolis precluded the possibility of any proper system of house drainage, for there being few sewers there were few drains, and consequently instead of drains from the houses to the sewers there were cesspools under almost every house. At the census of 1841 there were over 270,000 houses in the metropolis. It was known, then, that most houses had a cesspool under them, and that a large number had two, three, or four under them. Some of them were so huge that the only name considered adequate to describe them was "cess-lake." In many districts even the houses in which the better classes lived had neither drain nor sewer--nothing but cesspools; and many of the very best portions of the West End were "literally honeycombed" with them. And so jealous was the law as regarded the rights of private property that so late as 1845 owners were not to be interfered with as regarded even their cesspools, no matter how great the nuisance might be to their neighbours, no matter how dangerous to the community at large. Indeed, the Commissioners of Sewers had no power to compel landlords or house-owners to make drains into the sewers, and of their own motion the landlords would take no action. In the lower part of Westminster the Commissioners of Sewers had actually carried sewers along some of the streets, but they found "very little desire on the part of the landlords" to use them. "So long as the owners get their rent they do not care about drainage.... The landlords will not move; their property pays them very well; they will not put themselves to any expense; they are satisfied with it as it stands." Strange level of satisfaction! when one reads the following evidence given two years later before the Metropolitan Sewers Commission:-- "There are hundreds, I may say thousands, of houses in this metropolis which have _no drainage whatever_, and the greater part of them have stinking, overflowing cesspools. And there are also hundreds of streets, courts, and alleys, that have no sewers; and how the drainage and filth is cleared away, and how the poor miserable inhabitants live in such places it is hard to tell. "In pursuance of my duties, from time to time, I have visited very many places where filth was lying scattered about the rooms, vaults, cellars, areas, and yards, so thick, and so deep, that it was hardly possible to move for it. I have also seen in such places human beings living and sleeping in sunk rooms with filth from overflowing cesspools exuding through and running down the walls and over the floors.... The effects of the stench, effluvia, and poisonous gases constantly evolving from these foul accumulations were apparent in the haggard, wan, and swarthy countenances, and enfeebled limbs, of the poor creatures whom I found residing over and amongst these dens of pollution and wretchedness."[10] And this witness was unable to refrain from passing a verdict upon what he had seen:-- "To allow such a state of things to exist is a blot upon this scientific and enlightened age, an age, too, teeming with so much wealth, refinement, and benevolence. Morality, and the whole economy of domestic existence, is outraged and deranged by so much suffering and misery. Let not, therefore, the morality, the health, the comfort of thousands of our fellow creatures in this metropolis be in the hands of those who care not about these things, but let good and wholesome laws be enacted to compel houses to be kept in a cleanly and healthy condition." There were, it was said, "a formidable host of difficulties" as regarded the execution of improved works of house drainage. There was the opposition of the proprietors on the ground of expense; there were the provisions of the Act of Parliament,[11] which were so intricate as to be almost unintelligible and unworkable; there was the want of a proper outfall for the sewage; and the want of a supply of water to wash away the filth--a possible explanation for the existing state of abomination, but certainly not a justification for the prolonged inaction of successive Parliaments and Governments in allowing affairs to reach so frightful a pass, and for dooming the people to a condition of things which it was entirely beyond their power to remedy even as regarded the single house they inhabited. Just as everything connected with sewerage and drainage was so placidly neglected, and so fearfully bad, so also was it as regarded another matter of even more vital necessity, namely, the supply of water to the inhabitants of London for drinking, or for domestic, trade, or sanitary purposes. "Water is essential as an article of food. Water is necessary to personal cleanliness. Water is essential to external cleansing, whether of houses, streets, closets, or sewers." Manifestly, the supply of water was not a matter which the individual in a large community such as London could in any way make provision for by his own independent effort. And yet there was no public body in London, central or local, representative or otherwise, charged with the duty of securing to the people even the minimum quantity necessary for life. Early in the seventeenth century the New River Company was formed for the supply of water to London. And as years went on Parliament evidently considered it fulfilled its obligations in this respect by making over to sundry private companies the right of supplying to the citizens of London this vital requirement, or, as it has been termed, this "life-blood of cities"; and Parliament had done this without even taking any guarantee or security for a proper distribution to the people, or for the purity of the water, or the sufficiency of its supply. Practically, a generous Parliament had bestowed as a free gift upon these Water Companies the valuable monopoly, so far as London was concerned, of this necessity of life. Although by the middle of the nineteenth century there was no portion of the metropolis into which the mains and pipes of some of the companies had not been carried, yet, as the companies were under no compulsion to supply it to all houses, large numbers of houses, and particularly those of the poorer classes, received no supply. Indeed, in many parts of London there were whole streets in which not a single house had water laid on to the premises. In the district supplied by the New River Company, containing about 900,000 persons, about one-third of the population were unsupplied; and in the very much smaller area of the Southwark Company's district about 30,000 persons had no supply. Even in 1850 it was computed that 80,000 houses in London, inhabited by 640,000 persons, were unsupplied with water. A very large proportion of the people could only obtain water from stand-pipes erected in the courts or places, and that only at intermittent periods, and for a very short time in the day; sometimes, indeed, only on alternate days, and not at all on Sunday. "To these pipes," wrote a contemporary, "the inhabitants have to run, leaving their occupation, and collecting their share of this indispensable commodity in vessels of whatever kind might be at hand. The water is then kept in the close, ill-ventilated tenements they occupy until it is required for use."[12] The quality of the water which was supplied by the companies left much to be desired. That supplied by the New River Company was, as a rule, fairly good in quality; but that supplied by the other companies was very much the reverse. Financial profit being their first and principal consideration, they got it from where it was obtainable at least capital outlay or cost, regardless of purity or impurity; and almost without exception took it from the Thames--"the great sewer of London"--took it, too, from precisely the places where the river was foulest and most contaminated by sewage and other filth; and as there were no filtering beds in which it could have been to some extent purified before its distribution to householders, its composition can best be imagined. Looking at the great river even now in its purified state, as it sweeps under Westminster Bridge, any one would shudder at the idea of being compelled to drink its water in its muddy and unfiltered state, and of one's health and life being dependent on the supply from such a source. How infinitely more repugnant it must have been when the river was "the great sewer" of the metropolis. The great shortage of company-supplied water compelled large numbers of people to have recourse to the pumps which still existed in considerable numbers in many parts of London, the water from which was drawn from shallow wells. The water of these "slaughter wells," as they have been termed, appears to have combined all the worst features of water, and to have contained all the ingredients most dangerous to health. "If," wrote a Medical Officer of Health some years later, "the soil through which the rain passes be composed of the refuse of centuries, if it be riddled with cesspools and the remains of cesspools, with leaky gas-pipes and porous sewers, if it has been the depository of the dead for generation after generation, the soil so polluted cannot yield water of any degree of purity."[13] As all these "ifs" were grim actualities, the water of such wells was revolting in its impurity and deadly in its composition. Of Clerkenwell it was indeed stated positively that "the shallow-well water of the parish received the drainage water of Highgate cemetery, of numerous burial grounds, and of the innumerable cesspools in the district." On the south side of the river the water in most of the shallow wells was tidal--from the Thames, which is a sufficient description of the quality thereof--and where people did not live close enough to the river to draw water from it for their daily wants, they took it from these tidal wells. Vile as it was, it had to be used in default of any better. Where such wells were not available, the water for all household consumption was taken from tidal ditches which were to all intents and purposes only open sewers. A contemporary report gives a graphic picture of this form of supply[14]:-- "In Jacob's Island (in Bermondsey) may be seen at any time of the day women dipping water, with pails attached by ropes to the backs of the houses, from a foul, foetid ditch, its banks coated with a compound of mud and filth, and with offal and carrion--the water to be used for every purpose, culinary ones not excepted." An adequate supply of wholesome water has for very long been recognised as of primary sanitary importance to all populations, but with a densely crowded town population the need of care as to the quality of the supplies is peculiarly urgent. And yet, through the indifference of successive Governments, the people of the great metropolis of London were most inadequately supplied with water, and what water was supplied to the great mass of them, or was available for them, was of the foulest and most dangerous description. The inadequacy of supply not alone put a constant premium upon dirt and uncleanliness, both in house and person, but it intensified the evils of the existing sewers and drains, as without water efficient drainage was impossible. And the horrible impurity of the water affected disastrously and continuously the health of the great mass of the people. Many dire lessons, costing thousands upon thousands of lives, were needed before it was borne in on the Government of the country that the arrangements regarding the supply of water for the people of London required radical amendment. Much of the health of a city depends upon the width of its thoroughfares, the free circulation of air in its streets and around its buildings, and the sound and sanitary construction of its houses. In every one of these respects all the central parts of London were remarkably defective. The great metropolis had grown, and had been permitted to grow, mostly at haphazard. Large parks and open spaces there were in the richer and more well-to-do parts, and some handsome thoroughfares; but "there were districts in London through which no great thoroughfares passed, and which were wholly occupied by a dense population composed of the lowest class of persons, who, being entirely secluded from the observation and influence of better educated neighbours, exhibited a state of moral degradation deeply to be deplored."[15] Parliament had taken some interest as to the width of the streets, and had shown some anxiety for improvements in them. Hence, much local and general legislation was from time to time directed to control the erection of buildings beyond the regular lines of buildings. Thus the Metropolitan Paving Act, 1817, contained stringent provisions as to projections which might obstruct the circulation of air and light, or be inconvenient or incommodious to passengers along carriage or foot ways in certain parts of the metropolis. In 1828 the Act for Consolidating the Metropolis Turnpike Trusts, also, contained certain restrictive provisions, but these were rendered futile by the construction put upon its terms by the magistrates. Again, in 1844, further enactments were made by the Metropolitan Building Act to restrain projections from buildings; but after a short administration of its provisions it was found that shops built on the gardens in front of the houses, or on the forecourts of areas, did not come within the terms of the Act. And so the Act, in that very important respect, was useless. The action of Parliament had been mainly prompted by the necessity for increased facilities of communication, and by the desire to safeguard house property from destruction by fire; whilst the most important of all aspects of the housing of the people--namely, the sanitary aspect--received no consideration, and was completely ignored as a thing of no consequence. But whatever the motive of action by Parliament, the ensuing legislation was in the main inoperative or ineffective. The resolution of landowners to secure the highest prices for their property, and the determination of builders, once they got possession of any land, to utilise every inch of it for building, and so to make the utmost money they could out of it, defeated the somewhat loosely drawn enactments. Means of evading the legislative provisions were promptly discovered, and, in despite of legislation, builders, architects, and surveyors of the metropolis were unrestrained in their encroachments upon areas and forecourts--at times even were successful in breaking the existing lines of buildings in metropolitan streets or roads by encroachments which were only discovered too late to be prevented. Nor was there anything to prevent houses being built on uncovered spaces at the backs of existing buildings, thus taking up whatever air-space had been left between the previous buildings. Hence, great blocks of ground absolutely covered with buildings, back to back, side to side, any way so long as a building could by any ingenuity be fitted in. Hence the culs-de-sac, the small and stifling courts and alleys. Nor were there any regulations forbidding certain kinds of buildings which would be injurious to the health of their inhabitants. Hence the mean and flimsy and insanitary houses which were being erected in the outer circle of the metropolis, and which wrought havoc with the health and lives of the people. Hence, too, the erection, on areas and forecourts, of buildings which narrowed the streets, diminished the air-spaces and means of ventilation, and destroyed the appearance of the localities. And once up they had come to stay; for years were to pass before the Legislature created any effective means for securing their amelioration, and for generations they were permitted to exercise their evil and deadly sway over the people, and to scatter broadcast throughout the community the seeds of disease and death. The then existing actual state of the case was summed up by Dr. Southwood Smith in his evidence before the Select Committee of the House of Commons in 1840:-- "At present no more regard is paid in the construction of houses to the health of the inhabitants than is paid to the health of pigs in making sties for them. In point of fact there is not so much attention paid to it." Legislation against some of the evils which had already reached huge proportions, and which, as London grew, were spreading and developing, was not alone ineffective, but earlier legislation, in one notorious Act, had been the direct incentive to, and cause of evils. This was the Act which imposed a tax upon windows.[16] In effect this Act said to the builder, "Plan your houses with as few openings as possible. Let every house be ill-ventilated by shutting out the light and air, and as a reward for your ingenuity you shall be subject to a less amount of taxation."[17] The builder acted upon this counsel, and the tax operated as a premium upon the omission from a building of every window which could by any device be spared; with the result that passages, closets, cellars, and roofs--the very places where mephitic vapours were most apt to lodge--were left almost entirely without ventilation.[18] In effect, the window duties compelled multitudes to live and breathe in darkened rooms and poisoned air, and with a rapidly increasing population the evils resulting therefrom were being steadily intensified. Admirable was the comment passed upon the tax in 1843:-- "Health is the capital of the working man, and nothing can justify a tax affecting the health of the people, and especially of the labouring community, whose bodily health and strength constitute their wealth, and, oftentimes, their only possession. It is a tax upon light and air, a tax more vicious in principle and more injurious in its practical consequences than a tax upon food." Not until 1851 was the tax abandoned, but its evil consequences, wrought in stone and embodied in bricks and mortar, endured many a long year after. The existing laws or regulations as to building were wholly inadequate to secure healthy houses. And there was no public authority with power to compel attention to the internal condition of houses so as to prevent their continuance in such a filthy and unwholesome state as to endanger the health of the public. There was no power to compel house owners to make drains and carry them to the common sewer where it existed. No persons were appointed to carry into effect such communication. No persons were authorised to make inspection and to report upon these matters. The poor, or, indeed, the working classes generally, were powerless to alter or amend the construction of the dwellings in which they were compelled to reside, still less to alter their surroundings. Any improvement in the condition of their dwellings could only be by voluntary action on the part of the landlords, or of interference by Government to compel that measure of justice to the poor, and of economy to the ratepayers. Parliament failed to interfere with any effect; and as to the landlords or house-owners, their interest ran all the other way. Few persons of large capital built houses as a speculation, or had anything to do with them. Many, however, who were desirous of making the highest possible interest on their money acquired either freehold or leasehold land, and built cheap and ill-constructed houses upon it without the least regard to the health of the future inmates. And the small landlords were often the most unscrupulous with regard to the condition of the houses they let, and exacted the highest rents. Inasmuch as this freedom as regarded house construction had been going on almost from time immemorial, it was not only the newly-built houses which were bad. Earlier built houses had rapidly fallen into disrepair and semi-ruin, and were steadily going from bad to worse, and becoming ever less and less suitable for human dwellings. The following description[19] of parts of St. Giles' and Spitalfields shows what, under a state of freedom as to building, had been attained to in 1840, and is typical of what so extensively prevailed in the central parts of London:-- "Those districts are composed almost entirely of small courts, very small and very narrow, the access to them being only under gateways; in many cases they have been larger courts originally, and afterwards built in again with houses back to back, without any outlet behind, and only consisting of two rooms, and almost a ladder for a staircase; and those houses are occupied by an immense number of inhabitants; they are all as dark as possible, and as filthy as it is possible for any place to be, arising from want of air and light." Here is another description--that of "Christopher Court," a cul-de-sac in Whitechapel--given, in 1848, by Dr. Allison, one of the surgeons of the Union:-- "This was one of the dirtiest places which human beings ever visited--the horrible stench which polluted the place seemed to be closed in hermetically among the people; not a breath of fresh air reached them--all was abominable." It is needless to multiply instances. There is a dreadful unanimity of testimony from all parts of London as to the miserable character and condition of the houses in which in the middle of the nineteenth century the industrial and the lower classes were forced to live; the deficiency or total absence of drainage, the universal filth and abomination of every kind, the fearful overcrowding, the ravages of every type of disease, and the absolute misery in which masses struggled for existence. The density of houses upon an area has long been recognised as one of the great contributing causes to the ill-health of a community, but when coupled with the overcrowding of human beings in those houses, the combined results are always disastrous in the extreme. Overcrowding had been a long-standing evil in London; had existed far back in history. As London had grown, the evil had grown; and about the middle of the last century it was immeasurably greater than ever before, and its disastrous consequences were on a vastly larger scale. The great economic forces which resulted, in certain districts of London, in the destruction of houses and great clearances of ground, had largely reduced the available accommodation for dwellings, and the expelled inhabitants, chained to the locality by the fact of their livelihood being dependent upon their residence being close by, were forced to invade the yet remaining places in the neighbourhood suited to their means. As the circle of possible habitations contracted, while the numbers seeking accommodation therein increased, a larger population was crowded into an ever-diminishing number of houses. It was also a most unfortunate but apparently inevitable consequence that once a beginning was made to improve some of the streets and thoroughfares of London, and to substitute in any district a better class of houses and shops for those actually existing, the improvements necessarily involved increased overcrowding in that particular locality and in those adjoining it. But so it was. Thus, in the eighteen hundred and forties a new street--New Oxford Street--was formed. It was driven through "a hive of human beings, a locality overflowing with human life." Evidence given before the Commission in 1847 described the results:-- "The effect has been to lessen the population of my neighbourhood by about 5,000 people, and therefore to improve it at the expense of other parts of London. Some have gone to the streets leading to Drury Lane, some to St. Luke's, Whitechapel, but more to St. Marylebone and St. Pancras. The vestries of St. Marylebone and St. Pancras disliked this very much. Places in the two latter parishes which were before bad enough are now intolerable, owing to the number of poor who formerly lived in St. Giles'." And a year or so later, from across the river, came the complaint from Lambeth that "owing to the number of houses pulled down in Westminster and other places, there had been a great influx of Irish and other labourers which necessarily caused a great overcrowding of the miserable domiciles already overfull." This Lambeth complaint is specially interesting, as it refers to another great cause of overcrowding--the constant immigration into London of labourers and poor people in search of work or food. Owing to the ever increasing and urgent demand for house accommodation for the working and poorer classes, it became a very remunerative proceeding for the occupier of a house to sub-let it in portions to separate families or individuals, and the practice gradually extended to and absorbed streets hitherto belonging to the better class. The owner of a property let his whole house to a tenant; this tenant, seeing an easy way of making money, sub-let the rooms in it in twos or threes, or even separately, at a very profitable rate to individual tenants. Nor did the sub-letting end here, for these tenants let off even the sides or corners of their room or rooms to individuals or families who were unable to bear the expense of a whole room. And so the house sank at once into being a "tenement house"--that prolific source of the very worst evils, sanitary, physical, and moral, to those who inhabited them. Even the underground kitchens and cellars, which were never intended for human habitation, were let to tenants, and thus turned to financial profit.[20] It mattered not that they were without air or ventilation, or even light; it mattered not that they were damp, or sometimes even inundated with the overflow of cesspools; it mattered not that they were inhabited contrary to the provisions of Section 53 of the Building Act of 1844, for that section was of no operative effect whatever. It is true that "Overseers" were to report to the "Official Referees," who were to give notice to and inform the owners and occupiers of such dwellings as to the consequences of disobeying the Statute, and the "District Surveyor" was to carry out the directions of the Referees. But nothing was ever done--Overseers, District Surveyors, and Referees, all neglected their duties. Overcrowding was usually at its worst in one-room tenements, and in an immense number of cases in the metropolis one room served for a family of the working or of the labouring classes. It was their bedroom, their kitchen, their wash-house, their sitting-room, their eating-room, and, when they did not follow any occupation elsewhere, it was their workroom and their shop. In this one room they were born, and lived, and slept, and died amidst the other inmates. And still worse, in innumerable cases, more than one family lived in one room. When this one room was in a badly drained, damp, ill-constructed, and unventilated house, reeking with a polluted atmosphere, and that house was in a narrow and hemmed-in, unventilated "court" or "place" or "alley"--as an immense number of them were--the maximum of evil consequences was attained. The evils of overcrowding cannot be summed up in a phrase, nor be realised by the description, however graphic, of instance upon instance. The consequences to the individual living in an overcrowded room or dwelling were always disastrous, and, through the disastrous consequences to great masses of individuals, the whole community was affected in varying degree. Physically, mentally, and morally, the overcrowded people suffered. Not a disease, not a human ill which flesh is heir to, but was nurtured and rendered more potent in the human hothouse of the overcrowded room; and the ensuing ill-health and diseases not alone doubled the death rate, but increased from ten to twenty-fold, at least, the number of victims of disease of one sort or another--diseases dealing rapid death, or slowly but surely sapping human strength and vitality. In the report of the London Fever Hospital for 1845 a certain overcrowded room in the neighbourhood was described--a room which was filled to excess every night, sometimes from 90 to 100 men being in it; a room 33 feet long, 20 feet wide, and 7 feet high. From that one room alone no fewer than 130 persons affected with fever were received into the hospital in the course of the year.[21] One, whose very close experience of the conditions of life and circumstances of the poorer classes of London at the time of the cholera epidemic of 1848-9 entitled him to speak with special authority on the subject, thus summed up his views and conclusions:-- "The members of the medical profession, in the presence of these physical evils, when they are, as so often happens, concentrated, find their science all but powerless; the minister of religion turns from these densely crowded and foul localities almost without hope; whilst the administrators of the law, especially the chaplains and governors of prisons, see that crime of every complexion is most rife where material degradation is most profound."[22] And he quoted from the report of the Governors of the Houses of Correction at Coldbath Fields and Westminster the following passage:-- "The crowning cause of crime in the metropolis is, in my opinion, to be found in the shocking state of the habitations of the poor, their confined and foetid localities, and the consequent necessity for consigning children to the streets for requisite air and exercise. These causes combine to produce a state of frightful demoralisation. The absence of cleanliness, of decency, of all decorum--the disregard of any needful separation of the sexes--the polluting language and the scenes of profligacy hourly occurring, all tend to foster idleness and vicious abandonment. Here I beg emphatically to record my conviction that this constitutes the _monster mischief_." And then he himself adds:-- "If to considerations like these regarding the moral and religious aspect of this great question, be added those suggested by the indescribable physical sufferings inflicted on the labouring classes by the existing state of the public health in the metropolis, the conviction must of necessity follow, that the time is come when efforts in some degree commensurate with these great and pervading evils can no longer with safety be deferred."[23] This opinion was expressed three years after the Royal Commissioners of 1847 had said in their report:-- "There appears to be no available (legal) means for the immediate prevention of overcrowding; all we can do is to point it out as a source of evil to be dealt with hereafter." One gets a clue to the unceasing insanitary condition of the greater part of London and to the inhuman conduct of so many tenement house-owners when one realises that there was no legal punishment whatever for the perpetration and perpetuation of the insanitary abominations, no matter how noxious or dangerous they were, nor how rapidly or directly they led to disease or death. An order to abate a nuisance (which usually was not obeyed) appears to have been the only penalty, and it was only obtainable at great trouble and after great delays; and, even if obtained and the nuisance abated, there was nothing to prevent the offender at once starting the nuisance again. Offences of the most heinous description--amounting morally to deliberate murder--were perpetrated with absolute impunity. Houses which were scarcely ever free from fever cases were allowed to continue year after year levying their heavy death tax from the unfortunate inhabitants. In Whitechapel one house, inhabited by twelve or fourteen families, was mentioned as scarcely free from fever cases for as many years. "It is also a fearful fact that in almost every instance where patients die from fever, or are removed to the hospital or workhouse, their rooms are let as soon as possible to new tenants, and no precautions used, or warning given; and in some houses, perfect hotbeds of fever probably, where a patient dies or is removed, the first new-comer is put into the sick man's bed." Sanitary improvement was almost a hopeless task. There was a dead weight of opposition to it in the ignorance and recklessness and indifference of the poorer classes, the very hopelessness of being able to improve their condition. And there was an active and bitter opposition from those house-owners or lessees who for their own financial profit exploited the poorer classes. "There is one house in Spitalfields," said Dr. Lynch, "which has been the constant habitation of fever for fifteen years. I have enforced upon the landlord the necessity of cleansing and lime-washing it, but it has never been done!!... There are many landlords with whom nothing but immediate interest has any effect."[24] The favourite principle that an Englishman's house was his castle was used as a defence against any suggestion that the malpractices committed therein should be curbed. Others argued, "I am entitled to do what I like with my own." "We everywhere find people ready to declare in respect to every evil: There is not any law that could compel its removal, the place complained of being private property." All sorts of far-fetched and strained arguments were devised by them in the efforts to evade responsibility for the infamous condition of their property, and to defend and justify inaction. Fortunately some voices began to be raised as to the persons upon whom both equitably and morally the responsibility lay of improving the condition of things. "I would suggest," said a voice in 1837, "the idea of the landlords of many of the wretched filthy tenements being held responsible for their being tenantable, healthy, and cleanly." And the Commissioners in 1844 reported:-- "There are some points on which the public safety demands the exercise of a power on the part of a public authority to compel attention to the internal condition of houses so as to prevent their continuance in such a filthy and unwholesome state as to endanger the health of the public." And they recommended that:-- "On complaint of the parish, medical, or other authorised officer, that any house or premises are in such a filthy and unwholesome state as to endanger the health of the public, the local authority have power to require the landlord to cleanse it properly without delay." But ideas or recommendations were alike ignored by the Government and Parliament, and several years were to pass before any legislation was attempted which would make owners responsible for their misdeeds in matters affecting the public health, and would subject them to penalties for their misconduct. There were many other causes contributing largely to the insanitary condition of the people of the metropolis, prominent, if not most deleterious, amongst them being the widely-prevalent practice of interring the dead in the already overcrowded churchyards or burial grounds in the midst of the most densely populated districts of London--a practice resulting in "the slaughter of the living by the dead." Burial grounds long since utilised to their utmost for the disposal of the dead were utilised over and over again for graves which could only be dug in the débris of human remains, until the soil reeked with human decomposition; the surrounding atmosphere was polluted by the horrible process, and they became monstrous foci of infection. How extensive this evil was may be realised from figures given by Mr. Chadwick in a report to the Government:-- "In the metropolis, on spaces of ground which do not exceed 203 acres, closely surrounded by the abodes of the living, layer upon layer, each consisting of a population numerically equivalent to a large army of 20,000 adults, and nearly 30,000 youths and children, is every year imperfectly interred. Within the period of the existence of the present generation upwards of a million of dead must have been interred in those same spaces." And he asserted that:-- "The emanations from human remains are of a nature to produce fatal disease, and to depress the general health of whoever is exposed to them; and interments in the vaults of churches, or in graveyards surrounded by inhabited houses, contribute to the mass of atmospheric and other impurities by which the general health and average duration of life of the inhabitants is diminished." Too horribly gruesome and revolting are the descriptions of these graveyards--places where the dead were, so to speak, shovelled in as the filth of the streets is into scavengers' carts, and which "gave forth the mephitical effluvia of death"; such a one as that in Russell Court, off Drury Lane, where the whole ground, which by constant burials had been raised several feet, was "a mass of corruption" which polluted the air the living had to breathe, and poisoned the well water which in default of other they often had to drink. Or those in Rotherhithe, where "the interments were so numerous that the half-decomposed organic matter was often thrown up to make way for fresh graves, exposing sights disgusting, and emitting foul effluvia." The master hand of Dickens has given a more vivid picture of one of these places than any to be found in Parliamentary Blue Books:-- "A hemmed-in churchyard, pestiferous and obscene, whence malignant diseases are communicated to the bodies of our dear brothers and sisters who have not departed.... Into a beastly scrap of ground, which a Turk would reject as a savage abomination, and a Caffre would shudder at, they bring our dear brother here departed to receive Christian burial. With houses looking on on every side, save where a reeking little tunnel of a court gives access to the iron gate--with every villainy of life in action close on death, and every poisonous element of death in action close on life--here they lower our dear brother down a foot or two; here sow him in corruption, to be raised in corruption; an avenging ghost at many a sick bedside; a shameful testimony to future ages, how civilisation and barbarism walked this boastful island together." Interments in the vaults of the churches--then a common practice--were also a fruitful source of sickness and death. It mattered not whether or not the bodies were hermetically closed in leaden coffins, for "sooner or later every corpse buried in the vault of a church spreads the products of decomposition through the air which is breathed, as readily as if it had never been enclosed"; thus adding to the contamination of the atmosphere. The death-roll from this horrible condition of things cannot be gauged, but those most conversant with the matter were firmly convinced that it was the direct cause of fevers, and of all kinds of sickness among the people. Pollution of the atmosphere which people had to breathe, and upon the purity of which the public health in varying degree depended, was caused also by various businesses and processes of manufacture grouped together under the name of "noxious trades," such as bone-boilers, india-rubber manufacturers, gut-scrapers, manure manufacturers, slaughterers of cattle, and many others. In 1849[25] a description had been given of a street in Shoreditch which shows to what extent this evil had attained:-- "It is impossible to believe, passing through this main street, that so great a number of pigsties, bone-boileries, dog-and-cat's meat manufactories, and tallow-melting establishments, on a large scale ... should exist in a densely-crowded and closely-built locality. The noxious trades and occupations which so greatly abound here exerted a most deleterious influence upon the health of the inhabitants." Parliament, in 1844, had enacted with regard to several of these that it should not be lawful for any person to establish any such business at a less distance than 40 feet from the public way, or than 50 feet from any dwelling-house; and that it should not be lawful to erect a dwelling-house within 50 feet of such businesses. But these legislative restraints were utterly inadequate as any sort of check upon the evil; for, even if a nuisance were abated, there was no law to prevent its repetition, and so the evil promptly re-appeared. The stenches did not limit their sphere of action by feet, but distributed their abominations over large areas; and the manufacturers cared not what nuisances they subjected people to, nor how far the horrid smells were wafted by the winds, so long as they themselves could carry on a profitable business. And the intentions of Parliament were wholly frustrated by the District Surveyors, who were charged with the enforcement of the Act, and who wholly failed in their duty. As for slaughter houses, until 1851 any person could start one who pleased, and practically where he pleased, subject only to the shadowy restriction of the common law as to doing anything which might be considered a nuisance. And so these numerous and various abominations, mixed with the impurity of the atmosphere caused by the masses of smoke emitted from the chimneys of factories and private houses, and with the sickening smell from the Thames, spread sickness and death throughout great portions of the metropolis, and were one of the great causes of its insanitary condition. CHAPTER I, PART II Previous to the fifth decade of the last century it was only very rarely that the prevalence of disease, or any subject connected with the health of the community, received recognition by Parliament. In 1840 the Medical Society of London, in a petition to Parliament, called attention to the increase of smallpox, and to its preventability by vaccination, and to the imperfect means of vaccination throughout the country. The mortality from this--"one of the greatest pests that ever afflicted humanity"[26]--was very great. In one city in the south of England no less than 500 persons had died of it in one year. In London in 1839 upwards of 1,000 had died of it. And Parliament, after an unusual amount of discussion, passed an Act[27] for extending the practice of vaccination, and enacted that Boards of Guardians might contract with their Medical Officers or other medical practitioners "for the vaccination of all persons resident in their Union or Parish." And at the same time "inoculation" or "otherwise producing smallpox" was made penal--to the extent of one month's imprisonment. In 1846 there was a sudden display of Parliamentary energy in health matters. The total want of baths and wash-houses for the poorer classes of the people in the towns was brought under the notice of the Legislature, and, as it was deemed "desirable for the health, comfort, and welfare of the inhabitants of towns, &c., to encourage the establishment therein of baths, wash-houses, and open bathing places," an Act was passed giving power to the Parochial Authorities to establish such institutions and to borrow money for the purpose.[28] Their provision would have tended to an increased degree of cleanliness among the people, and consequently an improved sanitary condition, but it was long before many of these institutions were established, the local authorities being slow in availing themselves of the facilities thus offered, and this piece of legislation--like every other of the sort--being purely permissive or facilitatory. And in the same year Parliament so far awakened to the fact that certain causes of disease were removable, that in a preamble to an Act[29] it acknowledged that it was "highly expedient for the purposes of preserving the health of Her Majesty's subjects that better provision should be made for the removal of certain nuisances likely to promote or increase disease." The better provision made by the Act did not amount to much. There were two forms of insanitary evil to be combated: one the chronic insanitary condition of the masses of the people, the other the invasion of the country by some exceptional or unusual epidemic disease. As to the former, authority was given to certain public officers, on receipt of a certificate of two medical men, to complain of the existence of certain nuisances. The Justices before whom the case was heard might order the abatement of the nuisance; and if the order were not obeyed, the parties complaining might enter upon the necessary cleansing of such dwelling, and the cost of the same might be imposed on the owner or occupier. In London, the power of complaint was vested in the officers of those petty local bodies which have already been described, and, in their default, in the Boards of Guardians. Ludicrous, truly, was the idea that the countless thousands of nuisances existing in London could be remedied, or even temporarily abated, by so cumbrous, dilatory, and complicated a procedure as the complaint of an individual backed by the certificate (which would have to be paid for) of two doctors to the officer of a more or less hostile and self-interested local body, who might or might not bring the complaint before the Justices, whose decision, even if it were in favour of the complainant, could only effect a reform so far as the precise nuisance complained of was concerned, and that only temporarily, for were the nuisance renewed the whole procedure would have to be gone through again. Yet this was the "better provision" propounded and enacted by Parliament in 1846 for the regeneration of the sanitary condition of the great masses of the people of London. Nor was it even intended to be permanently available, for the Act was only to be in force for two years. The dreadful nemesis for such dense inappreciation by Parliament of its obligations to the community was, unfortunately, soon to fall heavily upon the unhappy people of the metropolis. Thousands of miles away in Hindoostan, Asiatic cholera of a deadly type had been playing havoc with the people of the country. Thence it was slowly but steadily moving westward; so much so that the desirability of making some preparations for defence against its invasion of England became apparent; and in 1847 a Royal Commission was appointed to "inquire whether any, and what, special means might be requisite for the improvement of the health of the metropolis, with regard more especially to the better house, street, and land drainage, ... the better supply of water for domestic use, &c., &c., &c." One important conclusion was at once forced upon the Commissioners, namely, that the great and vital task of making adequate provision for the sewerage of London could not be accomplished so long as it was entrusted to several bodies, each with a district of its own. "Everything," they said, "pointed to the necessity of operations being superintended by one competent body"; and they declared that it was expedient that a Commission for the entire drainage of the whole of the metropolis should be appointed with a special view to such measures, and with aid to carry them out. This report was followed in the ensuing year (1848) by an Act of Parliament[30] abolishing the various Commissions of Sewers (except those of the City), and creating in their stead one executive body whose members were to be appointed by the Crown. Wide powers were given to this central body: among them that no house was to be built or re-built without proper drains, and without proper sanitary conveniences, and that if houses built before the passing of the Act were not properly drained, the Commissioners might order the work to be done. The Metropolitan Commissioners of Sewers were duly appointed, and they divided the area over which they had jurisdiction into seven separate sub-districts, with a Commission for each. The creation of this body constitutes a great landmark in the sanitary evolution of London, for it was the first recognition by Parliament of the great principle of the unity of London; of the necessity--at least so far as regarded one matter--for one central governing authority for the numerous populations, and bodies, and districts which were becoming welded together into one mighty town and one vast community. It is true, the recognition extended only to this one matter, and that the Central Board was to be a Board nominated by the Crown, and without any vestige of representation upon it, but none the less it was a forward step towards a sounder and wiser system of government than that which had hitherto prevailed. That the new body failed to prove equal to the task imposed upon it was due as well to the constituent members thereof as to the imperfections of the machinery devised by the Act. Its failure, however, in no way controverted the soundness of the great principle thus, for the first time, recognised by Parliament. The evidence given before the Royal Commissioners brought into view the enormous area of filth and limitless insanitation in London: it displayed some of the principal sources of the excessive amount of disease and premature mortality; and to some extent it elucidated the principles and demonstrated the practicability of large measures of prevention. And it also disclosed the regrettable fact that since the epidemic of cholera in 1832 there had been little or no improvement in the sanitary condition of many parts of the metropolis--indeed, in most parts of it the evils were wider spread and acuter in form, whilst, owing to the increase of population, the numbers affected were vastly larger. All the while the Commissioners were sitting, the evil seeds of insanitation were producing a tremendous crop, and events actually occurring at the moment emphasised the crying need for some means of grappling with the intolerable existing evils. The whole class of zymotic diseases--diseases which constitute the true gauge of the healthiness or unhealthiness of a community--received a rapid and immense development.[31] From 9,600 deaths from such diseases in 1846, the number increased to 14,000 in 1847; and in this latter year the metropolis was visited by two epidemics which rendered the mortality of the last quarter of the year higher than that of any other quarter of any year since the new system of registration of deaths had been commenced.[32] Typhus fever produced fourfold its ordinary mortality--other diseases showed a similar increase--and towards the end of November influenza broke out and spread so suddenly and to such an extent that within five or six weeks it attacked no less than 500,000 persons out of 2,100,000--the then population of London. Altogether the excess of mortality in 1847 over 1845 was very close upon 50,000 persons. The attitude of Parliament and of successive Governments about this period, as regarded the insanitary condition of the masses of the inhabitants of London, is now almost incomprehensible. The plea of ignorance cannot be urged in exculpation, for their own Blue Books and official returns were there to inform them. Moreover, the existence of similar evils throughout the country, where they were on a very much smaller scale, was recognised both by the Government and Parliament. Lord Morpeth, a member of the Cabinet, speaking in 1848 in the House of Commons, said[33]:-- "It is far from any temporary evil, any transient visitant, against which our legislation is now called upon to provide. It is the abiding host of disease, the endemic and not the epidemic pestilence, the permanent overhanging mist of infection, the annual slaughter doubling in its ravages our bloodiest fields of conflict, that we are now summoned to grapple with." Yet they resolutely shut their eyes to the huge mass of misery and fearful waste of life which was going on at their very doors, and all around them. This was proved beyond controversy by their action in 1848. In that year the Government introduced into Parliament a measure which was, in effect, a comprehensive sanitary code, and which, if duly enforced, was capable of conferring vast benefit on the community at large. Describing the provisions of the Bill, Lord Morpeth said:-- "It will be imperative upon the local administrative bodies to hold meetings for the transaction of business; to appoint a surveyor; to appoint an inspector of nuisances; to make public sewers; to substitute sufficient sewers in case old ones be discontinued; to require owners or occupiers to provide house-drains; to cleanse and water streets; to appoint or contract with scavengers to cleanse, cover, or fill up offensive ditches; ... to provide sufficient supply of water for drainage, public and private, and for domestic use. "The permissive powers to be granted to the local administrative bodies ... include the power to make house-drains upon default of owner or occupier, to make bye-laws with respect to the removal of filth, to whitewash and purify houses after notice ... to require that certain furnaces be made to consume their own smoke ... to provide places for public recreation, to purchase and maintain waterworks." The Bill, which was duly passed and became an Act, in fact provided means for coping with many of the sorest dangers, it curbed some of the powers for evil which so many persons had such little scruple in exercising; it provided methods for bringing to punishment at least some of the evil-doers who hitherto had gone scot free; and it held out some prospects of the diminution of the huge death rate and still huger sick rate. Though a somewhat similar Bill, introduced in 1847, and which was withdrawn, had included the metropolis, this Act did not apply to the metropolis. Its application was limited to the rest of England and Wales. London--the capital of the kingdom--was, it was said, "reserved for a separate Bill." "The separate Bill," however, did not make its appearance. The subtle, all-pervading influence of vested rights was too powerful for any such reform to be attempted.[34] And so, the Government and Parliament, deliberately excluding the metropolis from this beneficial legislation, left untouched the centre and main emporium of disease, and left the people of London exposed on all sides to the merciless onslaught of the direst diseases which can afflict mankind. Cholera, however, the only power able to awe the Government, was now so close at hand that some special provision had to be devised for the protection of the public health. Parliament, this time not excluding the metropolis, re-enacted the trumpery "Nuisance Removal and Diseases Prevention Act" of 1846, with some slight enlargements, and one important addition, namely, authority for the appointment by the Privy Council of a General Board of Health, which might issue directions and regulations for the prevention of epidemic and contagious disease. Upon this slender thread Londoners were left dependent for such measures as might afford them some protection against the impending epidemic. No other help was at hand. Nor was there much time for help to be organised or preparations made, for cholera had reached Egypt and Constantinople, and by June, 1848, had crept forward to St. Petersburg. Isolated suspicious cases occurred in London in the summer of 1848,[35] then an undoubted case in Southwark on the 22nd of September, and then more undoubted cases, and the disease had secured a footing. As the winter approached it died down and ceased, having carried off some 468 victims. The Privy Council had appointed a General Board of Health, and early in November the Board issued regulations directing the Guardians to take the necessary measures for the cleansing of houses, the abatement of nuisances, and generally for the removal of all matters injurious to health. To direct is one thing, to get obeyed is another, and with some few exceptions, these directions were disregarded. Partly, the fault was Parliament's. The Act, by naming various local authorities, had created a divided power, and consequently a divided responsibility, which resulted in inaction, neglect, delay, and loss of life; and though the General Board of Health might require the Boards of Guardians and other local bodies to put the regulations into force, they had no power to compel them to do so, and in default of such power the General Board of Health was almost helpless. The cessation of the disease proved to be only temporary. Scarcely was 1849 entered on than the epidemic broke out again, steadily gathering momentum as the summer went on. In Bethnal Green there was an outbreak in the night--sudden and panic-striking--"consternation and alarm were spread abroad--the hurried passing and re-passing of messengers, and the wailing of relatives, filled the streets with confusion and woe, and impressed all with a deep sense of awful calamity." And the epidemic spread and spread until in one week in September (1849) the deaths from it amounted to 2,026.[36] Were the full facts known, the mortality was doubtless far higher. And then the epidemic began rapidly to abate, and by the end of the year had ceased, having slain some 14,600 victims.[37] Numerous and important were the lessons inculcated by this disastrous epidemic. It afforded the most definite evidence that had yet been obtained of the influence upon health of local conditions and pre-disposing causes. It showed that in the most violent and extensive outbreaks of the pestilence its virulence was invariably confined to circumscribed localities. It showed that the habitat of cholera and the habitat of fever were one and the same. Deaths from cholera took place in the very same streets, and houses, and rooms, which had been again and again visited by fever; and rooms were pointed out where some of the poor people had recovered from fever in the spring to fall victims to cholera in the summer. As it was tersely summed up by one of the most active and capable medical officers of the Board of Health:-- "We find but one cause of so much sickness, suffering and death--the prolific parent of all this diversified offspring--'filth.' "It is in filth, in decomposing organic matter, that the main causes of epidemic diseases are to be sought out--filthy alleys, filthy houses, filthy air, filthy water, and filthy persons." What the General Board of Health could do, it did, as was indeed to be expected from such sanitary enthusiasts as Lord Ashley, Dr. Southwood Smith, and Mr. Edwin Chadwick, but the local authorities were dilatory, lukewarm, or actually hostile, and their proceedings, where anything was done, were altogether inadequate for insuring those prompt, comprehensive, and vigorous measures so urgently demanded in the presence of a great and destructive epidemic such as malignant cholera. The system of house-to-house visitation was essential for the discovery and checking of the disease, but, wrote the Board, "nothing effective was done or attempted in the metropolis. We repeatedly and earnestly urged upon the Boards of Guardians the importance to the saving of life of making immediate arrangements for special measures of prevention, but our representations were made in vain. "The local authorities could not be induced to carry into effect the preventive measures we proposed." Several unions and parishes, among whom were some of the most wealthy and populous, positively refused to comply with the directions of the Board. In the case of Bethnal Green, just described, the Board issued a "Special Order." But even under these urgent circumstances "the Board of Guardians appointed no medical officer for five days, they provided no nurses, they established no hospital, they opened no dispensary, they appointed one inspector of nuisances instead of two, and they made no provision for extensive and effectual lime-washing." The explanation of the inaction and hostility of the local authorities lay in the fact that the various measures prescribed by the Act interfered with private interests, and especially with interests which were largely represented on the Boards of Guardians. Among the members of those boards there was often "an antagonistic power" at work which prevented proper attention being paid to the sanitary condition of the localities of the poor. In many instances, owners of small houses and cottage property, to which class of dwellings the provisions of the Act more particularly applied, were themselves members of such boards, and when this was not the case, they exerted an influence not the less powerful because it was indirect. This interest often conspired to impede efficient sanitary measures.[38] Local interests also operated, the apprehension being that if active and really efficient measures were adopted the trade of the neighbourhood would suffer. In one instance--an instructive one--where the epidemic had extensively prevailed among the poor, its existence was denied, and house-visitation resisted, till, after considerable delay and loss of life, a number of shopkeepers were attacked by the disease, and _then_, all opposition ceased. The evidence of the unfitness of the local authorities charged with the administration of the Act for the duties imposed upon them was overwhelming. The unfortunate position was accentuated and intensified by the fact that the General Board of Health had no power either of compelling the local authorities to do their duty or of itself acting in default of their neglect; and the absence of this first essential of effective administration hampered and crippled its action. The Board summed up its experience of this great visitation of 1848-9:-- "The evidence shows that where combined sanitary arrangements have been carried into effect the outbreak of the pestilence has been sometimes averted; that where not prevented, its course has been gradually arrested. "That where material improvements have been made in the condition of the dwellings of the labouring classes, there has been an entire exemption from the disease, and where minor improvements were made, the attacks have been less severe and less extensive. "That with reference to the measure of prevention, the immunity from the disease has been in proportion to the extent to which those measures have been carried into effect systematically and promptly." By the end of the year the epidemic was practically over. And then the usual thing took place. It is described a few months later by Dr. Grainger, who wrote:-- "In many of the most densely populated districts the inspectors of nuisances have been dismissed, the cleansing operations have been relaxed, and there is too much reason to apprehend that the courts and alleys will lapse back again into their accustomed filth, ... that houses proved by the evidence of medical officers, inspectors, and local authorities to be unfit for human habitation will long continue to remain 'pest-houses,' spreading disease around; and that, in the midst of these tolerated and accumulated evils, the industrious classes will continue as heretofore to be decimated by fever, or, should it again break out, by cholera."[39] CHAPTER I, PART III The "City" of London, though constituting territorially and by population but a small portion of the metropolis, affords much matter of deep interest in connection with the sanitary evolution of London, totally apart from those great economic forces emanating from it which have dominated the whole of London life. The "City" differed mainly, as has already been pointed out, from "greater London" in that it had a real and active governing body for its local affairs, and that that body was possessed of considerable powers for dealing with the sanitary condition and requirements of its inhabitants. That those sanitary powers were annually delegated to a body entitled the Commissioners of Sewers in no way diminished its sanitary authority or weakened its efficiency, for that body was practically a Committee of its own, and had authority, directly or indirectly, over nearly every one of the physical conditions which were likely to affect the health or comfort of its inhabitants. The "City" differed also in that it was able to obtain from the Government and Parliament powers which neither Government nor Parliament would grant to "greater London." It differed too in that from 1848 onwards it was in beneficial enjoyment of the services of a Medical Officer of Health. But in many respects the "City" was a microcosm of the metropolis; and though possessed of a local government, yet was it cursed with evils which were the terrible legacy left it by the ignorance, indifference, neglect, incapacity, or cupidity, of previous generations. The graphic reports of its Medical Officer of Health--Dr. John Simon--have left us a most vivid and valuable contemporary picture of the sanitary condition and surroundings of the people living in the favoured area about the middle of the last century, and they disclose, in no hesitating manner, the desperate evils prevalent therein. The Thames, "with the immeasurable filth" which polluted it, and its acres of mud banks saturated with the reeking sewage of an immense population, vitiated the atmosphere of the City, just as it did that of other parts of London. But sewers there were in the City, of one sort or another, over forty miles of them, and some of the filth of the City was carried away, at least into the river. House drainage into the sewers was, however, either lamentably deficient or non-existent, and cesspools abounded--abounded so freely that "parts of the City might be described as having a cesspool-city excavated beneath it." "It requires," reported Dr. Simon to his employers, "little medical knowledge to understand that animals will scarcely thrive in an atmosphere of their own decomposing excrements; yet such, strictly and literally speaking, is the air which a very large proportion of the inhabitants of the City are condemned to breathe.... In some instances, where the basement storey of a house is tenanted, the cesspool lies, perhaps merely boarded over, close beneath the feet of a family of human beings whom it surrounds uninterruptedly, whether they wake or sleep, with its foetid pollution and poison." For such evils, and such a state of things, he said, house drainage, with effective water supply, were the remedies which could alone avail; and it was only in the Session of 1848 that the authority to secure and enforce these remedies was vested by the Legislature in any public body whatsoever. The City was fortunately included, but the metropolis, with its two and a half millions of inhabitants, was unfortunately not. The unrestricted supply of water, he pointed out, was the first essential of decency, of comfort, and of health; no civilisation of the poorer classes could exist without it; and any limitation to its use in the metropolis was a barrier which must maintain thousands in a state of the most unwholesome filth and degradation. Even in the City, however, the supply of water was but "a fraction of what it should have been, and thousands of the population inhabited houses which had no supply of it." Nor was what was supplied by the Water Companies much to boast of. "The waters were conducted from their sources in open channels; they received in a large measure the surface-washing, the drainage, and even the sewage of the country through which they passed; they derived casual impurities from bathers and barges, and on their arrival were, after a short subsidence in reservoirs, distributed without filtration to the public." In some cases the scanty distribution was from a stand-pipe in a court or alley, for a very short time of the day. In other cases the water was delivered into butts or cisterns. Their condition is thus described:-- "In inspecting the courts and alleys of the 'City,'" he wrote, "one constantly sees butts, for the reception of water, either public or in the open yards of houses, or sometimes in their cellars; and these butts, dirty, mouldering, and coverless; receiving soot and all other impurities from the air; absorbing stench from the adjacent cesspool; inviting filth from insects, vermin, sparrows, cats, and children; their contents often augmented through a rain-water pipe by the washings of the roof, and every hour becoming fustier and more offensive. Nothing can be less like what water should be than the fluid obtained under such circumstances." It is interesting to observe that the evils of the system of water supply by private companies were, even in the "City," so manifest that Dr. Simon expressed his opinion that the only satisfactory solution of the difficulty in connection therewith was the acquisition by the public authority of the control of the supply, and he urged the adoption of the principle of what is now denounced by some people as "municipal trading." In every practical sense the sale of water in London was a monopoly. "The individual customer," wrote Dr. Simon, "who is dissatisfied with his bargain can go to no other market; and however legitimate may be his claim to be supplied with this prime necessary of life at its cheapest rate, in the most efficient manner, and of the best possible quality, your Honourable Court (the Commissioners of Sewers) hitherto possesses no power to enforce it." In the Public Health Act of 1848 the principle had been recognised by Parliament so far as towns in the country were concerned--local Boards of Health being authorised to provide their district with such a supply of water as might be proper or sufficient, or to contract for such a supply. He urged that the City should obtain a similar power. "All the advantages which could possibly be gained by competition, together with many benefits which no competition could ensure, would thus be realised to the population under your charge." But that solution of the difficulty was more than half a century in advance of its accomplishment so far as either the "City" or "greater London" was concerned. As to the atmosphere in the "City," there seems to have been no limit to the pollutions thereof, all of which were injurious to the health of the public. Numerous noxious and offensive trades were carried on in the most crowded places. Directly and indirectly, slaughtering of animals in the "City" was prejudicial to the health of the population, and exercised a most injurious influence upon the district. The number of slaughter-houses registered and tolerated in the "City" in 1848 amounted to 138, and of these, in 58 cases, the slaughtering was carried out in the vaults and cellars.[40] And there were very many noxious and offensive trades in close dependence upon "the original nuisance" of the slaughter-house, and round about it, "the concomitant and still more grievous nuisances of gut-spinning, tripe-dressing, bone-boiling, tallow-melting, paunch-cooking, &c., &c." Certain it is that offensive businesses of these and other sorts were carried on by their owners with an absolute disregard to the comfort or health of the public. The matter was a difficult one to deal with, as any severe restrictions might destroy the trade or manufacture and take away from the people the employment which gave them the means of earning a livelihood. Furthermore, such restrictions were usually resented as an infraction of personal liberty. Dr. Simon forcibly and conclusively answered this contention. "It might," he wrote, "be an infraction of personal liberty to interfere with a proprietor's right to make offensive smells within the limits of his own tenement, and for his own separate inhalation, but surely it is a still greater infraction of personal liberty when the proprietor, entitled as he is to but the joint use of an atmosphere which is the common property of his neighbourhood, assumes what is equivalent to a sole possession of it, and claims the right of diffusing through it some nauseous effluvium which others, equally with himself, are thus obliged to inhale." Some improvement in this respect was rendered possible by the Act of 1851, which enacted that whatever trade or business might occasion noxious or offensive effluvia, or otherwise annoy the inhabitants of its neighbourhood, "shall" be required to employ the best known means for preventing or counteracting such annoyance. But the remedy scarcely appears to have been availed of or enforced, and "greater London" was, as usual, excluded from the Act. Another more constant pollution of the air was that resulting from intramural burial. "Overcrowding" in the "City" was not limited to the living; it extended even to the dead, and though the dead themselves had passed beyond any further possible harm from it, yet their overcrowding affected disastrously those they had left behind. Here the evils already described as existing in "greater London" existed also in acute form. Two thousand bodies or more were interred each year actually within the "City" area, and the burial grounds were densely packed. And "in all the larger parochial burying grounds, and in most others, the soil was saturated with animal matter undergoing slow decomposition." And the vaults beneath the churches were "in many instances similarly overloaded with materials of putrefaction, and the atmosphere which should have been kept pure and without admixture for the living, was hourly tainted with the foetid emanations of the dead...." In Dr. Simon's words:-- "Close beneath the feet of those who attend the services of their church there often lies an almost solid pile of decomposing human remains, heaped as high as the vaulting will permit, and generally but very partially coffined." The Metropolitan Burials Act of 1852 effected a great improvement in this respect by putting a term to the indefinite perpetuation of this horrible evil. It gave the Secretary of State power to prohibit further intramural burials, and it gave the "City," and other local authorities, the power to establish burial places beyond the boundaries of the metropolis. But, even when thus stopped, years had to elapse before the condition of intramural burial grounds and vaults would cease to vitiate the air around them.[41] The atmosphere of the "City," the air which people breathed, was thus vitiated in varying degrees of intensity by numerous and various abominations--the polluted Thames, defective sewerage and drainage, offensive trades, intramural interments. As regards the houses in which the people lived, these were crammed together--packed as closely together as builders' ingenuity could pack them--many of them combining every defect that houses could have, and so situated that ventilation was an impossibility. "In very many parts of the City you find a number of courts, probably with very narrow inlets, diverging from the open street in such close succession that their backs adjoin, with no intermediate space whatsoever. Consequently each row of houses has but a single row of windows facing the confined court, and thus there is no possibility of ventilation, either through the court generally or through the houses which compose it.... Houses so constructed as to be as perfectly a cul-de-sac out of the court as the court is a cul-de-sac out of the street."[42] And the climax of insanitary conditions was reached when these densely-packed houses were overcrowded by human beings. The process of converting dwelling-houses into warehouses, or business offices, or for trade or manufactures was in full swing--a constant force--and so the number of houses for people to live in became ever fewer. And the "tenement houses," in which the great bulk of the working classes lived, became more and more crowded; houses wherein "each holding or tenement, though very often consisting but of a single small room, receives its inmates without available restriction as to their sex or number, and without registration of the accommodation requisite for cleanliness, decency, and health." The Census of 1851 had shown an increase of over 4,200 in the population of the "City," and a diminution of nearly 900 houses. "Probably," wrote Dr. Simon, "for the most part it represents the continued influx of a poor population into localities undesirable for residence, and implies that habitations previously unwholesome by their overcrowdedness are now still more densely thronged by a squalid and sickly population.... "It is no uncommon thing, in a room twelve feet square or less, to find three or four families styed together (perhaps with infectious disease among them), filling the same space night and day--men, women, and children, in the promiscuous intercourse of cattle. Of these inmates it is nearly superfluous to observe that in all offices of nature they are gregarious and public; that every instinct of personal or sexual decency is stifled; that every nakedness of life is uncovered there.... Who can wonder at what becomes, physically and morally, of infants begotten and born in these bestial crowds?..." Of overcrowding or "pestilential heaping of human beings," this matter of "infinite importance," he wrote:-- "While it maintains physical filth that is indescribable, while it perpetuates fever and the allied disorders, while it creates mortality enough to mask the results of all your sanitary progress, its moral consequences are too dreadful to be detailed." Pursuing his masterly analysis of the sanitary condition of the people in the "City" and its causes, he wrote:-- "Last and not least among the influences prejudicial to health in the City, as elsewhere, must be reckoned the social condition of the working classes.... Often in discussion of sanitary subjects before your Honourable Court, the filthy, or slovenly, or improvident, or destructive, or intemperate, or dishonest habits of these classes are cited as an explanation of the inefficiency of measures designed for their advantage. It is constantly urged that to bring improved domestic arrangements within the reach of such persons is a waste and a folly. "It is unquestionable that in houses containing all the sanitary evils enumerated--undrained and waterless, and unventilated--there do dwell whole hordes of persons who struggle so little in self-defence against that which surrounds them that they may be considered almost indifferent to its existence, or almost acclimated to endure its continuance. "It is too true that among the lower classes there are swarms of men and women who have yet to learn that human beings should dwell differently from cattle--swarms to whom personal cleanliness is utterly unknown; swarms by whom delicacy and decency in their social relations are quite unconceived. "My sphere of duty lies within the City boundary. "I studiously refrain from instituting comparisons with other metropolitan localities. * * * * * "I feel the deepest conviction that no sanitary system can be adequate to the requirements of the time, or can cure those radical evils which infest the under framework of society, unless the importance be distinctly recognised and the duty manfully undertaken of improving the social condition of the poor.... "Who can wonder that the laws of society should at times be forgotten by those whom the eye of society habitually overlooks, and whom the heart of society often appears to discard? "To my duty it alone belongs, in such respects, to tell you where disease ravages the people under your charge, and wherefore; but while I lift the curtain to show you this--a curtain which propriety may gladly leave unraised--you cannot but see that side by side with pestilence there stalks a deadlier presence, blighting the moral existence of a rising population, rendering their hearts hopeless, their acts ruffianly and incestuous, and scattering, while Society averts her eyes, the retributive seeds of increase for crime, turbulence, and pauperism." And what was the physical result of this state of living? "In some spots in the City you would see houses, courts, and streets, where the habitual proportion of deaths is far beyond the heaviest pestilence rate known for any metropolitan district aggregately--localities where the habitual rate of death is more appalling than any such averages can enable you to conceive. "Among their dense population it is rare to see any other appearance than that of squalid sickness and misery, and the children who are reproduced with the fertility of a rabbit warren perish in early infancy. "The diseases of these localities are well marked. Scrofula more or less completely blights all that are born ... often prolonging itself as a hereditary curse in the misbegotten offspring of those who, under such unnatural conditions, attain to maturity and procreation. "Typhus prevails as a habitual pestilence. "The death rate during the last five years has been at the rate of about twenty-four per 1,000 per annum. "The City of London appears peculiarly fatal to infant life. "Of the 15,597 persons who died within your jurisdiction in the five years 1847-8 to 1852-3, nearly three-eighths died in the first five years of life." To his employers he mostly appeals. He hopes that the statements in his reports may suffice to convince them of the necessity which exists in the "City" of London for some effectual and permanent sanitary organisation. "For the metropolis generally there is hitherto no sanitary law such as you possess for your territory." He pointed out that-- "Inspection of the most constant, most searching, most intelligent, and most trustworthy kind is that in which the provisional management of our said affairs must essentially consist. * * * * * "The committee was given power by the Act for the amendment or removal of houses presenting aggravated structural faults. "Wherever your Medical Officer of Health may certify to you that any house or building is permanently unwholesome and unfit for human habitation, you are empowered to require of the owner (or in his neglect yourselves to undertake) the execution of whatever works may be requisite for rendering the house habitable with security to life." And he urged that:-- "The principle might be distinctly recognised that the City will not tolerate within its municipal jurisdiction the continuance of houses absolutely incompatible with healthy habitation. "Here terminates my statement of the powers now vested in you for the maintenance of the public health. "Authority so complete for this noble purpose has never before been delegated to any municipal body in the country. "If the deliberate promises of Science be not an empty delusion, it is practicable to reduce human mortality within your jurisdiction to nearly the half of the present prevalence." The most valuable and weighty of all his conclusions was that affixing the responsibility for the existing mass of insanitation and consequent misery. With a courage worthy of all admiration he did not hesitate, regardless of the consequences to himself, to fix the responsibility and blame where they were due. "The fact is that, except against wilful violence, life is very little cared for by the law." Of Parliament he wrote:-- "Fragments of legislation there are, indeed, in all directions; enough to establish precedents, enough to testify some half-conscious possession of a principle; but for usefulness little beyond this. The statutes tell that now and then there has reached to high places the wail of physical suffering. They tell that our law makers, to the tether of a very scanty knowledge, have, not unwillingly, moved to the redress of some clamorous wrong.... But ... their insufficiencies constitute a national scandal, ... something not far removed from a national sin.... "The landlord must be held responsible for the decent and wholesome condition of his property, and for such conduct of his tenants as will maintain that condition." The clear, precise, and unqualified enunciation of such a principle must have given a shock to many of the members of the governing authority of the "City," and excited their wrath, the more especially as it was so absolutely sound and true. "The death of a child by smallpox," he went on to say, "would in most instances call for a verdict of 'homicide by omission' against the parent who had neglected daily opportunities of giving it immunity from that disease by the simple process of vaccination; the death of an adult by typhus would commonly justify still stronger condemnation (though with more difficulty of fixing and proportioning the particular responsibility) against those who ignore the duties of property, and who knowingly let for the occupation of the poor dwellings unfit even for brute tenants, dwellings absolutely incompatible with health." And then he proceeds to explain and justify and enlarge upon his assertion of the responsibility of the landlord. "There are forty-five miles of sewerage in your jurisdiction, ready to receive the streams of private drainage, and leaving the owners of house property no excuse for the non-performance of necessary works.... But ... the intentions of your Court, and the industry of its officers, have been in great measure frustrated by the passive resistance of landlords. Delays and subterfuges have been had recourse to in order to avoid compliance with the injunctions of the Commission." In his evidence before the Royal Commission of 1853-4 he said:-- "The poorer house property of the City is very often in the hands of wealthy people who have only the most general notion of its whereabouts, have perhaps never visited the place for which they receive rent, and in short know their property only through their agents. "Instances have come to my knowledge of the very worst description of property being thus held ignorantly and carelessly by wealthy persons. Often for years we can get at no representative of the property other than the agent or collector who receives the weekly rent for some anonymous employer." In his third Report to the Commissioners of Sewers he wrote:-- "It is easy to foresee the numerous obstacles which interested persons will set before you to delay the accomplishment of your great task. "When your orders are addressed to some owner of objectionable property--of some property which is a constant source of nuisance, or disease, or death; when you would force one person to refrain from tainting the general atmosphere with results of an offensive occupation; when you would oblige another to see that his tenantry are better housed than cattle, and that, while he takes rent for lodging, he shall not give fever as an equivalent--amid these proceedings you will be reminded of the 'rights of property' and of 'an Englishman's inviolable claim to do as he will with his own.' "Permit me to remind you that your law makes full recognition of these principles and that the cases in which sophistical appeal will often be made to them are exactly those which are most completely condemned by a full and fair application of the principles adverted to. With private affairs you interfere only when they become of public import, with private liberty only when it becomes a public encroachment. The factory chimney that eclipses the light of heaven with unbroken clouds of smoke, the melting house that nauseates an entire parish, the slaughter-house that forms round itself a circle of dangerous disease--these surely are not private but _public_ affairs. "And how much more justly may the neighbour appeal to you against each such nuisance as an interference with his privacy; against the smoke, the stink, the fever that bursts through each inlet of his dwelling, intrudes on him at every hour, disturbs the enjoyment and shortens the duration of his life. And for the rights of property--they are not only pecuniary. Life, too, is a great property, and your Act (of 1851) asserts its rights." "The landlord of some overthronged lodging-house complains that to reduce the number of his tenantry, to lay on water, to erect privies, or to execute some other indispensable sanitary work, would diminish his rental--in the spirit of your Act it is held a sufficient reply that human life is at stake--and that a landlord in his dealings with the ignorant and indefensive poor cannot be suffered to estimate them at the value of cattle, to associate them in worse than bestial habits, or let to them for hire at however moderate a rent the certain occasions of suffering and death." "Seeing the punctuality with which weekly visitation is made for the collection of rents in these wretched dwellings it would not be unreasonable to insist on some regulations for the clean and wholesome condition of his premises, water supply, and scavenging, &c." Such a regulation would "render it indispensable to the landlord of such holdings to promote cleanly and decent habits among his tenants--even to obtain security for their good behaviour." The picture thus presented of the sanitary condition of the people residing in the "City" about the middle of the last century is--it must be acknowledged--a terrible one; but it rests upon unimpeachable testimony. The very grave and serious conclusion, however, follows from it--that if the evils were thus terrible in the "City," with a comparatively small population, only a little more than a twentieth of that of the metropolis, and where there was a local government with wide powers for dealing with matters affecting the public health--how infinitely more serious was the condition of things in the "greater London" with its huge population, and where there was practically no local government, and no punitive law for insanitary misdoings and crimes. In some degree, the evils the people suffered under were of their own making, though many excuses can be urged in extenuation. In some degree, too, the people were unquestionably the victims of circumstances. But in the main, they were the victims of other people's iniquities. It was those circumstances which the Government should have altered, or, at any rate, have endeavoured to control or modify--it was the unlimited power to do evil that the Government should have checked and curbed; but "greater London" was virtually left outside the pale of remedial legislative treatment by Parliament. CHAPTER I, PART IV The great cholera epidemic of 1848-9 had deeply stirred public feeling in London. It had destroyed 14,600 people (and diarrhoea, its satellite, had destroyed many thousands more), and it had been "accompanied by an amount of sickness and physical misery beyond computation." But even all its horrors, and all the proofs it afforded of the desperately insanitary condition of the masses in the metropolis, were not sufficient to induce the Government to depart from its policy of neglect, or to wring from Parliament measures which would lay the basis for the alleviation of the sufferings of the working population of the metropolis, or which would remove even a small part of the evils which fell so heavily upon those least able to sustain them, and least able to remove them. The health of London was becoming worse every year. The number of persons dying from preventable disease had been steadily increasing. One gleam of hope there was, however. An increasing number of persons were becoming interested in the health of the people, and were awakening to the gravity of the subject, and to the public discredit and inhuman scandal of the existing condition of things--an awakening of interest which, in February, 1850, reached to the extent of a public meeting. The Bishop of London presided, and the meeting was rendered the more remarkable by speeches from Lord Ashley, then actively pressing sanitary and social questions forward, and by Charles Dickens. Lord Ashley said:-- "The condition of the metropolis, in a sanitary point of view, was not only perilous to those who resided in it, but it was an absolute disgrace to the century in which they lived. It was a disgrace to their high-sounding professions of civilisation and morality. They were surrounded by every noxious influence--they were exposed to every deadly pestilence.... The water they drank, the air they breathed, the surface they walked on, and the ground beneath the surface, all were tainted and rife with the seeds of disease and death.... "Let them look at another abomination--the existence of putrefying corpses in graveyards and in vaults amidst the habitations of the living--an abomination discountenanced by all the civilisation of modern days, as it was by that of the ancient days--the practice of intramural interments. "Could anything be worse than the graveyards of the metropolis? Under a surface of ground not amounting to 250 acres there had been interred within thirty years in the metropolis far more than 1,500,000 human beings. What must be the condition of the atmosphere affected by the exhalations from that surface?... "And what were the financial and social consequences of allowing such a state of things to exist? "At least one-third of the pauperism of the country arose from the defective sanitary condition of large multitudes of the people...." Charles Dickens said:-- "The object of the resolution he was proposing was to bring the Metropolis within the provisions of the Public Health Act, most absurdly and monstrously excluded from its operation.... Infancy was made stunted, ugly, and full of pain; maturity made old; and old age imbecile. "He knew of many places in London unsurpassed in the accumulated horrors of their long neglect by the dirtiest old spots in the dirtiest old towns under the worst old governments in Europe. "The principal objectors to the improvements proposed were divided into two classes. "The first consisted of the owners of small tenements, men who pushed themselves to the front of Boards of Guardians and parish Vestries, and were clamorous about the rating of their property; the other class was composed of gentlemen, more independent and less selfish, who had a weak leaning towards self-government. The first class generally proceeded upon the supposition that the compulsory improvement of their property when exceedingly defective would be very expensive.... "No one," he went on to say, "who had any knowledge of the poor could fail to be deeply affected by their patience and their sympathy with one another--by the beautiful alacrity with which they helped each other in toil, in the day of suffering, in the hour of death. "It hardly ever happened that any case of extreme protracted destitution found its way into the public prints without our reading at the same time of some ragged Samaritan sharing his last loaf or spending his last penny to relieve the poor miserable in the room upstairs or in the cellar underground. It was to develop in the poor people the virtue which nothing could eradicate, to raise them in the social scale as they should be raised, to lift them from a condition into which they did not allow their beast to sink, ... to cleanse the foul air for the passage of Christianity and education throughout the land, that the meeting was assembled. The object of their assembly was simply to help to set that right which was wrong before God and before man." The realisation of this object, noble as it was, was not easily attainable. The Vicar of St. Martin-in-the-Fields said that "the difficulty of legislation in these matters was to hit the medium between the rights of property and the rights of humanity." He might have added, with truth, that the difficulty had so far been met by sacrificing the rights of humanity to the rights of property. Lord Ashley had pointed out that they "had to contend with ignorance, indifference, selfishness, and interest;" or as Lord Robert Grosvenor more vigorously expressed it, in a phrase which should live in history as giving the key to the mystery of the slow sanitary evolution of this great city, they had to contend against "vested interests in filth and dirt." One thing was already absolutely clear, that it was hopeless to expect anything from the spontaneous action of land-owners or house-owners. "They knew it was quite impossible," said the Bishop of Chichester, "to bring the owners of even one small court or alley, much less the owners or occupiers of any large district, to concur in any measure for the general good of their particular locality." The fact was that nothing but the imperative directions of the law would secure the removal of evils or curtail the practice of infamous abuses--and even when the law was enacted for their remedy, nothing but its rigorous enforcement with adequate penalties would make it effective. As the result of the meeting, a deputation waited on Lord John Russell, the then Prime Minister. His reply was not encouraging. "In this city," he said, "there is very naturally and properly great jealousy of any interference either with local rights or individual will and freedom from control." That great jealousy proved to be so powerful that nothing was attempted by the Government except an abortive effort to deal with the loathsome and insanitary evils of intramural interments where vested interests were neither powerful nor loud voiced. The Act was so defective that it never came into operation, and two more years elapsed before the Government again essayed to deal with the subject. And in the meanwhile that most horrible evil was permitted to work its will upon the dwellers in the metropolis. To the enthusiasm of an individual, and not of the Government, was due the first effective attempt to grapple with one of the widespread, deep-seated evils which were working such havoc among the people. The most disastrous and vicious forms of overcrowding were at the time to be found in the so-called Common Lodging Houses--the sink of insanitary abominations. These were the temporary and casual abodes of the dregs of London humanity--of the tramps, and the unfortunates, and the mendicants and criminals, male and female--when they could afford the penny or pence to pay for their night's lodging. In most cases these houses were low brothels and hotbeds of crime and moral degeneracy, their foul and filthy condition making them great sources and propagators of contagious and loathsome diseases. In the "City" the authorities had power to regulate and control them. Not so, however, in the metropolis. There, no one had any authority in the matter, nor was there any authority for any one to have. Lord Ashley, truly discerning that the one and only way of dealing with this evil was by regulation and constraint, introduced a Bill[43] and actually carried it through Parliament, and two years later got another Act[44] embodying amendments which made it more effective. What the Common Lodging House owner or keeper--anxious to secure the utmost profits from his property and regardless of all consequences to others--would not do, he was, by those Acts, made to do. The houses which he devoted to this purpose, solely for his own profit, were placed under the control and inspection of the police, and had to be registered as "Common Lodging Houses." Overcrowding in them was checked by restricting the number of inmates who might be in each room; regulations (confirmed by a Secretary of State) were made, and steadily enforced, for the separation of the sexes; for the proper cleansing of the houses; and for compelling the keeper to give immediate notice of fever or any contagious or infectious disease occurring therein. The accumulation of refuse was to be prevented, and provision had to be made for adequate sanitary accommodation, for better drainage, and for sufficient water supply. A very brief experience showed that great practical benefits resulted from thus regulating these houses, and the amount of sickness and mortality in them became astonishingly small, considering the character of their inmates and the localities where they were situated; and inasmuch as the number of such houses was nearly 5,000, and the population in them about 80,000, the benefit was a really substantial one. How obstinate and pertinacious was the opposition of house-owners, or middlemen, to regulation and supervision of any kind is illustrated by a case reported by the Assistant Police Commissioner.[45] The owner of certain premises in St. Giles' had been often applied to, without success, to remedy some gross sanitary defects therein which had resulted in the loss of life by fever. Brought to bay at last, at the Police Court, and ordered to remedy the evil, he said that he was willing to do all in his power to abate the nuisance ... but, "he thought he ought not to be dictated to as to the way his property was to be managed." His words embodied the predominant spirit of the time. "There are," wrote the Assistant Police Commissioner in commenting upon this case, "owners of property whom nothing but the strong arm of the law can move." Unfortunately the Act did not go far enough. Single rooms occupied by families did not come within its scope. They constituted an enormous proportion of the habitations of the people, and they were allowed to continue the prolific cause of sanitary evils and of physical and moral degradation. Limited in its scope though the Act was, it afforded nevertheless one great object lesson--the lesson which since that time has been consistently preached by all who had actual experience as regarded the sanitary condition of the people of London--the lesson that the worst of the sanitary and social evils could only be effectually grappled with, on the one side by the supervision and regulation and constant inspection of the houses in which the poorer classes lived, and upon the other side by insistent compulsion of house-owners to maintain a certain standard of sanitation and cleanliness in those houses. That, however, was a course which Parliament for many years did not think it desirable to adopt, and which, when adopted in a tentative and half-hearted sort of way, suffered the usual fate of sanitary legislation--that of being neglected, opposed, evaded, or thwarted by land-owners, house-owners, middlemen, and by hostile local authorities. Lord Ashley also originated and succeeded in the same Session in obtaining from Parliament another Act of notable interest, namely, "The Labouring Classes Lodging Houses Act,"[46] which aimed at increasing the quantity of houses for working men by facilitating the establishment of well-ordered houses for such persons. It gave power to vestries to adopt the Act, and thereafter to purchase or lease land, and to erect houses thereon for the working classes, and to borrow money on the security of the rates for this purpose. In advocating his plan in the House of Commons he enforced the importance of the reform. He said:-- "Until the domiciliary condition of the working classes were Christianised (he could use no less forcible a term) all hope of moral or social improvement was utterly vain. Though not the sole, it was one of the prime sources of the evils that beset their condition; it generated disease, ruined whole families by the intemperance it promoted, cut off or crippled thousands in the vigour of life, and filled the workhouses with widows and orphans."[47] He specially mentioned one of the objections urged to this proposal for the construction of better houses--an objection which since then has invariably found expression when any amelioration of the housing of the working classes has been proposed to be done by a public authority. "It was said those matters ought to be left to private speculation. He should much object to that. Private speculation was very much confined to the construction of the smallest houses, and of the lowest possible description, because it was out of these the most inordinate profits could be made. Private speculation was almost entirely in that direction." He might have added that "private speculation" had hitherto had a completely free field in the sphere of housing, with all the evil results visible before them, and that it had aggravated and intensified the evil instead of removing or mitigating it. The debate in Parliament was interesting, as it drew from the Home Secretary an expression of the Government view of the situation. "After all," said Sir G. Grey, "it was not to the Government, it was rather to the efforts of individuals, and associations of individuals, that they must look for real and general improvement among the great body of the people. All that the Government could do was to remove obstacles in the way, and to present facilities by modifications of the law more useful than direct legislation."[48] An "association of individuals" had already been formed--"The Society for Improving the Condition of the Labouring Classes"--and work of this class had to the extent of over £20,000 been carried out by it. The new piles of buildings erected were eagerly availed of by people of the working classes, and in a sanitary point of view they at once demonstrated their very satisfactory immunity from disease. The Act, however, being a voluntary or adoptive Act, was not likely to be adopted and put into force by those by whom a certain amount of financial liability might be incurred as the result. As a matter of fact it never was put in force by any vestry, and it remained a dead letter. It was memorable, however, as embodying for the first time in legislation the idea that the housing of the people was a public matter with which a public authority might properly concern itself, even to the extent of competing with private enterprise, and pledging the rates as security. The supply of water to London, both as regarded quality and quantity, had, since the epidemic of 1848-9, been engaging the attention of Committees of Parliament, the belief that the epidemic of cholera had been increased and propagated by the filthy and impure water having given an impetus to the demand for ameliorative measures. In 1852 an Act[49] was passed by which the companies taking their water from the Thames were required to remove their intakes to some place above Teddington Lock, where the tide would not affect it, and the sewage of London would not be intermixed with it. This was a considerable step in the right direction, for though the river above Teddington Lock received the sewage of many large towns and villages, it was at least free from contamination by the sewage and filth of the metropolis. Other improvements were also enacted. Reservoirs within a certain distance of St. Paul's Cathedral were to be covered in, and all water intended for domestic use was to be filtered before being supplied to the consumer; and provision was also made for a constant supply of water by every company within five years after the passing of the Act. But the companies were given five years within which to effect the removal of the intake from the foulest parts of the river to above tidal reach--and thus for a wholly unnecessary term the cause which had wrought such havoc among the people was permitted to continue its disastrous effects. CHAPTER I, PART V The epidemic of cholera in 1849 had failed to produce any lasting effect upon the local authorities or the public opinion of London, and the nemesis of renewed neglect and indifference was once again to fall upon the metropolis. Cholera had kept hovering about. In 1852 a number of suspicious cases occurred in various districts. In 1853 suspicion passed into certainty, and the disease assumed the form of an epidemic--as many as 102 deaths from it occurring in the first week in November. Then it died down. In the following year it again appeared in more severe epidemic form over the whole of the metropolis. On one day--September 4th--there were 459 deaths from it. The climax was reached in the second week in September (almost the identical date on which the epidemic of 1849 occasioned the highest mortality) and there were 2,050 deaths from it.[50] In that one month 6,160 persons died from it, and from July 1st to December 16th, when it at last disappeared, there was a total mortality from cholera alone of 10,675 persons. Every conclusion which had been arrived at as regards the disease during the previous epidemics was confirmed by this third great epidemic, and many previous theories passed into the region of proved facts. Cholera was once more proved to be a filth disease, and in the main confined to filthy localities. The more defective and abominable the methods of drainage, the larger the number of victims. The filthier and more contaminated the water supplied for drinking and household purposes, the more numerous the cases, and the more virulent the disease. This was demonstrated beyond further question. The mortality on the south side of the Thames was above threefold what it was on the north side; and both as regarded water supply and drainage, South London was in a worse sanitary state than North London. The water consumed by the population there was generally worse than that on the north. Lying lower, too, the drainage had less chance of being conveyed away, and in the miles upon miles of open sewer ditches it was left to rot and putrefy in close propinquity to the houses and to poison the air. And the most remarkable proof was afforded by the effects of the consumption of water taken from different sources. In 1849 both the Lambeth and the Southwark Water Companies pumped the water they supplied to their customers from the very foulest part of the Thames--near Hungerford Bridge--with equally disastrous results. In the course of the following years the Lambeth Company removed its source of supply to a part of the river above Teddington Lock--the Southwark Company, however, went on as before. In the epidemic of 1854 the inhabitants of houses supplied with the water by the latter company suffered eight times as much as those supplied by the better water of the Lambeth Company, whilst the number of persons who died in the houses where the impure was drunk was three and a half times greater than that in the houses where the purer water was supplied. Of all the conclusions arrived at by those who had been engaged in combating the disease during this epidemic, the most important was that where cholera had become localised it was connected with obvious removable causes, and was in fact a preventable disease. Most unfortunately, and reprehensibly, many of those who could have done most to prevent it failed signally to take action. Once more, and this time in an accentuated degree, the widespread prevalence of the disease, and the frightful mortality, were distinctly due to the inertia, laxity, or deliberate neglect of those local authorities who by law were charged with the duty of cleansing localities and removing some of the causes of disease. The General Board of Health, of which Sir Benjamin Hall was President, did all that it could do. Medical inspectors were appointed by it to visit all the parishes most severely affected; and the fullest and minutest instructions were issued to the Boards of Guardians as to the course they should pursue, and the action they should take. But several of the Boards of Guardians took no notice of the instructions sent them; others sent unsatisfactory replies. In not one of the parishes in which the epidemic was most fatal was the preventive machinery, sanitary and medical, organised in accordance with the instructions; and although some parishes did more than others, yet, speaking generally, the administration of the sanitary and medical relief measures by the Boards of Guardians was inefficient in character and extent, except in some of the larger and more healthy parishes where they were least wanted.[51] At Rotherhithe, the Guardians declined to proceed with the removal of nuisances as entailing a useless expense. At Deptford, where cholera was at the worst, no Inspector of Nuisances was appointed, even for the emergency. Nor did Greenwich, where it was also bad, appoint one. In Bethnal Green, where memories ought to have been bitter, the authorities practically did nothing, although promising almost everything. In Lambeth, the parish was left without any adequate protection against the epidemic; and it was only after urgent remonstrances by the Medical Inspector, and after his threatening to place himself in communication with the coroner in any cases of death occurring in localities where the proper cleansing measures had not been carried out, that he succeeded in obtaining the adoption of measures even to a limited extent.[52] In Clerkenwell, the Guardians utterly disregarded the recommendations of the Board of Health, and from the first there was an openly expressed determination not in any way to be interfered with by the Board. And the disastrous state of affairs was, that the Nuisances, &c., Removal Acts gave the Board of Health no power to enforce upon the Guardians the execution of the regulations made. The whole sanitary administration--so far as any existed in London--was in a state of chaos, and the various local authorities were able, with absolute impunity to themselves, to ignore and even defy the General Board of Health. Of these authorities, as has been already said, there was a multiplicity, and it was no infrequent occurrence to find the administrative authority of some of them in the hands of parties directly interested in the continuance of the existing state of matters, evil though those were. In fact, the "vested interests in filth and dirt" were a power in local administration in "greater London," and the practical result was that the great majority of the population of the metropolis were left without any protection against the ravages of epidemic or other preventable diseases. The indifference of Parliament, moreover, had left London without any effective or systematic sanitary supervision; and in no part of it, except the "City," was there any officer conversant with the effect of local influences on the health of the population, or who could advise as to the sanitary measures which should be adopted. The Board of Health having had it brought home to them that, with their limited powers, they were unable to introduce order into this chaos, or to enforce even the most elementary precautions against the spread of the disease, their President addressed a letter on the 29th of January, 1855, to Lord Palmerston, the then Home Secretary (and a few weeks later the Prime Minister), in which he set forth the exact state of affairs as ascertained by his own observation and by the experience of some of the best and most well-informed medical men in London. In this letter he summarised the main causes of the insanitary condition in which the people of London were forced to live. He wrote:-- "The evidence on the localising conditions of cholera given in the report of Dr. Sutherland points to the following as among the more prominent of the removable causes of zymotic disease. "Open ditches as sewers. Want of sewers. Badly constructed sewers accumulating deposits and generating sewer gases. "The pollution of the atmosphere in streets and within houses from untrapped drains, from sewer ventilating openings in streets, and from cesspools, whereby the air was contaminated and the sub-soil saturated with filth. "Want of house drainage. "The absence of any organised daily system of cleansing, and the consequent retention of house refuse in or near dwellings. "Bad water, badly distributed. Unwholesome trades. Unwholesome vapours exhaled from the Thames. Cellar habitations. "Neighbourhoods, the houses of which are closely packed together with narrow overcrowded streets, alleys and courts so constructed as to prevent ventilation. Houses structurally defective, filthy, unventilated, and overcrowded--absolutely unfit for human habitation." And several others which need not be here enumerated. "Lastly, and applying to all these--multiplicity of local authorities, and the want of sufficient powers in such authorities to deal with these evils." "Great as these evils are in London," he wrote, "... there is not one among them that cannot be remedied if proper steps be taken. "The first and most obvious necessity in the metropolis is to sweep away the existing chaos of local jurisdiction." Included in that chaos were two Boards with great powers of taxation over which the ratepayers had no control.[53] One of them consisted of the persons appointed under the Metropolitan Building Act of 1844, who, at a cost of £24,000 a year, entirely neglected their work. The other, the Commissioners of Sewers, who had demonstrated their utter incapacity, the cost of whose establishment was "something extraordinary," and who in the five years of their existence had only attempted one great work--"the Victoria Sewer"--which cost a large sum, and which not many years after fell to ruins. The great epidemic of cholera, its attendant panic, its gruesome accompaniments, its revelation of the actual condition of the masses, and of the rottenness of the local authorities, and the growing outcry against the iniquity of such a state of things in a civilised and Christian country, brought matters to a head. The state of the Thames had also become a greater danger than ever to the community, and a more unbearable nuisance. As described by _The Lancet_ in July, 1855:-- "The waters are swollen with the feculence of the myriads of living beings that dwell upon the banks, and with the waste of every manufacture that is too foul for utilisation. Wheresoever we go, whatsoever we eat or drink within the circle of London, we find tainted with the Thames.... No one having eyes, nose, or taste, can look upon the Thames and not be convinced that its waters are, year by year, and day by day, getting fouler and more pestilential.... The abominations, the corruptions we pour into the Thames, are not, as some falsely say, carried away into the sea. The sea rejects the loathsome tribute, and heaves it back again with every flow. Here, in the heart of the doomed city, it accumulates and destroys." And the Government, compelled at last by the force of events to take some steps for the better sanitary government of the metropolis, and for remedying some of the evils the people suffered under, decided on taking action. Acknowledging the necessity for giving local government to "greater London"--the "City" of course already had its own--it proposed the creation of a central authority which should deal with certain matters affecting London as a whole, and local authorities which should deal with local affairs affecting their own localities. And, in 1855, a group of measures giving effect to these views, and containing also what amounted to a sanitary code similar to that in the Public Health Act already for years in force in England, was passed by Parliament. Those most important measures marked the end of one great period in the sanitary history of this great metropolis. Of that period it is to be said that there is none in the history of London in which less regard was shown for the condition of the great mass of the inhabitants of the metropolis; no period when the spirit of commercialism recked so little of the physical condition and circumstances of those upon whom, after all, it depended; no period when the rights of property were so untrammelled by any consideration for the welfare of human flesh and blood; no period when private individuals not alone so strained, for their own advantage or aggrandisement, the utmost rights the law allowed them, but far exceeded those rights, and too often successfully filched from the public that to which the law gave them no right. Never had there been a time in which the rights of property had been more insisted upon and exercised. Never a time in which land-owners, house-owners, and builders did as freely as they liked with their own, regardless of the injury or damage inflicted upon others; nor in which manufacturers carried on, without interference, trades for their own benefit, which were not merely offensive, but actually death-dealing to their neighbours. And throughout this period the people in their daily lives and circumstances were absolutely unprotected by any public authority, or by any local governing body. There was no one to help them to contend against the extremest exercise of real or even assumed rights. In this period London, the metropolis, had grown up, and had not merely been permitted by the Government and the Legislature to grow up practically without government, guidance, supervision, or restraint, but it had been absolutely denied any system of local government, and so been denied all provision for the sanitary needs of the community. In 1835 a large and liberal measure of municipal self-government was given to all the cities and towns and municipalities large and small of England and Wales--many of them not a tithe so populous as the great parishes of London--and a governing body, elected by the ratepayers, and with almost all the essential powers of local government, was instituted in each. But the Municipal Corporations Act expressly excluded the great towns which surrounded the walls of the "City" and which constituted the metropolis, and the law continued to recognise them only as rural parishes. Twelve years later, namely in 1847, the Towns Improvement Act was passed, by which towns of much smaller size were given facilities for obtaining considerable powers of local government. By it general sanitary provisions were framed, which, with the sanction of Parliament, might be applied in any town for the management by the local authorities of the supply of water, of drainage, of the paving, cleansing, and lighting of the streets, and the prevention of fires; and for the regulation of buildings, of slaughter-houses, of public baths, and of the interment of the dead. But even this more limited but still liberal system of local government was not extended to London, and once more the metropolis was excluded. The "City" did not wish to extend its own borders, and the authorities of the "City" viewed with dislike the idea of the creation at their very gates of local bodies which might develop into formidable rivals. And so "greater London" was left by successive governments and by Parliament to scramble along as best she could, and to suffer. And just as there was no local government so were there practically no laws safeguarding the sanitary condition of the people except the temporary and imperfect ones provided by the Nuisances Removal and Diseases Prevention Acts of 1848, and such very limited protection as the common law afforded. The Public Health Act of 1848--a sanitary code in itself--was an Act for England and Wales alone. The benefits it conferred were refused to London; and, as a consequence, the masses of her people were doomed to continue in circumstances of the utmost misery; year by year tens of thousands of her citizens were sent to an unnecessarily early death, and ten times their number were made to undergo diseases which even then were recognised as preventable. And all the time that she was thus left without a local government, without any permanent sanitary laws, other forces were at work inflicting ever-widening evil, and intensifying already existing evils. The population had increased by leaps and bounds, and the increasing trade of London had brought great numbers of workmen to the metropolis. The necessity for offices and warehouses had led to the substitution of such houses for houses previously used as residences. And so the growing population was forced to herd ever closer together, houses were packed thicker and thicker, and, in the central districts, every available spot of ground was built upon. And the overcrowding of human beings in those houses, and all the attendant ills, increased countless-fold. And the result was unparalleled, indescribable, unspeakable misery of the industrial and working classes, and of the lower and poorer orders. Not merely years, but generations of neglect and indifference on the part of the governing classes had multiplied and intensified in London every evil to which the poorer classes of a nation are liable. For long the great process of social and economic change at work in "greater London," and all that it entailed, was let go its own way--a way which, in default of the regulation and the alleviation a government should have given it, was beset with creakings and groanings like those of some badly constructed piece of machinery; only instead of machinery, inanimate and insensitive, they were the groanings, the agonies, of suffering thousands and tens of thousands of sick and perishing people, sinking annually into the abyss. All through the earlier half of the nineteenth century, in fact, London, the great metropolis, was left to evolve itself so far as regarded the public health and sanitary condition of the people. The tremendous import of such deliberate inaction by Parliament, and by successive Governments, is even now only partly comprehended. But the nemesis has been truly a terrible one. The injury wrought was in many ways irreparable, and we are still reaping the crop of evil sown by such seed--are still far from the end of the appalling consequences such a disastrous policy has entailed. FOOTNOTES: [1] See Parliamentary Papers, 1837-8, vol. xxviii. and P.P. 1839, vol. xx. p. 106, Dr. S. Smith. [2] 1840. P.P., vol. xi. p. 13. [3] Commission for inquiring into the state of large towns and populous districts, 1844. [4] Dr. Southwood Smith, P.P. 1845, vol. xviii. [5] Royal Commission, 1853-4, p. xii. [6] The Metropolitan Paving Act, 57 George III. cap. 29. [7] See Report of Vestry, 1856-7. [8] See Special Report of the Vestry, 1889, p. 208. [9] Report of Commission of 1845. [10] J. Phillips, p. 63, Metropolitan Sewers Commission, 1847. [11] See P.P. 1854-5, vol. liii. p. 249, &c. [12] Report of Medical Officer of Health for Clerkenwell, 1856. [13] See Report of Medical Officer of Health for St. Giles'. [14] Report of General Board of Health, 1850. [15] Report of Select Committee of the House of Commons, P.P. 1838, vol. xxviii. [16] 38 George III. cap. 40. [17] An opening only a foot square cost an additional 8s. 3d. tax per annum. [18] 1843, Commissioners on State of Towns. Evidence of W. E. Hickson, p. 436. [19] Select Committee, 1840. Evidence of J. Pennethorne, p. 166. [20] P.P. 1854, vol. xlv. p. 2. In part of the parish of St. Marylebone only there were 1,132 underground or cellar dwellings. [21] See Hansard, vol. cxv. 1851 (Lord Ashley's speech). [22] P.P. 1850, vol. xxi. p. 179 (Dr. Grainger). [23] P.P. 1850, vol. xxi. [24] Dr. T. Lynch, Medical Officer of West London Union (Holborn). [25] P.P. 1849-50, vol. xxi. [26] Hansard, 1840, vol. liii. p. 1110. [27] 3 and 4 Vic. cap. 29. [28] Expenses to be charged upon Borough Fund, and receipts to be paid into same. [29] 9 and 10 Vic. cap. 96. [30] 11 and 12 Vic. cap. 112. [31] P.P. 1850, vol. xxi. p. 4. [32] Metropolitan Sanitary Commission, 1848, 2nd Report. [33] Hansard, 1848, vol. xcvi. p. 392. [34] "Vested rights in crowded houses, deadly stenches, putrid water, foggy courts, and cesspools." See "Health by Act of Parliament," _Household Words_, 1850, vol. i. [35] P.P. 1850, vol. xxi. p. 42. [36] P.P. 1850, vol. xxi. p. 110. [37] In London in 1832-3 (population 1,682,000), the attacks were 14,144, the deaths were 6,729. 1848-9 (population 2,206,000), the attacks were about 30,000, the deaths about 14,600, so that in the last epidemic the deaths were more numerous than the attacks in 1832-3, whilst the attacks were more than double. [38] Dr. Grainger, P.P. 1849-50, vol. xxi. [39] P.P. 1850, vol. xxi. p. 147. [40] This was rendered illegal by the amended City Sewers Act of 1851. [41] See P.P. 1854-5, vol. x., General Report of Medical Council. [42] Simon, 1st Report, 1849. [43] 14 and 15 Vic. cap. 28. [44] 16 and 17 Vic. cap. 41. [45] P.P. 1854, vol. xxxv. p. 7. [46] 14 and 15 Vic. cap. 34, 1851. [47] See Hansard, 1851, vol. cxv. [48] Ibid. [49] "The Metropolis Water Act, 1852," 15 and 16 Vic. cap. 84. [50] See P.P. 1854, vol. xlv. p. 22. [51] See P.P. 1854-5, vol. xlv., Reports of General Board of Health. [52] Ibid. [53] See speech of Sir B. Hall in 1885 in House of Commons, Hansard, vol. cxxxvii. p. 715. CHAPTER II 1855-1860 THE Act "for the better Local Management of the Metropolis"[54] which was passed by Parliament in 1855 was the turning point in the sanitary history and evolution of London. It put a term to the chaos of local government in "greater London" and swept away the three hundred trumpery and petty existing local governing bodies. It created a legally recognisable metropolis by defining its component parts and boundaries. It established a definite system of local representative government in that metropolis for the administration of its local affairs. It conferred upon the new authorities not only the powers vaguely possessed and imperfectly, if at all, acted on by their predecessors, but a considerable number of new ones. It laid the basis of an organisation for the sanitary supervision of the inhabitants of each parish of greater London. And with the object of making provision for the effective treatment of some of the numerous matters affecting London as a whole--matters of a general and not of a local character--with which smaller local authorities could not possibly deal, and with the further object of securing a certain uniformity of administration by the new local authorities, it founded a central governing body for the metropolis. Simultaneously Parliament passed a new "Nuisances Removal Act for England"[55] which was made applicable to London, and which, coupled with the health provisions in the Metropolis Local Management Act, bestowed upon the metropolis a sort of code of sanitary laws in some degree similar to those enjoyed by other parts of England. And also an Act[56] making stricter provisions as to the construction of buildings in the metropolis. Though three Acts were thus passed, they formed but separate parts of one general plan of reform. Some little detail must be gone into as regards the system of local government thus initiated. For government in purely local matters--in each of the twenty-three largest parishes, definite Vestries, as distinguished from parishioners meeting in open Vestry, were constituted, the members thereof being elected by the householders of the respective parishes rated to the relief of the poor. The total number of members on any Vestry was not to exceed one hundred and twenty, and each year one-third of them were to retire, and an election to be held to fill their places. And as there were many parishes so small that to have constituted them separate local governing authorities would have perpetuated all the evils of small areas of local government, these small parishes were grouped together into "districts" of a fairly large size, for each of which--some fourteen in number--there was to be a governing body entitled "The Board of Works for the ---- District," the members thereof being elected, not directly by the electors, but by the smaller Vestries constituting the District. These new local governing bodies were thus representative bodies, the Vestries elected directly by the ratepayers, the District Boards indirectly elected; but both were constituted "the sanitary authority" for their respective areas, both were charged with the administration of local affairs, and so the term "Vestry" and the "District Board" may be taken as synonymous. The central body which was constituted for dealing with matters affecting London as a whole was named "The Metropolitan Board of Works." It was not directly elected by the ratepayers of London, but was elected by the aforesaid local authorities and by the "City." It consisted of forty-five members. Three were elected by "the Mayor, aldermen, and commons of the City of London in common council assembled." Each of the six largest Vestries elected two of their members to it; the other Vestries one each, and the District Boards of Works elected the remainder. It was thus representative of the whole of London--City and Metropolis included. Each year one-third of the members were to retire, and one-third to be elected in their place. This central Board was charged with many important duties affecting London as a whole. Foremost amongst them was the first essential of any sanitary well-being--the improvement of the sewerage and drainage of London. This new body superseded the Commissioners of Sewers, and was specially charged with the task of designing and carrying out "a system of sewerage which should prevent all or any part of the sewage within the metropolis from passing into the river Thames in or near the metropolis: and also make all such other sewers and works as they may from time to time think necessary for the effectual sewerage and drainage of the metropolis." It was also given general control over the sewage works, and power to make orders for controlling Vestries and District Boards in the construction of sewers in their respective parishes. Furthermore it was given power to make, widen, or improve, any streets or roads in the metropolis for facilitating the traffic, and certain powers of prohibiting the erection of buildings beyond the regular line of buildings. It was given power, too, to make bye-laws--for regulating the plans, level, and width, &c., of new streets and roads; for the plans and level of sites for building; for the cleansing of drains, and their communication with sewers; for the emptying, closing, and filling up of cesspools; for the removal of refuse, and generally, for carrying into effect the purposes of the Act--all which bye-laws were to be enforced by the Vestries and District Boards. Thus it was given large powers to deal with many of the matters which most affected the public health. But in some other such matters--essential for the effectiveness of the whole scheme--it was left strangely helpless. It was given no power to appoint a Medical Officer of Health for the metropolis to advise it as to matters affecting the health of London as a whole; or to appoint Inspectors of Nuisances to ascertain information upon sanitary matters and to carry out various sanitary duties. But, gravest and most deleterious defect of all, no authority was conferred upon the Board to compel any negligent or recalcitrant local authorities to carry out the duties imposed upon them by Parliament or by bye-laws of the Board. Those authorities might with absolute impunity neglect to carry out even the imperative directions of Parliament as embodied in the Act, and thus what Parliament emphatically enacted "shall" be done might be left undone, with the most disastrous consequences to the public health, not merely of the particular parish, but to the great community of London. The omission of some such provision made the Vestries practically independent bodies, and arbiters as to the administration or non-administration of various important provisions of existing or future Acts of Parliament, and afforded them the opportunity, so freely and widely availed of, of not performing duties against their own opinions or interests. As regarded these newly created local authorities--the "Vestries" and the "District Boards of Works"--the powers and duties conferred upon them were extensive. All the powers and duties of the previous local authorities as regarded paving, lighting, watering, and cleansing, or improving any parish, were transferred to them. The sewers, other than the main sewers, were vested in them, with the contingent duty of maintaining, repairing, and cleansing them, and they were given power to put sewers in every street. Also, they were given power, under certain circumstances, to compel owners of houses, "whether built before or after the commencement of this Act," to construct drains into the common sewer. Furthermore, no house was to be built without drains constructed to the satisfaction of the Vestry, or without sufficient sanitary conveniences, and they were directed to cause open ditches, sewers, and drains of an offensive nature, or likely to be prejudicial to health, to be cleansed, filled up, and covered. And they were required to appoint scavengers to collect the dirt and rubbish, or to contract for its removal. And each of the authorities was to appoint one or more Medical Officers of Health, whose duty it should be to inspect and report periodically upon the sanitary condition of the parish or district, and who would act as medical adviser to the Vestry in all matters relating to the public health, and was also to appoint one or more Inspectors of Nuisances to report as to the existence of nuisances or disease, and perform various other duties in connection with the sanitary condition of the parish. Provision was also made for the prevention of the sale of food unfit for human consumption. The Sanitary Inspector "might at all reasonable times inspect and examine any carcase, meat, poultry, game, flesh, fish, fruit, vegetables, corn, bread, or flour exposed for sale," and in case the same appeared to him to be unfit for such food it might be seized, and the magistrate might order it to be destroyed, and the person to whom it belonged, or in whose custody it was found, should on conviction be liable to a penalty of £10. By "The Nuisances Removal Act for England" the word "nuisances" was so defined as to include any accumulation or deposit which was injurious to health, "any premises in such a state as to be injurious to health, any pool, ditch, water-course, cesspool, drain, or ashpit, &c., so foul as to be a nuisance or injurious to health." The right to give notice to the sanitary authority of the existence of a nuisance was extended, and the process was facilitated. Notice might be given to the sanitary authorities by the person aggrieved, by the sanitary inspector, or by a constable, or by two inhabitant householders of the parish; and certain powers of entry were given to the local authority or their officer. The justices who heard the case might require the person offending to provide sufficient sanitary accommodation, means of drainage, or ventilation, to abate the nuisance, or to whitewash, disinfect, or purify the premises which were a nuisance, and could inflict a fine for contravention of the order of abatement; and, if the nuisance proved to exist were such as, in their judgment, to render a house unfit for human habitation, they were given authority even to prohibit the using thereof until it was rendered fit. Furthermore, as regarded certain noxious trades, including slaughter-houses and manufactories causing effluvia, which were certified by the Medical Officer of Health to be a nuisance, or injurious to the health of the inhabitants of the neighbourhood, the owner or occupier of the premises might be proceeded against, and, on conviction, fined. Against the monster evil of "overcrowding" Parliament made an attempt to legislate specifically, thus formally recognising the necessity for dealing with it. "Whenever the Medical Officer of Health shall certify to the local authority that any house is so overcrowded as to be dangerous or prejudicial to the inhabitants, and the inhabitants shall consist of more than one family, the local authority shall cause proceedings to be taken before the justices to abate such overcrowding, and the justices shall thereupon make such order as they may think fit, and the person permitting such overcrowding shall forfeit a sum not exceeding forty shillings." And an effort was also made to curtail the practice of living in underground rooms and cellars by defining what such a room or cellar was, and making liable to a penalty "whoever let, occupied, or knowingly suffered to be occupied, any room or cellar contrary to the Act."[57] As money was essential for the working of the Acts, over and above that for which rates could be levied, power was given both to the Metropolitan Board of Works and to the Vestries and District Boards of Works to borrow money on the security of the rates, and repayable by instalments, "provided always that no money should be so borrowed by Vestries or District Boards without the previous sanction in writing of the said Metropolitan Board." There were to be auditors of the accounts of the local authorities, who were to be annually elected at the same time and in the same manner as members of the Vestry. Finally, each Vestry and District Board of Works was to make to the Metropolitan Board of Works an annual report of its proceedings, including a report from the Medical Officer of Health; and the Metropolitan Board was to make an annual report of its proceedings, and present a copy to one of Her Majesty's Secretaries of State. The third of these Acts, "The Metropolitan Building Act, 1855," amended the existing laws relating to buildings in the metropolis, and laid down an elaborate code for the regulation and supervision of all new buildings. Most of this code related to the structure--the thickness of walls, &c., &c.--and had primarily in view the security of the house from destruction by fire. Only a few sections in the Act related to the infinitely more important matter of adequate provision for the health of the inhabitants, and those dealt with it in the most niggardly way. A minimum of one hundred square feet was laid down as satisfying the requirements of open space for air and ventilation around a dwelling; a minimum of seven feet in height was held to satisfy the requirements of any room in a house. And the supervision of every building, and every work done in or upon any building, was entrusted to the "District Surveyors"--officials taken over by the Metropolitan Board from the previous body, appointed under the Building Act of 1844, which had distinguished itself by its incapacity. These Acts practically laid down the framework of the machinery of the sanitary government of London, and struck the first real blow at the roots of the insanitary condition of the metropolis. The callous indifference and inaction of generations had left not a mere Augean stable to be cleansed, but a great city over 100 square miles in extent and containing two and a half millions of people, and the new authorities, when they came into existence, had not only to meet the daily needs of a vast existing population, but to make good the neglect of centuries, and to build up a sound and effective working system of sanitary administration. The task lying before them was one of enormous proportions, for on them rested the responsibility of effecting the sanitary redemption of the millions of the metropolis--as well as the infinitely greater duty of safeguarding future generations from similar sufferings and wrongs. It was, moreover, a task of almost superhuman difficulty, for arrayed against reform and amelioration were the powerful forces of "vested rights in filth and dirt." And adding to the difficulty was the huge inert mass of ignorance, and poverty, and helplessness of masses of the people. One principle contained in these Acts was of pre-eminent consequence--namely, the responsibility of "ownership." Hitherto owners had effectually escaped all responsibility as regarded the sanitary state of their property, and had dealt with their property exactly as they pleased, and regardless of the consequences to any one but themselves. Parliament now formally recognised and definitely laid down the principle that the "owner" was the person responsible for the insanitary condition of his property; and in addition declared that individuals would not in future be allowed to deal with their property in such a manner as to cause injury to the public health. But declaration of principles was one thing--their enforcement was another. Unfortunately, those who were charged with their enforcement were too often the persons directly interested in resisting reform, and in very many instances, where even a partial enforcement of these principles was attempted, the action was resented and vigorously resisted. The Metropolis Local Management Act came into force on January 1, 1856, and the Central Authority--the Metropolitan Board of Works--and the local authorities--Vestries and District Boards--having been duly elected, entered upon their duties. The first and most urgent work which the Metropolitan Board was charged to carry out was the main drainage of the metropolis, and at the outset, the new Board directed its efforts almost exclusively to the highly technical task of devising and considering and adopting plans for the construction of a great system of sewerage which should intercept the flow of sewage into the Thames, and should convey it by other means to a safe distance below London, whence it might flow into the sea. Any plan had, however, to be approved by the Chief Commissioner of Works. To him the Board submitted three plans, but none of them received such approval, and the matter was at a deadlock until 1858, when an Act was passed removing the veto of the Chief Commissioner of Works, and at the same time giving the Metropolitan Board power to raise a loan of £3,000,000, which up to that time it had no power to do. Within a week from the passing of that Act, the Board determined on a plan, and began arrangements for carrying it out. The plan adopted was to intercept all the sewage flowing into the Thames within the area of the metropolis, and to convey it by sewers to a distance, and to discharge it into the river at such a condition of tide as should take it still further out, so as not to return and become a nuisance to the metropolis. The proposed interception on the north side was by three main sewers, discharging at Barking--the upper, the middle, and the lower, with branches; on the south side, by two main sewers, discharging at Crossness. As the result of the Act there had been transferred to the Board 106 miles of main sewers on the north side of the Thames with 33 outlets into the river, and 60 miles on the south side with 31 outlets. A considerable number of these were offensive open sewers, others were defective in design and construction, whilst all required reconstruction to make them effective, and to fit them for connection with the new system. The Central Authority had thus a heavy task before it, and one which it would take years to perform. The local authorities, with simpler duties to perform, were able to get quicker to work. They appointed "Surveyors" in each parish to look after the multifarious duties in connection with the paving, lighting, and cleansing of the streets, with scavenging, and the removal of house and trade refuse, and with the construction and maintenance of local sewers and drains. In a sort of way some of this work had been done by the previous petty authorities; parts of it, therefore, were more or less familiar, and so not wholly new. But wholly new, and of very great importance, were the appointments which the new local authorities had to make for their districts of a Medical Officer of Health, and of one or more Inspectors of Nuisances to help him. The duties of the Medical Officer of Health were carefully prescribed by the Act. He was to inspect and report periodically upon the sanitary condition of the parish; to ascertain the existence of diseases increasing the rate of mortality; to point out the existence of any causes likely to originate or maintain such diseases, as well as to suggest the most efficacious mode of checking and preventing their spread, and various other important sanitary duties. These appointments were duly made, and some appointments also of Inspectors of Nuisances. Herein was involved the clear recognition of another principle of the utmost consequence--that of inspection--a principle very naturally held in abhorrence by all sanitary misdoers. It had previously been put spasmodically into operation, and with the best effects, on the occasions when Asiatic cholera was approaching or raging in the country, but when the panic had subsided it was promptly dropped, and every one was practically left free to commit any sanitary enormity with impunity. Henceforth, however, there would be the contingency of being found out for breaches of sanitary laws, and the eye of the law would, at least theoretically, be upon sanitary law breakers. The majority of the Medical Officers of Health entered energetically on their work, and thenceforward a constant light was thrown upon the sanitary condition of various parts of the metropolis by men who lived in the closest and most unceasing contact with the devastating evils afflicting the masses of the people. All were not equally efficient or energetic--all were not equally communicative--but the reports of many of them are full of interesting facts, of acute and instructive comment, and of wise counsel; and though holding office at the pleasure of their employers, many of these officers were courageously independent and outspoken in their criticism and advice.[58] Unfortunately, the reports had practically no circulation beyond the members of the bodies to whom they were made, if even they were read by them, and the recommendations made therein were too often absolutely ignored by those bodies, or, for reasons of self-interest, opposed. To us now, however, these reports are of the greatest value, being in many respects the most valuable official records existing on the subject. We learn from them, better than we do from any other source, as regards the various parishes of London, the nature, and in some measure the extent of the evils which existed, and the causes of those evils; we find in them opinions expressed and reiterated as to the best way of remedying those evils, and accounts of the results of the efforts made to remove or cure those evils. The reports set forth facts demonstrating the appalling misery which the great masses of the people of the metropolis endured; the loathsome foulness in which vast numbers of them habitually lived, and were allowed to live; the dreadful hardships they had to suffer; the fearful moral and physical contamination they underwent; the terrible death-roll--in great part preventable--and the ten or twenty-fold larger roll of victims of preventable illnesses and epidemics, with the consequent poverty which sickness entailed. We can bit by bit piece together from these reports a realistic picture of the sanitary condition of London as a whole during the successive periods of the latter half of the nineteenth century, and we can discern the action of the silent, steady, and irresistible economic forces which unintermittently dominated that condition. North and south in the metropolis, east and west, it was all the same, varying only in intensity, in extent, and, in some degree, in form; a harrowing and almost incredible story. And the remarkable concurrence of testimony from men acting independently of each other, and resident in wholly different parts of London, justifies the fullest confidence in statements uniformly harmonious. The metropolis is so large a place, with such marked differences between its component parts, differences in situation, and physical characteristics, and degree of development--differences in wealth and poverty, and in the occupations of their inhabitants--that the attempt to trace any special branch of its history is beset with the greatest difficulties. Especially is this the case when the subject treated of is so complex and comprehensive as that of the public health. It is manifest that all parts of the metropolis cannot be described simultaneously--whilst to go "seriatim" into the history of the public health in each separate locality would, by the very weight of detail, fail to convey an impression of the subject as a whole. The same objections apply to a "seriatim" historic treatment of the different branches of the public health. Moreover, the action of the central authority has also to be described in its proper place. And, still more important, the action of Parliament, and the principal Acts of Parliament relating to matters affecting the public health, either directly or administratively. How then can the subject be best treated with the object of presenting the main facts of the sanitary evolution of London, and deducing from them the lessons of experience and guidance for the future? Probably by a sort of compromise between these two methods--taking groups of districts instead of separate districts--and groups of matters pertaining to the public health, instead of separate subjects--and, furthermore, dealing with the whole subject in certain definite periods. Groups of parishes have already, for certain health purposes, been classified into central, eastern, northern, western, and southern. That classification can be adhered to here. And inasmuch as almost the only reliable statistics as to many matters relating to the public health are those afforded every decade by the census, the narrative can best be treated by taking decennial periods, and utilising the reliable information of the census for the deduction of conclusions which on any other basis might be unsound. This method, then, though in many respects imperfect, is adopted as probably the best for tracing the sanitary evolution of the great metropolis. Foremost among the central group, but standing by itself, and in the main outside the scope of the legislation, was the "City." To the description of its condition already given nothing need be added beyond the statement of the fact that the great economic forces at work therein were displaying their results in the "City" itself in very striking manner. Under their potent influence the population there had begun to rapidly decline. In 1851 it had been 127,533. In 1861 it had come down to 111,784. The number of inhabited houses was likewise rapidly declining. In 1851 there had been 14,483; in 1861 there were 13,218. Under the irresistible demands for greater business and trading accommodation, the inhabited houses there were being rapidly converted to the more profitable purpose of business offices, or warehouses. As the number of business premises and shops increased in a locality, so did the better-to-do residents leave it, and migrate to pleasanter or more healthy localities. Some of the houses thus vacated became promptly tenanted by numerous families of a lower, or even the lowest classes; until they too were converted to business purposes, and their inhabitants once more turned adrift to seek other habitation. Some of these people secured in the neighbouring parishes residence in one or part of one of those jerry-built and insanitary constructions which land-owners and builders were erecting as rapidly as possible upon any unbuilt ground which they owned, or which they could lay hands upon--the majority contented themselves with squeezing somehow into tenement houses already overcrowded. It cannot be too constantly borne in mind that this was one of the great forces in unceasing action in the metropolis, extending its sphere of action step by step, and stage by stage, and that as years went on, the various districts of the metropolis were, one and all, in varying degree, subject to the accompaniments and consequences of its different stages of growth. And the transition was further aggravated by the natural increase of population, and by another great force--the unceasing flow of immigrants into the metropolis, the majority in search of work, others of food given by charitable people, or of any other chance good thing or adventure that might turn up. And so, on January 1, 1856, the new local authorities of the metropolis began their great task. And about forty Medical Officers of Health began to examine into and inspect their respective districts, and to inform or advise their respective authorities. What did these men find when they got well into their work? What opinions did they form as to the fearful facts with which they were promptly brought face to face, and the great social problems with which they were confronted? And what did they and their employers, the Vestries and District Boards, do to carry out the legislation which Parliament had at last enacted? The first impression of one of them was that the possessor of the office of Medical Officer of Health[59] could never become popular, "his functions bringing him into constant collision with the apparent interests of many influential persons;"--in other words, with vested interests. Others took a less personal and wider view of their duties. Thus one of them[60] wrote:-- "We have to remodel an old system--a system on which has been for centuries engrafted by slow degrees all the undesirable elements we now wish to eradicate." Another[61] was impressed by the vast amount to be done even in his own parish:-- "From what I daily witness, I make bold to state that this Vestry has a Herculean task to perform to abate all the nuisances of Rotherhithe; nuisances which have grown uninterrupted for ages, and have become inveterate customs with many." If it was a Herculean task in one parish, and that a small one, what was the task for the whole of the metropolis? Another,[62] after a few years' experience of the working of the Act, summed up the actual position--the very kernel of the case--when he wrote:-- "The working of the Metropolis Management Act might often be characterised as a war of the community against individuals for the public good." And that is what, undoubtedly, it amounted to. Hitherto the "individuals" had had their own way unchallenged and unchecked, and countless thousands of the community had been sent to their doom. Now, in a sort of way, it was to be a war--a very just and necessary, and on the part of the community a bloodless war--to enforce upon land-owners, and house-owners and house-middlemen, obedience to the principle that "property has its duties as well as its rights," and that those individual rights should not be exercised--as they had hitherto so cruelly been--to the mortal injury of vast numbers of the community. And there was yet another aspect of their work being a war. It was war against disease and filth, and all the causes of insanitation, and against the consequent human suffering and misery, and degradation, in some of the very worst forms. That, unfortunately, was a never-endable war. Great successes might be won--complete and final victory never. The central group of parishes and districts outside the "City"--and lying to the north and west of the "City," consisted of St. Luke, Clerkenwell, Holborn, St. Giles', the Strand, and St. Martin-in-the-Fields, with a population of close upon 288,000--about one-ninth of that of the metropolis. Already in four of these, under the influence of the economic forces already described, the population was decreasing. Every portion of this central group was densely populated, and it contained two of the most crowded of all the areas of the metropolis--the Strand, which stood highest, and St. Luke's, which had "the questionable distinction" of being the second most densely populated parish. In St. Giles', which was "amongst the oldest, most densely peopled, and most deteriorated portions of London," the population in 1851 "did not appear capable of further increase, the district being incapable of expansion either by packing closer or by the addition of new houses." The eastern group consisted of the parishes or districts of Shoreditch, Whitechapel, Bethnal Green, Mile-End-Old-Town, St. George-in-the-East, Limehouse, and Poplar. In Whitechapel the population was stationary; in all the others increasing. The northern group of parishes and districts consisted of Hackney, Islington, St. Pancras, St. Marylebone, and Hampstead. In every one of these the population was on the increase, slightly in St. Marylebone, very rapidly in most of them, notably so in St. Pancras and Islington. The western group consisted of Westminster, St. James', St. George (Hanover Square), Paddington, Kensington, Fulham, and Chelsea. In St. James' the population was decreasing (having reached its apogee in 1841); in Westminster it was slightly increasing; in all the others rapidly increasing. The southern group, with a population roughly of about 700,000, consisted of the whole of that portion of the metropolis which was situate on the south side of the river. Beginning on the west, there was Wandsworth (which included Battersea), then Lambeth, Camberwell, Lewisham, with Woolwich and Plumstead on the extreme east, then Greenwich, Rotherhithe, Bermondsey, St. Mary, Newington, St. George-the-Martyr, Southwark, St. Saviour, Southwark, and St. Olave, in Southwark. Many of these were still mostly country. The various parishes and districts of the metropolis differed remarkably in their rate of increase of population. In all, the number of births was in excess of the number of deaths, but as this excess in no way accounted for the increase in many of them, the rest of the increase could only be accounted for by immigration--immigration either from other parishes or from outside London. And as it was with population so it was with the houses in which the people dwelt. In most of the central parts of London, houses crowded every available scrap of land, squares and open spaces being few and far between. Where there should have been streets of good width, there were narrow lanes of houses; where there should have been thoroughfares, there were cul-de-sacs; where there should have been space for through currents of air and for light, there were brick walls stopping both light and air. Figures giving so many houses to the acre convey little actual idea of the density of houses. Far more suggestive is such a statement as that made by the Medical Officer of Health in Limehouse (1861) that: "There would be no difficulty in marking out courts and alleys where the problem would seem to have been with the originators, how to enable the greatest number of people to live in the smallest amount of space." Or the description of St. Giles',[63] where, "exclusive of mews, there may be counted on the map upwards of seventy streets, courts, and alleys, in which there is no thoroughfare, or which are approached by passages under houses." Nor is it a matter of surprise that this state of things should have come about, when hitherto there had been practically no check whatever upon building. "It is to be regretted," wrote the Medical Officer of Health for Mile-End-Old-Town about his own district (1856), "that the great increase in the number of habitations should have been allowed to take place without some municipal direction, or some supervision competent to supply its place; the general salubrity of the district would certainly have been better secured.... But every owner of a piece of ground has had the opportunity of making the most of it for his own advantage and in real opposition to the public good." In nearly all the non-central parts of London houses were increasing rapidly. "Bricklayers are spreading the webs and meshes of houses with such fearful rapidity in every direction that people are being gradually confined within narrow prisons only open at the top for the admission of what would be air if it were not smoke. "Suburban open spaces are being entombed in brick and mortar mausoleums for the suffocation as well as for the accommodation of an increasing populace."[64] Thus in Islington there were 13,500 houses in 1851, and 20,700 in 1861; in Kensington 6,100 in 1851, and 9,400 in 1861. But what evoked comment was, that the evils of one sort or another connected with the crowding of houses together were being perpetuated. "Not only is it to be deplored," wrote the Medical Officer of Health for Whitechapel, "that the houses in most of the poor neighbourhoods are already too closely packed together, but the evil is increasing: for wherever there is a vacant spot of ground, more houses are built, thereby still further diminishing the healthiness of those already existing" (1860-1). From Hampstead--still but little built on--came a complaint of "the tendency among builders to cover the new ground as thickly and at as little cost as practicable." In Wandsworth "houses were erected and new streets formed without due regard to sanitary requirements, and in situations where good drainage seems impossible." In Fulham, "cottages out of number were constructed in the excavations of old brick fields with the soft refuse of bricks, habitations run in swamps and quagmires, and their foundations three parts of the year sopped with surface water." Efficient sewerage was so manifestly the basis of all wise sanitation that the want of sewers, and the abominable condition of those which existed, were general subjects of complaint. The Strand boasted of being "one of the best sewered districts in the metropolis," which, however, was not saying much for it. And in St. Giles' the sewerage was stated to be good, and "much above the average of the town." But such reports were quite exceptional. In Hackney, the principal sewer was the former Hackney Brook, which, from the increase of the population, and the drainage from other sewers, houses, cemeteries, and cattle-market, had become a foul open ditch--with very trifling exception wholly uncovered--and "emitting pestiferous noxious effluvia." In St. Marylebone, the sewers, themselves insufficient for the requirements of a growing population (1858), were, in many cases, so shallow as to cause rather than remove evil, for in certain places they flooded the basements, and in more than one house was witnessed the curious spectacle of the daily use of pumps to remove the foul liquids, as in leaking ships. In Paddington (1857-8), "the principles of good town drainage were completely ignored. The sewers were those which had been constructed at intervals, previous to 1846, in a piecemeal and unsatisfactory manner, as the thoroughfares were formed, without any regard to the requirements of the adjoining streets." The general direction of these sewers was "extremely defective. Numbers of them have a fall towards the summit or highest level of the street through which they pass; the bottoms are very irregular, running up and down and forming successions of hills and hollows." In Fulham, there existed scarcely the trace of a main sewer, open sewers and filthy ditches, conveying some part of the sewage to the river, the rest remaining in the cesspools. In Hammersmith, not only were sewers and ditches in a most fearful state of nuisance, but there was also "a morass of several acres in extent, having no outlet, which received the sewage from a large area, the noxious emanations from which must be regarded as highly detrimental to health." On the south side of the river matters were still worse. The greater number of the southern districts were situate nearly on the same level as high-water mark, if not indeed below it, and they differed from the other districts of London in their marshy character, their low level, and in the want of proper drainage dependent on that low level. The whole district suffered under the effects of a tide-locked, pent-up system of sewerage. In Greenwich, a very large number of streets were without main sewers. In St. Mary, Newington, "the great fact meeting us at every turn has been the large number of streets without main sewers therein." Rotherhithe, which lay from four to seven feet below high water, was exceptionally bad. The largest portion of the parish had no drainage whatever. There were about fifteen miles of open ditches which had been converted into open sewers, called in some official documents "Stygian pools," and serving "the double debt to pay of watercourse and cesspool." Among the ditches "one of the foulest in the whole neighbourhood of London" was the King's Mills stream, about one and a half miles long, which had not been cleansed for ten years. The sewer in Paradise Row was "in reality not a sewer," but "an elongated cesspool a mile in length," and during twenty hours daily it was waterlogged. The very boundary line of the parish for a long distance was "a wide, filthy, black, open sewer." In part consequent on the lack of sewers, house drainage was either non-existent or fearfully defective. In every part of the metropolis the evil was evident. In Clerkenwell the "drainage was either none or very imperfect. Numberless houses do not drain into the sewers." In St. Martin-in-the-Fields, "in the old streets and courts the drainage was the same as it was when the houses were built, some as far back as the reign of Elizabeth, and many in that of Charles I." In St. George-in-the-East (1856), "it is astonishing how few houses have availed themselves of the sewers." In Paddington, "the condition of the house-drains is far worse than that of the sewers. They include every possible variety of geometrical construction, from a circle to a square. Some have fallen in; others are choked with filth." In Lewisham (1856-7), "in several places there are reported to be nuisances of the usual character ... cesspools, no water, &c.--stinking ditches filled with sewage which can get no further--every abomination, and people apparently doing what they pleased as regards getting rid of their filth." Nor was it only in the poorer parts of London that the house-drainage was bad. In St. James' (Westminster) the Medical Officer of Health wrote (1861):-- "For the last two or three years the worst cases of neglected drainage have not been in houses inhabited by the poor, but in those inhabited by the wealthier classes of the community. It is to me frequently a matter of great astonishment to find how regardless those classes are, whose circumstances can command every comfort of life, of the sources of disease and death. This is not only seen in neglect of attention to drainage, but also in the neglect of ventilation." Nor was care being taken to provide drainage even to houses which were in course of erection. The Medical Officer of Health for Hackney, which was a growing district, reported (1858-9):-- "Building operations have recently been carried on with considerable activity, numerous new streets have been laid out and built on.... Unfortunately there have not been, and there are not at the present time, any means whereby the construction of proper drainage works could be enforced before the erection of buildings along the line of new streets, and the consequence has been that, to avoid the heavy cost of constructing effective sewers, the drainage works have been almost everywhere but very imperfectly carried out, and in many cases not even a brick has been laid for these purposes." The internal condition of the houses was very bad. In Clerkenwell, where there were over 7,000 houses, many of them were "quite unfit for human habitation"; not more than one-third were "in a satisfactory state." In Bethnal Green there were "disease-inviting houses"; in Whitechapel, such was the bad condition of many of the 2,734 houses which were inspected, that "they ought to be condemned as unfit for human habitation." In St. George-in-the-East, "the sanitary condition of the dwelling-houses is deplorable." Lambeth contained a greater number of inhabited houses than any other parish in the metropolis--nearly 22,000. The Medical Officer of Health, after the very limited inquiry possible within the first year of work, reported the unwholesome condition of 1,638 of them. From figures such as these--and they related to only a tiny fragment of the whole--one can get some measure of the way the sanitary condition of the houses throughout London had been neglected, and the indifference of the owners to the condition of the premises they let. Mention has been made of the vast number of cesspools which existed in London before the passing of the Metropolis Local Management Act. The investigations of the various Medical Officers of Health soon demonstrated that the previous estimates of their prevalence, and of the disastrous consequences they entailed, had been in no way exaggerated. Their disastrous results were at once recognised. The Medical Officer of Health for Whitechapel, in his report for 1858, wrote:-- "I must now direct your attention to the most important subject, in a sanitary point of view, which can be brought before you. I allude to the existence of _cesspools_, more especially such as are situated either in the cellars of inhabited houses, or in the small backyards, which are surrounded by the walls of houses filled with lodgers.... "No cesspool ought to be allowed to exist in London, for wherever there is a cesspool, the ground in its vicinity is completely saturated with the foul and putrefying liquid contents, the stench from which is continually rising up and infecting the air which is breathed by the people, and in some instances poisoning the water which is drawn from the public pumps.... "I am thoroughly convinced by the result of experience, that the existence of cesspools and overcrowding are the chief causes of ill-health." And the Medical Officer of Health for Camberwell wrote:-- "... Of all the abominations which disgrace and pollute the dwellings of the poor, the imperfect, rarely emptied, and overflowing cesspools are by far the worst ... they not merely poison the atmosphere without, but pour their emanations constantly, silently, deadly, into the interior of the houses themselves." Upon the quality and supply of the water which was essential for the life of the people, and upon which their health, and cleanliness, and sanitation absolutely depended, the information supplied by the Medical Officers of Health as to their respective districts brings home, far more than any general descriptions do, the full import and actualities of the great evils endured by the people, and the disastrous consequences entailed upon them. As to the water from the surface and tidal wells, which large numbers of them used and consumed, the opinion, though expressed in various terms, was unanimous. From Shoreditch (1860), the Medical Officer of Health wrote: "I have hardly ever exposed a sample of town spring water to the heat of a summer day for some hours without observing it to become putrid." In St. Giles' (1858-9), "the water of the wells was not deemed good enough (on analysis) for watering the roads." In St. Marylebone "44 public wells supplied water which was for the most part offensive to taste and smell." In Kensington (1860) "all the well waters of the parish were foul." In Rotherhithe (1857), "The water from the tidal well smelt as if it had recently been dipped from a sewer." The Medical Officer of Health for Lambeth declared (1856) that "the shallow well waters of London combined the worst features--they represent the drainage of a great manure bed." The people were driven to the use of the water from these wells owing to the deficient and intermittent supply of water by the various Water Companies--water supplied for less than an hour a day by one single stand-pipe in a court containing hundreds of people--water supplied only every second and third day, and none on Sundays, the day of all others on which it was most wanted; and the house-owners had provided no cisterns or reservoirs of proper capacity, and the Vestries had not compelled the house-owners to do so. In some parishes hundreds of houses had no supply at all. In some houses which had a supply the tenants were deliberately deprived thereof by the Water Companies, because the house-owner had not paid the water-rate. The defective supply had the disastrous effect of putting a constant premium upon dirt--dirt of person, of room, of houses, and their surroundings. And such drains and sewers as there were, were insufficiently flushed. Time after time the consequential evils were pointed out, and Water Companies and house-owners were vigorously censured. But the censure had little practical effect. The great inconveniences and evils, however, evoked the expression of opinion that the duty of supplying water to the community ought to be in the hands of the community. Even in 1844 it had been pointed out that:-- "Water is as indispensable for many purposes as air is for life itself, and its supply ought not to be allowed to depend on the cupidity or caprice of landlords or Water Companies." And the Metropolitan Sanitary Association had enunciated the principle:-- "That inasmuch as water is a prime necessity of life, attainable in large cities by combined effort only, and not to be denied to any without injury to all, its supply should not be dependent on commercial enterprise, but be provided at the expense of the community for the common benefit." And the Medical Officer of Health for St. George-in-the East wrote in 1856:-- "The water supply of your Parish is in the hands of a Joint Stock Company, called the East London Water Company, and is managed by persons who represent solely the interest of the shareholders, whose only anxiety is of course the dividends--the consumers are not represented at all. This appears to me to be a strange anomaly, a false position, and a monstrous inconsistency--as great as if the sewerage of London were committed to a Joint Stock Company. But so it is, and however great the danger, the Vestry has _no available_ remedy whatever in its hands." The principle had been conceded by Parliament so far as England was concerned--the large cities and even small towns having been authorised to undertake the supply of water; but London, the capital, was denied the power to do so--the duty was given to private companies, and the population of London was left to undergo untold sufferings. The quality of the water supplied by most of the Water Companies after the intakes had been removed to above Teddington Lock, and the filtration thereof before distribution for domestic use had been made compulsory, was considerably improved. But the filthy and dangerous character of the receptacles provided in many houses for it undid much of the good which would have come from the improvement in quality. The description given by one of the Medical Officers of Health was in the main true:-- "There is disease and death in the tanks, wells, and water-butts." Thus, in the great primary necessities of the public health--efficient sewerage and drainage, decent houses, good ventilation, pure air, a pure and ample water supply--the general conditions were almost inconceivably bad. These evil conditions, however, were far from constituting the whole of those under which the people of London suffered. Over and above them all was one which compelled the attention of the Medical Officers of Health the moment they had entered on their duties--"the gigantic evil," "the monster evil" of overcrowding. Not the mere crowding of houses together, evil though that was, but the overcrowding of people in those houses, and still worse, the overcrowding of the rooms of those houses by human beings. In every part of the metropolis there was overcrowding; worst in the centre, and the parts nearest the centre of London, but existing in the outer districts where houses still were comparatively few and population small. Centre, East, North, West, South, there was overcrowding, differing only in extent and acuteness of form. "Soon after I was appointed as Sanitary Adviser to your Board," wrote the Medical Officer of Health for Holborn (1856-7), "I found, dwelling in houses which were undrained, waterless, and unventilated, whole hordes of persons who struggled so little in self-defence that they seemed to be indifferent to the sanitary evils by which they were surrounded. "It is too true that among these classes there were swarms of men and women who had yet to learn that human beings should dwell differently from cattle, swarms to whom personal cleanliness was utterly unknown, swarms by whom delicacy and decency in their social relations were quite unconceived...." He mentions some instances too horrible to quote, and says: "Such were instances that came within my own knowledge of the manner and of the degree in which persons may relapse into habits worse than those of savage life, when their domestic condition is neglected, and when they are suffered by overcrowding to habituate themselves to the lowest depths of physical obscenity and degradation." In St. Luke "the houses swarmed with their human tenants." In Bethnal Green "our crowded streets and courts are becoming more crowded." In St. Pancras "in many houses the overcrowding is very great, each room being occupied by a family." In Islington, so overcrowded were some of the houses that the Medical Officer of Health had met with as little as 220, 190, 170, down to 135 cubic feet of air available for each occupant of a room. In Rotherhithe "almost all the houses were overcrowded with inmates." In Westminster, the Medical Officer of Health gave (in 1858) fifty examples of overcrowding in his district. In one house, in a room 13 feet long by 9 wide, and 7 feet high, there were 5 adults and 3 children; and in a lower room in the same house, 10 feet long by 9 wide, and 8 high, there were 4 adults and 5 children. There are no statistics whatever showing even approximately the number of cases at that time in which a single room was occupied by a family, but it is certain that vast numbers of families had to be content with that limited accommodation. Nor was that even the worst--for, in very many cases, more families than one lived in a single room, or the single family took in one or more lodgers. Life under such circumstances must have been, and was, awful. The Medical Officer of Health for St. Giles' wrote:-- "The houses whose rooms are occupied by single families were last year in a condition of squalor and overcrowding which it is difficult to conceive surpassed.... "In Lincoln and Orange Courts, the most glaring violation of the laws of health and of the requirements of civilised life was found. For instance, there are several small rooms in the backyards of Church Lane.... Each of the rooms measures about 10 feet by 8, and between 6 and 7 feet high. Each of them serves a family for sleeping, cooking, and all domestic needs. "... The air of these rooms was unbearable to a visitor, and to open the window was only to exchange one foul emanation for another." And the Medical Officer of Health for Clerkenwell wrote (1856):-- "In thousands of instances in this district, living, cooking, sleeping, and dying ... all go on in one room.... "If a poor man gets married he is pretty sure to have a large family of children, and at the present rate of mortality several will die of zymotic disease. "Hence, when a death occurs, the living and the dead must be together in the same room; the living must eat, drink, and sleep beside a decomposing corpse, and this in usually a small, ill-ventilated room, overheated by a fire required for cooking, and already filled with the foul emanations from the bodies of the living and their impure clothes. "This is an everyday occurrence in Clerkenwell, and constitutes a formidable evil." So great was the pressure for accommodation of some sort or kind, that even the cellars and kitchens in the basements of the houses were occupied as dwelling-places and overcrowded. In St. James', "the worst feature of the overcrowding was the very common practice of residence in cellars or kitchens. In the majority of cases the places are quite unfit for human residence. "... A cellar in St. Giles'," wrote the Medical Officer of Health for that district in 1858, "has been the by-word for centuries to express a wretched habitation unworthy of humanity. "Dating from the time of Charles I., the underground dwellings of our district attained the acme of their miserable notoriety from the pen and pencil of Fielding and Hogarth. "... The Building Act of 1844 contained stringent clauses against the use of such rooms unless they possessed requisites of area and ventilation, such as were out of the question in the cellars of St. Giles'. "The Metropolis Management Act (1855) repeated the prohibition of 1844, and in defence of the public health the Board have lately put this statute in force. This has been done without compromise. As separate habitations for occupation by human beings at night 'a cellar in St. Giles'' is no longer to exist." This was written in 1858, but in the following year he wrote:-- "The profit derived from letting the basement of these houses as dwelling-rooms was too strong a temptation for their owners, and many of the kitchens were let again as soon as the Inspector had reported them emptied." In the Strand (1856) underground rooms and kitchens were inhabited "notwithstanding that District Surveyors are numerous, and that the Metropolitan Building Act is in operation." In Westminster, "an examination of various portions of the parishes shows that large numbers of the poor occupy premises whereby they are not only deprived of the required quantity of air, but being situated below the level of the street, the ventilation is insufficient, the rooms generally damp, and when closed for the night the atmosphere is perfectly insufferable--mostly kitchens and cellars, evidently never intended to be used as sleeping rooms" (1858-9). The causes of the dreadful overcrowding which existed so extensively were many and deep-seated--springing from the very roots of the social and economic system. And they were of great force and widespread in effect. The cause to which the various authorities and Medical Officers of Health directly attributed it was the one immediately before their eyes--namely, the pulling down of houses which hitherto had afforded shelter, of a sort, to the people. As the Medical Officer of Health for St. Olave, Southwark, said (1860-1):-- "To effect street improvements--to build warehouses, or for some other purpose--the habitations of the working classes are broken up without any provision being made for them elsewhere. They are therefore driven by necessity to crowd into other houses in the same neighbourhood perhaps already overcrowded." An actual illustration was the case reported by the Medical Officer of Health for Limehouse:-- "The London Dock Company have, for the purpose of enlarging and improving their docks, pulled down not less than 400 houses in the parish of Shadwell, the homes of not fewer than 3,000 persons of the poorer classes. "... The neighbouring parishes are now suffering from an augmentation of their already overcrowded population." The District Board of St. Saviour, Southwark, stated that the evil of overcrowding "can scarcely be exaggerated, whether it be regarded in a physical, mental, or moral aspect." The principal of the causes are:-- "(1) The arbitrary power exercised by railway companies in ejecting the labouring classes from their homes without any obligation to provide for their domestic convenience. "(2) The existing law of (poor law) removal, any break in the three years' residence in the parish rendering them liable to removal to other distant parishes." The latter had, however, most probably, but very small effect. A great cause was that described by the Medical Officer of Health for Shoreditch:-- "There is a constant and rapid flow of population into Shoreditch. It is in this circumstance that I see one of the most alarming dangers to the health of the district. "The area does not enlarge, and yet year after year dense crowds of human beings are packed and squeezed into that limited area. The growth of the population has far outstripped the growth of the house accommodation. "The immense majority of the immigrants are precisely of that class which most largely increases the dangers of disease by thickening the population. You are largely burdened with the pauperism of other and wealthier districts. The burden is doubly grievous; for it taxes your property, your labour, and gives strength to the elements of disease amongst you. "It is probable that there is no spot in London more crowded with life than many places in Holywell or St. Leonard's. "Typhus--a disease more terrible than cholera--has made itself at home in the parish." And the Medical Officer of Health for Fulham wrote (1857):-- "... The daily necessities of the labourer's family draw so heavily on his earnings as to leave only a very small sum for the payment of rent, and hence the most limited house accommodation is sought for and endured...." The most powerful cause of all, however, was, undoubtedly, the overpowering instinct of self-preservation, or, in other words, the need of working, no matter under what conditions, for the only means of obtaining food for themselves and their families. That, as a rule, necessitated their being near the work to be done--and rather than lose that work any conceivable hardship or abomination would be put up with. Another of the great causes of overcrowding was high rent. "It must not be imagined," wrote the Medical Officer of Health for the Strand (1858), "that this system of overcrowding is altogether a direct consequence of a state of poverty. It certainly does not appear to be so, for among the Metropolitan Districts the Strand ranks seventh in order of wealth. "The overcrowding seems to be partly a result of the high rental which the houses and rooms of many parts of the district--so peculiarly well situate for business purposes--command, and partly of the 'middleman' system, in which so many of the houses in the occupation of the poorer residents are let. "The 'middleman' system, which obtains so largely in this metropolis, in the letting of houses of the kind referred to, is ruinous in its action upon the working classes. The rent paid for a single room often exceeds a sixth or fifth of the total income of the family...." In a case in Bow Street Police Court it was given in evidence that 21, Church Lane, St. Giles', was rented of the owner for £25 a year--that the rents recovered from the sub-tenants were £58 10s.--and the rents received by these sub-tenants from lodgers £120 per annum.[65] Overcrowding was not confined to the sleeping places of the people, for the same causes which cramped the available space for people at night, cramped also the space for very many of them during the day when they were away from their so-called homes. Of the overcrowding in factories and workshops, where so many of the working classes spent their days, and of the insanitary conditions in which they there worked, no mention is made in these earlier reports of the Medical Officers of Health, not because there were not any, but because the inspection or regulation of factories and workshops did not come within the sphere of their duties. Evidence in plenty there is on this branch of the subject in later years from those who could speak with authority in the matter, and it will be referred to hereafter, and that the state of things then described is equally applicable to this period is an inference so legitimate as to be tantamount to a certainty. That the bad conditions under which the workers worked were a great contributing factor in the insanitary condition of the people is a fact as to which there can be no question. Mention is made, however, of the overcrowding which existed in another large section of the community--namely, the overcrowding of children in some of the schools. The Medical Officer of Health for Whitechapel reported that there was much overcrowding, and in his report for 1857 gave some instances of it in his district:-- 18, _Charlotte Street_.--In a room 8 feet high, 7 wide, 10 long: 14 children and 1 mistress = 37 cubic feet each. 17, _Charlotte Street_.--Matters still worse; the room was underground; 10 feet wide, 10 long; about 7 feet high; 35 children and 1 mistress = 20 cubic feet each. 2, _Gorelston Street_.--672 cubic feet; 31 children and 1 mistress = 20 cubic feet each. In such cases the atmosphere must have been a rapid poison to those breathing it. There was another powerful contributory cause to the general insanitation of London, namely, the defilement of the atmosphere which people had to breathe. As one of the Medical Officers of Health said some years later:-- "We should remember that the air we breathe is as much our food as the solids we eat and the liquids we drink, and as much care should be taken that it is free from adulteration." London was already the greatest manufacturing city in the world, and the great volumes of smoke proceeding from the numerous factories undoubtedly deteriorated the quality of the air. But it was the noxious vapours proceeding from the various processes of manufacture classified as "noxious trades" which rendered the atmosphere in many parts of London dangerous to health. Many were the descriptions given of the almost intolerable evils. Thus the Medical Officer of Health for Rotherhithe reported in 1857:-- "In the mile length of Rotherhithe Street there are no less than nine factories for the fabrication of patent manure, that is to say, nine sources of foetid gases. The process gives out a stench which has occasioned headache, nausea, vomiting, cough, &c. Many complaints have been made by the inhabitants." From St. Mary, Newington, "the terrible effluvium of bone-boiling is freely transmitted over the district." Some manufacture in a yard in Clerkenwell (1856-7), which had existed until lately, was "one of the most abominable, exceeding anything that the imagination could picture." And in every parish or district of London there were slaughter-houses. "There are too many slaughter-houses in crowded districts," wrote the Medical Officer of Health for St. Pancras (1856-7). "It is impossible that slaughtering of animals can be carried on amongst a dense population without proving more or less injurious to the public health. "This it does in several ways--by occasioning the escape of effluvia from decomposing animal refuse into the air and along the drains, and by the numerous trades to which it gives rise in the neighbourhood which are offensive and noxious, such as gut-spinning, tallow-melting, bladder-blowing, and paunch-cleansing." Even in the Strand District there were (1856)-- "Nuisances arising from various branches of industry, the slaughtering of sheep and calves in the back-yards, and even in the cellars and kitchens, and the keeping of cows in the basements under private dwelling-houses, conditions which continue to exist in the most crowded parts of this district, and should on no account be permitted in such a district:" whilst in Westminster "pig-keeping existed to a very considerable extent." In some of the outer parishes the "foetid emanations" caused in the process of brickmaking added to the general impurity of the air. There were many other local causes of impurity of the atmosphere, some even caused by the Sanitary Authorities themselves. Thus the more thorough scavenging and removal of the filth of streets and houses, vitally necessary as that was, resulted in the accumulation of great heaps of filth in crowded centres. Thus the Medical Officer of Health for Fulham reported that:-- "The collection of dust heaps, and dust contractors' depôts, constitute a most injurious and offensive nuisance--enormous quantities of animal and vegetable matter are heaped together, from which the most noxious effluvia constantly arise." And the Medical Officer of Health for Rotherhithe pointed out (1858) that:-- "It is little use causing our own dust to be carted away if Rotherhithe is to become the receptacle of all the ashes and offal of a large neighbouring parish (Bermondsey). On a piece of land near the Viaduct there stands an immense heap of house refuse, covering an acre of ground at least, and forming quite an artificial hillock, the level of the surface having been raised 12-14 feet. The bulk of the heap is composed of ashes with a due admixture of putrefying vegetable matter and fish." A little later he reports it as 1-1/2 acres in extent, averaging 15 feet high, in one place as high as 20 feet. How to deal with these noxious or offensive trades was felt by some of the Medical Officers of Health to be a great difficulty. "We have the health of the community on the one hand," wrote the Medical Officer of Health for Lambeth; "the great manufacturing interests on the other.... We have all a common right to an unpolluted atmosphere, and it is our bounden duty to withstand any encroachments on that right. The personal aggrandisement of the manufacturer must not be achieved by the spoliation of the property, the comforts, and the lives of his poorer neighbours.... "But the manufacturing interest is not a thing to be trifled with. Destroy the manufactures of Lambeth, and you starve its population. There are nuisances of more benefit than of injury to the community," and he rather deprecated "a crusade against those interests, the untrammelled prosecution of which has raised this country to its present proud pre-eminence." Some of the Medical Officers of Health expressed decided views on the subject (1857):-- "Those who follow unwholesome trades led on by the thirst of gain," reported one Medical Officer of Health, "have no right to poison a neighbourhood and swell its mortality." The Medical Officer of Health for the Strand wrote (1856):-- "... The protection of the public health which has been committed to your charge is, beyond doubt, of infinitely more importance than, and should far outweigh the interests of, private individuals how numerous soever they should be." The Nuisances Removal Act, 1855, had given the local authority power on the certificate of the Medical Officer of Health to take proceedings against an offender, and had provided the means for inflicting a penalty. And in some instances it was used, for the Medical Officer of Health for Hackney reported:-- "Several proprietors of noxious trades having omitted to adopt the best practicable means for preventing injury to health, in some cases legal proceedings were taken against them." The Medical Officer of Health for Whitechapel declared there was no desire on his part to use the powers of the Act to the oppression of any individual or to insist upon the adoption of such arbitrary and stringent measures as shall drive wealthy manufacturers from the district. "All that is necessary to be insisted upon is that the business be so conducted that the health and comfort of the inhabitants shall not be injured." But whether it was from the unwillingness of the local authorities to prosecute, or the difficulties of enforcing the law, the nuisances continued to the great detriment of the health of the people. And over and above this combination of nuisances, there was the abominable smell from the river. That still was an evil. "Rotherhithe," wrote the Medical Officer of Health, in July, 1858, "in common with all other metropolitan riverside parishes, has suffered considerable inconvenience during the last month from the stenches arising from the filthy state of the Thames water. Perhaps in the annals of mankind such a thing was never before known, as that the whole stream of a large river for a distance of seven or eight miles should be in a state of putrid fermentation. The cause is the hot weather acting upon the ninety millions of gallons of sewage which discharge themselves daily into the Thames. And by sewage must be understood not merely house and land drainage, but also drainage from bone-boilers, soap-boilers, chemical works, breweries, and gas factories--the last the most filthy of all.... It is quite impossible to calculate the consequences of such a moving mass of decomposition as the river at present offers to our senses." As one sums up all these disastrous influences, or rather, these evil powers, unceasing in their work, by night and by day--in the overcrowded dwelling and the street--with their victims unable to escape, one realises somewhat the conditions under which great masses of the people of London were living. The result was a fearful mortality--an awful waste of human life. "Death," wrote one of the Medical Officers of Health, "finds easy victims in filthy habits, overcrowded rooms, impure air, and insufficient and ineffective water supply." The consequences were inevitable. "Wherever there are crowded apartments, imperfect or no drainage, offensive cesspools, dung-heaps resting against houses or close to inhabited rooms--wherever ventilation is impeded by the narrowness of courts and alleys, and wherever the inhabitants living under these unfavourable circumstances lose their self-respect, pay no regard to personal cleanliness, and consider a state of filth and offensiveness as their natural lot--there we find zymotic diseases in full force and frequency. Those attacked do not simply recover or die. I shall not be exaggerating when I say that all recovering from these complaints are permanently injured."[66] It is impossible to apportion the respective shares which these various causes of insanitation had in bringing about these dire results, but overcrowding was undoubtedly one of the principal. As to its disastrous effects the Medical Officers of Health were of one opinion. There was no single exception to the strong-voiced insistence upon this fact. "The main cause," wrote the Medical Officer of Health for the Strand (1856), "to which we must attribute the high mortality is the close packing and overcrowding which exists throughout the district.... Overcrowding and disease mutually act and react upon each other. "There is one circumstance of general prevalence throughout the district which, so to speak, almost paralyses these efforts of sanitary improvement--overcrowding--the overcrowding of parts of it with courts and alleys, the overcrowding of these courts and alleys with houses, the overcrowding of these houses with human beings" (1859). "The overcrowding of dwellings," wrote another,[67] "is one of the most frequent sources of sickness and decay at all ages." "Perhaps," wrote a third,[68] "there is no single influence to which a human being is exposed more prejudicial to his health than overcrowding in rooms the air of which cannot be perpetually and rapidly changed." "No axiom," wrote another,[69] "can be more positive than the connection of epidemic diseases with defects of drainage and ventilation ... the overcrowded localities being especially scourged by disease." The consequences were not confined to epidemic disease; other fatal diseases were begotten by it. "All medical writers," wrote the Medical Officer of Health for St. James' (1858), "are agreed that impure air from want of ventilation is the most potent of all causes of consumption." Not merely directly did overcrowding bring about fatal results. Indirectly it also led thither. It was recognised as a cause of intemperance and of the evils, moral as well as physical, which ensued from intemperance. "Men whose nervous systems became depressed, and the tone of their system generally lowered, became the subjects of a continued craving for stimulants."[70] Dr. Simon, Medical Officer of the General Board of Health, wrote:-- "In an atmosphere which forbids the breath to be drawn freely, which maintains habitual ill-health and depresses all the natural spring and buoyancy of life, who can wonder that frequent recourse is had to stimulants?" The evils were disastrous enough for the adult population, but they fell with more dire effect upon infants and young children. "Conditions more or less injurious to health gradually impair the matured energies and slowly undermine the fully developed constitution of the adult; but the self-same conditions, exerting their baneful influence on the infant or young child, nip the tender plant in the bud and speedily destroy its young life."[71] Throughout the whole of the metropolis the infantile mortality--that is, of children under five years of age--was very great: Almost without exception it was close upon, or over, 50 per cent. of all the deaths in the various parishes or districts. In Clerkenwell the infantile mortality, which was "nearly one-half of all the deaths," was characterised as "enormous"; but in Shoreditch it was actually one-half, being 50 per cent. (1858); in Bethnal Green it was over one-half, being 52 per cent. (1858); in St. George-in-the-East it was 53-1/2 per cent.--or, to put it otherwise, of 1,351 deaths in the year, 720 were of children under five. In Poplar it was more than half. In Islington, in 1857, nearly half. In St. Saviour, Southwark, 50 per cent. in 1860-1, "a waste of life which appears almost incredible." In Limehouse (in 1857) of 1,403 deaths 690 were under five. The Medical Officer of Health wrote:-- "It is when such wretched offspring, ill-nourished, ill-clothed, and in every way neglected, become exposed to the depressing influences of an impure atmosphere that they sicken, and such children when they sicken they die.... When the habitation of such children is an overcrowded, dilapidated tenement in some close, ill-ventilated court or alley, furnished with an undrained closet, surrounded by untrapped drains, and festering heaps of filth, we find ourselves astonished, not that so many die, but that so many survive." In some special places the mortality was still higher. Thus the Medical Officer of Health for Kensington reports in 1856:-- "In some places the mortality among infants under five years of age was at the enormous rate of 61·3 per cent. of the total deaths. "One of the most deplorable spots, not only in Kensington, but in the whole metropolis, is the Potteries at Nottingdale. It occupies about 8 or 9 acres, and contains about 1,000 inhabitants ... the general death-rate varies from 40-60 per 1,000 per annum. Of these deaths, the very large proportion of 87·5 per cent. are under five years of age." The Medical Officer of Health for Whitechapel (in 1858), after reporting that the total mortality under five years in the Whitechapel district is about 56 per cent., wrote:-- "How to overcome this frightful and apparently increasing amount of mortality of the young is a problem well worthy the attentive consideration of every citizen. The time may be far distant before this problem is solved; nevertheless it is my duty to chronicle facts, and although I may not be able to suggest a remedy to meet this evil, still the knowledge that so large an amount of infant mortality does exist in our district--I may say, at our very doors--will perhaps rouse the attention of the philanthropist, the man of science, and the man of leisure, to investigate its cause, and endeavour to mitigate it." Once more it must be called to mind that this mortality was not the whole of the evil, for it was indicative of widespread infantile sickness and disease among those who escaped the death penalty--sickness and disease impairing the health and strength of thousands upon thousands of the juvenile population. The facts set forth by many of the Medical Officers of Health must have enlightened many of the new local authorities as to the nature and extent of the work which it had now become their duty to perform, and the grave problems for which they were expected to find the best solution. The earlier annual reports of many of the Vestries and District Boards were poverty-stricken in the extreme, and were mostly confined to bald and uninforming tables of receipts and expenditure, which practically threw but little light upon the condition of their parishes. The Vestry of St. Mary, Newington, evidently anxious to prevent disappointment as to immediate results from its action, stated that:-- "In consequence of the previous want of adequate sanitary powers in the local authorities of this and other suburban parishes, so great an extent of sanitary improvement was required when the Vestry came into operation, that it was impossible the whole could be dealt with at once, at the same time acting with consideration for those who have to bear the effects of many years' neglect of those sanitary duties which are now found to be so essential." Lambeth Vestry expressed its desire to discover-- "In what manner a prompt and beneficial execution of the provisions of the Act can be secured without creating any serious increase in local taxation." One of the Vestries, indeed, gave the quaint explanation that one of the things which somewhat retarded sanitary improvement was "the novelty of applying compulsory powers to landlords." The desirability of securing parks and places of recreation for the people was one of the matters which first appealed to some of the Vestries and District Boards, and memorials were addressed to the Metropolitan Board urging the importance of their putting in force the powers conferred on them for the purchase of land for such purposes. Others directed their attention to the promotion in a small way of improvements in their parishes by widening streets and roads, and preserving open spaces--towards which, in some cases, they received a contribution from the central authority. A good deal of paving was done, and better measures taken for scavenging the streets and courts, and for the removal of refuse and dirt of all sorts. To local sewerage, as distinct from main sewerage, they also gave attention, and in 1856 designs for 45 miles of new sewers were sent in to the Metropolitan Board for approval, and £34,700 borrowed for the purpose; and in the following year for 46 miles of new sewers, and loans for £109,000. A fair amount of drainage work was also carried out--thousands of cesspools were filled in and drains made. Also a certain amount of inspection, with the disclosure of an enormous amount of insanitation. Thus, in the Strand District in 1856--where 813 houses were inspected--in 774, or 91 per cent. of these, works had to be done to remedy sanitary defects. In the following year 1,760 houses were inspected, and in 1,102 sanitary defects were found. In Poplar, of 1,299 houses which were visited, 795 required sanitary improvement. In Paddington 2,201 houses were inspected; in over 1,600 works had to be executed to put them in sanitary order; figures which showed that, roughly speaking, two out of every three houses were sanitarily defective. "The last year," wrote the Medical Officer of Health for Hackney (1857)--where 1,518 houses had been connected with the sewers--"has been a year of drainage." Parliament having enacted that the "owner" was responsible for the state of his property, this work had to be done at the expense of the owners; but how many decades had passed in which "owners" had spent nothing on the property, and had been receiving large rents; and how many cases of sickness and death had occurred in their houses, the result of the insanitary condition in which they had been allowed to fall, and in which they were allowed to continue. In Holborn such works cost the owners about £3,400 in 1857, and in Lambeth about £10,700. But the work thus chronicled touched little more than the fringe of the matter. Most of the local authorities had, out of a spirit of economy, or for some other reason, appointed only one Inspector of Nuisances; yet in nearly every one of their parishes there were thousands of houses--in Greenwich 11,000, in St. Marylebone 16,000, in Lambeth 22,000--and years would have had to elapse before the solitary inspector could have completed even one round of inspection and got the houses he inspected put in order; whilst the others would inevitably have been existing in, or falling into, a state of insanitation. For years, therefore, the most vile disease-begetting nuisances might not merely exist throughout the parish, but work endless evil without any interference, as indeed they did. Some of the Vestries put forward their economy as a claim for praise. Thus, the Wandsworth Board said that "a due and careful regard to economy had characterised all their proceedings," and the Vestry of St. Mary Newington said, in 1860, that it had carried out its operations out of current income and had incurred no debt. The Medical Officers of Health held their offices at the pleasure of the Vestries, and, therefore, if they valued their position, had to be cautious in their criticisms of the management of the affairs of the parishes. But their reports convey that the work which ought to have been done was not being done as rapidly as they wished. "I wish I could induce the Vestry to insist more upon having the poorer dwellings cleansed and lime-whited." And again, "The Vestry has the power to restrict the operation of underground rooms, yet it has not moved in this important matter."[72] The Medical Officer of Health for St. Giles' (1857) referred to the-- "Indisposition of the Board to do works and charge the owners"; and, referring to a special case, he wrote, "It becomes your duty to do something to prevent the production of disease among the neighbours." The Medical Officer of Health for St. Pancras wrote in 1856-7:-- "In many houses the overcrowding is very great. There is a clause under the Nuisances Removal Act by which the Vestry is called on to take proceedings before a magistrate to abate overcrowding, if it is certified to be such as to endanger health. No prosecutions have been taken under this clause." And again in 1859:-- "Very little has been done in this parish to abate over-crowding--extreme cases have been proceeded against. No systematic efforts have been made in this direction." And the Medical Officer of Health for Hampstead wrote (1856):-- "Nothing short of constant vigilance and inspection can keep the dwellings and premises of the people in a tolerably healthy state. I am not sure that your Board is blameless in some of these respects--an amiable, though weak, reluctance to act severely to any." And in 1857 he pleaded for the appointment of an Inspector of Nuisances, which, however, he did not get. The local authorities had their difficulties in dealing with many of these matters, even when they were disposed or anxious to do so, owing to-- "The imperfection of the powers conferred on them by the legislature, and to the great and stubborn apathy of a poor population." And the Medical Officer of Health for St. James' (1858) attributed blame to the public generally:-- "One of the greatest barriers to the practical efficiency of sanitary arrangements is the ignorance and carelessness of the public. It is frequently seen that where infectious illness occurs, little or no attention is paid to its infective character, and an unscrupulous intercourse is carried on between the members of infected families, not only amongst themselves, but amongst their neighbours, and thus these diseases are propagated in spite of every warning and precaution." "I regret," wrote the Medical Officer of Health for Whitechapel, "that the powers of your Board are not at present sufficient to compel the owners of small house property to provide an adequate supply of water for their tenants." The Medical Officer of Health for Westminster wrote:-- "Few of the objects of sanitary improvement can be fairly attained without intrenching upon private interests to an extent which would appear harsh and oppressive. One great obstacle consists in the habits of a great portion of the poor--generally deficient in cleanliness or order; they consider any endeavour to improve their dwelling as an interference, and throw every obstacle in the way. On the other hand, a large number are most grateful for what has been effected." But in many matters the local authorities would not take action. In only four parishes or districts in London had public baths and wash-houses been established under the Act of 1846, though where they were in existence "the benefits were immense by promoting habits of cleanliness." In Poplar in 1858-9 nearly 40,000 men, and 3,000 women, and 400 children availed themselves of the baths. In St. Pancras (1856-7) the laundry department, erected by the "Society for Establishing Public Baths and Wash-houses," was of great value in affording the poor housewife an opportunity of washing and drying her linen away from her one room, in which the family had to live night and day. "I have frequently seen a small room of this kind with from four to eight or even ten inmates rendered doubly unhealthy by these laundry operations, which produce a damp and almost malarious atmosphere." The Medical Officer of Health for Lambeth had pleaded for such an establishment in his district, but "the idea of erecting them seems quite abandoned by the Vestry." "I know nothing more objectionable in a sanitary point of view than the washing of foul clothes in the dwellings of the poor, and still worse the drying of them in courts and rooms already deficient of free circulation of air and light." Nothing, however, was done. But inaction far greater in gravity and infinitely more reprehensible was that relating to the housing of the people. The Medical Officer of Health for Whitechapel drew attention, in his report of 1857, to their power in this respect:-- "Docks, railways, warehouses, &c., &c., must be constructed for the increase of the trade of this great metropolis, but our construction of them ought not to prevent us from providing better habitations for the working classes whose labours effect these improvements; more especially as it is in the power of parishes by virtue of an Act of Parliament to encourage the establishment of lodging-houses for the labouring classes."[73] Not one single Vestry or District Board ever attempted to deal with the evils of bad housing and overcrowding by putting into operation the provisions of this Act. The occasional statement in the report of a Medical Officer of Health as to what was actually done in his parish, by showing what might have been done in any other one, brings into strong relief the incapacity or deliberate inaction of the local authorities of other parishes. Thus, in some parishes the Medical Officers of Health endeavoured to effect some diminution of overcrowding--for instance, the Medical Officer of Health for Islington reported that-- "In several instances the owners of dwelling-houses had been summoned for permitting the overcrowding of their houses; and the magistrate had fined the offenders." And the Medical Officer of Health for Holborn in the same year wrote:-- "Your Board has already done much to ameliorate the condition of this class of society (the poor and overcrowded) by compelling the owners to cleanse, drain, and ventilate their dwellings; to close cellars, to provide proper water supply, sanitary accommodation, and in many cases had abated overcrowding." But few of the Vestries followed, or attempted to follow, these examples, and in many of the most vital matters a deliberate inactivity was the prevailing characteristic of the Vestries and District Boards. "In several Vestries resolutions were actually moved with the view of averting the construction of sewers. It was thought by many persons of influence to be better to live in the midst of overflowing cesspools than to add to the defilement of the Thames."[74] The Medical Officers of Health did not confine themselves to merely reporting what was annually done to ameliorate the existing state of affairs. As was their duty, they made numerous and frequent suggestions to their authorities as to what it was best to do. And some of them, going further than this, sometimes endeavoured to inspire the members of the Vestries and District Boards with a sense of the gravity of their work, and with lofty views of their duty. Occasionally, even, they did not hesitate to censure their employers for inaction or lethargy. The Medical Officer of Health for the Strand wrote (1856):-- "To pave streets, and to water roads, to drain houses or even to construct sewers, however necessary these works may be, are among the least important of the duties which devolve upon you. But to improve the social condition of the poorer classes, to check the spread of disease, and to prolong the term of human life, while they are works of a high and ennobling character, are yet duties involving the gravest responsibility. Should less care be bestowed upon our fellow creatures than is daily afforded the lower animals? At the present moment the condition of many of the working classes is degraded in the extreme." The Medical Officer of Health for St. Saviour, Southwark, wrote (1856):-- "In all our efforts at sanitary improvement we are chiefly dealing with persons who in most instances have not the power of helping themselves, and who until of late have had no source to which they might apply for aid in rendering their dwellings clean and wholesome." The Medical Officer of Health in St. Pancras wrote:-- "All who have made themselves acquainted with the condition of many of the poor of London will agree with me when I say that before their moral or religious state is likely to be remedied, their physical condition must be improved, and their houses made more comfortable. On you devolves, to a great extent, the solemn responsibility for carrying out the preparatory work." The Medical Officer of Health for St. Martin-in-the-Fields wrote to his Vestry in 1858: "To permit such grievous evils as are to be seen in the worst localities of this great city is a contradiction to the teaching of Christianity ... such outrages on humanity as many of the abodes of the poor are permitted to remain. "It is unholy, it is unchristian, that people should herd together in such dens; and so long as such dwellings are allowed to be occupied our assumed religion must be a pretence and a sham...." And thus, the Medical Officer of Health for Bethnal Green:-- "To open out avenues through our cul-de-sac courts, to promote the sanitary condition of every house, to arrest by thorough drainage and removal of refuse the elimination of aerial poison, are the great duties that we have day by day to do. Though the task before us be great, the objects in view are immeasurably greater--to exalt the standard of life, to economise rates, and above all to decrease the sum of misery, disease, and death.... To supply the arm strong to labour, to substitute productive for unproductive citizens, to decrease the death-roll of the young, and to protract life beyond the present span, these are the tasks that sanitary science imposes on us." The Medical Officer of Health for Clerkenwell pointed out that-- "The poorer classes have not the means of remedying the defective sanitary conditions under which they are living. But the Vestry has this power." The Medical Officer of Health for St. Pancras made a calculation that nearly 1,200 deaths in the parish in 1858 were due to causes which might have been prevented by sanitary improvements. "To every death we may safely assume more than thirty cases of illness. This gives us 36,000 cases of preventable disease in the year." "You will see," wrote the Medical Officer of Health for St. James' (1856), "that by diminishing death and disease, you are diminishing poverty and want.... The sanitary question lies at the root of all others. It is a national one and a religious one. It is true that in the exercise of your powers you will often be met by the assertion of the rights of property, but the right of life stands before the right of property, and it is this recognition of the sacredness of human life that lies at the foundation of sanitary legislation." The Medical Officer of Health for Whitechapel wrote:-- "I have in this report, as in duty bound, spoken plainly; if in the opinion of some members of the Board too plainly, my apology is--the deep sense I entertain of the importance of sanitary progress; for upon the success that shall attend the labours of those engaged in this most sacred cause depends the improvement of the social, moral, and intellectual condition of the people." And the Medical Officer of Health for St. Giles' made this pathetic appeal for action:-- "While you are listening to the remainder of this report, I trust you will hold in your mind how many lives are being sacrificed every month to deficiencies in sanitary arrangements." It is only here and there in the earlier reports of the Medical Officers of Health that specific mention is made of intemperance, but every reference to the subject showed how largely "drink" affected the sanitary condition of the people and intensified and complicated the evil conditions in which the people were placed, and rendered any amelioration, physical, moral, or religious, infinitely more difficult. It was becoming more and more generally recognised that a very large proportion of the deaths and of disease were preventable. "Any skilled eye glancing over the mortality tables will observe that a considerable number of deaths might have been prevented." "We are now to a great extent aware," wrote the Medical Officer of Health for St. Saviour's (1856), "of the physical conditions on which the lives of individuals and communities depend." The Medical Officer of Health for Fulham wrote in 1857:-- "Sanitary science and experience have full clearly proved to us how great an extent the prevention of disease and its extension rests with us." But against contagion and infection no precautions whatever were taken, and so disease was sown broadcast throughout the community, and death followed. As to suggested remedies and action there was a chorus of absolute unanimity upon some points:-- "The principal cause of the extent of zymotic disease," wrote the Medical Officer of Health for Mile-End-Old-Town, in 1859, "is the defective state of the habitations of the poorer classes. The remedy for the evil is only to be secured by a systematic house visitation. "... Without a general house inspection it is impossible to secure the proper entry to and use of the expensive sewers which have been and are being constructed. "Having done so much for the streets, pavements, and drains, the improvements will lose half their salutary effect if the interior of the dwellings are not placed in a corresponding condition of wholesome cleanliness." "It is," wrote the Medical Officer of Health for Whitechapel, "to the interior of the houses that our attention must be directed, for it is here that the source of disease is usually found.... An habitual and detailed inspection of the houses occupied by the poorer classes is therefore essential." A house-to-house visitation was, indeed, the first essential. By no other means could the actual condition of the abodes of the people be ascertained, and the breeding places of disease be discovered, cleared out, and rendered innocuous. And as there was a never ceasing tendency on the part of the poorer classes to sink into a condition of uncleanliness, and on the part of their abodes to fall into dilapidation, or, as it was expressed, "a pertinacity for dirt," so was constant inspection and supervision of vital necessity for the maintenance of any improvements made. "There are," wrote the Medical Officer of Health for St. Pancras (1858), "many parts of the parish densely crowded. Some of the people have become so used to filth, they appear to prefer it to cleanliness; at any rate, they have not the energy to get rid of it and improve their condition. Such houses--perfect hotbeds of infectious diseases--ought to be visited two or three times a year...." The Medical Officers of Health had one valuable object lesson before them in the common lodging-houses, which, regulated and inspected by the police under the Acts passed by Parliament, had shown that even the very worst conditions of life could be ameliorated, and that the very lowest and most miserable classes of society were not beyond improvement. "The chief points which are regulated by the authorities (the Police) are cleanliness, drainage and water supply, the separation of the sexes, and the prevention of overcrowding. The testimony of all who are acquainted with the dwellings of the poor is concurrent as to the immense sanitary advantages gained by the provisions of the Common Lodging Houses Act, and the results had been to improve in a marked degree the health, habits, and morals of the persons using these places."[75] "The cleanliness, comfort, and ventilation of the licensed rooms in common lodging-houses offer a very marked contrast to those which are unlicensed."[76] To more than one of these officers the idea occurred that similar benefits would follow if tenement houses were similarly inspected. "I believe considerable good might be accomplished by a legislative enactment placing every house let out in weekly tenements to more than one family under similar regulations to those affecting common lodging-houses, and rendering landlords liable for permitting overcrowding to exist upon their property." The success of the common lodging-houses was due to the enforcement upon the owner of the first essentials of sanitation in the house he let to occupants, and to the regular "inspection" of his house to secure that those essentials were maintained in a state of efficiency. But it was just these two things that were most held in abhorrence by the majority of tenement-house owners in London. The Medical Officer of Health for the Strand, after describing the overcrowding of tenement-houses, wrote (1858):-- "No remedy it is feared will be found until all houses of the class alluded to, the rooms of which are let out as separate tenancies, shall be compulsorily _registered_ under the supervision of the Local Authority of the District in which they are situate, as fit for the accommodation of a certain number of persons, and no more." "This suggestion will doubtless excite the sneers of the ignorant, the fears of the weak, and the ridicule of the selfish, coupled with the usual expressions about interference with the liberty of the subject; but the upright and unprejudiced will not fail to perceive that it is the liberty and the health of the working classes, forming, as they do, so large a proportion of the mass of the people which it is sought to protect from the tyrannical and grasping covetousness of an avaricious few who care little whether the health of the working man be destroyed, or whether his children be reared up in such a way that disease and vice must almost necessarily result, provided they succeed in obtaining for themselves an additional percentage upon their investment." And the following year he again forcibly adverted to the subject. "When it is borne in mind that in some of the small courts in this District there are packed together as many persons as almost equal in number the soldiers congregated in a commodious barracks, is the high death-rate a matter of surprise? But what can be done? The authorities, general or local, cannot surely be expected to provide suitable dwellings for the people! Undoubtedly they cannot; but it is incumbent upon these authorities, in the interest of the well-being of all classes of the community, to place a prohibitive limit in regard of overcrowding upon the class of houses the rooms of which are let out as separate tenements, which would, without hardship upon their occupants, speedily produce the desired effect. Such a condition, practically speaking, already exists in regard of most of the Public Institutions of this country in which large numbers of persons reside; such a condition is enacted by law in regard of our emigrant ships: such a condition is enforced by Act of Parliament in regard of Common Lodging Houses: and in all these instances the principle works well. Is it reasonable, then, that in relation to the influence of over-crowding upon health and life, less care should be taken of the people who occupy the densely populated districts of our great towns and cities than is already provided by law for the inmates of our Common Lodging Houses, or for the paupers admitted into our Workhouses, or for the emigrants who leave our shores? Surely the injustice cannot but be apparent." Other suggestions were also made. The Medical Officer of Health for Whitechapel wrote (1859):-- "If the public is to enjoy health, and a freedom from the ravages of epidemic disease, a stop must be put to the present scheme of erecting houses in crowded situations; for although the rights of property are to be respected, yet, in my opinion, such rights are of secondary consideration when compared with the public health and the increased burdens which must be borne by the ratepayers to support those whose sickness is occasioned by the unhealthiness of the localities where they reside." Several urged the vigorous enforcement of the existing law. To the Vestry of Lambeth the Medical Officer of Health wrote in his report in 1856:-- "You must proceed actively against those who have raised the value of their possessions by ignoring the value of human life, who wilfully multiply disease by neglect of their pestiferous property." The Medical Officer of Health for Hackney wrote (1858):-- "I feel assured that it cannot be too widely known that individuals will not be allowed to deal with their property in such a manner as to cause injury to the public health. For although individual liberty has long been the boast of England, yet there is a point beyond which it cannot be tolerated with safety; and private good should always be made to give way to the public welfare." The greater the light thrown upon the sanitary condition of the people of London, the clearer became the fact that the principal blame therefor rested upon the house-owner, lessee, or middleman, or as Parliament defined him, "the owner." Many of the Medical Officers of Health were outspoken and unhesitating in their opinion as to the responsibility of the house-owner for the existing condition of the dwellings of the people. "The enemies of the poorer classes," wrote the Medical Officer of Health for Clerkenwell, "are the landlords, who know well that proper lodgings for the really poor do not exist. They know also that if they buy at a cheap rate any old premises not fit for a pig-sty and let them cheaply they will be sure to find tenants." If it was not the real owner of the house, it was the middleman or person or persons between the owner and the tenant. Rents were high in most parts of London where there was urgent demand for accommodation, and "the yearly rental is unfortunately in many cases still further increased by the 'middleman system'; many of the houses being rented by an individual who sub-lets them in separate rooms as weekly tenancies, and this at an increase of 20 per cent. (Strand 1856):-- "And thus it is that health and life are daily sacrificed at the shrine of gain." What sort of property some of them held, and the condition in which they allowed it to remain, whilst they drew their "gain" from it, is graphically illustrated by the Medical Officer of Health in St. Olave's, Southwark (1856). He thus described the houses in three small courts:-- "The whole of these houses are held by one person, and it is impossible to imagine any state much worse than the condition of everything connected with their drainage, &c. "Here, within a small area, are thirty-nine houses, all having open foul privies, cesspools all filled, and many overflowing. The yards are foul, dirty, damp, and wretchedly paved with small, loose, broken bricks--most of them are daily filled with the overflowing of the drains and cesspools, the drains are all untrapped, and scarcely a house has a proper receptacle for water; they are mostly broken, dilapidated, uncovered tubs, placed close to the cesspools, so as to absorb the foul gases emanating from them. The effluvium on entering any of these places is abominable, and greatly complained of.... "These three courts are thickly inhabited." In the following month he reported nineteen houses in two streets very much the same as above. In the next month twenty more--in the month after, thirty more. He might almost have had the general description printed, with blanks for filling up the number of such houses and where situated. If it had not been for the new Acts passed in 1855, this condition of things would doubtless have continued indefinitely. That condition had been reached under absence of inspection, or regulation, and freedom on the part of the owner to do as he liked; and had no laws been enacted to terminate it, no change would ever have been effected. And when efforts were made by the local authorities to remedy similar places, strong opposition was met with. Thus in Hackney (1856-7):-- "1839 nuisances have been rooted out. In very many cases prosecutions have been ordered by the Board. They were almost invariably opposed by the offenders, generally people of substance, with the advantage of able legal aid, in the most pertinacious and resolute manner...." The novelty of enforcing upon the owners the improvements deemed necessary naturally raised in the minds of some of the Medical Officers of Health the question as to the justice of such a proceeding. Those who discussed it were clear upon the point. Thus the Medical Officer of Health for Shoreditch (1856-7) wrote:-- "The question of putting houses into a condition fit for habitation has two bearings. It is, _first_, a question between the landlords and the tenants, whose health is sacrificed by neglect. It is, in the next place, a question between the landlords and the ratepayers. "If the landlords neglect to make the necessary outlay in improving their property, the expense of maintaining that property in its unhealthy condition is thrown upon the ratepayers, for these have to bear the burden of supporting the sick and the destitute." And the Medical Officer of Health for Clerkenwell:-- "At present the poor rates are raised by the parish having to pay the expenses of afflicted poor persons, whose misery has in most instances arisen from defective sanitary arrangements, the remedying of which ought to have been effected at the expense of the landlords, who derive their substance from the miseries of the poor." And the Medical Officer of Health for St. George's, Hanover Square:-- "I am compelled to say that the number of dingy and dilapidated houses is a proof either that the owners of house property do not exercise sufficient control over their tenants, or that they themselves are grievously neglectful of their duties to their tenants and to society at large. The health of the Parish should not be allowed to suffer through the default of either landlord or tenant.... Here there need be no scruple about interference with private property. "No man is allowed to sell poisonous food, and none should be allowed to sell poisonous lodgings, more especially as the effects of poisonous food are confined to the persons who eat it--the effects of unwholesome apartments may be diseases that may be spread." On the equity of compelling the owners to put their houses in order, there are many insisters. "It is but right," wrote the Medical Officer of Health for Fulham (1857), "that those who have hitherto fed their own resources by impoverishing others, should now in their turn make good the damage." The Medical Officer of Health for Poplar (1856), wrote:-- "While on the one hand we must not proceed in a reckless manner so to burden property as to render it entirely unproductive, yet on the other we cannot allow the labouring man, whose health is the only property he can call his own, to live in unwholesome places to the destruction of that capital, by which alone he is enabled to support himself and family." And the Medical Officer of Health for Mile-End-Old-Town (1856):-- "... To charge such property (viz., in bad condition and heavily encumbered) with the costs of thorough repair, would leave the owners in some instances, I am fully aware, destitute, but life is more sacred, and possesses higher rights than property, and it cannot be just to inflict or continue a public injury while endeavouring to spare and sympathise with the inconvenience of an individual." That the evil state of the dwellings of the poorer classes entailed a charge upon the public was also pointed out by the Medical Officer of Health for Bethnal Green, who, referring to the miserable homes in the parish, wrote:-- "From the cradle to the grave their inmates are a direct charge upon our funds." Happily the law was beginning to be enforced, and beginning to create a little alarm among some house-owners. "As landlords are now aware that their property will be visited in rotation by the Inspector, the necessary alterations and improvements are frequently effected by them in anticipation."[77] Others did the necessary work when ordered to do it by the sanitary authority. Others, however, not until legal proceedings were taken, and they were ordered by the magistrate to do it--and even then some would not obey the magistrate's order, and the work had to be done by the sanitary authority, and the cost thereof levied from the owner. One case was recorded by the Medical Officer of Health for St. Giles', in 1858-9, in which the authority of the law was more strongly asserted. "While speaking of the resistance met with in enforcing sanitary requirements, it may be here mentioned that the extreme step of imprisoning the owner of a certain house has been had recourse to for his obstinate refusal to comply with a magistrate's order." That disease and sickness among the people entailed a great loss and heavy burden upon the community appears scarcely to have received any recognition up to this, and yet it was a truth of far-reaching importance. That individuals suffered was of course clear, but that the community did was by no means realised. Several of the Medical Officers of Health promptly discerned how true it was, and in their earlier reports dwelt upon it, pointing out the effects, and emphasising their great importance. "It cannot be too often impressed upon our minds," wrote one, "that sickness among the poor is the great cause of pressure upon the rates; and everything that will tend to diminish the number of sick will be so much saved to the ratepayers."[78] "The greater the amount of disease," wrote another, "the larger the proportion of pauperism." "Of the causes of pauperism, none are so common as disease and death," wrote another. Indeed, a little consideration must have demonstrated its truth. Difficult as it was for the individual in health to earn a livelihood--when sickness fell upon him there was the instant and complete cessation of his wages, and there were expenses incurred by his sickness. If he recovered, there had been a long disablement from work, and a heavy loss. If, however, he died, the community suffered by the loss of his productive labour, and, where the victim was the breadwinner of a family, his widow and children but too commonly became a charge upon the rates. "High mortality in a district," wrote the Medical Officer of Health for Clerkenwell (1858), "especially among the poor who are the principal sufferers, does not relate simply to the dead; the living are also deeply concerned. Every death in a poor family causes an interruption to the ordinary remunerative labour, and produces expenses which have to be paid out of scanty wages. Hence the living suffer from want; the parish funds must be appealed to; families become parentless, and next comes crime." The Medical Officer of Health for Whitechapel (1858) wrote:-- "In the course of time the public will learn that sickness, with its concomitant evils, viz., the loss of wages, the calls upon clubs and friendly societies, the increased amount of charitable contributions, a heavier poor rate, &c., entails more expense upon the community than would be required to carry out sanitary improvements in widening streets, converting the culs-de-sac into thoroughfares, and in erecting more commodious houses for the poor." And the Medical Officer of Health for the Strand wrote:-- "Of every death which occurs in this district over and above the ordinary rate of mortality, the number of _cases of illness in excess_ must be a high multiple. And during every attack of severe illness the patient, whatever his position in life may be, must be maintained--if wealthy, at his own expense, if poor, at that of the community at large. And in the latter case, the community at large must thus suffer a direct loss. _Health is money_, as much as time is money, and sooner or later sickness must be paid for out of the common fund...." And the Medical Officer of Health for Shoreditch (1856) wrote:-- "To communities as well as to individuals there is nothing so expensive, so fatal to prosperity, as sickness. To a productive and labouring community, health is the chief estate.... A community is but a system of individuals--if one portion of that system be disabled by sickness, every other portion will feel the blow; the whole community will be taxed to support that part which is rendered incapable of supporting itself. It is then a plain matter of self-interest, as well as of solemn obligation, to exercise the most vigilant care in preserving to the poor their only worldly possession, their health and capacity for self-support." Nor did the danger to the great community of London, from the prevalence of sickness in any particular district, appear to have received the faintest recognition. And yet, in the matter of health, and protection from infection, all classes from the highest to the lowest had equal interest; for disease commencing or raging in one district is not long in spreading to other districts. The Medical Officer of Health for Chelsea (1857-8) wrote:-- "It cannot need any argument to prove that diseases of an epidemic or infectious nature cannot be arrested in their progress by the imaginary line drawn around the boundaries of the parish--that the smoke from the furnaces in Lambeth and Vauxhall must be wafted across the Thames and influence the health of the inhabitants of Chelsea, if not kept in check, and that evils of minor importance in Pimlico, on one side, and Kensington on the other, may be quite as prejudicial to the health of the neighbours residing on this side of the boundary as to those among whom they are generated." That any one locality had a duty to its neighbours, still less to London as a whole, as well as to the people of its own area, was beyond the range of the ideas of the vestries and district boards. Indeed, if their sense of duty did not induce them to look after and safeguard the people for whose sanitary condition they were immediately responsible, how could it be expected of them to be influenced by considerations as to those residing outside their area, and residing many miles away. And yet, by the very condition of things, this greater responsibility did exist. But the great fact that in the vital matter of the public health London was one great community, the various parts thereof being indissolubly welded together into one great whole, had not as yet apparently dawned upon the minds of the newly-created local authorities; nor, indeed, had Parliament even realised it, for it had left the forty and more of those authorities full freedom to scatter disease of the deadliest type from one end of London to the other, and to imperil the lives of London's inhabitants. The reports of one of the Medical Officers of Health give such an exceptionally complete and vivid description of the condition of the parish to which he had been appointed, and in which he worked, that a series of extracts from them are given. The parish was the parish of St. George-the-Martyr in Southwark, on the south side of the river, just opposite the City; "low-lying and flat, and about half a foot below Trinity high-water mark," with an area of 282 acres, and a population of about 52,000 persons, and the Medical Officer of Health was Dr. William Rendle, who speaks of himself as "an old parish surgeon." "If a loose drain conducts stenches into a man's house instead of out of it, if the concentrated filthiness of a gully is blown into a front door or window, if a house often visited with fever has not been cleansed or whitewashed for many years, if there is no water but putrid water filled with disgusting living creatures, and no butt except a rotten one, not even the most enthusiastic lover of things as they are can find fault with us if we try to alter these things for the better.... "Let us picture to ourselves the man of the alley come home from work. "The house is filthy, the look of it is dingy and repulsive, the air is close and depressing; he is thirsty: the water-butt, decayed and lined with disgusting green vegetation, stands open nigh a drain, and foul liquids which cannot run off are about it, tainting it with an unwholesome and unpleasant taste; the refuse heap with decaying vegetable matter is near, and the dilapidated privy and cesspool send up heavy, poisonous, and depressing gases. Such are the homes, may I say, of thousands in this parish?" He contrasts the public-house with that, and says: "The surprise is not so much that one man here and there reels home drunk and a savage, as that for every such a one there are not twenty. Gentlemen of the Vestry who have seen these things can bear me witness that I do not exaggerate. This is no fancied statement.... "This parish has always been remarkable for its deathly pre-eminence. Hitherto there has been no sufficient law. After this we shall stand without excuse.... "... Who is to say, when the question is improvement, as to where we shall stop? No doubt there is a question of more or less rapid progress, so as to hurt existing interests as little as may be.... "Our intrusive visits, as some would call them, into filthy and diseased houses, benevolent as they are, on behalf of those who cannot always help themselves, have example even in the most remote times and from the highest authority. The ancient authority was more imperative, and made it more a matter of conscience. In the ancient Jewish law it was ordained 'that he that owneth the house shall himself come and tell the Priest, saying: "It seemeth to me there is, as it were, a plague in the house."' The Priest was then to command the emptying it, so that "all in the house be not made unclean." He was then to cause it to be scraped within and about, and finally he was to pronounce when the house was clean, and might be again inhabited. "The Priest was, you perceive, the Medical Officer of Health under the Jewish law, and this text of Leviticus is the 13th section of the Diseases Prevention Act.... "From what I see of the parish we cannot without inconveniently close packing hold many more.[79] "The growth of our parish is not from births alone; some persons of course immigrate from other parts of England, but the greater part come from Ireland, bringing with them disease and poverty.... "I am afraid that the poor of other parishes are forced upon us. We increase in poverty, and, paradoxical as it looks, the poorer we get the more we shall have to pay. "There are now from 6-7,000 cases of illness per year attended by the poor-law surgeons. "Our poor work at the waterside, in the city, and at the docks; their productive labour helps to pay the rates of other parishes, but in difficulty and sickness they live and lean upon us. "Now as to _overcrowding:--_ In Lewisham there are 2 persons to an acre. " Camberwell " 13 " " " " Rotherhithe " 21 " " " " All London " 30 " " " " Newington " 104 " " " While we have 184 " " " And in one of the parts of the parish 244 " " " "Our parish is now almost completely built over. "In 1850, out of 1,169 deaths 565 (or one half) were under 5 years. "In Bermondsey, 506 out of 983. "Our parish and Bermondsey are quite ahead (of others) in this unenviable race towards death." "The contents of our sewers can only be discharged 4 hours each tide--8 hours each day--the remaining 16 hours daily they are reservoirs of stagnant sewage." "We are sadly deficient in sewers. At least 100 courts, alleys, and back streets are entirely without drainage.... Some of our sewers have remarkably little incline. That in Friar Street, a most important one, is so level from Bean Street to Suffolk Street that it has a most curious quality for a sewer, that of flowing either way equally well. "One very prevalent evil is loose brick drains which let the deadly gases into houses." "... We are a most melancholy parish, low in level and low in circumstances. The lowest and poorest of the human race drop from higher and richer parishes into our courts and alleys, and the liquid filth of higher places finds its way down to us. We receive the refuse as well as the outcomings of more happily situated places." His report for 1857 continued his description:-- "We lose annually 30 per 1,000--there are only two parishes worse than we are. Some at least of this mortality is preventable. If we could keep to the average of all London we should lose 300 less a year; or even to that of Bethnal Green we should lose 200 less. "Few people believe we are so bad as we really are, and if we do not believe we shall not of course try to mend it, but it cannot be denied. "The rich Londoners pay a low poor-rate. The poor Londoners pay a high poor-rate. This bears hardly upon us; it stifles us: more and more packed, more and more impoverished; with very little space between the poor ratepayer and the pauper, there is more sickness and death. "Density of population brings you more deaths, more sickness, more expense. "The dreadfully vitiated air of our courts and close rooms produces and fosters consumption." Commenting on the common lodging-houses, he wrote:-- "The police regulations for order, cleanliness, and prevention of disease are in the highest degree satisfactory.... The benefits are so great that the employment of the same regulations in the more crowded and filthier houses of the poor can only be a question of time. It is the highest humanity to quicken the progress. "Vestries have power sufficient for the purpose. The need is so great, so undoubted by those who have seen the evils with their own eyes, and the benefit to be obtained so certain, that if the local authorities do not enforce the improvements, the police will have to do it. "As to the overcrowding, I have brought many cases before you, each from illness resulting in difficulty of cure, constantly recurring. 'I can never get out of that house,' said the district surgeon of one of them. The eight rooms in this house were always full, the receipts £2 2s. a week, yet it was dirty, neglected, and overcrowded. So the poor live, and I may say, so they die." "As to some manufactories, some of them are very bad, and their pernicious influence spreads widely. I do not think any manufacturer should be obliged to leave; trades must, of course, be protected; but one man must not, to save a little expense in his building and machinery, be allowed to poison a neighbourhood, containing as this does some 30,000 people. "There are various ways of making almost all of them bearable." "In this parish are at least 4,000 houses rated under £10 a year, and containing 30,000 persons." 1858. _1st Quarter:_-- "Of smallpox and vaccination there are some who neglect this great precaution, and so not only imperil themselves but others. Here is the evil, and indeed, I believe, the reason why the disease is not altogether banished." "... A case registered as diphtheria occurred and died; it began in one of the very worst localities and then extended to opener and better places. Thus it is that modern society neglects the social condition of its poor, and the poor with a well-ordered revenge bring disease and death as a consequence." Referring to some tables he compiled, he said:-- "In this table appear 42 deaths from consumption; it has but recently become prominent how very preventable a disease this is ... the principal causes have here been made obvious enough: sleeping closely in ill-ventilated rooms, overcrowding, and bad ventilation." "It is now quite established that, with close overcrowded rooms--that is, by assiduously causing the continued breathing a tainted atmosphere--you may insure consumption in the most healthy. "3,500 years ago the Jewish legislator promulgated laws and duties almost identical with those we are now engaged in carrying out as new in the nineteenth century--but so it is." "... There is a great deal of carelessness touching human life, and a great want of common sense or serious thought in the preserving it. Much is left to chance. There is either fatalism or stolid indifference upon the matter pervading highest society, and the poor, driven as they are from richer districts into poorer neighbourhoods, can scarcely help themselves; they lose at last all healthy communication with richer or better neighbours, and all taste for pure air and healthy pursuits; they pack close, they descend a little, often a great deal, toward the lower animals, and so live neither for this world nor the next." "There are 7,000 houses in this parish. 890 of these have been visited this year, and in 756 the work ordered has been carried out--sometimes in a most slovenly manner--an apparent compliance with your orders. In the poorer districts the most incompetent men are employed to plaster over, patch over, whitewash, or cover over the evils ordered to be _not covered but amended_. Still a great amount of good work has been done. "... Overcrowding is the normal state in our poorer districts. Small houses of four rooms are usually inhabited by 3 or 4 families, and by 8, 16, or 24 persons, _e.g._, 133 inhabitants in 8 houses ... a filthy yard generally implies a filthy house and unclean habits" ... "this parish with its thousands of refuse heaps." "I know that we are on the right track. May Pole Alley, a cul-de-sac with its 23 houses and 180 people, was once a nest of infectious diseases. I attended some 10 cases of typhus there, some of them malignant enough to destroy life in 48 hours. With great trouble this court has been cleansed and amended. It is very much more healthy." 1858. _2nd Quarter:_-- "June--an exceedingly hot and dry month. You may judge of the effect of such temperature upon exposed dung-heaps, wet sloppy yards, and rotten, filthy, uncovered water-butts; three characteristics of this parish.... "The Surgeon of the District writes thus to the Board of Guardians: 'The smell is very bad from a horse-boiling establishment in Green Street, which causes a great increase of sickness near that part.' This of course refers to the bone boiling and other like establishments, of which there are, in this one small street, three cat gut manufacturers, one soap boiler, one horse slaughterer, and four bone boilers--all very offensive trades. I am receiving complaints in all directions as to this matter. I am inclined to think that this is not altogether just to the 20,000 inhabitants who live within the effluvia circle of Green Street." As to infantile mortality he writes: "I confess I see but little difference between that sanguinary ancient law that directly destroyed weakly and deformed children, and that modern indifference that insures at the very least an equally fatal result" ... "these disturbing truths involving so much trouble and expense, and giving us painful reminders of new duties, as well as of old ones neglected." He complains of having to neglect a great many cases of insanitation owing to want of staff. "... Of those upon whom orders come to remove nuisances, &c., a large number are objectors, and not a few positive obstructors...." "The items in this last table merit attention, and throw a sad sort of light upon the condition of the poor of this parish. We have visited 73 unclean and ruinous houses; 118 in which the water was stored in a most unwholesome manner; 163 in which the drains were defective enough to be disease producing; 72 in which the w.c.'s were more or less unfit for use; 110 yards sloppy, not paved, or ill-paved; and 138 in which there was no sufficient provision for house refuse.... "We are packing more and more closely. "In the great mass of our poorer habitations the allowance of breathing room is not more than 200 cubic feet per head--often as low as 120. In one house reported to me there were 30 in four rooms with only 2,410 cubic feet, or 80 cubic feet per individual. This must, of course, be premature death to many of them.... "We cannot overlook what is going on: improvements are being effected elsewhere, the dwellings of the poor are being destroyed, a few parishes are fast becoming pre-eminently poor, over-crowded, and filthy. I need not tell you that this parish is one that gets in this respect steadily worse from the improvement in others. "The temptation is very great to overcrowd; the poor family, however large, by crowding into one room, and by even taking a casual lodger in addition, obtains a sort of home at a cheaper rate, and the owner gets a much larger revenue out of what I must, I suppose, call human habitations. The resulting illness and death are considered inevitable, or are viewed with a stolid indifference." 1858. _3rd Quarter:_-- Of the greatness of the mass of prevalent evils he wrote: "I have often reported it here, but the very enormity of the evil blunts our appreciation of it...." There had been a high mortality in the Quarter. "We are once more, I believe, the worst parish in London...." "The back districts of this parish require relief, as much as Ireland ever did, from a class of middlemen who, with some few most honourable exceptions, grind out all they can from the most squalid districts, and carry nothing back in the way of cleanliness or improvement." He gives a long list of streets and courts and places where disease was rampant and deadly owing to the insanitary conditions. "It may perhaps be said that all this is in the order of nature, and cannot be prevented. My experience of a quarter of a century among these diseases points quite the other way. Providence does not intend that reservoirs of stinking putrid matter shall stand so close to the poor man's door as to infest him at bed and board.... In the Jewish scriptures the places for the purposes here mentioned are ordered to be without the camp, as far from the breathing and eating places as possible; and among us, as you see, when we tolerate such abominations, He visits us with death. It is the result of the irrevocable laws of nature often averted by what appear as happy accidents, but at last, when disregarded, deadly. Gentlemen, you are the trustees for life and death to a population of well-nigh 30,000 people, who from the force of circumstances are more or less unable to help themselves...." "Of course it cannot be expected that we can provide the homes of the poor with the orderly arrangements and benefits of these Institutions (Dispensaries, &c.)--that, however, will form no excuse here or hereafter for not carrying out the improvements we can easily achieve, and which a wise legislature has given us full authority to do." "Total deaths in Quarter ended October 2nd, 1858--369, of which 225 were of children under 5 years = 61 per cent!!" The whole tone of this report was such that he could not possibly continue as Medical Officer of Health to a then existing Vestry, and he resigned. He was succeeded by another very able man, Dr. Henry Bateson, from whose reports may be continued the description of this parish up to the census of 1861. "The onward moral and intellectual progress of the human race depends far more upon the sanitary state which surrounds it than has ever yet entered into our imaginations to conceive.... "We have suffered severely from the ravages of smallpox. Smallpox is a disease over which we have perfect control, and which, were vaccination thoroughly carried out, might be banished from these dominions." "... Men whose nervous systems become depressed and the tone of their system generally lowered, become the subjects of a continued craving for stimulants." "... Our wells are but the receptacles of the washings from our streets, the off-scourings from our manufactories, the permeations from our cesspools, and the filterings from our graveyards." 1860-1861. After five years' local government:-- "The circumstances are various and complicated, which contribute to prevent the improvement of the district, and even make the endeavour seem at times hopeless. No one can know the fertile sources that exist for producing in the mind this feeling of despair save those engaged in sanitary labours; or those perchance whose duty it may be to visit our poorest and lowest localities." ... "It is no light and easy work to remove the aggregate evils of centuries which, like the coral reefs of the ocean, have grown up silently and continuously to their present magnitude.... There are hindrances all around, some of which are unsurmountable, such as those arising from the imperfections of the law itself ... there are also vested rights, customs, ignorance, stupidity, and avarice, all of which have to be dealt with and overcome if possible." "Nature never pardons. Obey and it is well; disobey and reap the bitter consequences." Referring to some houses "of the worst description, having no yards, nor even windows behind, so that ventilation was impossible," he says: "I am sorry to say that there are numbers of similar houses still standing, and occupied by the most ignorant and degraded of our population--a class living almost in the neglect of laws human and divine; and as heedless about the present and the future as the very heathen themselves...." "The state and condition of the dwellings of the poorer classes are a stain upon our civilisation." "... No one can conceive, nor would they believe, unless eye-witnesses, the wretched circumstances in which vast numbers of families have to spend their lives. It is indescribable." "The daily task of keeping clean their houses and families, once a pleasure to them as well as a duty, having to be performed amid overwhelming obstacles on every side, from which no hope of escape remains to cheer them on, is gradually neglected and ultimately abandoned, their spirits become torpid and depressed, and this is necessarily followed by the derangement of the functions of the body. Finally they become reckless, and this recklessness increases the evil which gave it birth. There is action and reaction. What marvel then that, like unto those about them, they float down the ebb tide towards the dead sea of physical dirt and moral degradation. It has been truly said by Dr. Southwood Smith, 'The wretchedness being greater than humanity can bear, annihilates the mental feelings, the faculty distinctive of the human being.'" "The heedlessness shown in the building of houses is astonishing. No care is taken about the nature of the subsoil, the position, the ventilation, and means of cleanliness. They are run up anywhere and almost anyhow, and too often become the prolific source of disease." And he quotes: "No man has a right to erect a nuisance, and the public has clearly as good a right, as great an interest in enforcing cleanliness to prevent the outbreak of an epidemic as in requiring walls to prevent the spread of fire. Yet, where one is destroyed by fire, how many thousands are there destroyed by disease, the indirect result of such erections?" "We are desperately careless about our health, and apparently esteem it of small value. A great modern writer has truly said: 'The first wealth is health. No labour, pains, temperance, poverty, nor exercise that can gain it must be grudged. For sickness is a cannibal which eats up all the life and youth it can lay hold of, and absorbs its own sons and daughters.'" The descriptions here given enable us to realise how terrible and pitiable a state of things had been reached, and the depths of filth, and misery, and abomination into which the people had been allowed to sink through the indifference of Parliament, the absence of any local government, and the neglect or avarice of the "owners." One hope there now was. Parliament had at last made laws to remedy these evils, and local governing authorities had been created to administer and enforce the laws. In 1858 a Public Health Act was passed by Parliament, which put an end to the existence of the Board of Health, and transferred to the Privy Council the administration of the Diseases Prevention Act. And the Privy Council was authorised to cause inquiry to be made in relation to matters concerning the public health. In 1861 a medical department of the Privy Council was formed which has in many ways been of immense service to the cause of public health, and which, as time went on, developed towards a true Ministry of Public Health. All things considered, by the end of the first five years of the working of the new local constitution conferred upon the metropolis, a real beginning had been made in the sanitary evolution of the great city. Some of the grossest evils had been attacked, and a start made in lifting London out of the depths of the appalling slough of abominable filth in which it had become submerged. In some of the vitally important matters progress was material. The improvement in the water supply was considerable, the main drainage works had been started; the construction of many new sewers, the abolition of great numbers of cesspools, and the better drainage of houses, were all events of a decidedly satisfactory character. And the death-rate of London as a whole showed a slight decrease--from 23·38 per 1,000 in 1851 to 23·18 in 1861. In some districts there was an increase--in the majority, however, there was a decrease. But most encouraging of all was the direct evidence afforded by experience as to the effects of sanitary improvements. Thus, in Whitechapel, the Medical Officer of Health, in reporting that the cases of fever had diminished from 1,929 in 1856 to 190 in 1860, said:-- "This diminution may be fairly attributed to the additions made to the sewerage of the district, the improvements effected in the drainage of 2,172 houses, the abolition of 3,002 cesspools, the better paving of many of the courts, the systematic inspection, &c., of houses where fever occurred, the removal of 37,607 nuisances, and to the abolition of several offensive trade nuisances." And the Medical Officer of Health for Shoreditch wrote, in 1861:-- "That the diminished mortality and the lesser frequency of epidemic diseases are really due in great measure to sanitary works and inspection is proved by the diminution and even disappearance of certain forms of sickness from streets, courts, and districts where sewers have been constructed, ventilation provided, and other improvements effected; whilst, on the other hand, the districts still requiring those necessary reforms furnish far more than their proportion of the epidemic sickness and mortality." Philanthropic individuals were increasing their efforts for the improvement of the people; and societies, working on a self-supporting basis, were taking more active interest in the housing problem, and erecting model lodging-houses and more healthy habitations.[80] Public opinion was more interested than before in sanitary matters, and it was thought that the working classes had also in some degree awakened to the care of their own health. "Altogether," wrote the Registrar General, in his report on the health of London after the census figures of 1861 were known, "there is abundant proof of that increased regard for human life that attends civilisation." FOOTNOTES: [54] 18 and 19 Vic. cap. 120. [55] 18 and 19 Vic. cap. 121. [56] 18 and 19 Vic. cap. 122. [57] Section 103 of Metropolis Local Management Act. [58] There is in the library of the London County Council an almost complete set of these annual reports inherited from the Metropolitan Board of Works. Unless those sent to the Secretary of State, as directed by the Act, have been preserved, there is no other collection in existence. [59] St. Giles'. [60] Fulham. [61] Rotherhithe. [62] Hackney. [63] Medical Officer of Health, 1856. [64] "Lungs for London," _Household Words_, vol. i. p. 45, 1850. [65] P.P. 1852-3, vol. lxxviii. p. 327. [66] Clerkenwell, 1856. [67] Fulham, 1857. [68] Whitechapel, 1857. [69] St. Giles', 1859. [70] St. George the Martyr, 1859-60. [71] Strand, 1859-60. [72] Clerkenwell, 1860-1. [73] 14 and 15 Vic. cap. 34. [74] Shoreditch, 1859-60. [75] St. Giles', 1857-8. [76] St. Olave, Southwark, 1856. [77] Whitechapel, 1857. [78] Whitechapel. [79] Population went up from 51,824 in 1851 to 60,278 in 1896. [80] "The moral and social benefits conferred by these buildings has been immeasurable," wrote one Medical Officer of Health (St. Pancras). "They are institutions whose larger acceptance would save the lives of hundreds, and reclaim the morals of thousands," wrote another. CHAPTER III 1861-1870 THE Census of 1861 disposed of the various estimates of the population of London, and of the death-rates in its various parishes, and gave authoritatively the actual figures. From 2,363,341 persons in 1851, the population had gone up to 2,808,494 in 1861--an increase not very far short of half a million; and the number of inhabited houses had increased from 306,064 to 360,065. The natural growth of the population, or in other words, the excess of births over deaths, accounted for but part of this increase. The rest was due to the great stream of immigrants into London, which, notable previously, "continued to flow thither with unabated force." The increase was not equally distributed. The population of the central parts showed a decline. There the great economic forces were most powerful, and under their influence the population of the "City" had decreased by more than 15,000: that of Holborn and St. Martin-in-the-Fields by nearly 2,000 each: that of St. James', Westminster, by about 1,000, and two or three others slightly. But elsewhere--east, north, west, south--the increases had been great, and in some instances remarkable. Poplar had increased in the decade by 32,000; Islington by 60,000; St. Pancras by 32,000; Paddington by 29,000. And on the south side of the river, Wandsworth had increased by 20,000; Newington and Camberwell by 17,000 each; and Lambeth by 23,000. The rate of growth in the various wards or parts of the parishes showed, both as regarded persons and houses, great differences, the most rapid increases being in the parts nearest to the centre of London. A most material factor in the sanitary evolution of any great city, and especially so of London, is the introduction into its population of fresh elements from the outside. The returns collected by successive Census Commissioners gave considerable information upon this point. "London is the metropolis of the Empire," wrote the Commissioners of 1861, "and thither the representatives of other nations, of the Colonies, and of Scotland and Ireland resort; but it is chiefly the field in which the populations of the several counties of England find scope for their talents and their industry." The majority of the inhabitants of London in 1861 were indigenous, for 1,701,177 were born within its limits; 1,062,812 were born elsewhere. Of these 1,062,812, close on 36,000 were born in Scotland, 107,000 in Ireland, 19,000 in the Colonies, and 48,000 were foreigners. The remainder--amounting to about 893,000--were born in the extra-metropolitan counties of England and Wales. "Proximity to the metropolis, and the absence of manufactures at home, first drew the natives of these counties to London. The stream of immigrants from the south-western counties was large: Cornwall, Devon, Dorset, Somerset, and Wiltshire having sent 128,422 of their natives to be enumerated in London." Likewise the stream from Norfolk and Suffolk was large. But the great bulk of the immigrants came from the counties immediately around London. To put the figures in simple form--of every 1,000 inhabitants of London, 606 were born in London, the remaining 394 were born elsewhere. And the census provided also the means for ascertaining as correct a death-rate as could be arrived at. In 1851 the death-rate was 23·38 per 1,000; in 1861 it was 23·18--not much of a decrease, but satisfactory in showing that some of the evil powers of insanitation were stayed. It is, however, always to be borne in mind that either the death-rate, or the number of deaths, gives but an imperfect and incomplete picture of the sanitary condition of a population. It tells but the tale of those who have died of disease--it leaves uncounted and untold the far greater number of those who have been either temporarily disabled or maimed for life by disease. Estimates vary considerably as to the number of persons who suffer from disease and recover; and the proportion of recoveries to deaths varies in different diseases, some diseases being so much more deadly than others. But the sick-rate is always, and under all circumstances, very much greater than the death-rate. The mere taking of a census could have no visible or actual effect; the routine of life and the action of the various economic and social forces continued unchanged; but the information gained was of the utmost value. The figures and the facts recorded afforded startling demonstration of the immensity of London, and of the growing gravity and complexity of the great problems of London life. London was huge before--appalling almost in size and population; now it was shown to be huger than ever. Everything was on a more enormous scale. The masses of population were far larger, and were rapidly increasing; and with this increase everything concerning their existence became more and more complicated, and every reform more and more difficult. The removal of evils affecting their physical and social being would be a heavier task, the supervision of their conditions of life more onerous and exacting, and the provision of a government to secure their well-being a graver problem than ever. One of the great forces unceasingly at work, and one of the great contributory causes to insanitation and to the maintenance of a high death-rate was, undoubtedly, drink. It led to poverty and overcrowding, it led to ill-health and greater susceptibility to disease; and the evils acted and reacted upon each other indefinitely--a vicious circle from which there was no escape, overcrowding leading to a craving for drink, and drink resulting in poverty and therefore overcrowding with its attendant evils and high mortality. Since the unfortunate moment in 1830 when Parliament deemed it expedient "for the better supplying the public with beer" to give greater facilities for the sale thereof, and scattered broadcast throughout the nation the seed of unlimited evil, facilities for drink not only of beer but of spirits have been practically unlimited. Against this source of evil, which is often mentioned in their reports, neither Medical Officers of Health nor Vestries could contend, and had no power to contend. But all through the history of the sanitary evolution of London this deep underlying curse was present, acting as a perpetual clog upon sanitary and social progress--a horrible, all-pervading and tremendous power for evil. In the earlier years of this new decade of 1861-70 the central government--the Metropolitan Board of Works--was demonstrating the great utility of a central governing authority for London, and a task was nearing accomplishment which was absolutely the first essential, the very foundation of an improved state of the public health. It was engaged in pressing vigorously forward the great system for the sewerage and drainage of London designed for taking off the sewage and refuse waters of a prospective population of three and a half million persons, and the rainfall of a drainage area of 117 square miles. Until those works were completed no great degree of sanitary improvement could be expected. In 1861 the Board reported that a portion thereof had been finished, and as the work gradually progressed the Vestries were able to avail themselves of the deeper outfalls afforded, and to undertake drainage works in their several areas. By 1865 the great task was virtually accomplished. Eighty-two miles of main intercepting sewers had been constructed, and the sewage was being conveyed away by them several miles distant from London. Their completion enabled the Metropolitan Board to fill in the open sewers, which had so long polluted the atmosphere, and been such a fertile source of disease in the districts where they existed, and took away from the Vestries any excuse for delay in carrying out the construction and putting in order of the local sewers for which they were responsible. The central authority had thus brought into existence a gigantic system of sewerage by which the river near London ceased to be the main sewer of London, and the whole of the metropolis was relieved of many of the most powerful causes of fever, cholera, and other destructive diseases. It was a great work, admirably and expeditiously carried out, and it cleared the way for other sanitary reforms which were impossible without an effective general system of sewerage, yet which were essential if a satisfactory condition of the public health were ever to be attained. The central body also proved its great utility by securing uniformity in the sewerage and drainage works which fell to the duty of the local authorities to carry out. All plans by the Vestries had to be submitted to the Board so that the Board might see that they were consistent with the main system. Both main drainage and house drainage were thus steadily being extended and improved, but in many places things were still outrageously bad. Nor had the creation of fresh evils been effectually prevented, for from Bromley came the complaint that several new estates were rapidly being covered with small house property which drained into cesspools. And the Medical Officer of Health for Fulham wrote (1866):-- "The active operations of your Board have fortunately relieved the Fulham district to a large extent from that pregnant source of mischief--want of drainage; still there are large tracts of building land yet unprovided for, on much of which houses by dozens are being squatted without any regard to this great essential by the builders, save the horrid cesspool system. It is enough to have to counteract the evils of past imprudence without perpetuating them by such wilful recklessness...." The supply of water to the inhabitants of London was of equal importance to an efficient system of sewerage. The problem had by no means been solved by "The Metropolis Water Act" of 1852, which had enacted that within five years after the passing of the Act a constant supply should be given by the companies. Unfortunately, the supply was in the hands of various public companies over which the local governing authorities had practically little or no control, and, like all sanitary legislation of this period, the results were not commensurate with the intentions of the Legislature. An illustration of how insufficient the supply was, was detailed in a report of the Medical Officer of Health for Whitechapel in 1862:-- "A return has been made by the Inspector of 133 courts in the district. "Of these--in 48 which contain 388 houses and have a population of 3,233 persons the water supply is by stand taps only, from which the water flows daily (Sundays excepted) for a period varying from quarter to half an hour. "This intermittent supply is totally inadequate to the wants of the people." Parliament made an effort in 1862[81] to amend the law, and enacted that where a house was without a proper supply of water the owner or occupier might be required by the Vestry to obtain such supply, and if such notice was not complied with, the Vestry might do the necessary work and recover the expenses from the owner, and then require the water companies to supply the water. But the Act was of little practical value, and was made of less value by the inaction of the local authorities. A few extracts from reports of Medical Officers of Health show how thoroughly unsatisfactory and disastrous to the health of the people the existing condition of affairs was. The Medical Officer of Health for Fulham wrote in 1864:-- "The powers at present given by Statutes for enforcing a supply of water for domestic use are, within the Fulham district, all but inoperative. The cry amongst the cottagers is still for water--water without which all other sanitary appliances are at best abortive, without which in ample and continuous flow no community can be preserved in healthfulness. On this essential will depend the perfect working of our deep and costly sewers, on this alone will hang success in minor drainage matters. Water, that first and most important element of health and cleanliness, exists in name alone in masses of our cottage property here, and consequently neither purity of person nor of dwelling can be ensured." The Medical Officer of Health for St. Martin-in-the-Fields wrote in 1864 deploring that the new laws of the water companies did not provide for water being supplied on Sunday. "It is to be lamented that people should at any time have to go about begging water, and more especially so on Sundays, the very day they most require it." And the Medical Officer of Health for Westminster wrote (1864):-- "The water supply to many of the courts and alleys is very unsatisfactory. No Sunday supply. "It does seem a monstrous arrangement that for 52 days in the year the public should be deprived of that which they pay for, but have no means of substituting by anything else." And to complete the hardships which the people suffered under in the matter of water supply, if the house-owner did not pay the water rates when called upon to do so, the water company might cut off the supply of the people in the house. This was frequently done, and the Medical Officer of Health for Whitechapel recorded how for four months-- "The inhabitants of Tuson's Court, Spitalfields, had been entirely deprived of water in consequence of the water company refusing to continue any longer the supply, as the landlord had not paid the water rate." The quality of the water, though improved by the change of intakes to the part of the Thames above Teddington Lock, left very much to be desired. It was no longer contaminated by the entire sewage of the metropolis, but it was still by sewage poured into the river and its tributaries by towns higher up--Oxford, Reading, Windsor, Chertsey, Hampton, and others--and received, unchecked, the whole of the pollution, solid and fluid, of the district constituting the watershed. And this same water, after it had been so polluted, was abstracted from the river, sand-filtered, and pumped into the metropolis for domestic uses and distributed to the consumers.[82] The housing of the people was the problem which, above all others, was more and more forcing itself upon the attention of those whose work brought them into actual contact with the conditions of life of the great mass of the people who were in their charge; not merely the construction of the houses or their situation, but the accommodation afforded and the conditions of life therein. "Our forefathers," wrote one of the Medical Officers of Health, "knew nothing about the public health, and cared less. They added house to house, and street to street, according to their own will and apparent benefit, and so have left us this mingled heritage." And there were streets and courts and alleys which were not fit for human habitation, and which could never be made so; and thousands upon thousands of houses where "nothing short of a hurricane would suffice to displace and renew the air." London had enough to suffer under from the state of the existing houses, and an appalling task before her to remedy them, but not alone was this enormous evil practically unattacked, but fresh sources of evil were allowed to be created, and new houses were being erected which would carry into the future the evils which efforts were now being made to put an end to. "A house may be built anywhere," wrote one of the Medical Officers of Health in 1862, "and almost anyhow, provided all the rooms can be lighted and ventilated from a street or alley adjoining. The object of the builder is to save as much ground, materials, and expense as possible. The result is not difficult to foresee...." No regard, moreover, was had to the ground on which new houses were being built, though that was all-important for a healthy dwelling. "... Some of the new houses are built upon garden mould or old 'slop shoots,'" wrote the Medical Officer of Health for Paddington in 1870-1; "these thin and flimsy shells of lath and plaster truly merit the term 'slop buildings.' A dangerous moisture and miasma arises from houses built upon such an unhealthy foundation." How disastrous the results were to the inhabitants is pointed out by several Medical Officers of Health. The Medical Officer of Health for Mile-End-Old-Town wrote (1866):-- "... Many open places now built upon, or being built upon, have been for years the receptacles for all kinds of animal and vegetable refuse, and have become thoroughly impregnated with the products of their decomposition.... The result to the health of the occupants is daily realised by the excessive number of zymotic diseases and deaths which occur in them." The Medical Officer of Health for Limehouse wrote:-- "Ask about the general health and the houses. 'Never been well since coming in, and the children always ailing; and my husband says he feels more refreshed when he comes from his work than after he gets up in the morning. And then everything spoils; meat put into a cupboard is musty in a night. One can keep nothing.' "These are all new houses." And a few years later, referring to this same subject, he wrote:-- "A half mile off, a few years ago, there were some acres of gravel pits. The gravel had gone for road-making, &c. The large pit was then filled up on invitation of the owner, with the aid of the scavenger and others, with all the slush and filth of a large circle of contributors. When this fund of abominations became consolidated, it was built over in the usual style. They were soon occupied by tenants and lodgers. Now this site during the epidemic (of cholera) has been a great slaughter field--the mortality was shocking." And he added, "there are thousands of such houses built about London." The Building Act of 1855 was very far from being an effective prevention of such devices as these. It required a notice to be given to the Vestry before any new building was commenced, and a plan to be submitted for approval showing the proposed drainage and the levels of the building; but this requirement appears to have been by no means universally complied with, and some local authorities had great difficulty in getting notices of new buildings commenced within the district. And its restrictions were not sufficient to prevent the speculative builder in places from raising his block of houses in the fields with neither road or sewer for their accommodation, and with the frequent result of fever-stricken tenants. With the increasing knowledge of their districts gained by the numerous Medical Officers of Health distributed over the whole metropolis, the widespread prevalence of overcrowding in London, and the virulent evils, physical, social, and moral, consequent thereon, come into greater prominence and more vivid light than ever before. Throughout the central parts of London the process of demolition of houses of all sorts and sizes, inhabited by the well-to-do or by the poorest, was continuing. The street improvements which were being carried out in some places entailed extensive demolitions; whilst the construction of railways and the erection of large stations necessitated the destruction of hundreds of others, mostly those inhabited by poorer persons. Thus, in the improvements in the Holborn Valley, 348 houses, accommodating 1,044 families and 4,176 persons, were taken down and not replaced. And in St. Pancras, and many other districts, the dwellings of the poor were constantly being removed by railway expansion. The subject of the displacement of labourers in consequence of great public works in the metropolis was brought before the House of Lords in 1861 by Lord Derby.[83] "It affects," he said, "in the most vital manner the interests of a large portion of the population who are utterly unable to protect themselves against legislation, however unfavourably it may bear upon them. "In the metropolis and its suburbs sixty to seventy miles of new line (railway) are proposed--a great portion of these passing through the most crowded streets." He described specially the parish of St. Bartholomew's, in Cripplegate, with a population of about 5,000 inhabiting 500 houses. "Throughout it, there are not ten families who occupy a house to themselves, although the bulk of the houses contain only three rooms. The incumbent tells me the aristocracy of his parish consists of families who are able to indulge in the luxury of two rooms. But the greater number have one room, and one only, and this is sometimes divided between more than one family. "Half of these houses are under notice for the railway." And Lord Shaftesbury described a great demolition of houses which took place a few years previously in the neighbourhood of Field Lane, City: "1,000 houses were pulled down; 4,000 families, comprising 12,000 individuals, were turned out and driven into the surrounding tenements." Lord Granville suggested, as a remedy, the provision of cheap trains to carry artizans from healthy dwellings in the suburbs to the scene of their work, and Lord Redesdale said he had introduced clauses into the Railway Bill providing that the companies should run a cheap train every day. But, as Lord Shaftesbury pointed out,[84] that would not be sufficient, as-- "In some cases the men are under an engagement to their employers not to live more than a certain distance from the warehouse," in order that no time might be lost in executing orders. The remedy, moreover, could only be very gradual in its operation, and was quite inadequate to meet the existing emergency. This demolition of houses had thus the two-fold result of at once intensifying overcrowding in the remaining houses in the localities affected, and in extending the area of overcrowding by causing a migration to other localities, many of which were themselves rapidly becoming overcrowded. And this, combined with the natural growth of the population and the constant stream of immigration into London, resulted in overcrowding on a far larger scale than had hitherto prevailed. In Mile-End-Old-Town the West Ward had received in the decade 1851-61 an addition of 3,094 persons, whilst but 84 new houses had been built--the South Ward 1,372 persons and 71 new houses built. In Shoreditch, in 1863, "The tendency to overcrowding was increasing year by year. "Being mostly operatives, &c. ... accustomed to live near their places of employment, they were naturally unwilling to travel further than necessary, and so have accepted the readiest accommodation for their families." Of Whitechapel, the Medical Officer of Health wrote in 1865:-- "The evil of overcrowding is annually increasing, and if means be not adopted to check it, the overcrowding will soon become of an alarming extent.... "Houses formerly occupied by single families are let out in separate tenements, and every room now contains a distinct family; and to such an extent is this separate letting of rooms carried out, that from information given me there is not a single street in the parish of Whitechapel that is not more or less a nursery of pauperism in consequence of this sub-division of tenements." Away in the west, in Fulham, there had been a "flood of immigrants," chiefly of "the lower and labouring classes." The population had increased 30 per cent., and the Medical Officer of Health wrote (1865):-- "In watching the enormous accession of population to the Fulham district, one cannot otherwise than observe the constant tendency to overcrowding amongst the labouring people, whilst there seems every possibility of this human tide increasing. The tremendous demolition of the houses hitherto occupied by the working classes more immediately in London itself has dislodged thousands of families, whilst no systematised provision has been made for their reception." In Westminster the Medical Officer of Health wrote in 1865:-- "The dwellings of the poor were never in a worse or more unsatisfactory state than they are at present from the large number of houses that have been already demolished. The poor are now driven into the most wretched apartments, and which, in consequence of the increased demand, can only be obtained at the most extravagant rates. They are consequently compelled to herd together in one room, usually barely sufficient for half of those it is now made to hold." The south side of the river was much in the same plight as the north; but there, there was more room for expansion. The Medical Officer of Health for St. Saviour, Southwark, wrote in 1865:-- "The numerous improvements which continue to be made in and about the heart of London have so increased the value of house property that overcrowding has been almost inevitable. "... In a vast number of instances families numbering four to seven persons, ill or well, live, cook, wash, and sleep in rooms the dimensions of which are not greater than is now demanded for each sick person in the workhouse." The Medical Officer of Health for St. George-the-Martyr, Southwark, wrote:-- "In many of the districts of the metropolis between 60 and 70 per cent. of the population are compelled to live in one small overcrowded room, and in which every domestic operation has to be carried on; in it birth and death takes place; there plays the infant, there lies the corpse; it is lived in by day, and slept in by night." In the necessity for house accommodation all sorts of places were being pressed into use, and people driven into "places that are themselves unfit for habitation, not having the elements of life and health about them." The Medical Officer of Health for Paddington described, in 1867, how mews had been thus utilised:-- "In fact these back streets, originally built and intended for horses and vehicles, and only those persons without encumbrances who are engaged attending to them, have now become the resort of persons with large families following all kinds of business--rag, bone, and bottle stores, shops of various kinds, including beer-houses, builders, carpenters, smiths, tailors, sweeps, find accommodation here. Inhabiting the rooms above, too small, and unfitted with proper domestic accommodation for a family, live a vast population of all ages. These evils, rather than otherwise, are increasing." Into such houses and such rooms the people were by stress of circumstances compelled to go, and, as the Medical Officer of Health for St. Giles' pointed out (1863):-- "A larger rent can be obtained for the same room if it is overcrowded by a large family than if it be hired for only as many inmates as it can properly receive. Hence the interests of landlords are constantly on the one side, the health of the poor on the other...." What this pressure upon accommodation produced may be gathered from a few figures given by the Medical Officer of Health for Whitechapel:-- Houses. Rooms. Inmates. In Slater's Court, Whitechapel 10 31 170 In Marlborough Court 7 20 82 In Hunt Court 8 32 158 "In one room in Swan Court, having one window, seven persons slept--a man and his wife, the daughter aged 24 in consumption lying in bed, and four younger children; the cubic contents of the room were 910 = 130 cubic feet to each person. "In Bell Court four persons occupied a room with 94 cubic feet each. "In three rooms in Hayes Court, each 10 � 8 � 8 feet; each with only one window opening into a narrow court; each occupied by eight persons = 80 cubic feet to each person." The Medical Officer of Health for St. Pancras (1865) described some of the consequences of the conversion of a house, built originally for one family, into one inhabited by several families:-- "... At present these families occupy usually a single room only in a house of six or eight rooms adapted for only one family. The water supply is inadequate, and at some distance from the upper rooms, and there is but one closet, one dust bin, one coal cellar, and one wash house for the whole. No one is responsible for the cleanly condition of the closet, the water tank, the single staircase, the basement, the areas, and the yard, or for emptying the dust bin." One of the worst forms of overcrowding was when it resulted in what was described as "indecent occupation." For instance, as reported (1861) by the Medical Officer of Health for Whitechapel:-- "In a room in Windmill Court there slept the mother, two adult daughters, and two adult sons. "In another room in the same court, a man and his wife, the daughter aged 16, and three adult sons." In 68 instances the rooms were "indecently occupied," that is to say, adult brothers and sisters, or a father and daughter slept in the same room. And he wrote:-- "We may well inquire how such gross indecency and want of self-respect can exist in this country, which is usually considered to be the centre of civilisation, and where so much money is spent in imparting religious and moral instruction to the people--yet such is the state in which many of the inhabitants of this district live, as is ascertained on a house-to-house visitation." And in the following year he wrote:-- "On visiting the houses in low neighbourhoods it is by no means of unfrequent occurrence to find an adult brother and sister, a father and adult daughter, a mother and adult son, occupying the same bed. What good citizenship can be expected to be manifested by a class in whom the moral feeling is so low?" The Medical Officer of Health for St. James', in his report (1862), wrote:-- "This close association of several families in one house is productive of immense evil; it prevents proper parental control; it encourages an association of the sexes which leads directly to one of our greatest social evils; and is one of the most fruitful causes of the spread and fatality of zymotic diseases of childhood, and lays the foundation of the scrofula and consumption which every year carry off a fifth of all who die amongst us.... "It is almost impossible, amidst the filth and stench of dirty houses and imperfect drains, that the working man's family should be able to develop those moral and intellectual qualities which are, after all, more worth to the community than any saving of rates." The Medical Officer of Health for St. Martin-in-the-Fields, wrote (1865):-- "Rents have become so heavy that few labouring men can afford more than one room. Overcrowding in such rooms must increase, and with it the fearful results of men, women, girls, and boys, all sleeping in the same apartment. Neither religion nor morality can increase under the existing circumstances of our poorer classes. It is almost returning to the habits of our barbarous ancestors or the untutored savages of Africa and Australia." And the Medical Officer of Health for Holborn wrote:-- "Depend upon it, the moral and physical training of the people is more influenced by lessons--whether in health and cleanliness, or in religion and morality--that they are constantly receiving at their own firesides than by any extraneous teachings. "When a child has been allowed to grow up with a diseased body, and a polluted mind, in a wretched room, without light, without cleanliness, and without any notions of decency, our curative efforts, whether medical, missionary, or reformatory, are as mere patchwork compared with the great preventive precaution of keeping his home as pure, as decent, and as wholesome, as possible." No more powerful description can be given of the moral evils of overcrowding than that of Dr. J. Simon in 1865:-- "Where 'overcrowding' exists in its sanitary sense, almost always it exists even more perniciously in certain moral senses. In its higher degrees it almost necessarily involves such negation of all delicacy, such unclean confusion of bodies and bodily functions, such mutual exposure of animal and sexual nakedness, as is rather bestial than human. "To be subject to these influences is a degradation which must become deeper and deeper for those on whom it continues to work. To children who are born under its curse, it must often be a very baptism into infamy."[85] Overcrowding was not confined to tenement-house rooms alone. The great bulk of the working classes left their overcrowded abodes to do their day's work in overcrowded factories, workshops, and workplaces; and in very many such places men, women, and even children were crammed together in rooms where healthy existence was impossible. A great deal of information on this great branch of the sanitary condition of the inhabitants of London is given in the Reports from the Commissioners on Children's Employment, and in the very valuable reports of special inquiries instituted by the Medical Department of the Privy Council. One of these inquiries related to Bakehouses, of which there were about 3,000 in the metropolis in 1862.[86] As a rule the place in which the bread of London was made was what in houses in general was the coal-hole and the front kitchen. Very many bakehouses in London were stated to be in a shockingly filthy state, arising from imperfect sewerage and bad ventilation and neglect, and the bread must, during the process of fermentation, get impregnated with the noxious gases. The sleeping places were of the worst description,[87] some of the men sleeping in the bakehouse itself. Many bakehouses were infested with rats, beetles, cockroaches, and noxious smells. The smells from the drains were very offensive--the air of the small bakehouses was generally overloaded with foul gases from the drains, from the ovens, and from the fermentations of the bread, and with the emanations from the men's bodies; the air thus contaminated was necessarily incorporated with the dough in the process of kneading. Half of the bakehouses in London would, it was stated, require the application to them of the Nuisances Removal Act. Another inquiry related to the tailoring trade in the metropolis.[88] The places in which work was done were reported as varying much in their sanitary conditions, but almost universally were overcrowded and ill-ventilated, and in a high degree unfavourable to health. Some were underground, either in the basement of a house, or built like a large kennel in a small enclosed yard, and were such that no domestic servant would inhabit. In exceedingly few shops had there been any attempts at ventilation. The ventilation through the windows was practically inefficient, and instances were given of what had been found in sixteen of the most important West-end shops. In one an average of 156 cubic feet space was allowed to each operative, in another 150 cubic feet, in another 112 cubic feet. Deficient ventilation, heat, and draughts, were the causes of diseases. A paper read by Dr. E. Symes Thompson (Assistant Physician to King's College Hospital) at the Social Science Association Meeting in London, 1862, described the condition under which printers did their work. "Printers often work sixteen to eighteen hours a day in a confined and heated atmosphere; perhaps thirty men and as many gaslights in a low room without ventilation or chimney, where air only enters when the door is opened.... "Printing is only one of the many trades which entail the sacrifice of every hygienic necessity, and the cause of the unhealthy looks of the workpeople cannot fail to strike any observant person who may visit their workshops. The rooms are mostly low, the windows fixed, and there is often no chimney or other ventilation. "This is the case in large and small factories as well as in workshops--in the workroom of the milliner, the sempstress, or the bookbinder. "In many occupations, besides the evils alluded to, the air is charged with foreign matters, which are drawn into the lungs at each inspiration; _e.g._, the sorting and tearing up of dirty rags in paper manufactories. The dust and fluff arising in flax, woollen, and cotton factories, and in furworks, produce similar results--and brass finishers." And in another paper at the same meeting Mr. George Godwin detailed his experiences as regarded the conditions under which milliners, dressmakers, and other needlewomen worked. "In an upper room in Oxford Street, not 10 feet square, I have seen a dozen delicate young women closely shut up making artificial flowers; and there when business is pressing they work from 8 in the morning till 12 o'clock at night. "Many of the workrooms of fashionable milliners are similarly overcrowded, as are those where young girls are engaged in book-stitching." He gave as an example a house in Fleet Street. "The staircase is confined and without ventilation--the atmosphere is steaming and smells of glue. "In the first room looked into, 40 young women and girls were sorting and stitching books. There was a stove but no ventilation.... There were more than 200 persons in that house, pent up without provision of the first necessity of life--pure air. Poor creatures so placed are being slowly slain. "Other trades, such as cap and bonnet makers, trimmers, blond-joiners, &c., to which I have looked with some little care, are forced in many places to do just the same thing." "The extent of suffering entailed, and the loss to the community, it would be difficult to calculate. It is time that legislation should be tried to secure wholesome workplaces for the people. Interference is needed for thousands of persons--especially young females--the debilitated mothers _in posse_, should they live, of our future population. In our infant schools, too, where incalculable mischief is done by overcrowding, it is greatly required. The evil is sapping the strength of the land." "In several parts of London persons employed in making cheap clothing are boxed up in crowds, ... some striving to get a living in a death-giving atmosphere. "Shoemakers are often as ill-placed. In wretched apartments, in an ill-drained house, may be found men and boys huddled together without room to breathe." It was under such pitiable conditions that large masses of the working classes of London had to earn their daily bread. Lord Shaftesbury truly said that "the sanitary condition of these people was of national importance, not only on account of the waste of life, but the waste of health which every year threw thousands and tens of thousands upon the rates."[89] And large numbers of children were also employed under insanitary conditions, and were made to do heavy work for long hours, and the consequences to their health were disastrous.[90] That their constitutions should be undermined and their physical development should be most seriously deteriorated was a necessary result. There was a chorus from the Medical Officers of Health as to the evil sanitary consequences of overcrowding. "Overcrowded dwellings are among the most prolific sources of disease, immorality, and pauperism."[91] "Overcrowding--one of the elements by which disease is not only generated but sustained."[92] "Overcrowding is a constant source of fever." "The great difficulty of obtaining lodgment for the working classes has caused overcrowding of the poor in an unprecedented manner, and consequently the development of typhus which is considered to be bred in the pestilential atmosphere of overcrowded dwellings."[93] Overcrowding led to numerous, indeed to all sorts and kinds of diseases. The Medical Officer of Health for St. Pancras wrote:-- "It has been shown that consumption and the so-called tubercular diseases are developed by want of pure air more than by any other cause." And not alone did the overcrowding lead to disease, but it rendered it difficult if not impossible to check disease. "How is it possible," wrote one of them, "to prevent the spread and fatality of fever and whooping-cough when six or seven persons are shut up in one small room breathing the same air loaded with zymotic poison over and over again? "The danger of allowing a deadly atmosphere to be engendered by the crowding together of persons in a small room without sufficient ventilation is unfortunately not confined to the inmates of that particular room, but those diseases which are therein generated extend far beyond its immediate vicinity, and under some circumstances a large portion of a district will suffer in consequence."[94] Dr. Rendle, previously Medical Officer of Health for St. George-the-Martyr, in his evidence[95] before a Select Committee in 1866, said:-- "... The overcrowding exists to such an extent that the poor cannot by any possibility do other than breed disease, and when they breed it they give it to others." Lord Shaftesbury said:-- "As to the effects of all this overcrowding, can anything be more prejudicial to the human system than the filthy squalor, the foetid air, and depressing influences of these dwellings? "When you ask why so many of the working men betake themselves to the ale-house or gin-palace, the answer lies in the detestable state of their homes. "I have had it from hundreds of both women and men that this cause, and this cause alone, has driven them to the use of ardent spirits.... Nine-tenths of our poverty, misery, and crime, are produced by habits of intoxication, and I trace those habits, not altogether, but mainly, to the pestilential and ruinous domiciliary condition of the great mass of the population of this metropolis and the large towns of the country."[96] "No bodily labour induces an exhaustion of the vital powers comparable to that resulting from the habitual breathing of air contaminated by the overcrowding of human beings."[97] For children born under such circumstances of overcrowding and filth, and in such insanitary surroundings, birth was mostly followed by an early death. "Infancy in London has to creep into life in the midst of foes," as the _Times_ truly remarked in 1861. Among the greatest of these foes was overcrowding. The statistics of infantile mortality are fairly reliable, and, so far as there are errors, those errors were in understating and not overstating it. In St. Giles', in 1861, 43-1/2 per cent. of the total number of deaths were of children under five years of age. "This enormous infantile mortality," wrote the Medical Officer of Health, "is unfortunately only what is customary in our district." In the Strand, 1861, the percentage of deaths under five annually exceeded 45 per cent. of the total deaths. In Westminster, in 1861, there were 1,685 deaths, 770 being those of children under five--of which in St. John's parish, out of 834 deaths, 427 were under five--or over 50 per cent. In Bethnal Green in 1862 it was close upon 60 per cent. In the Potteries, Notting Dale, with a population of 1,100, the deaths of children in 1870 under five were 63 per cent. of all deaths. In 1871, 72 per cent. On the south side of the river the same tale was told. In Wandsworth 42 per cent. in 1861; in Battersea 45 per cent. in 1862; in Rotherhithe, in 1862, nearly 50 per cent.; in Bermondsey, in 1863, 57 per cent. "It certainly," wrote the Medical Officer of Health for Fulham, "could not have been intended by Providence that of all the children born, nearly one-half should die without attaining one-fourteenth part of the threescore years and ten allotted to mankind--and yet we see the yearly realisation of this astounding fact." Other causes besides overcrowding contributed to this great mortality. "Poverty," wrote the Medical Officer of Health of Poplar, "with its concomitants--defective nourishment, want of cleanliness and ventilation, malaria, overcrowded dwellings, deficient supply or impure quality of water--these all act with unerring force upon the tender constitutions of the young." And another wrote:-- "What with overcrowding, insufficient food, and inattention to cleanliness, it is almost impossible an infant can resist an attack of the commonest disorder." And some places were in such evil sanitary condition that child life was impossible therein. Of two Courts in Islington the Medical Officer of Health reported in 1863:-- "Young children cannot live there. All that are born there, or are brought to reside there, are doomed to die within two years." The state of the public health generally as the result of all these sanitary abominations was very unsatisfactory. In 1863 the mortality of London was unusually high. The Medical Officer of Health for St. Giles' wrote:-- "The year has been conspicuous for a high mortality resulting from the prevalence of epidemics to an unusual degree--smallpox, scarlatina, typhus." The following year he reported to have been-- "A year of exceptional mortality.... Death rate 29·74 per thousand, or, if the deaths of parishioners in hospitals be included, 31·10.... Tubercular diseases, of which consumption affecting the lungs is the most important, were as usual intensely fatal in our district." The Medical Officer of Health for Whitechapel drew attention to the increase of mortality in his district. He was evidently puzzled and perplexed by it, and "candidly confessed" his inability to account for it. "I may, however, venture a few conjectures." Among them was this very suggestive one--"that a change has taken place in the constitution of the people so that they are now less able to bear the effects of disease than formerly." Suggestions and recommendations for ameliorating this appalling condition of things poured in upon many of the local authorities from their Medical Officers of Health. Upon several points there was an absolute consensus of opinion. One of these was that all houses let out in separate tenements and inhabited by many families should be registered by the local authorities--that rules and regulations should be made for their management, and that constant inspection by the sanitary authority was an absolute necessity if the proper conditions of health were to be maintained. The Medical Officer of Health for Bethnal Green wrote:-- "All sanitary evils fall with greatest force upon those who are unable to quit the scene of their misery or to provide the means for its alleviation. "Nothing but adaptation of the present houses to the necessities of healthy existence and the demolition of those houses that are unfit for human habitation can contribute so much to life and strength." A Committee of the District Board in Poplar wrote (1866):-- "It would be a satisfactory alteration of the law if no houses were allowed to be tenanted unless a certificate that these premises were fit for habitation were first obtained from the District Board of Works." And the necessity of constant inspection was even more vigorously expressed. The Medical Officer of Health for Hackney wrote (1861):-- "The experience of the past year again shows the necessity of keeping up a regular and efficient supervision of the interior of houses.... "It is only by repeated and careful inspection of the dwellings of the poor, and an inculcation at these visits of the necessity for keeping clean their rooms that epidemic diseases can be kept in check." The Medical Officer of Health for St. James' wrote (1862):-- "The nuisances which are removed, are constantly recurring. It is only by constant inspection and by supervision repeated systematically from day to day, and week to week, that those nuisances can be kept down which are ever ready to destroy the life, and at one and the same time sap the health and undermine the morality of the community." The Medical Officer of Health for Whitechapel wrote:-- "If it were not for the vigilance of the Inspectors in visiting the houses of the poor, nuisances would remain altogether unattended to; for very few of the poor dare to make a complaint from fear of being compelled to quit their tenements." The Medical Officers of Health recognised that much of the bad condition of the dwellings of the poorer classes was due to the people themselves. Thus the Medical Officer of Health for Westminster wrote (1865-6):-- "It is much to be regretted that in certain districts of the parish only a temporary good is effected by a sometimes lavish expenditure on the part of the proprietor. The habits of the people are such that it is almost impossible to do anything for their benefit. Not only are they filthy in themselves, but they take every opportunity to break, destroy, and steal anything that may be of value, and what is even worse they appear to negative any sanitary precaution effected for their benefit." But the broad truth was that the real, the primary responsibility rested upon the "owners." Theirs was the property. And them it behoved to keep that property in a condition which was not a danger to the community and to the State. The Medical Officer of Health for Whitechapel wrote (1865):-- "The duty and interests of landlords appear to be at variance as regards their doing to their houses what is absolutely necessary for the well-being of their tenants. It is unquestionably the duty of landlords to keep the houses which they let out in separate tenements to the poor in a healthy condition; but this is not always done even if compulsory orders are signed and summonses issued.... "Many of the landlords of small house property fully understand and carry out the rights of ownership, but fail to carry out the duties which are enjoined upon them as owners." The Medical Officer of Health for Islington, referring to some vile property in his parish, wrote (1863):-- "Landlords of such property as this will rarely do anything out of consideration for the health or lives of their tenants; compulsion alone will extort amendments. What is needed here is the closure of the fatal houses until made fit for human habitation." How an "owner" could manage his property can be gathered from the following report of the Medical Officer of Health for Paddington (1863), which called attention to "the insanitary condition of a block of houses (about thirty in number) which had been for many years notoriously liable to the invasion of epidemics and to the prevalence of those diseases which are the known product of sanitary neglect--badly constructed and dilapidated, and wanting in the commonest appliances of cleanliness. All were the property of one individual who had been repeatedly urged to put them in a proper sanitary state." But it was not until stringent compulsory measures were taken that he began to do so, and some years elapsed before they were really done. Here is another dreadful case of overcrowding and insanitation--this time in St. Marylebone (1868). Edwards Place:-- "Ten six-roomed houses occupied by 84 families, 277 persons, houses very dilapidated, many unfit for human habitation. Orders for sanitary work are continually being sent out by the Vestry to the owner of this wretched property. "A rental of £10 per annum would be an extravagant sum to pay for either of these miserable dwellings, yet more than three times that sum is expected from the destitute and indigent people who inhabit them." Read by the light of the knowledge that insanitary property meant disease, and disablement, and death to a very high percentage of its occupiers, the proper compulsion to have applied to "owners" such as these would have been proceedings before a Coroner's jury for culpable homicide if not for actually deliberate murder. The community has a right to be protected from the evil results of the miserable housing of the poor. Mr. George Godwin said in 1862, at the meeting of the National Association for Promoting Social Science:-- "It should be no answer to the requirement of a certain cubical space for each occupier, that the financial resources of the parties will not admit of it. "A man is not permitted to poison with prussic acid those who are dependent on him because he is poor; neither should he be allowed on that ground to kill them with bad air and set up a fever-still for the benefit of his neighbours." Parliament, under the pressure of a slowly-developing public opinion, and in view of the ever accumulating evidence and proof of the almost incredible insanitary condition in which great masses of the people of London were living, was beginning to show less reluctance to discuss and deal with some of the multifarious matters affecting the public health. In 1860 it passed an Act which, however well intentioned, was not of much effect. It was an effort to secure more wholesome articles of food and drink for the public by preventing their adulteration. The past history of such legislation was rather interesting.[98] In 1731 an Act has been passed prescribing a penalty for "sophisticating tea." "Several ill-disposed people frequently dyeing, fabricating, very large quantities of sloe-leaves, &c., in imitation of tea, and colouring or staining and dyeing such leaves, and vending the same as real tea to the prejudice of the health of His Majesty's subjects." "In year 1766-7 a further Act was passed inasmuch as 'such evil practices were increased to a very great degree to the injury and destruction of great quantities of timber, wood, and underwoods.' "Coffee had also been the subject of legislation, 'burnt scorched, or roasted peas, beans, &c.,' being used to adulterate it. "In 1816 an Act was passed against the adulteration of beer and porter, and the use of molasses, liquorice, vitriol, quassia, guinea pepper, or opium, and a lot of other ingredients being prohibited." "In 1836 an Act was passed against the adulteration of bread." And now in 1860 it was enacted that "every person who shall sell as pure or unadulterated any article of food or drink which is adulterated or not pure," should on conviction be fined. The Vestries in the metropolis were empowered to appoint analysts. The appointment was voluntary on the part of the local authorities, and, if analysts were appointed, their duties were confined to receiving and analysing articles submitted to them by the purchasers, and certifying the results. The purchasers had to pay the cost. No officer was appointed to obtain samples or to enforce the Act. And the Act is therefore worthy of note more as an illustration of the inaction of the local authorities than for any effect it had as regarded the prevention of adulteration. In 1863 Parliament passed the "Bakehouse Regulation Act,"[99] which enacted that every bakehouse should be kept in a cleanly state, should be frequently lime-washed, and should be properly provided with proper means for effectual ventilation, and be free from effluvia arising from any drain, privy, or other nuisance. Also its use as a sleeping-place was prohibited, and the onus of enforcing the provisions of the Act was imposed upon the local sanitary authority. And in 1863 it declared[100] that the law made in 1855 as to the inspection and seizure of unwholesome food--meat, poultry, flesh, fish, vegetables, fruit, &c., &c.--was defective, and that other and more effectual provisions should be substituted therefor; and others were accordingly substituted. By an Act in 1864 the main principles contained in previous Factory Acts were carried a stage further, in some instances even to trades carried on in private houses. "Every factory to which this Act applies shall be kept in a cleanly state and be ventilated in such a manner, &c., as to render harmless dust, &c." Unfortunately the main breakdown in the metropolis in regard to nearly all the ameliorative sanitary legislation of Parliament was directly caused by the very local authorities who had been specially created for the purpose of administering those laws. Primarily they were responsible for the failure of very much of that legislation, and they never seem to have at all realised, or been impressed by, the gravity of their trust, or by the great responsibility to their fellow-citizens which their position entailed. Even in comparatively small matters their ingenuity in counteracting the intentions of the Legislature was remarkable, as can be seen from the following passage in a report of one of the Medical Officers of Health:-- "I refer specially to the Sanitary Acts, to the Adulteration of Food Act, and to the Metropolitan Gas Act, in each of which cases the powers entrusted to them have not been carried out. "They appointed an examiner under the Adulteration of Foods Act (1860), and also under the Metropolitan Gas Act (1860), but the person appointed had no tools given him with which to perform the work entrusted to him. "Both the Acts are dead letters in the parish. As to the Metropolitan Gas Act, it conferred a large benefit, both as to purity and cost, on the metropolis, but the Vestries failed to carry out a single effective or important provision of that Act." In 1860, also, an Act had been passed empowering the local authorities in the metropolis to provide vehicles for carrying persons suffering from infectious diseases to hospital, and so obviating the danger to the public of such persons being conveyed in cabs or other public vehicles. That Act was also inoperative. The Vestries and District Boards, however, did perform a considerable amount of useful work. Local sewerage and drainage works were on the whole effectively dealt with. The rest of the work done was mostly of the routine order, such as scavenging and paving and lighting, though even that was not always done in the most sensible way, as exemplified in Paddington (1866). "The street sweepings of mud collected by the scavengers are stored in enormous quantities in the middle of the parish in a closely inhabited neighbourhood. Here it is allowed to decompose, &c. If it were intended to contrive an arrangement for developing malaria in the midst of a town population nothing could be better adapted for the purpose." A few of them had soared to the height of widening a street, or acquiring some small open space; in most, if not all, of these cases receiving financial help from the central authority. But as to the main causes of the prevailing insanitary evils, their aversion to active measures was constantly in evidence; equally so where the enforcement of the law would have entailed cost on the owners of insanitary houses. In some matters the plea of defects in the legislation might have been justifiably urged by them; in others they were often much hampered by the dilatory procedure attending proceedings for enforcing the sanitary provisions of the Metropolitan London Management Act. One of the Medical Officers of Health gives an illustration:-- "A very great nuisance was reported to us. We visited it, but had to wait a fortnight before the Vestry met in order to get leave to apply for a summons. The magistrate requires a week before hearing the case, and then he gives a week or two to do the work. So for a month or five weeks the nuisance may remain." The result was that infectious disease was given a long opportunity to spread itself unchecked through a whole district; an opportunity which it freely availed itself of. Complaints were also made by some of the Medical Officers of Health that in attempts to enforce the law against "overcrowding" the magistrate leant very much to the landlord. This, too, might have acted as a discouragement to them. What, however, is certain is, that the Vestries and District Boards were not attempting to grapple with the most crucial questions of all--the overcrowding, and the housing. The Medical Officer of Health for Clerkenwell pointed this out, so far as his parish was concerned (1861):-- "The principal sanitary improvements during the last five years related almost exclusively to the drainage, whilst the overcrowding and impure state of the dwellings of the poor have been but little interfered with." The more serious blemish was pointed out by Dr. Hunter in his report of 1865 to the Medical Officer of the Privy Council on the subject of overcrowding, and the removal of persons from houses about to be destroyed:-- "There is no authority which can deal with London in these matters as a whole, and they are matters in which uniform treatment is quite necessary. The local authority which finds the whole of its district overcrowded, naturally hesitates before beginning action which may relieve one house only to overfill the next, and may reasonably think that such action, unless done thoroughly, not only through the district, but through the whole capital, might prove hurtful."[101] And his opinion is weighty. But the local authorities were very far from doing what they might have done to abate many of the insanitary evils connected therewith. Dr. William Rendell said[102]:-- "We have had till now but one Inspector of Nuisances--an unwilling man.... "This is not a question of a defect in the law. These bodies have the power of appointing Inspectors, but when Inspectors are appointed it brings of course a large amount of work in low property, and expense and trouble are incurred. Therefore the easiest way to avoid it is not to have Inspectors enough, so that the work may not be found out." In fact, the fuller the information on the subject is, the more clear it is that most of them did not want to move in the matter. The evidence of witnesses, not under Vestry control, examined before the Select Committee on Metropolitan Local Government in 1866, throws some light on this point. Mr. James Beale, himself a vestryman, said:-- "I have seen a great want both of intelligence and ability among vestrymen. "I should say you may divide Vestries into divisions--one-third, as a rule, are of the right class of men who ought to be returned, and two-thirds are not of the class who ought to represent the intelligence or the property of the districts from which they are sent. "The powers of Vestries are administered with too great a regard to economy. Efficiency is always sacrificed to economy. If an Act of Parliament requires them to do certain things, it is as a rule avoided." He attributed the failure of the Vestries to the inferior calibre of the persons composing them--"they agree to resolutions, but do not carry them out. The ratepayers take no interest in the elections in our parish. There is a large number of the owners of small house property in the Vestries who regard with great disfavour any increase of the rates, however beneficial the increase might be to the general health of the district." But some witnesses went further. Dr. William Rendell, who had been Medical Officer of Health for St. George-the-Martyr, said:-- "I believe, the law being new to the Vestry, they did not quite understand the mode of carrying it out; but it was partly from corrupt motives, for on one occasion one of the principal members of the Vestry, an owner of considerable property in the parish, called me aside and requested me to pass over certain property of his that I found in an extremely bad condition. I did not pass it over, of course. The chairman of the local committee was, as I thought, appointed as a positive obstructer of sanitary measures; at all events he acted as such. The obstructions arose from an unwillingness to incur expense for fear of increasing the rates, and from an interest that the members of the Vestry had in keeping up the present state of things." Jobbery, and the exercise of influence to obstruct and defeat the law, are hard to prove, especially after the lapse of years, but one fact which stands out conspicuous, and which is incontestable, shows how reprehensibly the great majority of the Vestries and District Boards failed to administer laws which in the interests of the public health, and therefore of the public welfare, it was their duty to administer. Deliberately, and in the light of knowledge, they would not make adequate arrangements even for the sanitary inspection of their respective districts. Thus, in Bethnal Green, in 1861, there was a population of 105,000 persons, and 14,731 houses. The Vestry appointed one single Inspector of Nuisances to cope with the insanitary conditions of this city of houses, and of this mass of people. Shoreditch, with a population of 129,364 persons, and 17,072 houses, also one Inspector. St. George's, Hanover Square, with 88,100 persons and 10,437 houses, one Inspector; Paddington, Bermondsey, and several others, all with large populations and thousands of houses, one Inspector each.[103] A few had appointed two Inspectors: St. Marylebone with 161,680 persons and 16,357 houses, and Islington with 155,341 persons and 20,704 houses. Kensington, Lambeth, and Limehouse, had appointed three Inspectors each. St. Pancras headed the list with four, but its population was close upon 200,000 living in close upon 22,000 houses. How could it be expected that one Inspector could within a year possibly inspect even one tithe of the places which it was his duty to inspect apart altogether from other duties he ought to perform? The Vestries and District Boards had the facts constantly before their eyes (in the returns of work made to them by the Medical Officer of Health)--the numerous insanitary houses unfit for human habitation, the overcrowding, the terrible amount of sickness and misery, and they could calculate from the one man's work, the number of houses in the parish which were in a condition dangerous to the health of their inmates, and to the public health generally. The salary of an Inspector was so paltry that they had no excuse on the ground of economy; and the conclusion is inevitable that either they did not care what the sanitary condition of the people was, or that "vested interests in filth and dirt" were so powerful on those bodies that filth and dirt must not be interfered with at the expense of "owners" upon whom the cost of improvement must fall. And a grimmer light is thrown upon these figures by the following statement of the Medical Officer of Health for Lambeth made in 1889, but referring to 1869. "The Sanitary Inspector of twenty years ago (that is to say of 1869) was an unskilled workman, holding that which might almost be regarded as a sinecure office; an official recruited into the services of the Vestry from the rank of ex-sailors, ex-policemen, or army pensioners. A knowledge upon sanitary matters acquired from a course of technical training was not expected from him." The treatment meted out to some of the Medical Officers of Health also showed the hostility of the Vestries to action. Numerous are the passages in their reports complaining of their recommendations being ignored. These officers were miserably paid, allowing even for their being able to take private practice. The Medical Officer of Health for Lambeth was stated to have been the worst paid--receiving only £200 a year for the performance of duties attaching to an area of 4,000 acres with 23,000 inhabited houses upon it, inhabited by 162,000 persons. Dr. W. Farr (of the Registrar General's Office) said:-- "I believe that in certain districts in London the Medical Officer of Health is under all sorts of restraints. If he is active, they look upon him with disfavour, and he is in great danger of dismissal."[104] The Vestry of St. James', Westminster (1866), checked the zeal of their Medical Officer, Dr. Lankester, whose salary was £200 a year, by reducing it to £150 after a year or two when they found he was very earnest in his work. Dr. Rendell, the Medical Officer of Health for St. George-the-Martyr, Southwark, resigned "in disgust that he was not allowed to carry out the duties of his office." Once more the approach of Asiatic cholera--the nemesis of insanitation, and of "fainéant" local authorities--created anxiety.[105] It had been widely prevalent in Europe in 1865, and had even shown itself in England, and it stirred into spasmodic and panicky activity the local authorities of London. In Lambeth a systematic house inspection was inaugurated; 987 houses were examined--735 of them required sanitary improvements. In Bethnal Green 2,018 were inspected--955 required cleansing and purification. In many other parishes and districts extra sanitary work was done. The disease made no further demonstration in the winter, but in April, 1866, a case was reported from Bristol, then one from Swansea--then from other places; and in July the Privy Council issued Orders in Council putting the Disease Prevention Act in force in the metropolitan area. On July 18th, from Poplar, the first case in the metropolis was reported. Two days later an alarming number of cases in parts of East London. Regulations were issued by the Privy Council defining and requiring the specific services which local authorities ought to render the public. Some parishes appointed extra Sanitary Inspectors. Thus in Hackney, where there had been but one, four additional ones were appointed; in St. James' two; in Camberwell two; in Lambeth two; in St. Mary, Newington, five extra were appointed. Some of the work which was reported brings into striking prominence the extraordinary inefficiency hitherto of the authorities in dealing with insanitary houses as well as the neglect into which houses had been let fall, and which was tolerated by those who were responsible for the health of their districts. In Lambeth 6,935 houses were inspected in 1866; 3,983 improvements were effected. In Camberwell, 5,594 houses were inspected; in 4,324 sanitary work had to be done. In St. Mary, Newington:-- "A house-to-house visitation was commenced August 4th, and concluded on November 20th, in which period the Sub-Inspectors called at 12,919 houses. "A record was thus obtained of the condition of nearly every house in the parish. The house-to-house visitation was carried out with but little real opposition, and with a great deal of satisfaction.... Strict impartiality was the rule of action, and all classes and those in every station were alike subject to inquiry." As the summer went on, the mortality from the cholera increased--it reached its acme on August 1st, when there were 204 deaths from it, and in the week ending August 4th when the total of 1,053 was reached.[106] During the 23 weeks of its prevalence 5,548 persons died--of whom 3,909 died in the East Districts alone, and 702 on the South side of the river. And by the end of the year it had gone. That the mortality should have been so much smaller than on previous visitations was attributed to the fact that London was unquestionably less filthy at the time of this outbreak. "A comparison of the mortality with that of former cholera years," wrote the Medical Officer of Health for St. Giles', "demonstrates that sanitary work--imperfect as it is--has deprived the disease of much of its power." "The power," wrote the Medical Officer of Health for Fulham, "of sanitary arrangements to check the progress of such a formidable disease was clearly evidenced." The Medical Officer of Health for Lambeth wrote:-- "I believe the great sanitary improvements effected in the parish in providing proper drainage, abolishing many miles of open stinking ditches, and the removal of other nuisances, rendered an outbreak of cholera, such as experienced in former years, very improbable.... Moreover, by the employment of sanitary arrangements for treating the sick, Lambeth and other parts of the metropolis were saved from the ravages of the pestilence experienced on former occasions." That the epidemic had been as disastrous as it was, was, however, attributed to "an illegal and most culpable act of the East London Water Company. In contravention of the 4th Section of the Metropolis Water Act of 1852 that company distributed for public use a water (and a most improper water) which had not passed through its filter beds; and strong evidence was adduced to show that the outbreak was occasioned by this illegal and most culpable act." One result of this epidemic was to demonstrate, at the cost of thousands of lives, that the system of private water companies supplying the community with this necessity of life was absolutely opposed to the interests of the community. Dr. Simon, in summing up his report (1869) on the water supply to the metropolis, wrote:-- "I have been anxious to show what enormous risks to the public are implied in any slovenly administration of water supplies: yet as regards the London supply, what imperfect obedience to the law, and in some cases what flagrant and systematic disobedience was exhibited (at the time of the cholera outbreak in East London in 1866); and above all what criminal indifference to the public safety was illustrated by the proceedings of the Southwark and Vauxhall Company." As regarded this latter company:-- "Not only had there been the long-standing gross inefficiency of the apparatus of subsidence and filtration, but the administrators of the supply had from time to time dispensed to a great extent with even a pretence of filtration, and during some time had, worst of all, either negligently or wilfully distributed as part of their supply the interdicted tidal water of Battersea Beach. "It seems to me that the public is hitherto very imperfectly protected against certain extreme dangers which the malfeasance of a water company may suddenly bring upon great masses of population. Its colossal power of life and death is something for which till recently there has been no precedent in the history of the world; and such a power, in whatever hands it is vested, ought most sedulously to be guarded against abuse." Cholera was once more a blessing in disguise, though it seems hard that the sacrifice of thousands of lives should have been required to move Government and Parliament to fresh measures for the protection of the people from it and the other deadly diseases which unceasingly worked such deadly havoc among them. But the proof given by it was so overwhelming and decisive as to the insufficiency of the existing sanitary law, and the inefficiency of the local authorities, that Parliament felt forced to take action. The measures taken were of such increased comprehensiveness and stringency, that the passing of the Sanitary Act of 1866[107] marked another great step in the sanitary evolution of London. The Act applied to England and Wales--and this time actually included the metropolis. The previous definition of the term "nuisance" was enlarged, and "overcrowding" was now for the first time declared to be a "nuisance." "Any house or part of a house so overcrowded as to be dangerous or prejudicial to the health of the inmates" was henceforward a "nuisance" and punishable as such. And it was further enacted that "where two convictions for overcrowding of a house, or for the occupation of a cellar as a separate tenement dwelling-place" should have taken place within three months, it should be lawful for the magistrate to direct the closing of such premises for such time as he might deem necessary. Under another extension of the term "nuisance" the industrial classes got the shadowy boon of all factories, workshops, and workplaces (not already under special Acts), being made subject to the sanitary supervision of the local authorities; and those authorities were given power to inspect such places to ascertain if they were kept in a cleanly state, were properly ventilated, and not overcrowded so as to be dangerous or prejudicial to the health of the inmates. A section in the Act aimed at the inefficiency and inaction of the local authorities, and made it obligatory (no longer optional) upon them to make inspection of their districts. "It shall be the duty of the Nuisance Authority to make from time to time, either by itself or its officers, inspection of the district, with a view to ascertain what nuisances exist calling for abatement under the powers of the Nuisances Removal Acts, and to enforce the provisions of the said Acts in order to cause the abatement thereof." An effort was also made to check the spread of infectious disease by giving the local authority considerable powers as regarded disinfection. It was enacted that the local authority might provide a proper place for the disinfection of clothing and bedding which might have been rendered liable to communicate disease to others; and the authority was empowered to maintain carriages for the conveyance to hospital of persons suffering under any infectious or contagious disease. A blow was struck at the iniquitous but common practice of letting a room where there had been dangerous infectious disorder, until it had been disinfected. And provision was made for the establishment of a hospital for the reception of the sick. All these were most considerable reforms, and would have been most useful had they been given effect to and properly enforced. The most important and wide-reaching provision of the Act was that directed against overcrowding. The 35th Section enacted that regulations might be made by the Sanitary Authority (in other words, the Vestry or District Board) for fixing the number of persons who might occupy a house, or part of a house, let in lodgings, or occupied by members of more than one family. Houses so let were to be registered by the Vestry. The regulations could fix a certain number of cubic feet of air space which should be available for each person. By this means the number of persons who might live in a house, and in the rooms of the house, could be limited. That was the plan--simple enough in appearance--which Parliament devised for contending with the great evil of overcrowding. And then, as regarded the sanitation of the houses when registered, it enacted that regulations should contain provisions for their being put into and kept in a clean and wholesome state. And to secure this being done, regulations were made for their inspection. It was an original and comprehensive scheme of reform. It struck at the root of the two great evils--overcrowding and insanitary dwellings; at overcrowding, by the limitation of the number of persons inhabiting a house, or part of a house, and at insanitary dwellings by a series of regulations enforcing the necessary measures for a decent standard of sanitation. But it was something far more than this. It was the declaration of principles of the utmost importance. It was a declaration of the principle that the responsibility for the condition of the "houses let in lodgings" should be on the shoulders of the "owner" of the house. It was the declaration of the principle that the "owner" should not be allowed to use his property to the detriment, to the injury of the public. It affirmed, so far as London lodging or tenement houses were concerned, the great principle, abhorred by so many "owners," that "property has its duties as well as its rights." The Act was, however, even more remarkable for the recognition it contained of another principle of vital importance to the people of London--the principle of central authority over local sanitary authorities who neglected their duties. Hitherto the local authorities were practically their own masters, and could with absolute impunity neglect to put the provisions of the existing health laws into operation; and "often their inaction had been an absolutely inexcusable neglect of duty." A power of appeal against this inaction was given. Where complaint was made to a Secretary of State that a nuisance authority had made default in enforcing the provisions of the Nuisances Removal Acts, he could, if satisfied after inquiry that the authority had been guilty of the alleged default, make an order limiting a time for the performance of the duty, and if the duty was not performed within that time, he could appoint some person to perform the duty and charge the costs to the authority. And where the local authority had made default in instituting proceedings against some sanitary law breaker, he could order the chief police officer to institute them. These provisions were a recognition of the fact, long patent to even the blindest, that local authorities did not do their duty, and of the necessity of devising a means of securing that a necessary public duty should be done. The fact was emphasised a few years later by the Royal Sanitary Commissioners, who pointed out (1871) that-- "However local the administration of affairs, a central authority will nevertheless be always necessary in order to keep the local executive everywhere in action." The real underlying truth now beginning to be discerned was that in the matter of health or disease, London could not be treated in bits, each governed by an independent body, but must be regarded as, what it really was, one single entity or whole. In another way also was the principle of central authority very clearly affirmed. The Vestries were not to have a free hand in making their regulations under the 35th Section. Any they made had to be approved by a Secretary of State. This was a considerable limitation of the freedom of the Vestries, but it secured more or less uniformity in the powers of the local authorities in this particular matter. But the vigorous administration by all the local authorities of the laws passed to secure the health of the public, was even more greatly to be desired; for, from force of circumstances, the consequences--one way or the other--could not be confined to the sphere of action of each local authority. The lives and welfare of the inhabitants of this vast city are so closely, so inextricably interwoven that, in matters affecting the public health, the action or inaction of one authority may vitally affect the health and the lives, not alone of its neighbours, but even of the people of the city as a whole. Disease and death are no respecters of municipal boundaries, and are not hemmed in or restrained by lines drawn upon maps or recorded in Acts of Parliament. This community of interest of the inhabitants of London was, however, scarcely, if at all, recognised by the general public--it was but seldom the motive to action by the local authorities--but some of the Medical Officers of Health now and then referred to it in their reports. Thus the Medical Officer of Health for Mile-End-Old-Town pointed out (1863) that-- "An untrapped drain, an overcrowded house, an unventilated alley, a rotting dungheap, or a foul closet, may spread disease and sorrow in an entire neighbourhood." And the Medical Officer of Health for Paddington pointed out (1870-1) that-- "The danger of harbouring a contagious disease is not confined to the individual suffering--it is a matter that concerns the community." And the Medical Officer of Health for Whitechapel wrote (1865):-- "Here I would remark, that a uniform system of inspection of all the houses in the several districts in London which are let out in separate tenements should be repeatedly and systematically adopted; for if all the Vestries and local Boards do not act together in this important matter, hotbeds of epidemic diseases will remain undiscovered which will serve as centres from whence such diseases may emanate, and extend over the entire metropolis. The whole population of London, therefore, is interested in the prompt removal of nuisances." Immediately on the passing of the Act some of the Vestries made efforts to deal with overcrowding under the Section which enacted that-- "Any house so overcrowded as to be dangerous or prejudicial to the health of the inmates" is to be considered a "nuisance." That, however, was only a temporary remedy, and affected only overcrowding. Section 35 went to the root of the matter when it insisted that in addition to the prevention of overcrowding, the house in which the people lived should be kept clean and in sanitary condition. "The very foundation of our sanitary structure," wrote the Medical Officer of Health for St. George-the-Martyr, "depends upon the right housing of the poor." The Section 35 was promptly put in force by a few of the Vestries--Chelsea and Hackney being the first to make Regulations and to enforce them. Under the Regulations, whenever the Vestry deemed it desirable to put them in force in respect to any house let in lodgings or occupied by members of more than one family, the number of persons allowed to live in that house was fixed on a basis of 300 cubic feet of air for each adult for sleeping, or 350 for living and sleeping, and the owner had to reduce the number of lodgers to the number so fixed on receiving notice to that effect. The Regulations further directed that-- "The owner of such house shall cause the walls and ceilings of every room, and of the staircase and passages, and yards of such house to be well and sufficiently coloured or limewashed, or otherwise thoroughly cleansed once (at least) in every year. "He shall cause every room and the passages to be ventilated. "He shall provide such accommodation for washing, and such a supply of water for the use of the lodgers as shall be satisfactory to the Vestry's Officers;" and sundry and numerous minor directions. The Medical Officer of Health (Chelsea), after the first year's work, reported that the number of houses in the parish inhabited by two or more families was very great, and in many cases their condition was deplorable, and it was found necessary to embrace whole streets as well as courts and alleys in the registration. By 1869 the registration in Chelsea had been completed, and in 1870 the Medical Officer of Health wrote: "I have seen no reason to alter my opinion of the beneficial action of the measure by which we have been able to bring under direct and constant supervision the majority of the houses occupied by the poorer classes in this parish...." The most satisfactory results followed also in Hackney. Its Medical Officer of Health reported in 1867 that nearly 5,000 houses had been measured and examined, and in a large proportion of cases the numbers of persons allowed to inhabit them had been fixed. And as to the result of the enforcement of the Regulations, he wrote (1869): "A very large number of families now occupy two rooms who formerly lived and slept in one. The gain in health and morality has therefore been considerable." Poplar was another of the District Boards which made and enforced the Regulations. The Medical Officer of Health for the north part of the District reported (1868):-- "Extensive improvements have been already effected, but the work must still be systematically continued, for even when every house in the district has been put into good sanitary state (which is far from being the case as yet), it will be necessary to maintain a constant and watchful system of re-inspection to ensure their being kept in order. "Of the 1,610 houses inspected nearly all required more or less sanitary improvement, and 630 were registered as containing more than one family, and therefore coming under the Board's regulations as to registration." But if a few of the Vestries made real efforts to utilise the Act, others of them either made only a pretence of doing so, or refused altogether. The reports of the Medical Officer of Health for St. Giles' (1866-7) present a typical picture of the attitude and conduct of these bodies. "A most important amendment of the sanitary laws was made by the 'Sanitary Act,' of which Section 35 gives precisely the powers which, not last year only, but every year since the constitution of the Board, the Medical Officer has demanded for the efficient discharge of his functions in respect of houses inhabited by the poorer classes. That section has given to the local authority the power of making bye-laws for the regulation of sub-let houses, and of enforcing the observance of its rules by penalties. "In St. Giles' District, it is this class of houses almost exclusively which need the supervision of the sanitary authorities, and which become without that supervision nests of filth and disease. "Accordingly, soon after the passing of the Sanitary Act, bye-laws were adopted by the Board, and sanctioned by the Secretary of State for the regulation of sub-let houses.... "The Board proceeded to inform owners of all sub-let houses that such houses must be registered in conformity with the Regulation. The intention of the Board was to apply with all proper discrimination, but quite universally and impartially, the powers vested in them in regard to sub-let houses.... The systematic application of these powers by the Board would have done for sub-let houses what the systematic application of the police of their powers under other Acts had done for common lodging-houses. Cleanliness and decency would have been universally secured, and would have been maintained with a minimum of inspection by a fine for every gross violation of the regulations. "But against a system that should work thus directly and efficiently to the sanitary good of the district, the interests of numbers of house-owners and agents were at once arrayed, and these speedily organised an influential deputation to the Board. "The opposite interests, those of the families dwelling in the close and miserable rooms of these sub-let houses, found no organised expression. "The Board resolved to recall the notices which had been issued for a systematic registration, and to apply their powers, in the first instance, only to selected instances of flagrant and continuous sanitary neglect." And yet overcrowding in tenement-houses in St. Giles' was dreadful. Here are some instances of it on the authority of the Medical Officer of Health in 1869. "These houses have for the greater part a family in every room. "In King Street there are 254 families in 273 rooms. " Lincoln Court " " 164 " " 168 " " Little Wild Street " " 139 " " 182 " " Wild Court " " 109 " " 116 " " In Whitechapel (1867), rules and regulations were adopted by the Board. "Unfortunately," wrote the Medical Officer of Health, the Act was permissive, not compulsory. "I brought under the notice of your Board several houses which in my opinion ought to be registered. "... The Board having reserved to itself the power of determining as to the propriety of causing any house to be placed upon the register, this enactment, which was framed not only for the improvement of the moral and physical condition of the poor, but for the benefit of the whole community, has been carried into effect in only one instance." In Islington, draft Regulations were prepared, but it does not appear that they were ever adopted. In Paddington, the Vestry decided against putting the Regulations in force. In Westminster, "such obstacles were offered by the holders of small property" to the Regulations that they were not enforced. And on the south side of the river the story was very much the same. The sting of the enactment was that it put house-owners to the expense of putting the house into, and maintaining it in, habitable and sanitary repair, and to the expense of annually painting or lime-washing it; the provision of proper ventilation--of sanitary and washing accommodation, and for a supply of water: in fact, of doing to the houses that which was essential for the health of their occupants. The Regulations simplified and shortened, and made more effective, the processes for enforcing penalties for breaches of the sanitary laws--all which was of course unpalatable to the sanitary law-breaker. And so the great bulk of the local authorities would have nothing to do with this 35th Section or its Regulations. The law was not compulsory, but permissive--and they availed themselves of that permission. But the Vestries and District Boards who took no action, and allowed the principal provision of the Act to be a dead letter, proved by their conduct their deliberate determination not to impose what was a just expense upon the "owners," even though the not doing so should result in a frightful annual sacrifice of human life, and in an untold amount of human suffering and misery, and a long train of physical and moral evils of the very worst character. That the Act had been successfully administered by some two or three Vestries proved that it was quite a workable measure--so no excuse could be raised on that ground by the recalcitrant Vestries. Their attitude is an irrefutable proof of their selfish indifference to human suffering where it clashed with the "rights of property," and of their incapacity for the position they held as guardians and trustees of the people. "The slaughter-houses and cow-houses are ordered to be whited at least twice a year, while the houses of the poor are allowed to remain for years without this important means of purification." The problem of overcrowding was, undoubtedly, a most difficult one--and some of the Medical Officers of Health were realising how difficult it was to treat with any hope of success. Thus the Medical Officer of Health for Bethnal Green set forth the state of his parish in 1867:-- "The population of Bethnal Green has now nearly reached 120,000, and we have no more house room than heretofore. The consequence is that overcrowding is as great as ever; and although the Public Health Act of 1866 was framed to obviate this great evil, it is practically unworkable, owing mainly to high rents (which in some cases have increased as much as 50 per cent.), dearness of provisions, scarcity of employment, and the imposition of taxes for the first time upon the tenant; and many families who could ordinarily afford to occupy a whole house have been obliged to let lodgings; others who have occupied two rooms have been obliged to put up with one; and where overcrowding has existed, and the law enforced, the people have merely removed to other houses and thus perpetuated the evil which it was the intention of the Legislature to obviate." But doing nothing while overcrowding got worse was not likely to make the problem less difficult. Except, then, in a few parishes overcrowding was permitted to pursue its own course unchecked, to the great benefit of the various "owners," and to the great misery of great masses of the people, and the evil extended itself year by year and became steadily acuter. And this, too, after Parliament had placed in the hands of the local authorities large powers specially designed for coping with an evil which was eating into the very vitals of the community. So rapid was the increase of population that the increase in the number of houses did little to mitigate the over-crowding; nor was the construction of the majority of the houses conducive to the health of those who went to inhabit them. London ground was being rapidly covered with buildings. "Many large tracts of our formerly open spaces have been rapidly covered, nay densely packed with buildings. "The operations of the builder have annihilated acres of garden ground by the hundred." "Little garden plots, green spots, open spaces, were being absorbed and swallowed up one after another, and covered with houses.... "Apparently each builder does that which seems good in his own eyes." Paddington afforded an interesting example of this growth. A space near Ranelagh Road, about 25 acres, had almost all been built upon within the last 15-20 years. The streets were 40 feet wide. Here were 900 houses packed with 12,000 people, or 469 persons to the acre (1871). And another example near Paddington Road, where 275 houses had been built, and the population was 493 to the acre, showing-- "A high density of population such as ought not to have been tolerated under a wise municipal policy." The rapidity of the increase was extraordinary. In Lambeth in the year 1866-7, 1,078 houses were erected. In Battersea in 1868-9, 1,530 houses were erected--a large number of which were filled with people within a few days or weeks of their completion. The newness of a house, however, gave no guarantee of its sanitary fitness, and a great proportion of them were of the most objectionable and insanitary description. All the art and craft of the speculating builder was too often exercised to evade such legal provisions as there were for the protection of the public, and to get the largest profits he could for the worst constructed house, and the result was that very many of the new houses were little better than the worst of the old ones. Unfortunately, the law was very ineffective to prevent this. As was pointed out by the Medical Officer of Health for Fulham (1871), the sanitary legislation for the metropolis had never been accompanied by an amalgamation of the Building Act with the general sanitary statutes. "The Building Act still works an independent course, and it is not too much to say of it that, whilst its provisions deal strictly with the strength and quality of bricks and mortar, they utterly fail to ensure for us dwellings, especially for the working classes, which have the least pretensions to perfection in sanitary conditions. A large number of habitations of this description have been completed and occupied during the last few years both in Fulham and Hammersmith, and take the place of our former fever dens in fostering disease. Unfortunately the Sanitary Authorities see these wretched structures raised before their eyes, and have no power to check their progress. It is truly to be hoped that this anomaly will soon be remedied." Such as the houses were, however, they were quickly inhabited. The Medical Officer of Health for Paddington gives a graphic description of the result in his parish (1871):-- "There has been for some years a large influx of persons, mostly of the working class, coming from over-crowded and unwholesome houses of other districts of the metropolis. Large numbers of the newly-built houses being let out in tenements and single rooms attract a class of persons barely able to obtain necessaries of life; amongst these are not a few of intemperate and demoralised habits, with feeble vital stamina, consequently there is, and will be, a larger proportion of sickness, chronic pauperism, and death in the parish than formerly. "This deterioration of race has for some time been recognised by Medical Officers of Health. * * * * * "It must be remembered that most of the working people are fixed to the spot, and cannot get a periodical change of climate, or remove from a locality in the event of impending ill-health, or of contagious disease breaking out near them. "It is of no avail to lament over the laws of absolute necessity, but all parties should combine in a demand for that even-handed justice to the working ranks which, though it may not interfere with a stern destiny which confines them to a life of toil, is bound at least to provide that the theatre of that toil shall be free from the pollutions that endanger the functions of life, and uncontaminated by contagion and death. "I must say it is a scandal to the present constitution of society that the reverse of this continues from year to year in spite of all suggestions of Medical Officers of Health, and the warnings of experience. In vain does one plague after another ravage the family of industrial orders, and like doomed men they stand amidst the harvest of death looking earnestly, but in vain, to the Legislature for that help which no other power can give. Parents, children, and friends, drop around them, the victims of a poisoned atmosphere; while they hear and feel successive warnings, the irrevocable law of necessity fixes them to the spot, and they cannot flee from the danger." The Central Authority, the Metropolitan Board of Works, had, during the decade, been doing much useful work affecting the public health, of London, in addition to its great work, the great system of main drainage. It had undertaken and had completed several large street improvements by 1870, intended to provide new and improved means of access from one part of the town to another. "The Board had to supply the deficiencies resulting from centuries of neglect: it had also to keep pace as well as it could with the wants of the ever-increasing population, and the needs of a traffic which grew relatively even more than the population," and each work contributed to the improvement of the public health, by facilitating and increasing the circulation of air in crowded neighbourhoods. Another matter, important also in reference to the health of the metropolis, had also occupied their attention, namely, the acquisition or preservation of open spaces in London for public recreation and enjoyment. A piece of land, of over 100 acres in extent, was acquired and opened to the public as Finsbury Park in 1869; and on the south side of the river, in Rotherhithe, some 63 acres of land were purchased in 1864, and converted into a public park a few years later. On the outskirts of London there were a number of commons and other tracts of open ground available for public resort, to which the public had no legal rights, and which were rapidly being absorbed by railway companies or builders. London was thus in danger of losing open spaces which were urgently required in the interests of the public health. Parliament, after an inquiry by Select Committee, passed the "Metropolitan Commons Act"[108] in 1866, which prescribed a mode of procedure under which the commons in the neighbourhood of London could be permanently procured for the people of London, and the Metropolitan Board set to work to procure them. The acquisition of Hampstead Heath was happily arranged in 1870. Another great work was also undertaken by the Central Authority--namely, the embankment of the Thames. The offensive state of the river had been greatly enhanced by the large areas left dry at low water on which sewage matter collected and putrefied; and the only way of removing this cause of mischief was by confining the current within a narrower channel. Parliament passed an Act in 1863, entrusting its execution to the Metropolitan Board, and the work was soon after commenced. Thus in these matters, all of which were closely associated with the public health, the sanitary evolution of London was progressing, and the Board was giving visible demonstration of the necessity of that which had so long been denied to London--namely, a central governing authority to deal with matters affecting London as a whole. The Board, in their report for 1865-6, stated they were: "Deeply sensible of what remained to be done to remedy the neglect of past ages, and to render the metropolis worthy of its position as the chief city of the Empire;" but they were hampered by the want of means to enable them to carry out desired improvements. "It cannot be questioned," they wrote, "that direct taxation now falls very heavily upon the occupiers of property in the metropolis.... It appears to the Board that the most equitable and practicable mode of raising the necessary funds would be by imposing a portion of the burden on the owners of property. It cannot be denied that the interest of the latter in metropolitan improvements is much greater than that of temporary occupiers, and yet at the present time, the occupiers of property in the metropolis bear almost the whole cost of the improvements effected by the Board. It is hoped that the representations made by the Board will satisfy the Legislature of the injustice of the present state of things, and lead to some equitable remedy." The visitation of cholera was doubtless in the main accountable for the excess of energy displayed by Parliament about this period in matters affecting the public health. In the same session that the Sanitary Act was passed, a measure of considerable importance to the consumers of water in London was passed, though many years would elapse before its effect would be appreciable. This was "The Thames Purification Act." "Whereas ... the sewage of towns situate on the river Thames above the metropolis is carried into the river, and thereby its waters are polluted and the health and comfort of the inhabitants of the valley of the river below those towns of the metropolis are affected," powers were given for the diversion therefrom of the sewage of Oxford, Reading, Kingston, Richmond, &c., &c., "whose cloacal contributions to the stream were distributed to masses of the people of London." No less than 56 towns, it was said, cast their impurities into the river. And in the following year the scope of the Thames Conservancy Board was extended and very stringent care exercised to prevent unnecessary pollution of the river. And in 1868 the river Lea, another of the water suppliers, was placed under a Conservancy Board. In 1867 an Act of far-reaching consequence was passed, making vaccination compulsory. In 1836 an Act[109] dealing with this matter laid it down that the parent of a child, or the occupier of the house in which a child was born, might, within 40 days, give notice to the Registrar as to the vaccination of the child. There was no punishment for the neglect to do so, and no penalty for refusal to give the Registrar the information. This new Act, which came into operation on the 1st of January, 1868, enacted that-- "Every child shall be vaccinated within three months of its birth." The Act was to be administered by the Poor Law Authorities; and Boards of Guardians might appoint public vaccinators and establish vaccination stations. In 1867, also, another Act of very great consequence was passed dealing with one important element in the sanitary evolution of London, to which no reference has yet been made, namely, the provision of hospitals for the isolation of infectious or contagious disease, for the prevention of mortality, and for the speedy restoration of the sick to health. There is, indeed, no part of sanitary work requiring more constant attention than the protection of the community from the spread of infectious diseases, and this is best secured by hospitals affording proper provision for isolation and treatment of infectious cases. Next to the adoption of proper measures for the prevention of disease, a suitable provision for the speedy restoration of the sick to health is obviously of the greatest importance to the community. So far as the absolutely destitute were concerned, all had, by the law of England, subject to certain conditions, right to food, shelter, and medical attendance; and they accordingly received gratuitous medical treatment at workhouses, or dispensaries, and in sick wards. Indeed, any person suffering from an infectious disease might, if willing to become a pauper, take advantage of such provision as was made by the Guardians of the Poor, the provision being imperfectly isolated wards and buildings attached to the several Metropolitan Workhouses and Infirmaries. Those not so willing were compelled to remain at home, a source of danger to those around them, and if poor, with insufficient medical attendance and nourishment. For a long time the only special provision for certain infectious diseases for the whole of London was that in the London Fever, and the London Smallpox Hospitals, both of which were maintained by private charity. Happily, where neither the State nor the local authorities did anything, charity stepped in, and on a larger scale supplied an inevitable want; and medical charities grew up to give relief in time of sickness to those of the working classes of society who were unable to provide for themselves, but this was mostly for non-infectious or non-contagious diseases. None of the Vestries or District Boards gave any sign of making provision for those who were not paupers, although the duty of giving opportunity for isolation of infectious persons whose diseases made them dangerous to others, be they paupers or not, devolved upon them under the Sanitary Act of 1866 as the Sanitary Authorities concerned in the prevention of the extension of disease. "Indeed it must be admitted," wrote the Medical Officer of Health for Chelsea some years later, "that the Vestries never recognised their responsibilities (as sanitary authorities) from the very first." Grievous scandals having occurred in the treatment of the sick in many of the metropolitan workhouses, the Government of 1867 decided on a great measure of reform. Once more the necessity of central government had to be recognised, and by the Metropolitan Poor Act of 1867 a Board--elected by the Poor Law Guardians, who themselves were elected bodies--was created as a central authority to relieve Poor Law Guardians of the care of and treatment of paupers suffering from fever and smallpox who could not be properly treated in workhouses, and to provide for their treatment and accommodation, as well as that of the harmless insane of the metropolis. The Board was entitled the Metropolitan Asylums Board, and consisted of 73 members; 55 of whom were elected by the various Boards of Guardians in London, and the remaining 18 being nominated by the Home Secretary. In the early stage of its existence its duties were strictly confined to those of the pauper class suffering from these diseases.[110] Admission to its hospitals could be obtained only on orders issued by the relieving officers, and those admitted became, if they were not so already, "pauperised" by admission and _ipso facto_ paupers; but later its scope was extended, and it became the Hospital Authority for infectious diseases in London, and afforded another illustration of the necessity for having one central authority for matters relating to the public health of the inhabitants of the metropolis. The erection of hospitals was at once commenced. The first was opened in January, 1870, and the isolated treatment of many cases of infectious disease was of great benefit to the community. In 1867, too, Parliament again dealt with the condition of the workers in Factories and Workshops. The legislation dealt with the kingdom as a whole, but inasmuch as London was so great a manufacturing city, it affected also the masses of the working population of the metropolis. The Commissioners on Children's Employment, who had been at work since 1862, had completed their inquiry, and made many recommendations, and in the concluding part of their fifth report, dated 1866, they wrote:-- "We heartily trust that we may have thus, in some degree, contributed to bring the time nearer when so many hundreds of thousands of your Majesty's poorer subjects of the working classes--especially the very young and those of the tenderer sex--will be relieved from the totally unnecessary burden and oppression of overtime, and night work; will be confined to the reasonable and natural limits of the factory hours ... will perform their daily labour under more favourable sanitary conditions, breathing purer air, amid greater cleanliness, and protected against causes specially injurious to health and tending to depress their vigour and shorten their lives." Only in 1867 was factory legislation at last of an approximately general character. "Fully two-thirds of the century in which England's industrial supremacy swept to its climax was allowed to pass before even an attempt was made to regulate on sound general principles the recognised and inevitable workings of unchecked individualism in the industrial field."[111] The Act of 1867[112] made better provision for regulating the hours during which children, young persons, and women, were to be permitted to labour in any manufacturing process conducted in an establishment where fifty or more persons are employed--the regulation being in the direction of less onerous conditions of labour. And by another Act passed at the same time--"The Workshop Regulation Act, 1867,"[113] the protection afforded to workers in factories was extended to workers in smaller establishments, so far as regarded the regulations relating to the hours of labour to children, young persons, and women. "Workshop" was defined as-- "Any room or place whatever (not a factory or bakehouse) in which any handicraft is carried on by any child, young person, or woman, and to which the person employing them had a right of access and control." No child under 8 was to be employed, and none between 8 and 13 was to be employed more than six and a half hours a day--and sundry other directions. The workshops, moreover, were to be kept in a proper sanitary state, and the administration of the sanitary provisions of the Act was placed in the hands of the local authorities--the Home Office Inspectors having concurrent jurisdiction. These Acts had a two-fold effect in the direction of sanitary evolution: the improvement of the sanitary conditions under which the people worked, and the prohibition of work entailing consequences detrimental to the physical well-being of the workers. Their effect would have been of the greatest value in London had they been vigorously enforced. Some of the Medical Officers of Health endeavoured to enforce the Act. Thus the Medical Officer of Health for the Strand reported to his employers (1868-9):-- "During the past year the provisions of the Workshops Regulation Act, 1867, have, so far as practicable, been enforced." And the Medical Officer of Health for St. George, Hanover Square, wrote (1870-1):-- "I have endeavoured to carry out the Workshops Act by the abatement of overcrowding, by enforcing due ventilation, and closing at the legal time, so as to prevent the scandal and suffering of dressmakers still being compelled to toil for 16 hours." But the silence of others on the subject told its own tale and pointed its own moral. Active inspection was essential for success, but inspection was not encouraged by the Vestries or District Boards, and the intentions of the Legislature were once more frustrated by the failure of the local authorities to do their duty. After four years Parliament took the duty away from their incapable hands and transferred it to the Factory Department of the Home Office. One other Act of importance Parliament also passed about this time, "The Artizans' and Labourers' Dwellings Act, 1868." Sanitary legislation has as yet done little more for old property, and the whole of Central London was old property, than to improve the drainage, and occasionally to cleanse or whitewash some small fraction of it; and there remained the fact that numerous districts or conglomerations of houses were unreformable, and when the most was done to them that could be done under the law were still unfit for human habitation. In the previous year a Bill had been introduced into Parliament by Mr. Torrens:-- "The objects of which were, first, to provide means for taking down or improving dwellings occupied by working men which were unfit for human habitation; and secondly, for the building and maintenance of better dwellings instead. But the Act of 1868 retained the former only; the latter having been struck out of the Bill during its progress through Parliament. "The intention of Parliament was to provide the means whereby local authorities might secure the effectual repair of dilapidated dwellings, or, when necessary, their gradual reconstruction."[114] The Act conferred powers far exceeding any heretofore possessed by the local authority for effectually dealing with houses unfit for human habitation. "On the report of the Medical Officer of Health that any inhabited building was in a condition dangerous to health, so as to be unfit for human habitation, the Vestry, after certain inquiries, &c., was to have power to order the owner to remove the premises, and, in default, themselves to remove them; or they might order the owner to execute the necessary structural alterations, and in default, might either shut up or pull down the premises, or themselves execute the necessary work at the owner's expense."[115] The Act proceeded upon the principle that the responsibility of maintaining his houses in proper condition falls upon the owner, and that if he failed in his duty the law is justified in stepping in and compelling him to perform it. It further assumed that houses unfit for human habitation ought not to be used as dwellings, but ought, in the interests of the public, to be closed, and demolished, and to be subsequently rebuilt. Use began to be made of the Act soon after its passing, but the operations under it can be more conveniently described in the following chapter. The energy of Parliament had a most beneficial effect, and many of the Medical Officers of Health bore testimony to the encouraging sanitary progress which was being made. Thus the Medical Officer of Health for Fulham wrote (1868):-- "Our district is gradually and most manifestly improving in all those great features of hygiene which are truly essential where such masses of people congregate together." And the Medical Officer of Health for St. Martin-in-the-Fields, who wrote in 1864 that:-- "The spread of sanitary knowledge is slow"-- Wrote in 1868:-- "Upon the whole, I am of opinion that all classes, even the very poorest, are much more alive to their own interest in supporting measures for the maintenance of health." The Medical Officer of Health for St. Mary, Newington, wrote (1871):-- "The knowledge of a compulsory power, as well as the spread of sanitary knowledge, and a greater appreciation of it, has led to a vast amount of sanitary improvement. "I can but express a strong conviction that the sanitary measures carried out are working slowly but steadily a vast improvement in both the morale and physique of the inhabitants of this metropolis in particular ... a great work is progressing, the effects of which will be seen more and more as years roll on, and will be recognised in the greater comfort, better health, and augmented self-respect of the people, and in an increased and increasing improvement in the homes of those on whose strength or weakness must depend in no slight degree the position for better or worse of the English nation." The Medical Officer of Health for St. George the Martyr, in his report for 1870, makes a retrospect of fifteen years:-- "When the Vestries began (1856) their mighty task they had to contend against evils and prejudices which had their origin in far away back generations, and which have cast down their roots deep and intricate into our social system.... "The Acts under which the Vestries had to work were very imperfect. Opposition was strong on every hand, the magistrates sympathised with the defendants. Property and its rights were apparently invaded; and property and its rights have always claimed more support than property and its duties. "What was our physical condition? (in 1855). "In every yard were one or more of 'the foulest receptacles in nature,' namely, cesspools; these gave off, unceasingly, foul effluvia, filling meat safe, cupboard, passage and room. The smell met you on entering the house, abode with you whilst you remained in it, and came out with you on leaving it. The parish was burrowed with them, and the soil soddened with the escape of their contents. The emptying of them proved a true infliction. They have now been emptied for the last time, filled up with coarse disinfecting materials.... They would not now be endured for a moment, yet with what difficulty they were abolished. They were clung to as if some old and honoured relic was about to be ruthlessly torn from its possessors." Dr. Simon, the Medical Officer to the Privy Council, gave, in his report of 1868,[116] a view of sanitary progress in the country generally, much of which applied equally to London:-- "It would, I think, be difficult to over-estimate, in one most important point of view, the progress which, during the last few years, has been made in sanitary legislation. The principles now affirmed in our statute book are such as, if carried into full effect, would soon reduce to quite an insignificant amount our present very large proportions of preventable disease. It is the almost completely expressed intention of our law that all such states of property and all such modes of personal action or inaction as may be of danger to the public health, should be brought within scope of summary procedure and prevention. Large powers have been given to local authorities, and obligation expressly imposed on them, as regards their respective districts, to suppress all kinds of nuisance and to provide all such works and establishments as the public health preliminarily requires; while auxiliary powers have been given, for more or less optional exercise, in matters deemed of less than primary importance to health; as for baths and wash-houses, common lodging-houses, labourers' lodging-houses, recreation grounds, disinfection-places, hospitals, dead-houses, burial grounds, &c. And in the interests of health the State has not only, as above, limited the freedom of persons and property in certain common respects: it has also intervened in many special relations. It has interfered between parent and child, not only imposing limitation on industrial uses of children, but also to the extent of requiring that children shall not be left unvaccinated. It has interfered between employer and employed, to the extent of insisting, in the interests of the latter, that certain sanitary claims shall be fulfilled in all places of industrial occupation.... "The above survey might easily be extended by referring to statutes which are only of partial or indirect or subordinate interest to human health; but, such as it is, it shows beyond question that the Legislature regards the health of the people as an interest not less national than personal, and has intended to guard it with all practicable securities against trespasses, casualties, neglects and frauds. "If, however, we turn from contemplating the intentions of the Legislature to consider the degree in which they are realised, the contrast is curiously great. Not only have permissive enactments remained for the most part unapplied in places where their application has been desirable; not only have various optional constructions and organisations which would have conduced to physical well-being, and which such enactments were designed to facilitate, remained in an immense majority of cases unbegun; but even nuisances which the law imperatively declares intolerable have, on an enormous scale, been suffered to continue; while diseases which mainly represent the inoperativeness of the nuisance-law, have still been occasioning, I believe, fully a fourth part of the entire mortality of the country. And when inquiry is made into the meaning of this strange unprogressiveness in reforms intended, and in great part commanded, by the Legislature, the explanation is not far to seek. Its essence is in the form, or perhaps I may rather say in the formlessness, of the law. No doubt there are here and there other faults. But the essential fault is that laws which ought to be in the utmost possible degree, simple, coherent, and intelligible, are often in nearly the utmost possible degree, complex, disjointed and obscure. Authorities and persons wishing to give them effect may often find almost insuperable difficulties in their way; and authorities and persons with contrary disposition can scarcely fail to find excuse or impunity for any amount of malfeasance or evasion." To this review by one of the ablest and most experienced of men of the time in matters relating to the public health, it must, however, be added that so far as the metropolis was concerned, "the meaning of this strange unprogressiveness" was not so much the formlessness of the law, as the fact that the interests against the enforcement of many portions of the law were predominant, and the non-administration of the law was due far more to that circumstance than to any ambiguities or obscurities in the laws. "Vested interests in filth and dirt" were all powerful on the greater number of the local authorities of London, and so the law which would have interfered with those interests was left severely unadministered. Against these interests it was difficult to struggle--especially when there was no compulsion upon the administrators of the laws to administer them. Sheltered under a permissive, they would not exercise a compulsory power--a power entrusted to them with the control of public money for public good. The true cause of the inoperativeness of the law was, in a way, pointed out by the Medical Officer of Health for St. James', Westminster, when he wrote (1869-70):-- "The great deficiency of the Act of 1866, as of all other English legislation on sanitary matters, is that no public prosecutor is appointed. If Vestries neglect to prosecute, and individuals do not see their way to it, people may be killed by infectious diseases to any extent." And the Medical Officer of Health for St. Giles' expressed a similar opinion when he wrote (1870):-- "The duty of making these sanitary improvements should be imperative instead of permissive. It was wise, at first, perhaps, that our sanitary legislation should be tentative and experimental; but experience having proved its necessity it should be made more stringent." But neither of them got so far as to see the natural and simple remedy, that where a local authority for one reason or another would not administer the laws made by Parliament, the central authority should step in and do the work at the cost and expense of the recalcitrant local authority. If one set of people failed in their duty to the public, it was but right that where such tremendous issues were at stake as the health and physical well-being, not merely of the people of one parish but of over three and a quarter millions of people--and all that their health and well-being implied--the administration of the law should be placed in hands that would administer it. That, however, was but part of the great problem, though it would have gone a long way in ameliorating things. The other necessity was the strengthening and altering of the law which itself stood in need of many and large changes before a sure foundation could be laid for the future health of the great community resident in the great metropolis of London. And other matters which ultimately were to have great influence towards the solution of some of the worst of the health difficulties in London were coming into view, and assuming form and substance. Tramways, with their facilities of traffic, were about to be started. In 1869 three private Acts were passed, authorising the construction and working of tramway lines in the metropolis, and in the following year several more private Acts and "The Tramways Act, 1870," which was a general measure. Its main object was to provide a simple, inexpensive, and uniform mode of proceeding in obtaining authority for the construction of tramways, and to give the local authorities the power of regulation and control. In London the Metropolitan Board of Works was constituted the "local authority" under the Act; and that Board was empowered to apply for a Provisional Order itself to construct tramways, and lease them to other persons, and was given, with the approval of the Board of Trade, a compulsory power of purchase after a period of twenty-eight years on certain conditions. And in 1870 another Act of the most far-reaching importance was passed, "The Elementary Education Act," which prescribed the establishment of a School Board for London, and which in process of time would exercise vast influence towards a cleaner, brighter, healthier life than any hitherto within the reach of the masses of the population of London. But though progress was being made in many ways, the progress had not affected infantile life. "The dreary catalogue of human misery" given in the statistics of infantile mortality was as dreary as ever. In every part of London those statistics were appalling. In 1867, in the Whitecross Street District of St. Luke, no less than 64·4 per cent. of the mortality for the district consisted of deaths among children under five years of age. In 1868 it was close upon 61 per cent. In Bethnal Green, in 1869-70, of 3,378 deaths, 1,900 were under five = 56·3 per cent. In a sub-division of Whitechapel, in 1865-6, close upon 58 per cent. were under five; in Poplar a fraction short of 47 per cent. In Kensington, in 1866, 40·6 per cent. were under five. Each year the Medical Officer of Health for Fulham drew attention to, and protested against, the high rate, nearly 50 per cent., of infantile mortality under five, in 1867-8. In Wandsworth, in 1870-1 = 47 per cent. In Camberwell, in 1868 = nearly 50 per cent. In St. Mary, Newington, and in Rotherhithe = 50 per cent. In Bermondsey, in 1869-70 = 56 per cent. In certain streets the percentage was much higher. Thus in Paddington (1870-1):-- Woodchester Street 56 per cent. Cirencester " 65 " Clarendon " 72 " The high infantile mortality betokened high infantile sickness, but of it no records have ever been kept. FOOTNOTES: [81] 25 and 26 Vic. cap. 102. [82] See P.P. 1866, vol. xvii. Report of Royal Commission. [83] Hansard, vol. clxi. p. 1061. [84] Ibid., vol. clxii. p. 148. [85] P.P. 1866, vol. xxxiii. [86] See P.P. 1863, vol. xxv. Report by H. S. Tremanheere to the Home Secretary, 1862. [87] "In a bakehouse in St. Martin's Lane, eight men slept in one room (separated from the bakehouse) which had nothing that deserves the name of a window" (Report of Medical Officer of Health, 1864). [88] P.P. 1864, vol. xxviii. Sixth Report of the Medical Officer of the Privy Council (1863). [89] Hansard, 1864, June 16, p. 1835. [90] See Reports of the Commissioners on Children's Employment, 1864-6. [91] Shoreditch, 1863. [92] Westminster, 1861-2. [93] 1863-4. [94] Whitechapel, 1861. [95] P.P., vol. clxxxvi. Select Committee of House of Commons on Medical Local Government, 1866, p. 259. [96] Hansard, 1861, vol. clxi. p. 1070. [97] Report of Commissioners. P.P. 1864, vol. xxii. p. xlix. [98] See P.P. 1874. Report of Select Committee on the Adulteration of Food, &c. Evidence of H. Owen. [99] 26 and 27 Vic. cap. 40. [100] Ibid. cap. 117. [101] P.P. 1866, vols. xxxiii.-iv. [102] Select Committee on Metropolitan Local Government. [103] See P.P. 1867-8, vol. lviii. Return of Inspectors of Nuisances, &c., 1866. [104] Select Committee on Metropolitan Local Government, 1866. [105] P.P. 1867, vol. xxxvii. [106] P.P., vol. xxxvii. p. 275. [107] 29 and 30 Vic. cap. 90. [108] 29 and 30 Vic. cap. 122. [109] 6 and 7 Wm. IV. cap. 86. [110] See Report of the Metropolitan Asylums Board for 1886-7. [111] See the Edinburgh Review, January, 1903. [112] 30 and 31 Vic. cap. 103. [113] 30 and 31 Vic. cap. 146. [114] Report of Select Committee on the working of the Artizans' and Labourers' Dwellings Improvement Act, 1882, p. iii. [115] Ibid., p. iv. [116] P.P. 1868-69, vol. 32. CHAPTER IV 1871-1880 IN 1871, the decennial Census once more afforded reliable information as to the population of London, and gave the means of ascertaining much else of the greatest value. The population had gone up to 3,254,260 in 1871, from the 2,808,862 it had been in 1861, an increase of 445,398. But the rate of increase was declining. The decennial increase of population which had been 21·2 in 1841-1851, 18·7 in 1851-1861, had further declined to 16·1 in 1871. The returns showed that London contained 2,055,576 persons born within its own limits, and 1,198,684 persons born outside its borders. "Whence came these multitudes of both sexes, equal in themselves, without counting those born there, to a number greater than the inhabitants of any other European city?" More than 607,000 of them came from the chiefly agricultural eastern, south-eastern, and south-midland counties surrounding the metropolis. A large contingent of 147,000 was drawn from Devonshire, Wiltshire, Somersetshire, and the other south-western counties. The west-midland counties sent up 84,000. 41,000 persons had come from Scotland, 91,000 from Ireland, 20,000 from the Colonies, and 66,000 from foreign parts. In fact, over 37 per cent. of the population of London in 1871 were immigrants into the great metropolis--a great rushing river of humanity. The returns were also of special interest in showing the changes in the distribution of the population. Speaking broadly, the previous movements were being continued--a diminishing population in the central parts, an increasing population in the outer parts. It appeared to be inevitable that-- "As the trade of London continued to increase, so the districts which lay close to the great centres of business must be expected to be occupied more and more with warehouses, and less and less with the miserable dwelling-houses which had hitherto sheltered its poor and working-class population." The diminution of the population of the central parts of London was in no way a symptom of decay: it was, in reality, proof of the reverse, being the result of increasing trade, commerce, and wealth, which required more house accommodation for the carrying on of their enormous operations. The great economic forces were in fact as active and powerful as ever. In the City the population had fallen in the decade from 111,784 to 74,635. In every one of the six parishes or districts composing the Central group the population had likewise decreased. In the Eastern group, the population of three had decreased, whilst in the others there were increases--notably so in Poplar, where there was an increase of 37,000, and in Bethnal Green, where there was an increase of 15,000. In the Northern group all had increased, except St. Marylebone--the increase in Hackney being over 41,000, and in Islington over 58,000. In the West, there were also large increases--Fulham 27,000, Paddington 21,000, Kensington 50,000. Only St. James' (Westminster) and Westminster had decreased, and they in reality belonged more to the centre than to the west. On the South side, with the exception of Christchurch, St. Olave, and St. Saviour's--all in Southwark--and Greenwich, there was an increase in all the parishes or districts, the increases in some being very large; 40,000 in Camberwell, 46,000 in Lambeth, 55,000 in Wandsworth. The figures thus furnished by the Census enabled a fairly accurate calculation to be made as to the death-rate. It now appeared to be 24·6 per 1,000 living. The Registrar General, in his report for 1873, entered into a comparison with previous years which may be assumed to be as accurate as any such calculations could be. The mortality was as high as 29·4 in 1854. It was 26·5 in 1866 (when cholera was epidemic), and it was as low as 21·5 in 1872, and 22·5 in 1873. "The mortality never having been so low in any two consecutive years since 1840, and by fair inference never so low in any two years since London existed." This was distinctly encouraging, demonstrating as it did the good results ensuing upon the great works of improved drainage and sewerage, and a healthier water supply. As to the housing of this huge population, it was shown that the number of inhabited houses had increased from 360,035 to 419,642. The reports of many of the Medical Officers of Health throw much additional light upon, and explain or elucidate the facts set out in the Census, and carry on the narrative into later years of the matters recorded by the Census Commissioners. Thus, as regarded the reduction of the population in the central group of parishes, the Medical Officer of Health for the Strand District ascribed it in part to the new Law Courts, and to the circumstance that residential houses were, in increasing numbers, becoming converted into business premises. "But," he added, "it is also probably in some measure due to the greater facilities for locomotion to suburban homes"; which is notable as almost, if not absolutely, the first recognition of this cause affecting the population. In St. James', the decrease of population was "due to the fact that the district had increasingly become the centre for clubs, hotels, and splendid shops. The result had been an enormous rise in the value of houses, and a gradual extrusion of the less wealthy and important residents." In St. George-in-the-East, the Medical Officer of Health stated that:-- "The decrease of population was due to houses being taken by a railway company, by the Poor Law Guardians for an infirmary, for a church, &c." How considerable the clearances were in some districts may be inferred from the figures given by the Medical Officer of Health for St. Giles' in 1871. "The clearances in the City of London for the purposes of erecting a new market, and a viaduct, and in the Strand district to form a site for the proposed Law Courts, have aggravated the evil of overcrowding. To effect these improvements (or chiefly so) the large number of 18,358 persons have been removed. Strand, 6,998; St. Sepulchre (City), 4,188; St. Bride (City), 4,211; Saffron Hill, 2,961." And in St. Olave, on the south side of the river, the Medical Officer of Health wrote:-- "Since the census of 1861, 436 houses have been pulled down, clearing away whole streets and courts for the formation of railways and the extension of warehouses, displacing 961 families comprising 3,556 persons." Consequent upon these clearances, and the people having to find dwelling room somewhere, the transition of houses built for a single family into tenement-houses continued in full swing. The Medical Officer of Health for St. Mary, Newington, reported (1873) that year by year the better class of houses were becoming less and less inhabited by a single family. The Medical Officer of Health for Paddington gave a very clear description of the process. "There is a very dense packing of population," he wrote (1873), and he mentioned some instances:-- "Brindley Street with 801 persons living in 65 houses. Hampden Street " 876 " " 78 " Waverley Road " 900 " " 72 " "Builders intended these houses at first for one respectable family, but ... in violation of common sense and decency they are let out in tenements and single rooms, without those essential conditions of a dwelling which landlords should in all instances be compelled to provide. "There is yet in reality no law to prevent the creation of unhealthy districts as long as five or six families are allowed to live in one house intended for a single family.... Houses should be built with reference to the future health of the people who will have to live in them. "And now, while the fields are open and still unbuilt upon, it would be worth the attempt to overcome the destructive influences likely to be established in building tenement dwellings as the population gathers in this and other neighbourhoods. They will some day be hives of pauperism." Furthermore, in some parishes, the natural growth of the population was very rapid. In Islington, for instance, the Medical Officer of Health wrote:-- "The Life Balance Sheet of your parish for 1875 shows that your losses and gains leave you 4,376 lives to the good, or in other words 4,656 deaths and 9,032 births have been registered in the parish of St. Mary, Islington." And the Medical Officer of Health for St. Marylebone wrote (1877):-- "If we compare the annual number of births with the deaths, we shall find that every year some 1,200 or 1,500 more persons are born in the parish than die in it; and what, it may be asked, becomes of the surplus population? The only answer is, that it migrates; it could not remain in the parish for the simple reason that there is no room, all available spaces in St. Marylebone have long been built upon, and the houses occupied, many of them crowded." To the migration rendered necessary by the natural growth of the population, and by the diminishing number of houses in the central parts, was added the ceaseless stream of fresh immigrants into London. These vast numbers had to find house accommodation somewhere, and they found it, in their tens of thousands, in various parts of the less central portions of the metropolis. In Kensington, for instance, the Medical Officer of Health stated (1871) that the larger portion of the increase of nearly 41,000 in the ten years was due to immigration. The Medical Officer of Health for Fulham drew a graphic picture of this inrush of humanity. "The steady growth of London westward has thrown among us a vast and teeming population of the working classes, as well as those of more well-to-do condition, and for the housing of the former many blocks of wretched and most miserably constructed dwellings continue to be erected with the most utter disregard for drainage or other sanitary appliances now so essential. That part of Fulham, once open fields, is still being rapidly covered with streets and houses of this character, and many open spots in Hammersmith are being filled in the same way. Our healthy neighbourhood may thus be made ere long a land of sickness and disease unless some check is given to such speculative buildings. Our natural advantage with all our care will not avail us against such utter recklessness." The increase of 21,000 in Paddington drew from the Medical Officer of Health the query-- "... Whether any and what steps should be taken to prevent the wholesale influx of a colossus of pauperism with the consequent burdens of poverty and sickness." It had already driven the people underground for shelter, for in 1871 he described how-- "Many of the underground kitchens in Leinster Street (and four others named) have been inspected where the poor people are found living like Esquimaux in underground cave dwellings--places with impure air, want of light, admitted only through a grating in front, the upper sash of the window being often out of repair, or nailed up." The rapid increase of population in London would not have been accompanied with such serious results to the public health as it was, if the houses which were being so rapidly built for the people to inhabit had been constructed on sound sanitary principles. But this was very far from being the case, and the evils described in the last chapter in this respect continued over an enlarged area, and in accentuated form. It is now almost incredible that the laws should have been left in such a state as to enable builders, without any legal check, to put up the houses they did. The Medical Officer of Health for Mile-End-Old-Town pointed out (in 1872) that "The position and structure of houses has a very distinct bearing upon the public health, yet very little regard is given to sanitary principles in their construction.... The class of small houses for the crowded occupation of the poorer classes is generally built either upon 'made ground' composed of refuse and débris of all descriptions, the organic portion of which presently fills the houses with various disease-producing gases, or upon newly opened ground saturated with miasma, without the least attempt at protection by means of previous drainage or properly protected excavated foundations." And in 1876 he reverted to the subject:-- "Water, air, and light are nature's disinfectants and preventions of disease. They are abundantly provided, but more meagrely and inefficiently used, and indeed practically ignored, by architects, builders, owners, and occupiers...." A witness before a Select Committee testified in 1874[117] that:-- "Houses were being built upon the soil--any soil, in point of fact--and the foundations of houses consisted very often of nothing but manure, and old boots, old hats, or anything thrown into it." The Medical Officer of Health for Poplar wrote (1873):-- "The continued rapid increase in the number of new streets and houses in various parts of the district presents many unsatisfactory features. "In most cases, before the buildings are commenced, the gravel is dug out, and the hole filled up with so-called brick rubbish, but in reality with road-sweepings, the siftings of the dust yards and similar refuse. The dwelling-houses, mostly of the poorer class, are largely built of soft ill-burnt bricks, and are tenanted generally as soon as they are finished--frequently even before they are complete. "As a matter of course the walls are still damp, the streets unpaved, and the residents suffer often very seriously in their health." The Medical Officer of Health described ten acres of houses in Hackney as "almost entirely built upon a great dust heap," built, too, of porous bricks and bad mortar. And another witness before a Select Committee in 1882 described how, in the other end of London--in Wandsworth--on an estate "which practically might be considered a small town," the ground has been filled in to a depth of six or seven feet with filth of every description, and houses have been rapidly built upon it. The results to the health of the inhabitants were disastrous. This, however, by no means completed the description of the evil condition of the buildings. The Medical Officer of Health for Shoreditch wrote (1876-7):-- "Not only was the health of the inhabitants endangered by the presence of a large number of old decayed brick drains, but also by many new drains which had been carelessly laid. Their joints leaked; in some places neither cement nor clay had been used, and pipes had been connected with drains at right angles." And the Medical Officer of Health for St. George-the-Martyr added his testimony (1877-8):-- "Not only may the materials of which our buildings are constructed be thus defective, but the drainage may be and is indeed mostly laid carelessly and imperfectly.... An eminent Civil Engineer, one who has had a very large experience in this division of his profession, informs me that 90 per cent. of the houses built are imperfectly drained, that the drains are laid in a reckless manner, the joints often not cemented, and that the way in which they are laid is unscientific and dangerous. No wonder we have continued ill-health of the occupants." The Medical Officer of Health for Fulham described in 1872-3 how in "Fulham New Town" the basements of the houses had been built below any available sewerage, with the result of constant floodings of cesspool matter to the great danger of the public health. And the materials of which the superstructure was made were as bad as they well could be. Porous, and half baked, and broken bricks being used, and mortar mixed with garden mould or road scrapings--"some without a particle of lime in it." In Battersea Fields-- "You will find them there putting the houses together in such a way that you may kick the walls down with your feet."[118] The Medical Officer of Health for Whitechapel put the subject very tersely when he wrote in 1880:-- "In the construction of houses the only thing that appears to be considered is that of cheapness." Until near the end of this decade of 1871-1881, a building could be constructed without any supervision of the materials, and any number of structures which could not be occupied without danger to life or health might be put up, for no one had power to interfere. The London Building Act had no adequate clauses to secure the effectual purity of new dwellings, nor had the Sanitary Authority any power to check the practice of building houses on rotten filth. And so all these evil practices were very widely indulged in; for though there were many respectable men among builders of small houses, there were many who, regardless of all consequences, covered the suburbs with "small, rotten houses." And immense numbers of the people were absolutely unprotected either by the Government or by the local authority from abuses which entailed upon them ill-health and death, and from practices which created and spread disease throughout the community. The Medical Officer of Health for St. George-the-Martyr, Southwark, referring to "the dishonest and scandalous way" in which some houses were built, said (1877-8):-- "From the greed of a few builders this traffic in human life, and in what makes life valuable, is openly and defiantly carried on. Under such circumstances full health is impossible. Yet for the success and permanence of natural existence a high standard is absolutely necessary." Of builders such as these it may be truly said that having created a _damnosa hereditas_ in one place, they moved on to create fresh ones in others, and no one prevented them. So glaring were these evils that a Select Committee, which sat in 1874 on the Metropolitan Buildings and Management Bill of that year, recommended-- "That the District Surveyor or the Metropolitan Board shall have full power to stop the progress of any building in which the materials or construction is calculated to be dangerous or injurious to health, and to summon the builder or owner before the magistrate." At the rate houses were being built, the defective Building Laws were a grave disaster. In the two parishes of Bow and Bromley in Poplar, in the five years ending March, 1878, notices were approved for 1,981 new buildings. In Hackney, in the year 1876-7, notices were given of intention to erect 800 new houses, and the extension of streets and houses into the fields had gone on so rapidly that by that time there were but few fields left in the district, or even large grounds belonging to any of the houses. In Kensington it was reported in 1875 that the increase in the number of new houses brought into occupation had for a considerable period averaged 700 annually. In Wandsworth, in 1874-5, notices were received for 887 new houses. In 1877-8 for 1,432 new houses. " 1878-9 " 1,845 " " 1880-1 " 3,073 " And in every place land was being grabbed for building purposes. The Medical Officer of Health for Whitechapel wrote in 1879:-- "We are now paying very dearly both in health and money for the errors of preceding generations in their having allowed houses to be packed closely together.... Several cases have recently occurred in this district of landlords erecting dwelling-houses in the back-yards of those houses which were formerly occupied by a single family. This is a serious evil and ought to be prevented. We have power to prevent the overcrowding of rooms, and we certainly ought to have power to prevent the cramming together of houses on sites of insufficient size for the healthy existence of the tenants." Even burial-grounds were not sacred, nor were public authorities even immaculate in this respect. Thus in St. Luke:-- "The Quakers' burial-ground by the side of Coleman Street is now (1876) in progress towards being covered with buildings, and a portion was taken by the London School Board for the erection of a school. In the process of excavation for the foundation, human remains were discovered." And the areas at the backs of houses were also being rapidly covered over. The Act of 1855 had provided that 100 superficial feet should be left open-- "But the exigencies of trade have led the Metropolitan Board of Works and the District Surveyors to permit the area on the ground storey to be covered over."[119] In fact, the insufficiency of the laws as regarded buildings intended for human habitation, and the mal-administration or non-administration of those laws which existed, resulted in the creation of evils which inevitably and most injuriously affected the health of the public, not merely at the time, but for many years to come. The Medical Officer of Health for St. Giles', in 1871, pointed out the necessity of a change of the law. "It is very much to be desired that the law gave more stringent powers to local authorities to prevent the re-erection of buildings upon the old sites, so that the new buildings might not become as unfavourable to health as the old ones.... Such a perpetuation of mischief ought not to be permitted, and the rights of landlords should be subordinated to the public good." The condition of existing, as apart from new, houses also stood in need of many changes of the law to effect their redemption. The necessity was forcibly portrayed by the Medical Officer of Health for St. Marylebone in 1870. He wrote:-- "Of all the obstacles that stand in the way of anything like effective sanitary operations, not only in St. Marylebone, but in nearly every other district of the metropolis, there are none so formidable, so apparently irremediable as the miserable house accommodation provided for the labouring classes. Year after year I am called upon to tell the same unvarying story of rotten floors, broken walls and ceilings, windows and roofs that let in the wind and the rain, chimneys that will not let out the smoke, and of these wretched tenements being crowded with honest, hard-working people, from the cellars to the attics." Parliament continued in this decade the greater solicitude about and interest in matters connected with the public health, which it had recently been showing; and the first year of the decade, 1871, is noteworthy for the adoption by Parliament of a measure which had far-reaching effects upon the sanitary evolution of the metropolis. This was the creation (by "The Local Government Board Act, 1871") of a Central Government Authority for the supervision by Government of the sanitary authorities in England and Wales, and also of those in London. Matters relating to the health of the people had become so large a portion of the work of government, that the necessity had forced itself upon Parliament of concentrating in one department of the Government the supervision of the laws relating to the public health, the relief of the poor, and local government. The new authority, which was entitled the Local Government Board, was not a representative body, but was a Government Department. It was to consist of a President, appointed by the Queen, and of the following "ex-officio" members--the Lord President of the Privy Council, all the Secretaries of State for the time being, the Lord Privy Seal, and the Chancellor of the Exchequer. All the powers of the Poor Law Board were transferred to it, also certain powers and duties vested in Her Majesty's Privy Council. Several of the powers vested in or imposed on a Secretary of State, relative to health matters, were also transferred to it. Henceforth no bye-laws made by the sanitary authorities in connection with their duties were to be of any force until approved by the new Board. Also the Board was to possess, in reserve for great epidemic emergencies, a power to issue directions under the Diseases Prevention Act, 1855. But with the exception of such special cases, the function of the new Central Authority in regard of local sanitary action was primarily one of observation and inquiry. The various Vestries and District Boards of the Metropolis being sanitary authorities thus came under the supervision, and in some respects under the control, of the new Central Government Board, instead of, as previously, under a branch of the office of the Secretary of State for the Home Department; but to all intents and purposes they retained their liberty of administration, or, to state it more accurately, their liberty of non-administration. Their relations to the elected central body, the Metropolitan Board of Works, remained unchanged. In 1871, also, Parliament dealt with the water supply of London. The essential importance to the health of the population, especially in large towns, of an adequate supply of wholesome water was becoming more generally recognised. "Without water life cannot be sustained, cleanliness cannot be maintained, sanitary measures are at a standstill, drains become blocked, offensive and deleterious gases are retained or driven back into the dwellings, disease is caused and fostered, and public as well as private injury caused in all directions." The Act of 1852 had failed to secure for the inhabitants the advantage which they ought to have long since enjoyed, of a well-regulated supply of water in their houses for domestic purposes. A Select Committee of the House of Commons recommended that every company should afford a constant supply of water to each house,[120] so that the water might be drawn direct and fresh from the company's pipes at all times during the twenty-four hours, and free from the pollution so often acquired in dirty receptacles. And a Royal Commission, appointed in 1867, after an elaborate inquiry,[121] declared that earnest and prompt efforts ought to be made to introduce the constant service system to the furthest extent possible in the metropolis. The Report of the Royal Commission is memorable for the very strong expression of opinion that the water supply of the metropolis should be consolidated under public control. The duty of supplying the inhabitants of a city with water had from a very early period been regarded as a peculiarly municipal function, and the supersession of the municipalities by joint stock companies was a comparatively modern innovation. Thus far, however, Parliament was not disposed to go. But (by the Metropolis Water Act, 1871) Parliament--contenting itself mostly with "mights"--directed that any company might propose to give a constant supply of water, or the Metropolitan Board of Works might apply to a company for it; failing both of which, and under certain conditions, the Board of Trade might require a constant supply to be provided. Also every company should-- "On Sundays, as on other days, supply sufficient pure and wholesome water for the domestic use of the inhabitants within their limits." But the Act did not curtail the power of the companies to cut off the supply to a house if the water-rate was not paid by the landlord or owner. An opinion was expressed on this point by the Medical Officer of Health for St. Mary, Newington, in 1872:-- "I maintain that water is absolutely necessary for the health, cleanliness, and sanitary condition of every one, and that if a monopoly of its supply is granted to any company, no power of withholding it should be allowed. "In the present and increasing crowded condition of our poorer houses the act of one person may enable a water company to refuse it to a household of ten or twelve people.... I do most strongly protest against a continuation of a power which in its exercise undermines the very foundation of sanitary improvement." Little, however, was done either by the Metropolitan Board of Works, the Board of Trade, or the companies to avail themselves of the optional provisions of the Act. "Perhaps," wrote the Medical Officer of Health for Wandsworth, "there never was an Act of Parliament so completely ignored in many districts as the one in question." "The companies," wrote another Medical Officer of Health, "are too busy in looking after their trade interests to concern themselves much about the health of the people." And the constant supply to the people of London was postponed to the distant future. In 1871 another subject also claimed the attention of Parliament. An epidemic of smallpox of unexampled severity began at the end of the year 1870, "the like of which had not been known in England since vaccination was first practised." It increased in London at an alarming rate until it reached its height in May, 1871, when 288 people died of it in one week, and it killed in London alone, in that one year, 7,876 persons. And as it was reasonable to assume that one death represented at the very least eight or ten times the number of cases of that most loathsome disease, the results were frightful, and the injury inflicted upon the community, present and future, disastrous. At one time more than 2,000 smallpox patients were under the care of the Metropolitan Asylums Board, and the admissions into the Board's hospitals about the same time averaged 500 a week. In a report on the subject the Committee of the House of Commons wrote:-- "It is impossible to say what ravages might not have been the result of the smallpox epidemic of 1870-1 had it not been for the efficiency and energy of the Asylums Board. Although the prophylactic virtues of vaccination have been recognised on all sides, it must be remembered that as yet but a small part of the growing population has been subjected to the operations of the Compulsory Vaccination Act." And they expressed "their strong sense of the great services rendered to the metropolis by the managers." The prevention of smallpox by vaccination was not yet a very potent factor in the diminution of that disease. Only slowly could the Compulsory Vaccination Act of 1867 produce effect, and as the appointment of public vaccinators and the establishment of vaccination stations had been made only optional, the mortality of the outbreak in 1870-1 had been but little, if at all, modified by it. The epidemic, however, was used by some to enforce a lesson. Thus the Medical Officer of Health for St. James' wrote:-- "The lesson of the great epidemic of smallpox is the necessity for vaccination. "The history of no other disease supplies so assuredly and necessarily the means of its entire destruction." And the managers of the Metropolitan Asylums Board, in a report issued in 1871, wrote:-- "The necessity for re-vaccination when the protective power of primary vaccination has to a great extent passed away, cannot be too strongly urged. No greater argument to prove the efficacy of this precaution can be adduced than that out of upwards of 14,800 cases received into the hospitals, only four well-authenticated cases were treated in which re-vaccination had been properly performed, and these were light attacks." Parliament passed an Act in 1871, making the appointment of paid Vaccination Officers compulsory on all Guardians, and the law generally more effective. Likewise in 1871 Parliament dealt with another matter affecting the public health, and placed on record its opinion of the Vestries and District Boards by relieving them of the duty of enforcing the sanitary provisions of the Workshops Act, which they had failed to carry out, and transferring it to Government Inspectors appointed by the Home Secretary. This was quite an unprecedented amount of sanitary legislation by Parliament in one year, and is very notable as showing the greater position health matters were assuming in the opinion of the nation, and the greater necessity Parliament felt itself under for dealing with them. An improvement as regarded the food of the people of the metropolis was also commenced about this time. The Corporation of the City of London had undertaken to carry out the provisions of Part III. of the Contagious Diseases Animals Act, 1869,[122] and had purchased the site of Deptford Dockyard for the purpose of a cattle market, and for the reception and slaughter of foreign cattle. The market was opened in 1871, and the system of inspection there inaugurated secured the good quality of a great portion of the meat consumed in London. In the following year (1872) the purity of certain articles of the food and drink of the people engaged the attention of Parliament. Under the Act of 1860 the Vestries and District Boards might each appoint an analyst, but the great majority of them availed themselves of the permissive character of the Act, and did not appoint one. A sidelight is thrown upon the effect of this inaction of the local authorities by evidence given in 1862 by a master baker named W. Purvis. He said:-- "When the Act passed for preventing the adulteration of articles of food and drink there was an immediate apprehension among those bakers in the trade who adulterate their bread that they would be liable to have their bread frequently analysed, &c. But when it was found that no sufficient means were provided by the Act to meet the expenses of this kind of active and constant supervision (the purchaser having to pay the analyst), they became confident again, and have resumed their practice of adulteration without any fear of detection."[123] It was felt now that some further move should be made, and Parliament added another Act for preventing the adulteration of food, drink, and drugs to the long list of those which had gone before. "Whereas the practice of adulterating articles of food and drink and drugs for sale in fraud of Her Majesty's subjects, and to the great hurt of their health and danger to their lives, requires to be repressed by more effectual laws than those which are now in force for that purpose-- "Be it enacted----"[124] This Act made it incumbent upon all Vestries and District Boards to appoint public analysts to analyse all articles of food, drink, and drugs, on the request of any parishioners, on payment of a fee; and imposed the duty upon them of procuring and submitting for analysis articles suspected to be adulterated, and on their being certified to be so, of taking proceedings before a magistrate, who was given power to impose severe penalties. The offences were more clearly defined, and the expense of executing the Act was to be paid out of the rates. The Act did much good, but the amount of good was not to be judged by the number of prosecutions and convictions. "Its deterrent effects were undoubtedly great."[125] A Select Committee of the House of Commons, which had been appointed in 1872 to inquire into the subject, recommended the repeal of previous Acts dealing with the subject, and the enactment of a new and more compulsory measure, and in concluding their report they said: "Your Committee believe it will afford some consolation to the public to know that in the matter of adulteration they are cheated rather than poisoned. Witnesses of the highest standing concur in stating that in the numerous articles of food and drink which they have analysed, they have found scarcely anything injurious to health." In 1875 a further Act dealing with this matter was passed amending and strengthening the existing law. In September, 1872, another notable step in the sanitary evolution of London was taken in the creation of an authority for the protection of the metropolis against the importation of disease by sea from foreign countries or from home ports. "It is now acknowledged," wrote the Port Medical Officer of Health in his first report, "that, as a natural result of the insular position of the kingdom, and the vast extent of our commerce, the sanitary condition of shipping and of the floating population must exercise a considerable influence on the health of the country as regards the importation and transmission of epidemic diseases ... the urgent advisability of using all means to prevent the introduction of disease into this the largest port in the world is sufficiently apparent." Hitherto the prevention of the importation of the various sorts of disease into London by vessels trading to the Port of London from all quarters of the world had been confided to the officers of Her Majesty's Customs, and was of the most superficial and inadequate character. The district assigned to the Port of London Sanitary Authority extended from Teddington Lock to the North Foreland, and was 88 miles in length. It included 8 sets of docks and 13 "creeks." In the section of river lying between London Bridge and Woolwich Arsenal Pier, about 10 miles in length, there was a constant average of no less than 400 vessels of all descriptions moored on both sides of the river, more than 90 per cent. of which had crews on board. The creeks were more or less occupied by barges containing manure, street-sweepings, gas-liquor, bones and other varieties of foul cargoes, inasmuch as depôts for the storage of these materials existed on the banks. And lying in the docks there was an average of between six to seven hundred vessels, over none of which had the sanitary authorities on the sides of the river any control whatever. This was a most unsatisfactory condition of things, and left London open to the practically unchecked importation of infectious and contagious disease of every kind. By "Provisional Order" of the Local Government Board, the Corporation of London was constituted the Sanitary Authority of the Port of London,[126] and was made responsible not only for taking proper steps, under Orders in Council, to prevent the introduction of cholera, but was required also to carry out, within its allotted area, the provisions of the various Nuisances Removal Acts and Prevention of Diseases Acts for England, and the Sanitary Act of 1866. Its authority extended only to things afloat. Whatever was landed came within the province of the local Sanitary Authority, except things landed in the docks, and things "in bond," which were under the control of Her Majesty's Customs. The work was undertaken at considerable expense by the Corporation out of the City's cash, and at no charge to the ratepayer. And a Medical Officer of Health for the Port and some Inspectors were appointed. It was the duty of the Port Medical Officer-- "To inspect, before landing, all emigrants that arrived in the Port from the Continent for purposes of transhipment, and to isolate all suspected cases, and to carry out all Special Orders in Council relating to the prevention of cholera, or other epidemic diseases." He was also charged with the duty of inspecting, at Gravesend, any cases of sickness on inward-bound vessels reported to the authorities by the officers of Her Majesty's Customs. As to the prevention of the importation of epidemic diseases other than cholera, reliance was placed upon a speedy and proper examination of vessels as soon as possible after they had come to moorings. A large proportion of these vessels required constant general inspection. Among the various other duties, fumigation and disinfection of vessels, also of clothing, were not the least important. For isolation of the sick a hospital ship was maintained at Gravesend. The work done by the Port Authority was, in spite of many limitations and difficulties, considerable; and the inspection of thousands of ships, the cleansing and fumigation of foul or infected vessels, the removal to hospital of seamen suffering from infectious or contagious disease, and the disinfection of clothing were, sanitarily, of the greatest advantage to the inhabitants of the metropolis. In another matter Parliament, in 1872, made a completely new departure. It declared that "it was expedient to make better provision for the protection of infants entrusted to persons to be nursed or maintained for hire or reward in that behalf." And it inaugurated a plan for the protection of the health of the most helpless of its numerous charges--a plan embodied in the Infant Life Protection Act. "Houses of persons retaining or receiving for hire two or more infants for the purpose of nursing must be registered." The Local Authority (the Metropolitan Board of Works) was to cause a register to be kept and make bye-laws, and might refuse to register an unsuitable house. And the registered owner must keep a register of the children, &c., &c. If proved to the satisfaction of the local authority that such person has been guilty of serious neglect, or is incapable of providing the infants with proper food and attention, the house might be struck off the Register, and penalties be imposed--six months with hard labour, and up to £5 fine. The start made was slow, only six houses having been registered in 1876; but the Act laid the foundations of a scheme which has had considerable developments. Specially valuable is it to have the views of one of the foremost men of his time upon the phase of opinion existing at this period upon the general question of the public health. They help to mark progress along the road. The late Mr. W. E. Forster, speaking at the meeting of the British Association at Bradford in 1873, said:-- "I think our aims in this direction are higher than they used to be. We are aiming not only at preventing death, but at making life better worth living by making it healthy. And we no longer forget that in fighting our battle against disease it is not only those who are killed that are merely to be considered, but also the wounded. In those terrible inflictions of preventable disease throughout the country the loss of life is very sad; but even more sorrowful to my mind are the numbers of our fellow-creatures--fellow-countrymen and women--who are doomed to struggle and fight the battle of life under the most severe conditions because of wounds they have received from preventable diseases." While Parliament was thus legislating on several matters considerably influencing the sanitary well-being of the people of the metropolis, the powerful economic and social forces also affecting it were silently and uninterruptedly continuing their work with never-ceasing energy. With the marvellous industrial developments of the time, trade, and commerce, and businesses of various kinds and sorts were spreading over a wider area, and constantly claiming accommodation to carry them on; and the process continued of the conversion of residential houses into offices and shops and warehouses and workplaces. The increase of houses in other parts of London, rapid as it was, barely kept pace with the increase of population, whilst it had practically done nothing as yet to relieve overcrowding in the central parts of London. The excessive density of the population was a great sanitary evil. "It is a well established law," wrote the Registrar General in 1872, "that, other things being equal, the insalubrity of a place increases with the density of the population, and that the fevers generated in crowded dwellings have a tendency to spread among the whole of the population." And it was already pretty generally recognised by Medical Officers of Health that the chief condition affecting the mortality of a locality was the density of population. The Medical Officers of Health never ceased pointing out the evils of overcrowding. "Overcrowding," wrote the Medical Officer of Health for Whitechapel in 1877, "concerns the whole community, as is strikingly shown by the spread of many diseases which are, perhaps, in the first instance endemic, and confined to these overcrowded places, but which soon become epidemic and extend over large areas, attacking, indiscriminately, all classes." And their reports are full of instances which had come under their observation. Thus, in 1871, the Medical Officer of Health for Whitechapel wrote:-- "At No. 13, Goulston Street, I found in the back room of the ground floor, closely contiguous to three closets and a dust hole, one man, six women, and three children sleeping there. The room measured 12 � 9 � 7 feet, giving only a cubic space of 756 feet for ten persons." He mentioned also "a room in Cooper's Court, occupied by man, wife, and seven children, which contained about 630 cubic feet of space, which allows only 70 feet for each." And numerous other cases of overcrowding and indecent occupation, and a case in which the dead body of a child had been retained in a room for fifteen days. Passing on to the larger aspects of this dreadful overcrowding, he wrote:-- "It is manifest that persons living in such circumstances must become so enfeebled in health as to be unfit for any employment which requires much physical strength. The mental capacity of such persons is also so low as to prevent them earning a livelihood in any occupation requiring much thought, and the consequence is an increase of paupers or of criminals, or perhaps of both." "Consumption and the whole tubercular class of disease are chiefly caused by the defective ventilation of dwelling-houses, and particularly of sleeping rooms, in which at least one-third of one's existence is passed." And the Medical Officer of Health for Paddington, in his report for 1871, wrote:-- "Serious evils of physical and moral character are found to afflict the population of these overcrowded houses. The want of fresh air, habitual uncleanliness, bad washing accommodation, with other unsanitary conditions, favour the spread of contagion. There is a notable increase of tubercular and consumptive maladies in our large cities, and the low form of vitality engendered in people who do not enjoy fresh air, leads to the abuse of stimulants and tobacco." In 1874 he wrote:-- "... Eighteen per cent. of the whole deaths--a formidable proportion--are from the tubercular class of diseases: a greater proportion than zymotic. The 206 deaths from consumption at ages between 20 and 60 show that there exists some general cause silently working great mischief and undermining the constitution of parents at a period of life in health and strength when they can least be spared from their families." And he added:-- "Large numbers of sickly and weakly children abound in the tenement-houses of our thickly populated streets." Nor were the homes of the people the only place where overcrowding worked its evil will. Many children--how many there is no means of knowing--suffered from it in the schools which they attended. The following extracts from reports of an Inspector of the School Board[127] present a vivid picture of the condition of many schools in existence so late as the year 1874. 1. ---- _School_. "This is a wretched place, a disgrace to the metropolis. The 'school' is held in an old dwelling-house in Clerkenwell. The house was at one time used as a stable. The approach is most unwelcome, and on entering the schoolroom (upstairs) a most deplorable picture presented itself to the eye. Fifty children crowded together in a small, dingy, shapeless room with space for sixteen, and the window and door carefully closed--in fact, the latter and the doors downstairs carefully bolted. The sooner this place is closed the better." 2. ---- _School_. "As regards the accommodation provided, thirty-six young children were sitting in an upper room into which the rays of the sun on a bright day in June could not enter--twilight in mid-day." 3. ---- _School_. "It would be impossible for words to describe the inefficient state of this so-called school. Eighty-two children of different ages--boys and girls--huddled together in a miserable, badly lighted, badly ventilated room, affording accommodation for twenty-three at the utmost. "No books, no apparatus, no seats; floor and bare walls: the 'teacher' an aged man, standing in the midst of a crowd of children and wielding a cane to keep the 'scholars' quiet, and thus the time goes on." 4. ---- _School_. "This is not a school--it seems a baby-farm. Seventeen children in a small, filthy hovel. There were four infants a few months old; one lay on a small bed, another in a small cot, and the two others in positions which I cannot here describe. The little ones were quite naked. The woman who pretends to look after this 'school' was engaged in a back yard washing. From the woman down to the infant, all here seemed steeped in ignorance and wretchedness." Here is a case reported by the Medical Officer of Health for Whitechapel, so late as 1880:-- "A schoolroom at 11, Pelham Street, Spitalfields; 9 feet long � 8 � 8. There were twenty-five children aged 4-7, and the master and his wife, in all twenty-seven persons, giving 21·3 cubic feet for each." And here is a report of an early crêche, or baby farm, also in Whitechapel, in 1879:-- "The Sanitary Inspector found on the ground floor of 24, Freeman Street, Spitalfields, a woman and twenty-five children all under three. They were left in charge of the occupier of the room from nine until 5.30 p.m., who was paid 3d. per week per child. The room was 15 feet � 7 � 7, thus affording 28 cubic feet of space per child!! The room was badly ventilated, there were neither chairs nor seats, the children were on the floor, which was in a wet and dirty condition." The other causes of insanitation were also flourishing. "Noxious businesses" of various kinds continued to pollute the atmosphere, despite legislation against them, and the existence of local authorities charged with the administration of that legislation--a permanent pollution all the year round, and from which there was no getting away. Very commonly the arches under the railways were used for making and storing artificial manures, the smell from which was intolerable. The Medical Officer of Health for St. Mary, Newington, 1871:-- "The private manure-mixing yards have ever been the cause of much annoyance and illness to those living in the neighbourhood. One of these," he added, "had for years been complained of." And yet the Vestry had not shut it up. And the air was tainted and vitiated by the emanations from them, the owners having no vestige of regard for other people's health. Another cause of insanitation was the existence of slaughter-houses throughout London, in the most crowded parts, and in close propinquity to dwelling-houses; indeed, in the yards of some of them were slaughter-houses, with all their unpleasant concomitants. Cow-houses, too, also close to houses, were numerous, and, in the outer parts of London, even piggeries. A great opportunity was lost in 1874 for greatly diminishing, if not actually terminating, the great "nuisance" of slaughter-houses. By an Act passed in 1844, it was declared absolutely illegal, on the expiration of thirty years after the passing of the Act, to carry on certain noxious businesses in any premises nearer a dwelling-house than 50 feet, or nearer a public way than 40 feet--the business of slaughtering being among the number. Until 1851 there was no control over slaughter-houses; any one could conduct a slaughter-house who pleased, subject only to the common law as to doing anything which might be considered a nuisance.[128] The Metropolitan Market Act, passed in that year, required that all slaughter-houses should be licensed by the justices, thus establishing some form of control over them. When, in 1874, the expiration of the thirty years drew nigh, doubts were raised by those interested in their continuance as to the interpretation of the Act of 1844. The Select Committee, which was investigating the subject of "Noxious Businesses," stated that no evidence had been given before it to show that any of these trades when properly conducted affect the health of the persons living near the premises, and Parliament, accepting this view, passed an Act which undid the enactment of 1844, and allowed slaughter-houses to be continued indefinitely under license. At the same time it conferred on the central authority, the Metropolitan Board of Works, power to make bye-laws with respect to certain noxious trades. And so this fertile cause of insanitation--slaughter-houses--was perpetuated to the present time. There was, however, a far more general and potent cause of disease and death, and general detriment to the public health, than the pollution of the atmosphere by noxious trades, and that was the reckless scattering abroad of infectious or contagious diseases by persons afflicted with or in contact with such diseases. The Metropolitan Asylums Board had already erected hospitals, and were doing a vast amount of good and preventing the spread of disease. But by the people themselves the seeds of infection were scattered broadcast. Dr. Simon, the Medical Officer to the Privy Council, in his Report of 1865, wrote:-- "As to contagions already current in the country, practically any diseased person scatters his infection broadcast, almost where he will--typhus or scarlatina, typhoid or smallpox, or diphtheria, ... the present unlimited license seems urgently to demand restriction." But the license to kill remained without restriction, except that of entering a public conveyance.[129] As the Medical Officer of Health for St. Mary, Newington, wrote in 1871:-- "How many are the ways in which the spread of contagious disease is, as it were, invited, no one knows better than a sanitary officer. Washing, mangling, needlework, go on in many an infected house; children, aye adults also, the sick and the sound, mix indiscriminately. I have even known the exhibition, as a sight, of the corpse of a smallpox patient...." And the Medical Officer of Health for Paddington called attention (1873-4) to-- "The extreme indifference displayed with regard to these diseases (measles, &c.), by many of the lower and middle class is an unmistakable sign of an ignorant belief that they are natural events; and such a belief leads to a carelessness of management much to be condemned. "... The working classes generally visit freely during sickness, allowing their clothes to become saturated with contagious poison." The Vestries and District Boards did do a certain amount of disinfection; but more than three years after the Sanitary Act of 1866 was passed, in twenty-nine districts (out of thirty-eight) no proper disinfecting establishment in accordance with the requirements of the law had been provided (Strand, 1869-70). The Medical Officer of Health for St. James', Westminster, pointed out (1870-1) that in London there was-- "No legal obligation on the part of the head of a family or landlord, or a medical man, to declare the presence of scarlet fever to the sanitary authority. The consequence is, that long before any knowledge of the existence of the disease has been obtained by the Medical Officer of Health the disease has spread far and wide. If it were not so melancholy, one feels inclined to deride the folly and ignorance of a so-called civilised and enlightened nation allowing such a cruel and terrible scourge as this to pass over the country without any attempt to control it." "In sixteen years we have lost 479 persons by scarlet fever in St. James'. Where one person dies, 10-20 get it and get well. It is vain to calculate the pecuniary expense of such a curse, but every one can make something like an approximation to the cost of such a waste of human life, and form an opinion of the vast benefit of legislation that should put a stop to this disease." The Medical Officer of Health for Paddington referred (1876) to the disastrous results of cases of infectious illness not being notified to the sanitary authority, and so enabling precautions being taken to stamp out the infection. "Such a state of matters, with the annual huge mortality consequent thereon, will continue until an educated people, conscious of its duties and jealous of its rights, demands from a tardy executive the intervention of the legislature to prevent it." The Vestries and District Boards were gradually doing a good deal of useful work of the sort which did not much conflict with private interests. The great main drainage works of the Central Authority had enabled them to improve and extend their sewerage and drainage works, and from 1856 up to March, 1872, they had borrowed from the Metropolitan Board of Works £757,000 for this purpose;[130] and the total length of brick and pipe sewer which they constructed in that period was very close upon 700 miles. "The large amount which has been expended on works of sewerage and paving, shows that the local authorities in the metropolis have not been unmindful of the requirements of their several districts." St. Giles' reported in 1872 that its sewerage was very complete, "not a single street or court being without a sewer." St. Marylebone reported in 1877:-- "£33,500 has been spent in new sewers in the parish in the last three years, and £7,000 is to be spent. Over three miles of new sewers were constructed. These are large items in our parochial expenditure, but the fact cannot be ignored that the sewerage of the parish had got into a disgraceful and indeed dangerous condition. "In some of the finest streets and squares of the parish the sewers were but little better than elongated cesspools." Bermondsey reported, in 1872, that the entire district was drained into low level sewers, all open sewers, tidal and other ditches, and cesspools having been abolished; £5,200 expended in widening and improving certain streets, £92,000 spent in sewerage, paving, and other improvements. St. Mary, Newington, reported in 1871 that the whole of the open sewers and tidal ditches had been covered over; that the drainage was in a satisfactory condition, and that within a few pounds of £400,000 had been spent since 1856 in various parish works and maintenance. In the Wandsworth district (1873-4):-- "The enormous sanitary works carried on by the Metropolitan Board of Works and the Board of the District have, by drying the soil and altering the waterlogged condition which formerly prevailed, completely changed the sanitary aspect of the locality." Not all the work reported as done, however, was done as satisfactorily as was to be desired. Thus the Medical Officer of Health for St. James', Westminster, wrote (1871-2):-- "Sewers and drains being out of sight admit of a great amount of 'scamping' work. "Speaking from experience, some of the local sewers in St. James' are specimens, I hope unique, of the extent to which 'scamping' can be carried." And the Medical Officer of Health for Shoreditch wrote (1878) that:-- "Some of the new drains (being so badly laid) are more dangerous than the old." The arrangements for water supply were also in some few parishes, in process of years, being slowly improved. In Lambeth, in 1872, 646 houses without proper water supply were provided with it; and in 1873, 804 houses. Read one way, this was satisfactory. Read the other, it was a revelation of the number of houses in Lambeth which had been left until 1873 without that great essential of health--a "proper water supply." A large amount of street paving had been done, and a few small street improvements had been carried out. Considering the very limited staff of Inspectors which it suited the policy and purposes of the Vestries to appoint, a fair amount of sanitary inspection was done in some parishes and districts. The striking fact about the inspections made is the very high proportion of houses in which the sanitation was defective. In Bermondsey, in 1879, where 1,577 houses and premises were inspected, 1,495 notices were served. In Limehouse, in 1879, 1,411 houses were inspected; and 1,070 orders for sanitary amendments issued. In Shoreditch, where there were 15,500 houses, the two Sanitary Inspectors appear to have done a lot of useful sanitary work. In 1877-8, 5,465 separate nuisances dangerous to health were abated. If anything like a similar proportion prevailed generally throughout London, the housing of its huge population was indeed in a dreadful state. In some ways the local authorities were awakening to their responsibilities, and beginning to avail themselves of some of the provisions placed by Parliament at their disposal. In Paddington, St. Giles', and Rotherhithe, the Vestries had adopted the Baths and Washhouses Act of 1846, and thus helped to promote habits of cleanliness, and to diminish some of the insanitary evils consequent on the tenements being turned into temporary wash-rooms. And in St. James' (Westminster) and Lambeth, mortuaries had been provided, which, in some cases, at any rate, obviated some of the insanitary evils consequent on the retention of dead bodies for long periods in single-roomed tenements where death had been caused by contagious or infectious diseases. More action was being taken, too, as regards the disinfection of rooms where there had been cases of infectious disease. Thus in Lambeth in 1877-8, 824 houses were disinfected. Here and there, too, the owners of noxious trades were being compelled to adopt methods rendering their businesses less insanitary and objectionable to their neighbourhoods. The Local Government Board had caused an elaborate inquiry to be made by Dr. Ballard as to-- "'In what measure and by what means nuisances and injury to health from offensive businesses might be avoided,' and the report led to quite a satisfactory result. "It showed that by the application of such knowledge as was at command, all or nearly all businesses that are in a serious degree offensive might be carried on either without offence, or with such important reduction of offence, as should make it tolerable, or even trivial."[131] In Fulham several piggeries were closed by law; not without regret, apparently, for the Medical Officer of Health stated in his report:-- "It certainly is very hard on the pig keepers individually, but it is in accordance with the recognised law of civilisation, that the interests of the few must be sacrificed to the welfare of the many." Upon one course of action all the Medical Officers of Health were in agreement--the absolute necessity of inspection and supervision of the houses of the people. In season and out of season they advised it, and urged it as the most essential and the most useful of all duties. In support of these views they could point to the results of inspection and supervision in the registered Common Lodging Houses. In the parish of Spitalfields (in Whitechapel, 1880) there were 109 of these houses containing 454 rooms registered to accommodate 3,992 lodgers. The class of persons occupying them were, notoriously, the very lowest. "We failed to learn that any respectable mechanic with his wife and family ever applied at these houses for lodging accommodation. Yet," reported the Sanitary Inspector (1880), "we discovered no case of overcrowding. The bedding was clean; the yards and closets were in a good sanitary condition; there was a good water supply, and the walls and ceilings of the houses were clean." If these results were obtainable in dealing with the worst classes, in the overcrowded parts of Whitechapel, _a fortiori_, inspection and supervision would have been productive of similar benefits among the general tenement population. The Medical Officer of Health for St. George-in-the-East referred to the low mortality in model lodging-houses, where also there was supervision. "There we find good sound dwellings, &c., &c. No overcrowding is permitted, only a certain number in family being accepted as tenants. Cleanliness on their part is expected--enforced if necessary--or a notice to quit is speedily given." While thus recommending inspection, supervision, and compulsory rules, another view was also expressed.[132] "As laws have been enacted for the abatement of overcrowding, it is easy to say: 'let those in authority put them in force'; but I much fear unless the question is taken up with a spirit of love towards the poorer and more ignorant classes by the upper and middle classes, and measures adopted to give instruction to the poor in matters concerning their physical well-being, the existing state of things will long continue." "No class will become civilised by being left to themselves, as unfortunately is the case in the numerous back slums of London, but improvement, physically and socially, can only be effected by a superior class mixing and associating with a class below them." The Medical Officer of Health for Poplar wrote:-- "The poor want more than model dwellings, more than warmth, food and clothing; they want humanity, and the knowledge of the laws governing health." Unfortunately those remedies were, at best, a matter of considerable time, and improvement could be but of slow growth. Immediate measures were required to cope with the appalling evils, and for the house-owners, even more than for the unfortunate tenants, were supervision and compulsory rules requisite. But not one tithe of the Vestries and District Boards would enforce against owners the regulations under the 35th Section of the Sanitary Act of 1866. Though something was being done as regarded the inspection of houses and the repair of sanitary defects, hardly any progress could be said to have been made for the improvement of the dwellings of the poor. The Artizans' and Labourers' Dwellings Act (Torrens) of 1868 was to a small extent being made use of. In some parishes houses considered by the Vestry or District Board as unfit for human habitation had been closed, and were only allowed to be reopened upon proper repairs having been carried out. In other cases where no amount of repairs could put the house into habitable condition, the landlord was directed to pull down the buildings (without his receiving any compensation), and, in default, the Vestry could pull it down at his expense. The site remained unoccupied, until the owner or landlord used it again for building purposes, or sold it to some one else. In St. Giles' (1873-4) the District Board has been enabled under the Act to enforce "considerable improvements in and immediately adjoining the worst parts of St. Giles'." (Houses in yards and courts were demolished.) In St. Luke the total number of houses "pulled down or closed" amounted by the year 1875 to 104.[133] In Holborn the Board had been-- "Applying or threatening to apply the Act to houses that could be fairly subjected to it. Besides having 150 houses, chiefly belonging to one owner, put into a complete sanitary repair, it has been actually applied to 136 houses; 70 thoroughly repaired, 40 demolished, 26 to be rebuilt, and 10 to be closed." There were many difficulties in using the Act. Notice of houses being unfit had to be given to "owners." A certain case in Chelsea was mentioned where-- "There were freeholders, lessees, under-lessees, and sub-lessees, and their trustees and mortgagees, and besides there were the occupiers." But in the great majority of parishes or districts no steps were taken under the Act. The Act did not give any compensation to the owners of condemned property, as Parliament had declared by it that compensation should not be given to those who permitted their property to fall into such a state, whilst at the same time extracting the fullest benefit from it. To such a doctrine there was, of course, the strongest hostility by all those who held the opinion that a man might do as he liked with his own, and extract from it the uttermost farthing regardless of the infliction of disease and suffering and death upon those who were so unfortunate as to become his tenants, and reckless as to the injury his action was inflicting upon the community at large. And so:-- "The reluctance of the local authorities to take away a man's property was insuperable, and consequently no very great demolition took place." The Medical Officer of Health for St. Pancras wrote (1876):-- "The Act is almost inoperative. The highly penal nature of this statute, which in the event of demolition gives no compensation to the owner whose property is destroyed, makes Courts of Justice extend every possible leniency to the owner. Moreover it does not contemplate any scheme for the reconstruction of the houses demolished, or other provision for population displaced...." And the Medical Officer of Health for St. James', Westminster, where no action was taken under it, wrote (1872-3):-- "It is scarcely necessary to say that such an Act could not be acted upon without the grossest injustice to the owners of property, and the infliction of the greatest hardship on the poor." But there was another view, much nearer justice, which was given expression to before the Select Committee in 1881. "An owner of property who allowed his property to fall into such a miserable state as to be unfit for human habitation is not a man that deserves the slightest consideration of any kind from Parliament--he ought to be treated rather as a criminal than an owner of property. To compensate him is a mistake entirely." And the Medical Officer of Health for Whitechapel said it was his opinion that-- "If the landlord leaves his house in a very bad state, and will not listen to any representations, he ought not to be paid by the public when he is creating a nuisance." The Act of 1868 having helped so little to a solution of the housing problem, and the matter being one of ever-increasing urgency, an effort was made to deal with it in 1875, when a Bill for facilitating the improvement of the working classes in large towns was introduced into Parliament by Sir R. A. Cross, and was carried. It often happened that in some of the worst slums, the houses were the property of several owners, and it was not therefore in the power of any one owner to make such alterations as were necessary for the public health. The Act[134] of 1875 contemplated-- "Dealing with whole areas, where the houses are so structurally defective as to be incapable of repair, and so ill-placed with reference to each other as to require, to bring them up to a proper sanitary standard, nothing short of demolition and reconstruction. Accordingly, in this case, the local authority, armed with compulsory powers, at once enters as a purchaser, and on completion of the purchase proceeds forthwith to a scheme of reconstruction."[135] An official representation, that the houses within a particular area were unfit for human habitation, was to be made to the Central Authority, the Metropolitan Board of Works, by the Medical Officer of Health of a Vestry or District Board, and the Metropolitan Board was empowered to declare the same to be an unhealthy area, and to make an improvement scheme in respect of it. If it decided that an improvement scheme ought to be made, it should forthwith make such a scheme, which, after sundry formalities, was embodied in a Provisional Order which had to be confirmed by Parliament. The compensation to be paid for the property so taken might be settled by agreement between the Metropolitan Board of Works and the owner, but where no agreement was arrived at, an arbitrator was to be appointed by the Secretary of State. The arbitrator was to assess the compensation at the fair market value of the lands concerned, due regard being had to the nature and then condition of the property, but no additional allowance was to be made in respect of the compulsory purchase of the area. The value settled, and the land having passed into the hands of the Metropolitan Board of Works, the obligation was imposed on that body of pulling down the buildings, and selling, or letting, the cleared ground for the erection of improved dwellings for the same number of people. The hardship of working class and poorer persons being turned out of houses and no other accommodation being provided for them was formally recognised in this matter, and the scheme had to provide for the-- "Accommodation of at the least as many persons of the working class as may be displaced in the area ... in suitable dwellings which, unless there are any reasons to the contrary, shall be situate within the limits of the same area, or in the vicinity thereof. It shall also provide for proper sanitary arrangements." The Act was intended to relieve owners of such property without loss or benefit, and several representations as to unhealthy areas were made to the Metropolitan Board. The facts stated in these representations and subsequently brought out in evidence in the public inquiries held, were illuminating as to the terrible depths which the conditions of life of numbers of the people had been allowed to reach, without the intervention of the law, or the staying hand of the freeholder, lessees, or sub-lessees, who derived financial profit from the property. The Medical Officer of Health for Limehouse described one of them:-- "The area, though not large, contained abominations sufficient for an area three times its size. Here were crowded houses, built no one knows when; how they stood was a marvel, their walls bulged, their floors sunk, an indescribable musty odour pervaded them; water supply, drainage, closets, all were bad, and in my opinion, nothing could remedy such a state of things short of pulling down the rickety buildings." "The area is inhabited by about 800 people, and the death-rate is about 36 per 1,000." In another of these schemes, in one Court (Sugar Loaf Court) the death-rate was 105·2 per 1,000. The Medical Officer of Health for the Strand gave a report on the sanitary state of Bedfordbury:-- "Bedfordbury is the black spot of this parish. It and the contiguous courts are a little over three acres. Population census of 1871 = 2,163. It is a long narrow street of 47 houses with courts leading out of it on either side. Some of the courts are blind and very narrow, thus rendering light and air difficult of access. "These 47 houses are so old and dilapidated that it is quite impossible to make them fit and proper habitation for the poor to live in. * * * * * "Even this bright and sunny morning the staircases were so dark that you could not see a single stair--there was not a scrap of ventilation, and no means of getting light or air to them. "No. 37 is occupied by 33 people living in six rooms; on the second floor the two rooms are tenanted by two families, respectively five and seven, and the third floor by two families of six each." No. 41 was very similar. "These two houses may be taken as a type of the condition of the houses in Bedfordbury." "Off this street were various Courts, one of them of six three-roomed houses; its width three feet five. Another Court--seven houses, 20 rooms in all--population 71. All of them apparently as bad, or worse, than those in the street--miserable hovels, the birthplace of disease and vice, and centres for infectious diseases, which are likely to spread through the whole community." The births and deaths were almost equivalent. In 1872, there were 92 births and 95 deaths. In 1873, there were 108 births and 108 deaths. "In 1874, there were 95 deaths and only 82 births. The deaths are exclusive of those people who have been removed from the neighbourhood and gone elsewhere to die, either in the hospital or the workhouse, where a great many people at the present time do go to die." Of the overcrowded rooms he says:-- "Here legions of crimes and legions of vices unite, fostering diseases of body, weakened intellect, and utter destruction of the soul; leading inevitably to a career of wickedness and sin." Confirmatory of the Medical Officer of Health's description, was that given in a memorial to the Metropolitan Board by 118 persons: "The Clergy, Medical Men, Bankers, Residents, Professional men, and Traders of the parish of St. Martin-in-the-Fields, in support of a scheme of improvement." "Bedfordbury, with its swarming, ill-built, badly ventilated, rotten, inappropriate, unsavoury tenements, has seemed to us a very forcing pit of immorality." "In it there are 797 people living on one acre of land." "There is a very large number of interests to be paid for. There is first the freeholder; then there is the first lessee; then there are numbers of under-lessees, and all the trades of those little shops, and they ought all to get something." And another area was the "Great Wild Street Scheme," in the parish of St. Giles'-in-the-Fields.[136] "This area has long been a hot-bed of disease. It contains about 5-1/2 acres, and 227 houses stand upon it inhabited by 3,897 persons. Great Wild Street 58 houses containing 926 persons. Drury Lane 31 " " 425 " Princes' Street 14 " " 315 " Wild Court 14 " " 346 " "Many of the courts and passages are approached by a narrow passage under a house at either end which renders ventilation very defective. Some of the houses are built close together and have dark passages and staircases, others have no back yards, and their sanitary arrangements are placed in the basement. Health under such circumstances is impossible. This part of St. Giles' has long been noted for its heavy sick and death rates, especially from diseases of the respiratory and pulmonary organs, and from typhus fever and other zymotic disorders in their most contagious forms."[137] Dr. Lovett, the Medical Officer of Health, stated that diseases were very rife in it, and a very high rate of mortality as compared with the number of cases. And he added, "The district is a nest of zymotic diseases of the most contagious kind. In 1874, 27 cases of typhus were sent to Stockwell Hospital. This state of things cannot be dealt with under Torrens' Act. The houses are built so close together, the people are so huddled together ... you must make a clean sweep of the buildings." Another of these insanitary areas was Pear Tree Court, in Clerkenwell, "consisting of small tenements of an exceedingly inferior description. All are more or less calculated to engender disease and filth. The condition of the property has been such as to be a reproach to the neighbourhood. "Occupied by the very poorest of the community. When disease made its appearance it has been fostered and engendered and continued by the state in which the property and its surroundings have been--the death-rate is nearly double of that which prevails over the whole parish. "Some of the tenements are of the most wretched description--some constructed of lath and plaster--some wooden houses--the floors rotted partly by the cisterns, partly by rain coming in. "In some cases the sanitary convenience is in the very rooms themselves--also the water-butt--thereby engendering and perpetuating the worst kind of zymotic disease: the chosen home of fever and also of smallpox. "An entire absence of ventilation. "... When we come to those occupying only one room each, and remembering that in many of these rooms the closet, the water-butt, the water supply, and everything else was contained in the room itself, and that there was no provision for manure, ashes, or refuse of any kind, you can easily conceive what a wretched state of things that presents. On the average there were 2·80 persons per room permanently occupying them. So it cannot be wondered at an outbreak of the zymotic disease finding a resting-place there, and that such a locality becomes a plague spot in the neighbourhood, and extends its ravages thence into healthier neighbourhoods." Some of the houses the Medical Officer of Health had known to be in the same state for the last 36 years. "... An ill-constructed, unhealthy warren;" some were "regular old shanties--you could hardly find anything like those in the metropolis, they are worth looking at as a curiosity." "Some in Clerkenwell Close are large and very old wooden houses, all tumbledown. There is no straight line in roof or windows--the windows are like cabin windows." One more case is worth giving details about, as it is one of those rare cases in which one gets a more continuous account of the effects of slum ownership than is usually accessible.[138] This was the Little Coram Street scheme, in St. George, Bloomsbury, in St. Giles' District, comprising 119 houses--1,027 inhabitants. The Medical Officer of Health, in his representation to the Metropolitan Board, gave a minute description of the place. "The houses are principally let to cab owners, who stable their horses in the lower floor, and reside with their families in the rooms over; they are without back yards, and the rooms mainly derive their ventilation from the staircase leading out of the stable, so that the air is contaminated by the noxious gases which issue from it. All the closets are inside the houses; there are no dustbins, and the drinking-water is often obtained from underground tanks, which serve both for stable, cleaning, and culinary purposes. "These houses are unfit for human habitation." "The district now represented as unfit, &c., constitutes the worst part of the parish of St. George, Bloomsbury, and has been notorious for years as largely contributing to the sick and death rates of the sub-district." In 1862 it was reported that it had "habitually a much higher mortality than the rest of the parish." In the following years "the mortality was seriously increasing there." In 1870 smallpox broke out first in it, and 25 cases occurred in a short time. During the same year the deaths in Chapel Place from three classes of disease--the zymotic, pulmonary, and tubercular--having been 17, the death-rate to population was 70 per 1,000 without reckoning those from other causes. In 1871 the general mortality was 50 per cent. greater in it than that in the parish, whilst that of cholera was four times greater. In 1874, nine cases of typhoid and typhus fevers occurred in it, "and the locality was conspicuous for diseases and premature deaths." In 1876 scarlet fever was prevalent. Asked what class of disease the people chiefly suffer from, the Medical Officer of Health replied:-- "Mostly from debility--zymotic diseases, and infectious diseases--such as whooping cough, typhus, typhoid fever, cholera, diarrhoea, measles, scarlet-fever, &c., &c., smallpox, and gin liver disease.... They are obliged to resort to gin on account of the close and depressing condition in which the people live in these Courts free from the public eye. "The women have to stop at home; they do not get out, and therefore do not get any excitement. Then they take their drops. You can often see women at twelve o'clock in the day drinking in public-houses." The Parochial District Medical Officer said:-- "The houses are so old that the air is really poisonous; it is full of miasma and dirt ... all the whitewashing and ventilation in the world would do no good. The condition of the property has got worse year by year." These are but some of the cases about which "representations" were made to the Metropolitan Board of Works--sufficient, however, as illustration of others. And what an awful and appalling picture they present. Had the condition described been only temporary, a mere passing phase, it would have been dreadful enough; but it had been going on for years--it was permanently so--producing year after year its fearful crop of misery and crime, of disease and death, and scattering broadcast the seeds of disease and death, the "owners" all the while exacting the uttermost farthing they could in rents from the miserable inhabitants, and placidly and remorselessly giving disease and death in return: going on, too, during twenty years of government by "local authority"--Vestry and District Board--and nearly ten years after the passing of the Sanitary Act of 1866, with its provisions for the abatement of overcrowding and the maintenance of a certain standard of cleanliness. A few years' experience of the working of the Housing Act of 1875 proved that it was dilatory, cumbrous, and costly to the ratepayers of London. The arbitrator frequently awarded to owners of places unfit for habitation compensation equal or almost equal in amount to what would have been given if the houses had been good and sound. This the Metropolitan Board felt to be an injustice to the ratepayers upon whom the charge fell, and an encouragement to owners of houses occupied by poor people to allow them to fall into or remain in a dilapidated condition. In the year 1879 the Board accordingly made representations to the Government, and suggested that the owners of unhealthy houses should not be compensated in proportion to the profit they derived from such houses, but according to their value as places pronounced unfit for habitation. The Board also pointed out--"the great loss entailed upon the ratepayers by the obligation which the Board was under to provide for the accommodation in suitable dwellings in the same area of at least as many persons as were displaced. This obligation rendered it necessary for the Board to sell, at a very low price, ground, which, with the dilapidated buildings upon it, had cost the Board seven or eight times as much, and which, if the Board had been free to dispose of it for commercial purposes, and to provide for the dispossessed people elsewhere, would have realised a much higher price."[139] On the six areas which had been sold to the Peabody Trustees it was estimated that the Board--or in other words, the ratepayers of London--would lose the large sum of £562,000. The Board suggested that it should have power to dispose of the cleared ground for commercial purposes, and to provide for the re-housing of the displaced families in other parts of London. This latter suggestion was not adopted, but Parliament passed an Act in 1879 which to some extent lessened, though it by no means removed the defects of which the Board complained, for the Board declared that "after careful consideration, it thought it well not to prepare any more improvement schemes until some further experience has been gained of the working of the Amendment Act of 1879." And in 1879, also, an Act[140] was passed which nominally "amended," but in reality destroyed the real good of Torrens' Act of 1868, and gave the owner power to require the local authority to purchase the premises which had been condemned as unfit for human habitation, and which the local authorities were to rebuild and hold--thus practically relieving the worst class of slum house "owners" of any consequences for their malpractices, relieving them, too, in the most open way at the expense of the ratepaying public, as it empowered the Vestry "to levy a rate of twopence in the pound to bear this expense as well as that of building sanitary dwellings on the site." By one means or another it invariably worked out that the slum owner obtained large sums for his vile property, and that the public had to pay heavily for his iniquities. The work which was within the power of the Vestries and District Boards to do, in connection with the sanitary condition of houses, was far more wide-reaching in extent, and more immediately effective than any the Central Authority could do under its powers. Practically the Vestries had under their supervision the sanitary condition of all the houses of London. Moreover they could act upon their own initiative, whereas the Central Authority could only act when representations were made to it. But with few exceptions, they resolutely fought shy of dealing with the crucial evil--the condition of the tenement-house population of the metropolis. "There is no doubt," wrote the Medical Officer of Health for Paddington, in 1871, "from the abundant experience and records of the Sanitary Department of this and other Vestries, that houses let out in single rooms, and to several families, have endangered the life of people, have favoured the spread of contagion, and are a source of pauperism and degradation." The various Health Acts gave them power to deal with most of the prevalent nuisances. But no Act gave them such rapid and effective means of action, or so fixed upon the owner the responsibility and cost of keeping his houses which he let as tenement-houses in proper sanitary order, as did the Act of 1866 by its 35th Section. This Act had conferred power upon them to make effective bye-laws or regulations as regarded such houses; and in 1874 the Sanitary Law Amendment Act conferred further powers upon them. Regulations could now be made as to the paving and drainage of premises, the ventilation of rooms, the separation of the sexes, and to securing notices being given to the Medical Officer of Health, and precautions being taken in case of any dangerously infectious disease occurring in a registered house. By such regulations the notification of infectious disease occurring in tenement-houses could have been made compulsory, and such notification would have been of the very utmost value in enabling sanitary authorities to combat the ravages of infectious disease. The regulations struck at the root of the very worst and most prevalent evils in the homes of the people, and had they been enforced, would have been a charter of health to millions of the people. The Medical Officer of Health for Chelsea, in one of his reports, well enforced their importance. "When it is remembered that the whole of the labouring population occupies but part of the house in which their families live; that in many houses three or four families live together; and not infrequently each family occupies only a single room; and when it is considered that whenever necessary all such houses may be registered, it will at once be seen how important is this regulation."[141] These sections nevertheless remained absolutely a dead letter in nearly every one of the metropolitan districts, and even the newly constituted Local Government Board did not exercise its power of declaring them to be in force in any district. From a return compiled in 1874 it appears that:-- (_a_) In only seven parishes or districts[142] were regulations made and enforced; how imperfectly even in these is illustrated by Lambeth where, in 1873, 47 houses only had been registered--there being 29,000 in the parish, one half of which were probably let in lodgings. (_b_) In six districts regulations were made but no attempt made to enforce them. (_c_) And in twenty-five parishes or districts no regulations whatever had been made. In Hackney and Chelsea alone was any widespread use made of the regulation. The explanation usually put forward of the determination on the part of the Vestries not to enforce the sanitary laws as regarded houses was their regard for the financial interests of the ratepayers. But the real ground of their aversion was that action would put house-owners to expense. "Vested rights in filth and dirt" were strongly represented on the Vestries and District Boards. As a witness said before a Select Committee in 1882:-- "So long as vestrymen own little properties, and so long as their relations and friends do the same thing, and they are all mixed up in a friendly association, you can never get the prevention of the continuance of unhealthy tenements carried through."[143] And not only was there a passive but often an active opposition to work being performed which it was their duty to do. A general inspection would have shown what houses ought to have been made subject to such regulations, but it would also have exposed too publicly the iniquities of house-owners, and would have entailed a heavy expense on those who left the houses in a perpetual state of dilapidation, insanitation, and filth; and so the staff of inspectors was kept as low as possible. A thorough enforcement of the regulations would have necessitated a supervision of their houses by the owners in addition to expense. Many straws showed which way the wind blew. Thus the Medical Officer of Health for Bethnal Green wrote:-- "It is by the constant inspection and reinspection of property inhabited by careless and destructive tenants that most good can be done. I recently felt it my duty to recommend a house-to-house inspection of the whole parish--a procedure urgently required to ascertain the condition of the drainage and water supply arrangements. I regret to say this recommendation was not acted upon." And the Medical Officer of Health for St. Pancras, in referring to house-to-house inspection, wrote:-- "This most important branch of all sanitary work has received as much attention as the number of the sanitary staff will admit." And so the regulations were not made, or if made were not enforced. And, as the result, the great masses of the working classes, and the poorer classes in the metropolis, were by the deliberate decision of the great majority of Vestries and District Boards deprived of the protection which Parliament had devised and provided for their sanitary and physical well-being; and all the well-known evils of overcrowding were indefinitely perpetuated. Apart from the sense of duty or responsibility to the people which ought to have appealed to them, there were other motives which might have done so. The Medical Officer of Health for Paddington called attention to one of them in 1872. He wrote:-- "The costliness of preventable disease is enormous. "(_a_) Sanitary supervision. (_b_) Removal to hospitals. (_c_) Disinfection. (_d_) Expenses in hospital. (_e_) Cost of burial. (_f_) Loss of work in wages. (_g_) Loss of life to the community. (_h_) Cost of widows and children." And the Medical Officer of Health for Whitechapel wrote in 1871:-- "... As the local rates are continually increasing for the relief of sickness and the support of widows and orphans, the building of asylums for the insane, and the providing of workhouse infirmaries for the debilitated and prematurely old, it is probable that local boards will direct more attention to the condition of the houses of the poor than they have hitherto done." The cost was brought home to them in 1871--"an exceptional year of mortality caused by the continued spread of smallpox." "It has been," wrote the Medical Officer of Health for Lambeth, "one of the most alarming and expensive epidemics that have visited the country for a century. The cost in a pecuniary sense has been great, but it is nothing as compared to the cost of human life. "... I know of no disease that can be made so preventable as this." The Medical Officer of Health for St. George-the-Martyr wrote:-- "No extravagance can be compared with that of sanitary neglect. Pounds are willingly paid for cure, where ha'pence would be grudged to prevent. Some diseases we can create, most we can propagate, and send on their errand of misery and destruction." In 1878 the Medical Officer of Health for Whitechapel again referred to the subject:-- "It may be asserted without fear of contradiction, that all money laid out for the improvement of the public health will secure an ample dividend.... "The alleviation of suffering and the prolongation of human life is the duty of every noble-minded man to endeavour to promote. "It cannot be too frequently reiterated, too extensively known, that the rich not only pay a heavy pecuniary penalty, but often suffer a heavy affliction in themselves and families by neglecting to improve the sanitary condition of the houses and localities occupied by the poor. It is well known that defective sanitary arrangements in the poorer localities are the chief causes of disease among the poor, and when a contagious disease is once located it soon assumes an epidemic form and attacks, indiscriminately, all classes of the people." These views were sound and true, but the contingencies described always appeared remote, and arguments of more immediate and remunerative results were constantly present. If the conduct of the Vestries and District Boards was reprehensible for not administering the existing laws for the improvement of the sanitary condition of the poorer classes, and if the consequences of their deliberate inaction were so fatal to the lives of countless thousands of the people and so disastrous to the well-being of the community, the conduct of the "owners" of the houses, for the manner in which they allowed their tenants to live, was still more so. "I often wonder," wrote the Medical Officer of Health for St. George-the-Martyr (1874-5), "what many of the owners of property think man was created for except indeed that he should be housed in foul, wretched dwellings in order that money may be put in their purses, and so they may reap where they have not sown. A grim kind of harvest that will prove. Surely the owners have neither humanity nor justice on their side when they allow their houses to become hotbeds for the fostering and spreading of disease, moral and physical, and in which it is impossible either to maintain cleanliness, or support health, or practice morality. There are thousands of such houses.... "The only true and lasting foundation upon which the glory and safety of a nation can be built, must be upon the cultivation of the moral and physical powers belonging to man." The "owners" were of all classes. An experienced witness[144] before the Committee of 1881, who had acted as arbitrator in some of these cases, referring to some of the worst slum areas in London, said:-- "It came before me that a great many people in life better than that supposed, do draw considerable incomes from insanitary house property." "Some of these worst places are held by rich gentlemen and ladies." "The class of landlords we have here are very shrewd money-making men, and they would not show much consideration to their tenants." The Medical Officer of Health for St. George-the-Martyr, Southwark, reported (1876-7):-- "We have heard denounced, times out of number, and in the strongest terms, the conduct of the holders of small property as being most selfish, and they themselves the most persistent and obstinate opponents of sanitary measures and improvements; and moreover that this class formed a considerable portion of our Vestries. However this may be, they cannot claim a monopoly to this unenviable distinction.... "Much of the small class property is placed in the hands of agents who neither hold nor cultivate any interest in the welfare and comfort of the tenants. "To get the most rent with the least possible trouble and outlay seems to comprise their whole duty (of course there are exceptions). "How much better in all respects would it be that the owner himself should give some personal supervision to his property and to the state of those who dwell in it." And there was another class of "owners"--the middlemen--"the very curse that is incident in all society." "There are a great many middlemen dealing with these properties. A great deal of it is to let out in lodgings. A man goes and buys this wretched property at public auction in different parts of London to pay him 10 or 12 per cent., and he underlets it at so much a room to weekly tenants." "It is these small men who go into it to make a profit, and screw the poor, wretched holders down to the last farthing--in fact they get as much as they can out of the property, and do as little as they can." Some of the Medical Officers of Health referred to the difficulties of getting the "owners" to do anything to keep their property in order. Thus the Medical Officer of Health for St. James' wrote (1877-8):-- "On eastern border of parish a large number of houses are now increasingly being underleased in order to be let out as tenement-houses.... Dealers in these houses make enormous aggregate rentals out of the improvident working people whom they thus herd together; and persistent efforts on the part of the sanitary officers are needed to goad some of these 'landlords' into keeping their 'property' in a decent condition." With a very large number of house-owners and other sanitary misdoers, nothing but the vigorous administration of the law would induce them to abate nuisances or do anything for their tenants. "I am quite sure," wrote the Medical Officer of Health for Hackney in 1880, "that a prompt and strict enforcement of the various sanitary Acts is beneficial not only to tenants, but landlords, because the latter will not allow tenants to occupy their houses who frequently bring them under the notice of the sanitary officers." With many, however, the fact that the law had been put in force against them, and would, if necessary, again be put in force was sufficient. "The number of statutory notices this year was not much more than half. Owners have carried out the necessary works for fear of being summoned." And numerous other reports were to the same effect. But a vigorous administration of the sanitary laws against owners was the very last thing which it was of use looking to the Vestries or District Boards for. Some of the Vestries and District Boards put pressure upon their Medical Officers of Health to prevent energy upon their part. Thus the Medical Officer of Health for St. Pancras in 1875 tendered his resignation, giving the following reasons:-- "That while I am held responsible for the sanitary condition of the parish, I am denied that assistance in outdoor inspection of houses either visited with contagious diseases or habitually in an unsatisfactory condition, which I believe to be necessary. I feel that the severe condemnation which a house-to-house visitation of the poorer parts of the parish has received from a majority of the sanitary committee must of necessity hopelessly weaken my authority with the sanitary inspectors, and render nugatory my efforts to carry out the Sanitary Acts...." Parliament was passing some useful legislation for the improvement of the public health, and taking some action against some of the more heinous existing abuses. Several of the evils already described connected with the building of houses were dealt with in an Act[145] passed in 1878. It was at last declared to be--"expedient to make provisions with respect to the making, filling up, and preparation of the foundation of sites of houses and buildings to be erected within the metropolis, and with respect to the quality of the substances to be used in the formation or construction of the sites, foundations and walls of such houses with a view to the stability of the same, the prevention of fires, and for purposes of health." The Metropolitan Board of Works was empowered to make bye-laws respecting the foundations and sites of houses to be constructed, and with respect to the material used in the construction of such houses and of the walls and buildings; and the Board issued a set of comprehensive regulations upon the subject. "Considerable opposition was manifested by builders before the Secretary of State." But, nevertheless, the regulations were sanctioned and approved. And in the same year (1878) Parliament had passed an Act which materially improved the sanitary conditions under which men, women, and children worked in factories and workshops.[146] Guided by experience, Parliament had gradually been extending the operation of the previous Acts from one trade to another, and as Lord Shaftesbury said:-- "The general result had been to introduce and establish a system of order, content, and satisfaction. The children in the factories presented quite a different appearance from that which was their characteristic in former times; they were now hale and stout." And the Factory and Workshops Royal Commission[147] in 1876 wrote:-- "The improvement in the sanitary arrangements and ventilation of factories had been most marked in recent years; and the cases in which young persons and women suffer in labour unfitted for their years, or in which young persons and women suffer physically from overwork, are now, we believe, as uncommon as formerly they were common. "Much of this great improvement is undoubtedly due to factory legislation." The Act directed that:-- "A factory or workshop should be kept in a cleanly state and free from effluvia arising from any drain, or other nuisance." And that they should "not be so overcrowded while work is carried on therein as to be injurious to the health of the persons employed therein, and should be ventilated in such a manner as to render harmless, as far as practicable, all the gases, dust, &c., generated in the course of the manufacturing process and that may be injurious to health." By subsequent order of the Secretary of State, 250 cubic feet air space were to be given to each adult during the day, 400 cubic feet after eight o'clock at night. It was to be "the duty of the sanitary authority to make such inquiry and to take such action thereon as to that authority may seem proper for the purpose of enforcing the law." A very material factor in the health of the people was dealt with in this Act--namely, the condition of the bakehouses where the daily bread of the community was prepared. Legislation as to bakehouses had been left unchanged since the Act of 1863, and in harmony with the usual disregard of their duties by the local sanitary authorities, little use was made of that Act. The Royal Commission of 1875 reported that it was "only here and there that any active steps had been taken by the local authorities to carry out the provisions of the Bakehouse Act." By the Act passed in 1878 the Bakehouse Regulation Act of 1863 was repealed, and the duty of regulating the sanitary condition of bakehouses was transferred from the local authority to the Inspectors of Factories. In 1878, also, the Contagious Diseases Animals Act was passed. Primarily it was directed to the protection from cattle plague of the cattle of the country, and the prevention of the spread of disease, which had been entailing heavy losses upon their owners, and very stringent precautions were imposed. But it contained also some very valuable provisions as to the condition of cowhouses and dairies, and early in 1879 the Privy Council issued an Order providing for the registration of all persons carrying on the trade of cowkeepers and purveyors of milk, for regulating the lighting, ventilation, cleansing, drainage, and water supply of dairies and cowsheds, for securing the cleanliness of milk stores, milk shops, and milk vessels, and for protecting milk against infection and contamination. Inspectors were appointed by the Board. "At the time of the passing of the Order the London cowsheds were, with few exceptions, unsuitable in construction and in sanitary arrangements. By opposing the renewal of licenses the Metropolitan Board succeeded in abolishing from two to three hundred of the worst of them, and obtained improvements, amounting to entire reconstruction, in the remainder. In the larger dairies and milk stores much improvement was also effected." It was this Act of 1878 which drew from the Medical Officer of Health for Whitechapel the following remarkable passages in his report; passages which are enlightening as to the prevalent views of the time. "We have a striking instance of the great interest that is shown in the protection of property and the comparatively little value that is attached to the health of the people in the recent Act--'The Contagious Diseases Animals Act 1878.' "As regards the laws which are in force for the protection of the health of cattle, which may be looked upon as property, I have nothing to complain; but as a health officer I may express my surprise that similar laws to those which are now in force respecting disease in cattle are not enacted to prevent the spreading of infectious and contagious diseases among the people. At present there is no general law in force to compel persons, who may become acquainted with the existence of an infectious disease in a dwelling-house, to give notice of the same to the Sanitary Officer.... "Surely it is more important to protect the lives of the people than to protect from loss the dealers in cattle; but until the care of public health is considered to be of more importance than the care of property, little improvement in the laws relating to health can be expected." "The preference which is given by our law makers to the protection of the supposed vested rights of property above that of public health is likewise shown by the rejection of the several Building Bills for the amendment of the Building Act. "The opinion of the House appeared to prevail that 'a man has a right to do what he likes with his own, as regards the building of as many houses as can possibly be packed together on his own land, without taking into consideration the health of the people who are to inhabit them, or the health of those in the immediate neighbourhood.' So long as the Building Act as regards open spaces at the rear of houses remains unaltered, so long will unhealthy houses continue to be built." Some of the more capable of the Medical Officers of Health in their reports did not content themselves with mere tables of the births and diseases and deaths in their parishes, and a narrative of the principal incidents in their work during the year, but pointed out the defects in the laws, and made suggestions as to the best ways of coping with some of the great sanitary evils daily confronting them. Based upon actual experience, their views and suggestions were entitled to great weight, and were often of very great value. One point, and that the most important of all, finds expression in the reports of more than one of them, namely, that the administration of many of the health laws should be compulsory instead of permissive, and that merely declaring a law compulsory without providing the means for making it compulsory was of little use. What was wanted in London was a real central authority which should have power to make the local authorities carry out the orders of Parliament. This did not exist, for the Metropolitan Board of Works had no such powers, and the Vestries and Districts Boards were independent local governing authorities acknowledging no master and free to obey or disobey Acts of Parliament just as they pleased. "It has been one of the great faults of our sanitary arrangements and legislation for London," wrote the Medical Officer of Health for St. James' in 1872, "that the metropolis has not been regarded as a whole, and that through the ignorance, or carelessness, of one District or Local Board the whole of the others may be put in peril." * * * * * "It is impossible, with our present municipal machinery, in London, at any rate, to exercise all that power which is necessary for the prevention of the spread of infectious diseases." And the Medical Officer of Health for Whitechapel in 1873 wrote:-- "If any alteration is made in the constitution of the Metropolitan Board of Works it would be desirable to add to its functions that of a sanitary supervision over the whole metropolis." And in 1881 the Medical Officer of Health for Kensington wrote:-- "London is grievously in need of a Central Sanitary Department to establish something like unity in the sanitary arrangements of its 39 divisions.... Every other large centre of population has but one sanitary authority." Though much more time, thought, and labour, were being devoted than ever before to matters relating to the public health, and with very beneficial results, one matter appeared to be quite unaffected thereby, for none of the great measures of sanitary improvement which had been carried out since the central and local authorities had come into being seem to have had any effect during the 1871-80 decade upon infantile mortality. If anything the figures appear higher. In St. George-in-the-East in 1871-2 the deaths of children under five years were 51 per cent. of all the deaths. In Mile-End-Old-Town in 1872-3, out of a total of 2,200 deaths, 1,087, or practically 50 per cent., were deaths of children under five, a mortality which evoked the comment from the Medical Officer of Health:-- "Apart from congenital causes, a large majority of these young lives would, under conditions more favourable to existence, be preserved.... It is certain that the present generation of London children is physically degenerate." And a year later he wrote:-- "I consider about two-thirds of the infantile mortality attributable to neglect, improper feeding, impure air from overcrowding, and general bad management through ignorance and carelessness of parents and nurses." In Kensington, away in the west, the average annual infantile mortality over a period of ten years--1863-73--was 42 per cent. of the total deaths. The Medical Officer of Health for Whitechapel wrote (1873):-- "There must be something very wrong in the condition of the people when we find that out of all children born about one-fifth die before they are one year old, and one-third before they are five." In the north part of his district in the quarter ended December 28, 1872, the rate of mortality of children under five was 61·1 per cent., whilst in the quarter ended September, 1873, in Goodman's Fields the rate was 72·4 per cent. In St. George-the-Martyr, Southwark, in 1873-4, of 1,256 deaths 694 (= 55·3 per cent.) were under five. In the same year the Medical Officer of Health for Paddington wrote:-- "In taking fifteen streets typical of the ordinary condition of the dwellings in which the working-class reside, I find the annual proportion of deaths under five ranges from 41 to 75 per cent. of the total deaths.... "The deaths from all causes in eighteen such streets varies from 21·7 to 50 per 1,000." The Medical Officer of Health for Limehouse wrote in 1874:-- "As usual we find that of 1,000 deaths more than 500 are those of children under five." Two years later it was 53 per cent. Nor was it only in the central parts of London that the infantile mortality was so frightful. In Wandsworth, the mean annual rate during the years 1865-74 was 49·6 per cent. The infantile death-rate did not diminish as the decade proceeded. In Islington in 1875-6 the infant mortality was "much about the same" as it had been twelve years previously. In Kensington it had increased to 46·3 in 1878; in St. George-the-Martyr to 57·7 per cent.; in St. Pancras in 1877-8, of 5,068 deaths, 2,212 (or 45·6 per cent.) were of children under five. The Medical Officer of Health for Poplar wrote (1877-8):-- "The deaths of children under five years have been more than half the total of deaths--truly a 'massacre of the Innocents.'" The Medical Officer of Health for Islington wrote (1880):-- "The number of deaths of children under one year is still painfully large.... Children seem to be born for little else than to be buried." Passing from record to comment, there are some striking passages in the reports of the Medical Officers of Health. Thus the Medical Officer of Health for Paddington wrote:-- "... Of infantile mortality one is tempted to ask whether the provision of so much life, such a prodigality of being, to be followed so soon by an almost Pharaoh sacrifice of it, is necessary to the multiplication of the race." And the Medical Officer of Health for St. Marylebone (1877):-- "It is sad, and in a sanitary point of view, humiliating to contemplate, that for every three children born in Marylebone, one dies before reaching the age of five years; 'tis true that in this respect Marylebone stands in no worse position than other large parishes in the metropolis, nor so bad as in the majority of them, but the knowledge of this fact will, I apprehend, afford but slender consolation to those who know from experience and daily observation that hereditary diseases, habitual neglect, unwholesome dwellings, together with other preventable causes, are largely concerned in the sacrifice of infant life." And the Medical Officer of Health for Rotherhithe (1881):-- "Whilst the houses' drain-pipes, from defective construction and workmanship, and want of being cut off from the main sewer, act as much as sewer ventilators as channels for removing filth ... whilst overcrowded houses and foul smells in living and sleeping rooms are taken as a matter of course; whilst infectious disease is sedulously propagated first by concealment, and then by criminal exposure and neglect, ... so long the yearly recurring Herodean massacre of helpless children, whose almost sole use in life appears to be the providing of fees for doctors and undertakers, will continue, in spite of all efforts of sanitary authorities and sanitarians." The evil done, however, by bad sanitary conditions was not limited to the children who died. Probably ten or twenty times the number of those who died went through the illness and survived--but of those many were injured in constitution for life. In other respects, however, sanitary progress was being made, and slowly but steadily the conditions of the health of the public were improving. Undoubtedly the main causes of that progress were the great system of main drainage and sewerage which had relieved London of the incubus of enormous accumulations of the deadliest filth in its houses, and of an open main sewer through its midst; and the greater quantity, and improved quality, of the water supplied for household consumption which relieved her inhabitants from the necessity of drinking liquid sewage. And the construction of sewers in nearly all the streets, and the substitution of an effective system of house drainage instead of the abomination of cesspools, was also a great stride to improvement. Since 1856 plans for the construction of a total length of nearly 1,000 miles of local sewers had been submitted to the Metropolitan Board for their approval, many of them being in substitution of old and shallow ones for which the Board's new main and intercepting lines afforded the means of improving the gradient and outlet. In their report for 1881 the Metropolitan Board of Works gave "a brief summary" of what it, as the Central Authority, had accomplished since 1856. "There was the great main drainage work which had cost about five and three-quarter millions, an undertaking which 'although fruitful of good results, and of greater magnitude than anything of a similar kind that had previously been accomplished, has left, as might be expected, few visible marks of its existence.'" It is rather the Thames embankments and broad new streets which remind the inhabitants of London of the great changes and improvements that the Board's operations effected. "On the north side of the Thames, from Blackfriars to Westminster, and from Grosvenor Road to Battersea Bridge, and on the south side, from Westminster to Vauxhall, embankments have been made which, whilst reclaiming from the river a considerable extent of ground, have substituted for the unsightly and offensive mud banks that formerly prevailed, handsome river walls, with broad and commodious thoroughfares, relieved and ornamented by public gardens. New streets have been made, some of the principal of which are Queen Victoria Street, Southwark Street, Northumberland Avenue, Commercial Road, and the new thoroughfare from Oxford Street to Bethnal Green; many other leading thoroughfares, which had become inadequate for the increased traffic of the present day, have been widened and improved, greatly to the convenience and comfort of the public; and liberal grants of money have been made by the Board to the authorities in aid of the cost of smaller street improvements which have not been of sufficient extent or importance to be carried out by the Board. "Two new parks have been provided, in districts previously unsupplied with such places of needed recreation. Public gardens have been laid out and are maintained in the neighbourhood of dense populations; and suburban commons, to the extent of about 1,500 acres, have by the action of the Board been secured in perpetuity for the undisturbed enjoyment of the public. "Many areas formerly covered with dwellings unfit for human habitation have been cleared, under the operation of the Artizans' and Labourers' Dwellings Improvement Act, and the ground let to societies which have undertaken to build, and in some cases have built, improved dwellings, in which the humblest class of the working population can live with health, decency, and comfort." These and many consequential improvements, and the better paving of the streets, and the better cleansing of streets, places, and yards, the more rapid removal of filth from London, had made the general conditions of life much less unwholesome. The work, too, being done by the Metropolitan Asylums Board was greatly diminishing the dangers of infection in the metropolis, as well as restoring to life and health thousands who would otherwise have fallen victims to disease. And by "The Poor Law Act, 1879," the Vestries and District Boards were authorised to enter into contracts with the Board, for the reception and treatment of infectious sick who were not paupers, thus in a measure depauperising the Metropolitan Asylums Hospitals. And a very large amount of most valuable work was done by the Port Sanitary Authority; in the year 1879-80 over 15,000 vessels of all classes having been visited and inspected, the infectious sick removed, and disinfection carried out. Writing of the year 1877 the Registrar General said:-- "London maintains its position as the healthiest city in the world. During the past year its prosperity was indicated by a birth-rate above the average of the preceding 10 years, while a remarkably low death-rate bears testimony to the success which has attended the efforts that have been made during the last half of a century to promote the public health and safety." Among the public authorities from which much might have been hoped in the way of improving the public health of the inhabitants of London was the School Board. The Board stood in an exceptionally favourable position for moulding the physical constitution of hundreds of thousands of children and of successive generations, but education appeared to have almost excluded the consideration of health. In 1871 the Board resolved "that it is highly desirable that means shall be provided for physical training, exercise and drill in public elementary schools established under the Board." But beyond this, little if anything was done, and even it was not made applicable to the girls. And no Medical Officer was appointed, and no systematic means organised for the prevention of the diffusion of diseases by the schools. Indirectly, however, good results were flowing from the schools. The attendance of the children at the schools took them out of their overcrowded tenement-homes for several hours in the day; their playgrounds afforded better means of exercise; the cleanliness expected of them raised their ideas as to cleanliness; the supervision over them was of great use in improving their conduct and character, all helped to improve their physical condition. But how infinitely greater the improvement might have been, not merely at the time but to the rising generation, if the School Board had given greater attention to this branch of the children's welfare. About 230,000 children were in attendance in the Board's Schools in 1880. The really encouraging feature of the general position was that a larger section of the public was taking an interest in matters relating to the public health. In Battersea, wrote the Medical Officer of Health (1881):-- "Much assistance is now derived from the general public, who are more alive to the necessity of sanitary measures than at any previous period." The Medical Officer of Health for St. George-the-Martyr, Southwark, reported:-- "The health of the people occupies the thought and consideration of an ever-increasing number," and he quoted the declaration of the head of the Government that "the sanitary question lies at the bottom of all national well-being." The Medical Officer of Health for North Poplar stated that-- "Gradually the labouring portion of the population, which so largely outnumbers the remainder with us, is becoming educated to the fact that they must neither breathe air, drink water, nor take food, polluted by filth." But, as a whole, public opinion was more or less inert. "The apathy of the public in matters of health is truly lamentable." Nor was all the apparent progress as genuine as appeared on the surface. The Medical Officer of Health for St. Mary, Newington, in his report of 1874 disclosed this material fact. Writing of some Returns which he had prepared of sickness in seventeen years, he said:-- "In the period we have seen the end of many fever haunts. We have seen hundreds and hundreds of the old tenements removed and new abodes raised in their stead; but with it, alas! we have seen all the defects of new buildings, all the defects of badly laid drains, all the evils of work ill done, its dangers too often not capable of recognition until sickness and death forced the discovery. We have seen too often in the new houses defects of ventilation, of construction, of drainage, and of overcrowding: we have seen many an evil allowed by law, and over which we cannot extend our sanitary rules. We have also to contend with the indifference, the carelessness, the blindness of the people themselves--intemperance and crime stand in our way...." But in 1881 he wrote: "Sanitary work has borne fruit." The progress of sanitation is almost necessarily slow. "There is not," wrote one of the Medical Officers of Health, "a more difficult task than that of carrying out sanitary reform, for although every one agrees that sanitary laws should be put in force, they are greatly objected to when they interfere with one's self." And another wrote:-- "Nuisances crop up, are removed, and re-appear. _It is a continuous warfare due to many causes_, such as carelessness and wilfulness on the one hand, and accidental circumstances on the other." And another:-- "The sanitary labours of your officers increase year by year as the population becomes denser, and the need for sanitary precautions grows more urgent." And underneath all was the view expressed by the Medical Officer of Health for Islington (1881):-- "I fear the public have not even yet learned to regard health as a matter of infinitely greater moment than rates and taxes." How far-reaching were the effects of disease was admirably set forth by Dr. Simon:-- "I do not pretend to give any exact statement of the total influence which preventable diseases exert against the efficiency and happiness of our population, for it is only so far as such diseases kill, and even thus far but very imperfectly, that the effect can be reported in numbers. Of the incalculable amount of physical suffering and disablement which they occasion, and of the sorrows, and anxieties, the permanent darkening of life, the straitened means of such subsistence, the very frequent destitution and pauperism which attend or follow such suffering, death statistics testify only in sample or by suggestion."[148] Few people realise the infinite importance of health to a great community. As one of the Medical Officers of Health truly wrote:-- "It is a question whether the greatness of countries will not in future to a very large extent depend upon the standard of public health." One of the very best and most experienced of the men who held the responsible office of Medical Officer of Health during the last half century--Dr. Bateson, the Medical Officer of Health for St. George in Southwark--in his reports often dwelt upon this aspect of the subject:-- "The only true and lasting foundation upon which the glory and safety of a nation can be built must be upon the cultivation of the moral and physical powers belonging to man." "... The quality of a race is of far more importance than the quantity." "Health to the majority of the population is their only wealth; without it they become pauperised." "The welfare and safety of this country need a healthy, stalwart race of men--men who can labour and endure." And in his last report (1878), after twenty years' service as Medical Officer of Health, he quoted the Prime Minister (Lord Beaconsfield) as saying:-- "The health of a people was really the foundation upon which all their happiness and all their powers as a state depended. If the population of a country was stationary, or that it yearly diminished, or that whilst it diminished it diminished also in stature and strength, then that country was ultimately doomed." "Nothing," said Dr. Bateson, "could be more solemn and emphatic." "For the success and permanence of national existence a high standard of health is absolutely necessary. To maintain in its integrity the vast power which England now wields, and to retain the high position which she now holds will depend upon the nation's health." Before considerations such as these, how lamentable the blindness of those who could not see that even a measurable expenditure in health matters would have been productive of immeasurable benefits; how reprehensible the conduct of those who refused to administer laws which it was their duty to administer, and the administration of which would have been of inestimable value to their fellow citizens; and how disastrous their studied inaction to the great metropolis, and through it, to the nation itself. FOOTNOTES: [117] Select Committee on Metropolitan Buildings and Management Bill, 1874. P.P., vol. x. [118] Evidence of G. Vulliamy, Select Committee, 1874. Superintending-Architect to that Board. [119] See Report of Select Committee, &c., 1874, Q. 23,445. [120] Select Committee of 1867. [121] P.P., 1868-9, vol. xxxiii. [122] 32 and 33 Vic. cap. 70. [123] See P.P. 1863, vol. xxv. Report by Tremenheere on Bakehouses, p. 113. [124] Adulteration of Food and Drink and Drugs Act, 1872, 35 and 36 Vic. cap. 74. [125] P.P. 1874, vol. vi. [126] Issued on the 17th of September, 1872, and renewed the 25th of March, 1873. [127] Final Report of the School Board for London, 1870-1904. [128] See Select Committee on Noxious Businesses, 1873. P.P., vol. x. [129] See Sections 25 and 26 of the Sanitary Act, 1866. [130] See Report of Metropolitan Board, 1871-2. [131] P.P. 1878-9. Report of Local Government Board, vol. xxix., p. xiii. [132] By the Medical Officer of Health for Whitechapel, 1878. [133] P.P. 1875, vol. lxiv. [134] "The Artizans' and Labourers' Dwellings Improvement Act," 38 and 39 Vic. cap. 36. [135] See Royal Commission Report, 1884. [136] 1877, 24th March. [137] Inquiry by Cubitt Nicholls, March 24, 1877. [138] Appendix. Select Committee Housing, 1881, p. 354. [139] See Report of Metropolitan Board, 1888. [140] 42 and 43 Vic. cap. 64. [141] The Medical Officer of Health for Chelsea (writing of his own parish). [142] Chelsea, Hackney, Shoreditch, Lambeth, St. George (Southwark), Camberwell, Plumstead. [143] Goddard, 1882, Select Committee, p. 576. [144] Mr. Hunter Rodwell, Q.C., M.P. [145] 41 and 42 Vic. cap. 32. [146] 41 Vic. cap. 16. [147] P.P., vol. xxix. [148] J. Simon, vol. ii., 1874. CHAPTER V 1881-1890 THE census of 1881 showed that the population of London was 3,816,483 persons--an increase this time of well over half a million of persons in the decade. In the central parts of London, with the single exception of Clerkenwell, the resident population continued to decrease. In the City, the decrease was nearly one-third; in the Strand nearly a fifth, and the parish of St. George, Hanover Square, was now added to the list of those on the decline. In the East, in Whitechapel, Shoreditch, and St. George-in-the-East, the population had declined, whilst in Bethnal Green the increase had been at a much slower rate. But Mile-End-Old-Town, where there had been a good extent of unbuilt-on ground, had added over 12,000 to its population; and Poplar over 40,000. In the North, with the single exception of St. Marylebone, all the parishes showed increases; Hackney, the great increase of over 60,000, and Islington the still larger one of nearly 70,000. In the West, there were large increases in Paddington and Chelsea, in Kensington an increase of over 42,000, and in Fulham over 48,000. In the parishes nearer the centre--St. George, Hanover Square, St. James' (Westminster), and Westminster, the population had decreased. On the south side of the river, with the exception of the parishes of St. Olave, and St. Saviour--both in Southwark, and near the City--every parish or district showed an increase. Notably was this the case in Camberwell, where the increase was 75,000, and most remarkable of all, Wandsworth, where the huge increase of over 85,000 persons was recorded. Thus the movements of population were shown by this census of 1881 to be very much on the same lines as those in 1871--a diminution in the central parts, and increases of various magnitudes in the outer parts. Interesting information was once more given as regarded the constituent parts of the population. It was shown that of the residents in London in 1881, the proportion of persons born in London was practically the same as in 1871. Of every 1,000 inhabitants in London, 628 were born in London, 308 in the rest of England and Wales, 13 in Scotland, and 21 in Ireland--the rest elsewhere. The flow of people from the country to London was thus continuing at much the same rate, and the metropolis was still being fed with labour at the expense of the agricultural districts.[149] "A contingent untrained in the pursuits of town life" was thus annually thrown upon the labour market of London. But they imported a fresh strain of healthy country people into the constituent elements of the town population, and helped to stay part of the deterioration which necessarily ensued from the insanitary conditions of life in London. As to the causes of the shifting of the population in London, the same story continued to be told by the Medical Officers of Health. Thus the Medical Officer of Health for the Strand wrote (1882-3):-- "The material decrease in population is largely connected with the gradual transition of houses from residences into business premises, the construction of new and wider thoroughfares, and the erection of public buildings, combined with the resulting consequence inevitably associated with such changes, a considerable augmentation in the rental or annual value of house property." In St. James' (1882)-- "The large decrease of population (3,754 in last decade), coupled with the fact that the rateable value still has an upward tendency, clearly shows that the character of the parish is undergoing rapid change--offices, warehouses, and clubs taking the place of residences as the centre of trade continues to increase and move westward, and greater facilities are afforded for business men to live in the suburbs." Some of the Medical Officers of Health were perturbed by the class of persons coming into their district. Thus the Medical Officer of Health for Whitechapel drew attention to the fact that of the 70,435 people in his parish no fewer than 9,660 were foreigners, mostly Russian and Polish Jews. Others of them were feeling anxious under the ever increasing numbers. The Medical Officer of Health for Paddington wrote (1881):-- "Occupying, as the population of Paddington does, a limited area with definite boundaries which do not admit of extension, a continually increasing population can only mean a continually increasing complexity of the problems of sanitation." Upon one most interesting point as regarded the influx of population into London the Medical Officer of Health for Lambeth threw some valuable light.[150] "The evil of overcrowding is aggravated by causes which derive their origin from the effects of that condition itself. A lowered standard of health, always the accompaniment of close building, is a factor in the further increase of pressure in an already congested district. An unsatisfied demand in the labour market for physical strength is a necessary outcome of that quality in the district affected. Muscle and bone in such a locality is at a premium, and that which cannot be supplied in its full development from within must be sought and obtained from without." "Here, then, is a vicious circle of concurrent cause and effect. Overcrowding is the cause of physical weakness: physical weakness results in an unsatisfied demand in the labour market: the unsatisfied demand is the cause of an influx from without: again that influx results in overcrowding." Once, then, that the influx of the physically strong began to diminish--the element which had contributed most to the maintenance of the physical vigour and health of the population of London--it was evident that deterioration would ensue, and the only means of counteracting that result was to improve to the utmost possible the sanitary conditions in which the people lived. The census of 1881 is remarkable as being the last to show an increase of country-born immigrants into London. That tide was soon to begin to ebb. The immigrants, however, were far from being all of a desirable character. The Medical Officer of Health for Camberwell pointed this out:-- "A considerable percentage of our population is composed of persons whose natural tendency is to grovel--beggars, thieves, prostitutes, drunkards, persons of feeble intelligence, persons of lazy and improvident habits, and persons who (like too many of the poor) marry or cohabit prematurely and procreate large families for which they are totally unable to provide; and such persons gravitate from all quarters to large towns and there accumulate.... A large town like London will always attract undesirable residents." With the increasing population the number of houses in the metropolis increased also. From 418,802 inhabited houses in 1871 the number had gone up to 488,116 in 1881, and the same tale was told as to the crowding of houses on the land as in previous years. The Medical Officer of Health for Bethnal Green (1880) stated that in his parish most of the available ground was already fully built over. The Great Eastern Railway Company, the School Board for London, and the Metropolitan Board of Works, were largely demolishing small house property. "If this sort of thing goes on much longer," he wrote, "it looks very much as if London in a few years would become a huge agglomeration of Board Schools, intersected by railways and new streets." The correct record of the population enabled once more an accurate death-rate to be calculated. The death-rate, which had been 24·6 per 1,000 in 1871, had fallen to 21·3 in 1881. That was most gratifying testimony to the good results following the sanitary work carried out, under many difficulties, in London, and an encouragement to perseverance. The vital subject of the housing of the huge masses of the people of London was, during all the earlier years of this decade of 1881-90, uppermost in the minds of those who were solicitous for their welfare. The Act of 1879 had done but little to help to a solution of the tremendous problem. A short experience of it, and of "Cross's" Housing Act, had shown that instead of "owners" being visited with heavy penalties for their iniquities, they were being actually rewarded. In fact, they secured under these Acts not only a full, but an inordinately high compensation for their property--regardless of its infamous condition--and the ratepayers of London were mulcted in large sums to pay them for it. "I desire," said the Medical Officer of Health for Hackney in 1883, "to express a very strong opinion that it is most unfair to the ratepayers that they should be compelled to pay for uninhabitable property which has been allowed by the owners to get into a dilapidated state for want of substantial repairs such as cannot be required under the Nuisances Removal Acts...." The first scheme which was initiated by the Metropolitan Board in 1875 was only completed at a net cost of £151,763, which sum had to be borne by the ratepayers of London; though why they should have been made to pay for the "owners" neglect which had led to the evil conditions of his property is not very clear, except that Parliament willed it so. By 1882 the total number of insanitary areas dealt with by the Metropolitan Board, or in process of being dealt with, was fourteen. The houses in these areas had been inhabited by 20,335 persons in 5,555 separate holdings, 3,349 of which consisted of one room only.[151] They were acquired by the Board at a cost of £1,661,000. Parliament had imposed upon the Board the obligation to provide accommodation for at least as many persons of the working classes as were displaced by the destruction of the houses on these areas. As the Board were not empowered to undertake the building of the houses in which to re-accommodate the displaced persons, the sites, after having been cleared, had to be sold to persons or companies, who were put under the obligation to erect workmen's dwellings thereon; but inasmuch as the land had been bought at its value for commercial purpose, which was far higher than its value for residential houses, this Parliamentary obligation entailed upon the Metropolitan Board, and through them upon the ratepayers of London, an enormous loss. The Goulston Street scheme in Whitechapel, for instance, was acquired at a cost of £371,600. When sold, under the conditions imposed by Parliament, it realised only £87,600; and the Whitecross Street scheme (in St. Luke's), which cost £391,000, when sold realised £76,350. The whole of the transactions, so far, resulted in a net loss to the Metropolitan Board, or in other words, a net charge upon the ratepayers of London of over £1,100,000. As Mr. Chamberlain described the result, in an article he contributed to the _Fortnightly Review_ of December, 1883:-- "Torrens' and Cross' Housing Acts are tainted and paralysed by the incurable timidity with which Parliament ... is accustomed to deal with the sacred rights of property.... "The individual wrong-doer is to remain unpunished--retribution for his sins is to be exacted from the whole community." The enormous cost of carrying the Acts into effect stayed the hand of the Metropolitan Board, while the length of time, stretching out into years, required for the various proceedings, militated against the success of the schemes so far as providing residences for the displaced people. An example of the working of the Act was described in 1883 by the Rev. S. A. Barnett.[152] "In 1876 the dwellings of 4,000 persons in this parish (Whitechapel) were condemned as uninhabitable, and the official scheme for their demolition and reconstruction was prepared. During the next four years the 'scheme' ploughed its course through arbitration and compensation with a puzzling slowness. "It was indeed a 'killing slowness,' for, during all those years, landlords whose claims had been settled spent nothing on further repairs; tenants, expecting their compensation, put up with any wretchedness; while the Vestry, looking to the approaching reconstruction of the houses, let streets and footways fall to pieces. It was not until 1880 that the needful demolition was seriously begun. Since that date the houses of some thousands of the poor have been destroyed." And then he described the slowness of the reconstruction, and added:-- "Such is the seven years' history of the Artizans' Dwellings Act in a parish under the rule of the Metropolitan Board of Works." He expressed his opinion that the prime source of the evil was not in the law, but in the local administration; but the complications of ownership, the endless legal difficulties and formalities, the numerous arbitrations, necessarily consumed years of time before the land could be cleared for building, and then the actual building of the new houses was by no means rapid. The mode of procedure was attended with such difficulties and disadvantages, and the administration of the Acts so clogged, that a Select Committee of the House of Commons was appointed and sat in 1881, and again in 1882, to inquire into the causes of the want of success, and to consider in what way the law might be further amended so as to make it really workable. The condition imposed as to re-housing, and which was so rigorously insisted on, did not by any means achieve the desired result. According to Mr. Lyulph Stanley[153] in 1884: "Not one single person of all the poor displaced in the carrying out of the Gray's Inn Road improvement, powers for which were obtained in 1877, had been re-housed by the Board." The Medical Officer of Health for Whitechapel, in his evidence in 1881, also showed that many of those in the houses which were to be pulled down were not working men at all. "Many of the people do not come into the Whitechapel District for the purpose of getting employment. They have other motives; they come from all parts of the country; a great many are tramps, and come up for the purpose of begging, some for stealing, and some to obtain the advantage of the charities which exist in London, and many of them to get out of the way and hide themselves." By this time, moreover, the possibilities of getting accommodation further afield was beginning to come into view. "With the facilities for coming by the early trains and the various tramways that we have now at a cheap rate, the rents of many of the inhabitants of Whitechapel would not be increased by moving from it." That the obligation to re-house was imposed alone upon the public authorities and upon railway companies was rather inequitable. In many districts the destruction of houses, and the unhousing of the inhabitants, was carried out on a far larger scale by private owners, and no such obligation was imposed upon them. The policy, therefore, was decidedly onesided, and was very costly to the ratepayer who was in no way responsible for the proceedings of the private house-owner who had caused all the trouble. The Committee reported in June, 1882. They expressed their opinion that-- "Nothing would contribute more to the social, moral, and physical improvement of a certain portion of the working classes than the improvement of the houses and places in which they live." They stated that "very great hardship would often follow if the provision for the replacement in or near the area of displacement were wholly done away with." "The special calling of many of the work people, the hours of their work, the employment of their children, the maintenance of their home life, the economy of living together in a family, the cheapness of food owing to the nearness of the great evening markets, &c., render it very desirable that a large portion should be enabled to re-house themselves in or near their old houses of living, and if no fresh dwellings be provided the evils of overcrowding will at once increase. * * * * * "Still, it is equally true that these observations do not apply to the whole population. Many without any special calling may live in one place as well as another. The facilities of transit recently offered by cheap trains, by boats, by tramways, &c., have enabled many to live in the suburbs who can do so consistently with their calling." "Your Committee are of opinion that the existing law, which requires that the improvement scheme shall provide for the accommodation of, _at the least, as many persons_ of the working class as may be displaced, may be relaxed, and that the accommodation to be required should vary from half to two-thirds." As a matter of fact very few, if any, of the families thus dispossessed returned for the purpose of occupying the new buildings. Indeed one witness[154] said that-- "Neither the Peabody Trustees, nor--more or less--the other Artizans' Dwellings Companies would take in the class of people who had been displaced." The Committee called attention to the importance of favouring in every way facilities of transit between the metropolis and its suburbs by an extension of cheap workmen's trains. And they also recommended that-- "All existing sanitary legislation should be more fully enforced, especially in those parts of the suburbs where buildings are so rapidly springing up." A Bill was at once introduced into Parliament, the object of which was to lay down such rules for estimating the value of the premises to be purchased as would prevent the owners of insanitary property obtaining an undue price for it--"the intention of Parliament being that the owner should not gain by having allowed his property to fall into an insanitary state." It was passed, and as an Act it further empowered the Secretary of State, under certain circumstances, to dispense with the obligation of re-housing the people to a greater extent than one-half of those displaced. Into the detailed intricacies of many of these Housing Acts it is really useless to enter; and the enumeration of the details tends to obscure the broad and essential features of the whole subject. In the effort of the "owners" to repudiate the responsibility for their or their predecessors' infamous neglect, and to shift the blame for the appalling state of affairs on the middlemen and the occupiers; in the effort of the middlemen to evade their responsibilities by availing themselves of every obstructive device the law so lavishly placed at their disposal, and of both of them to extort the utmost amount of money they could for their disease-begetting, death-distributing property; the unfortunate occupiers were the immediate sufferers and victims, and a huge wrong and injury was inflicted upon the community. It was mere tinkering with the subject to pass an Act removing some petty technical difficulties for putting some previous and very limited Act in force, and to diminish the expense and delay in carrying out the Act. It was farcical to amend the Standing Orders of Parliament, fixing twenty instead of fifteen as the minimum number of houses in any one parish which could be acquired by the Metropolitan Board without preparing a re-housing scheme, as if that would revolutionise the condition of the housing of the people of London, and yet something not far short of revolution was required if the housing of the people was to be reformed, and put on a proper sanitary basis. It is manifest that what was being dealt with by these Acts was only a fragment of the great housing question, and that such destruction of insanitary buildings as could possibly be effected by these means would amount to but a fraction of those unfit for human habitation in London, and would not touch the thousands of inhabited houses in every parish of London which were insanitary in varying degree, and dangerous to the individual and public health. It is clear, too, that if the insanitary conditions of the housing of the people were to be dealt with on a large scale, and with success, measures must be taken to secure the sanitary condition of the houses which such legislation did not touch. Otherwise general improvement was impossible, and existing conditions must continue indefinitely to flourish, and to produce their inevitable and enormous crop of deadly evil. How urgent was the need for reform in some parts of London may be gauged from the description of the condition of things in Bethnal Green in 1883, given by the Medical Officer of Health of the Parish:-- "The portions of the district I have examined include nearly 2,000 houses. "I have visited and carefully examined almost every one of these houses, and I must confess that a condition of things has been thereby revealed to me of which I had no previous conception, for I do not think I visited a single house without finding some grave sanitary defect; in a very large number the walls of the staircases, passages, and rooms are black with filth, the ceilings are rotten and bulging, the walls damp and decayed, the roofs defective, and the ventilation and lighting most imperfect. "The dampness of the walls is in some instances due to defects in the roof, but in many the moisture rises from the earth owing to the walls being constructed without any damp-proof course.... "In almost every house I visited I found the yard, paving, and surface drainage, in a more or less defective condition, a quantity of black foetid mud having accumulated in places." And all this was nearly thirty years after Bethnal Green had been endowed with a local sanitary authority. Returns given occasionally by the Medical Officers of Health revealed the appalling state of insanitation in which people still lived; streets where in nearly every house nuisances dangerous to health were found to exist; a "Place" in St. Pancras where the death-rate in 1881 had been 57 per 1,000, or 2-1/2 times as much as that for London; a "Place" in St. Marylebone with 22 six-roomed houses, where the births were less in number than the deaths, and the existing population were extinguishing themselves. And overcrowding had increased in many parts of the metropolis, and some of the Medical Officers of Health had come to regard it as inevitable and impossible to prevent. The reports of the Select Committees of 1881 and 1882, and the outbreak of cholera in Egypt in 1883 which awakened apprehensions of its spread to England, quickened public interest in the sanitary condition of the metropolis, evoked a stronger expression of public opinion upon the existing evils, stirred up lethargic Vestries and District Boards to some special show of activity, and awakened the Local Government Board, and brought it into the field as an active inciter of the local sanitary authorities to adequate efforts to improve the sanitary condition of the people, and to grapple with the terrible problems of insanitary dwellings, of overcrowding, and the consequent physical misery and degradation of hundreds of thousands of the people. The position of affairs had become clearer than it had ever been before, and its magnitude and importance was beginning to be appreciated, and the iniquities which were being allowed, and the evils which were tolerated, were coming more into the light of day and were being better understood and realised. Though in many ways there had been progress and improvement, yet in many others, of the most vital consequence, it was evident things were scarcely moving at all. It was now manifest that at the rate the demolition of slums and the re-housing of the people could be carried out, a very great length of time must elapse; so great that the remedy must be of the slowest, whilst, by itself, it would be wholly inadequate; and it was beginning to be realised that many of the local authorities, instead of administering the laws they were charged by Parliament to administer, were even obstructing and opposing sanitary reforms. Once again the alarm of cholera woke up the Vestries, and some of the recorded results of such wakening are an illuminating exposure of the normal state of inaction on their part, and of the chronic insanitary condition of their parishes not revealed at other times. In Westminster:-- "In anticipation of cholera a thorough inspection by a house-to-house visitation through the whole of the united parishes has been undertaken. Naturally many defects were found, and directions given as to what was required. The work has been completed and I consider that the parishes are now in a very satisfactory condition." In Poplar, 2,114 houses were inspected, of which only 334 were found to be in good order. In Lambeth, six men were engaged temporarily for the purpose of a special inspection. "11,493 houses were visited; 5,594 required sanitary improvements.... In many houses several defects were reported, bringing up the total of sanitary improvements to 12,014." In Bermondsey, no fewer than 5,992 notices were issued for the execution of sanitary works which were required. The Sanitary Act of 1866 had enacted that-- "It shall be the duty of the Nuisance Authority to make, from time to time, either by itself or its officers, inspection of the district with a view to ascertain what nuisances exist calling for abatement under the powers of the Nuisances Removal Acts, and to enforce the provisions of the said Acts in order to cause the abatement thereof." But by many Vestries the duty had been either entirely neglected or very imperfectly performed. The Medical Officers of Health were unceasing in pressing upon their employers the necessity of inspection. "It is only by the constant inspection and re-inspection of property inhabited by tenants of this class (tenement-houses) that the houses can be kept in decent sanitary condition," wrote the Medical Officer of Health for Bethnal Green. "My opinion of the value of regular house-to-house inspection throughout the year," wrote the Medical Officer of Health for Poplar, "is more confirmed than ever, and that such is needed for the proper sanitary supervision of the district." "It is by constant inspection," wrote another Medical Officer of Health, "that the Vestry can best do its duty in preserving the lives and health of its parishioners." "Facts are stubborn things," wrote the Medical Officer of Health for St. Mary, Newington, after 28 years' sanitary work himself, "and they clearly demonstrate the necessity for a continual supervision of the dwellings of the poor (more especially) and for as constant an attack on all removable insanitary conditions. This after all is the real work to be done." But the Vestries and District Boards paid little heed to this advice. Naturally, inspection was not welcome to sanitary defaulters or misdoers; naturally, the light of the sanitary policeman's lantern into the dark places of slum-owners and 'house-knackers' was resented. It was an invasion of the rights of property, of the privacy of an Englishman's home, even if he did not live in that home himself, but let it to somebody else to live in. "Why should not a man do as he liked with his own?" And so, as inspection was, from the house "owners'" point of view, an unpopular thing, too much money was not spent by Vestries upon Sanitary Inspectors' salaries, and even in the best inspected parishes or districts the portion inspected was small indeed compared with the whole of the parish or district. How much was left undone, and left undone for years, was proved over and over again by whole areas being represented by their Medical Officers of Health as insanitary, or by their having to shut up houses as unfit for human habitation. The attempt made by Parliament in 1866--in the scheme embodied in the 35th Section of the Sanitary Act--to provide a remedy for overcrowding, and to secure the maintenance of a moderate standard of cleanliness and sanitation in the tenement-houses, had been an excellent one; and Parliament improved the scheme in 1874 by extending its scope. Almost the whole of the existing evils lay in these tenement-houses, for it was there where the great mass of the disease, filth, and misery of London was to be found, and there where the greatest overcrowding, and the deepest moral and physical degradation existed. But with the few exceptions already described practically no use had been made of the powers. "Vested rights in filth and dirt" had still too large a representation upon, and too powerful a grip of the local sanitary authorities for any action to be adopted which would entail trouble upon the possessors of those rights. Some Vestries, for form's sake, had made regulations but never put them in force. A few had tentatively put them in force, and promptly dropped them. A large proportion of them did not take even that much trouble, but simply ignored them altogether; and so, some seventeen years after the Act was passed, the whole scheme had ceased to be operative, and was in complete abeyance. In December, 1883, the Local Government Board, having realised the gravity of the situation, endeavoured to get the Vestries and District Boards to take action, but the Local Government Board could not compel them to make such regulations, as there was no power of compulsion, and there was no penalty for refusal to enforce or even to make them.[155] The Vestries and District Boards were, in fact, masters of the situation, and could act or not act, just as they pleased--and most of them did not act. Various were the excuses made by the Vestries for doing nothing. The feeling which prevailed in the Vestry of Clerkenwell was that-- "The regulations generally were of such an inquisitorial and troublesome character that they were unsuited to an Englishman's home. For instance, it was shown that in some cases even clergymen occupied lodgings which would be reached by these regulations." And yet there were 4,700 houses in the parish to which such regulations would have been applicable, and where their application would have been of the utmost benefit to thousands of families. And from 1866 up to 1884 this power might have been, but was not used. The Vestry of Bethnal Green was-- "Unanimously of opinion that it was unnecessary to make the regulations, and considered the existing powers sufficient." The Vestry of St. George-in-the-East resolved-- "That whilst fully recognising the necessity of continuing to carry out with vigour the general sanitary laws, the Vestry did not consider it advisable in the present depressed condition of trade in the parish to incur the additional expense of enforcing special sanitary regulations for houses let in lodgings" (estimated to number above 4,000). In Westminster, the District Board resolved that no further steps should be taken as regarded making or enforcing regulations, as the Board-- "Already possessed ample powers under existing statutes to enable it to deal promptly and effectively with such sanitary defects as the proposed regulations are intended to remedy"--a contention which, if true, threw discredit upon themselves, as there were thousands of filthy and insanitary abodes in that district which were not dealt with at all. St. Pancras Vestry refused (1883) to make regulations, though its Medical Officer of Health had made more than one appeal to them to do so. "I would beg to remind the Vestry that until proper regulations are made and enforced in St. Pancras for this class of houses, the Vestry have not exercised to their full extent the powers they possess for improving the condition of their poorer parishioners, and that the moral and physical welfare of those who are least able to help themselves is a question which concerns the Vestry as much, if not more, than any other it is their duty to consider." And in the following year he wrote:-- "Upon the Metropolitan Sanitary Authorities rests a great responsibility, for it is absolutely within their power to insist upon all dwelling-houses being maintained in condition fit for human habitation, and they may, within limits, prevent overcrowding, which is no less disastrous to health than to morality. "I have repeatedly recommended the Vestry to adopt regulations for houses let in lodgings, and have pointed out the power they would then possess for ensuring tenemented houses being maintained in proper sanitary condition. I would desire, in my last report, to urge upon them the further consideration of this subject." There were doubtless difficulties in putting regulations such as these in operation--as, indeed, there are in putting all laws in operation--but two Vestries had put them most successfully in operation, and therefore the difficulties were not so great as those who were opposed to them insisted. Some of the Vestries stated that they could equally well attain the same results under the powers of the Nuisances Removal Acts; but that was not the fact, for there were many and considerable advantages in this form of procedure over the procedure prescribed in other Acts relating to health and sanitation. Indeed, the Medical Officer of Health for Fulham declared (in 1884) that-- "This section gave almost all the legal power that could be wished for to place the dwellings of the poor in a proper sanitary condition." And in the following year he wrote:-- "It will therefore in future be the fault of the Sanitary Authority if the dwellings of the poor are not kept as they should be." The Medical Officer of Health for Camberwell, discussing the general aspect of the matter, wrote (1884):-- "I cannot help remarking on the feebleness which constantly spoils the best intentioned sanitary legislation, and which is conspicuous in the enactments relating to houses let in lodgings. "The Local Government Board have declared that certain enactments are in force, but they cannot compel the Vestries to frame any regulations of their own, nor even can they compel Vestries to carry out and enforce regulations which the Vestries have framed and the Board have sanctioned. "Now I am one of those who think that by the judicious regulation of lodging-houses of certain kinds, and in certain localities, very much good might be effected, and much advantage would accrue both to the lodgers and to the public. But it is clear that it ought never to have been left to individual Vestries in a place like London, to adopt or not to adopt, the enactments referred to, simply according to their pleasure, still more that they should never have been allowed to frame inconsistent orders or regulations.... "The opportunity (of the Act of 1874) might have been seized, not for giving an empty power to the Local Government Board, but for requiring the Metropolitan Board of Works to frame suitable regulations for the whole of the metropolis, which the Vestries might have been required to enforce as they are required to enforce other provisions of the Sanitary Acts." A similar opinion was expressed by the District Board of St. Olave, Southwark, which, after stating that it had been one of the first to make regulations, it had been found unnecessary or impracticable to enforce them, went on to say:-- "The fact of the enactment having been practically inoperative throughout the metropolis, ... it was considered that it would be unjust to enforce stringent regulations in the district, while in other parts of the metropolis regulations might differ in principle, and be neglected in practice: and what the Board wanted to see was a system of sanitary regulations which should be strictly uniform throughout the metropolis, and in which there should be no option on the part of local authorities of enforcing or neglecting." The explanation of this general inaction was the simple and obvious one that on those bodies there were many whose interests ran counter to the adoption of the Act, and what its adoption entailed; the sanitary obligations, the annual lime-washings, &c., would entail expense; they were not going to inflict the cost upon themselves or upon their friends if they could avoid doing so. And as they could avoid it, the great bulk of the local authorities deliberately ignored the remedy devised by Parliament, and with most reprehensible callousness let the evils go on and increase. But while they remained inactive, death and disease did not. Progress in sanitation was retarded also somewhat by other circumstances. The Medical Officers of Health were under no obligation to reside in their district, and were at liberty to take private practice, and so the whole of their time was not given to their public duty.[156] But furthermore, they were in a state of dependence on their employers, which naturally would often prevent their reporting fully upon sanitary matters, though, happily, there appear to have been few who were influenced by this consideration. And some of the Vestries and District Boards did not hesitate to put pressure upon their Medical Officers to prevent energy on their part. It was stated in evidence before the Select Committee in 1882 that a Medical Officer would very soon "bring a hornet's nest round his ears if he attempted to do his duty strictly and independently." Lord Shaftesbury declared, in 1884,[157] that he was quite certain that-- "They would never have the laws of health properly given effect to, until they asserted the independence of the Health Officers." Nor were the Sanitary Inspectors as efficient as they might have been, though there had been a great improvement in the class of man appointed. The Chief Sanitary Inspector for Clerkenwell[158] reported:-- "The two men (in Clerkenwell) are not very active. It is the greatest trouble I have to get the men to do their duty." "The Sanitary Inspectors have not always shown as much zeal and interest as they might have done, but lately they have improved.... It is openly talked about in a good many districts in London that a system of bribing goes on."[159] But those who were energetic were also discouraged by the same pressure which damped some of the energies of the Medical Officers of Health. The Medical Officer of Health for Fulham wrote, in 1884:-- "So many are the vested interests that Sanitary Officers are obliged in the performance of their duty to interfere with, that they must be prepared to meet with injustice and opposition in almost all directions. It is not at all surprising that the dwellings of the poor in London should be in an insanitary condition seeing the great obstacles public sanitary officers have in the performance of their duties." And yet there were many who did their work well, and who did much to improve the conditions of living of those who were under their care or charge; and did it in the face of many obstacles and much discouragement, and of all the opposition that vested interests could bring to bear against them. Many of the Vestries and District Boards were not only not above reproach, but were strongly to be condemned. Sir Charles Dilke, then President of the Local Government Board, speaking in 1883, said:-- "There were some parishes in London which had very zealously tried to work the existing law, but, on the other hand, there were more parishes the government of which was a flagrant scandal." And Mr. Chamberlain, in an article in the _Fortnightly Review_ of December, 1883, wrote:-- "In the metropolis, where the evil is greatest, the want of an efficient and thoroughly representative municipal government stands in the way of reform. "The Vestries, often in the hands of cliques and chosen at elections which excite no public interest, are largely composed of small house-property owners, who cannot be expected to be enthusiastic in putting the law in force against themselves." And in the House of Commons, on the 4th of March, 1884, Sir Charles Dilke stated that-- "In Clerkenwell, the two joint dictators of the parish, who had control of the Vestry and its leading Committee, one of them being Chairman of the principal Committee, were the largest owners in the whole district of Clerkenwell of bad or doubtful property.... In Clerkenwell there were fourteen house-farmers on the Vestry and twelve publicans who seemed to work very much with them." Nothing more decisively demonstrates the hostility of the Vestries to the Act of 1866, indeed to all this branch of sanitary reform, than the fact that they would not make adequate provision for the performance of the sanitary duties imposed on them by divers Acts of Parliament. A return compiled by the Medical Officer of Health for Bethnal Green in 1885, from information supplied him by the Medical Officers of Health of thirty-eight Vestries, shows how the local sanitary authorities crippled sanitary work by a wholly inadequate staff of Inspectors. Number Number of Parish or District. of Inhabitants to Inspectors. each Inspector. Greenwich 1 148,545 Newington 1 117,870 Mile-End-Old-Town 1 111,607 Lambeth 4 69,683 Poplar 2 86,671 Bermondsey 1 88,770 Shoreditch 2 62,754 St. Pancras 4 60,389 Paddington 2 55,567 Marylebone 3 50,294 Hackney 4 56,431 Bethnal Green 2-1/2 51,958 Camberwell 4 59,500 In the whole of the metropolis there were 103 Inspectors of Nuisances--a rough average of one Inspector to about 40,000 of the population. How could it be expected that one Inspector could look after a town of 40,000 people? Consistently, and, year after year, insistently, did the bulk of the Medical Officers of Health complain of the lack of sufficient Sanitary Inspectors, and point out the necessity for more Sanitary Inspectors; some begged for them--but to nearly all these appeals the Vestries turned a deaf ear. Every now and then some incident occurred or some exposure was made of some abominations of insanitation which were a revelation of the extraordinary methods adopted by some men in utilising land for building houses regardless of all sanitary consequences whatever to others. In the _Times_ of December 18, 1883, an article was published entitled "A Curious Site for Industrial Dwellings." "The things which are done in London under the shadow of legal right are sometimes startling." In Bethnal Green were two disused burial-grounds--"Globe Fields" and "Peel Grove." Parliament authorised a railway line to be constructed through "Globe Fields." Foundations had to be made for the arches, and trenches had to be dug in the burial-ground. The Medical Officer of Health, on inspecting the place, found a horrible condition of things. But with many precautions against loosing some virulent epidemic in the locality, the human remains were removed and re-interred elsewhere, and, it is stated, part of the ground was built over. Fuller particulars were given as to the Peel Grove Cemetery. The ground, several acres in extent, had been leased by a pawnbroker and started as a cemetery as a speculation. The statements made by the writer in the _Times_ are specially illuminating. The cemetery was opened about 1840 without consecration. The Bishop refused to consecrate the ground as burials had taken place in it already, and as some difficulties were consequently experienced, the speculating pawnbroker acted, it is said, for some years as chaplain. Ultimately, somehow or other, a chaplain was appointed. About 20,000 persons had been buried in it, six deep, and packed as closely as it was possible to pack them--not even earth between the coffins, so anxious was the owner to economise space; large numbers who died of cholera in 1849 having been buried there. The last interment took place in September, 1855. In 1883, the ground having served one financial purpose, it became desirable to utilise it for another financial purpose, and the proposal was made to erect houses upon it, and an agreement was entered into with a builder for the erection of blocks of dwellings thereon. This builder commenced excavations for the purpose of laying foundations, and he had sent in drainage plans for a block of industrial dwellings to the Vestry of Bethnal Green. "Is such an obvious violation of the laws of health and decency to be permitted?" said the writer. "The Vestry are alive to the situation, and appear to be willing to do all in their power to avert the catastrophe. But the law on the subject is by no means clear.... It is little short of scandalous that such doubts should exist. It is repugnant to every feeling of decency and propriety to invite human beings to live in densely packed crowds over a charnel-house." The sanitary condition of any city or district must, as has already been pointed out, depend very largely upon the system of local government in existence at the time, and its efficiency or inefficiency. This was specially true of this great metropolis with its millions of people, its vast extent, its great diversities. To all intents and purposes the main features of the local government of London had undergone little change since 1855. There was still the "City" with its special law, special area, and special government, to which had been added the Port Sanitary Authority. And there was the Central Authority, the Metropolitan Board of Works; and there were the local sanitary authorities, the Vestries and District Boards--and to them had been added the Metropolitan Asylums Board, another indirectly elected central body. But there were very manifest and prominent defects of the very gravest nature in this system of London government, and in 1884 the Government of the day made an effort to construct a better system. Sir William Harcourt introduced the London Government Bill into the House of Commons. "While London grew," he said,[160] "the Corporation remained stationary." "The central body must deal with the large affairs, ... a central body doing all the great things." "The central principle of the Bill is this, that there should be some common control over the Vestries which shall give them a uniform action for the benefit of the whole community instead of leaving them as they now are, independent of any such control." "What is the great evil? It is that the metropolis is broken up into fragments acting on a different principle, some doing ill, and those who do well suffering in consequence of the ill-doings of their neighbours." "When the danger (of invasion of cholera) threatens a great metropolis like London, all must desire and want a central authority which should advise, which should assist, which should compel every part of the community to take those measures of precaution which are necessary for the safety of the whole. No such authority exists at this time. "If a Vestry refuses to make sanitary bye-laws, or to carry out a proper system of sanitary inspection, you are absolutely powerless to compel them to do so. A single parish may become a plague-spot in London from which disease may be spread all around, and the Metropolitan Authority have no authority to make the parish do as it ought to do." Mr. Gladstone said[161]:-- "The local government of London is, or, if it is not, it certainly ought to be, the crown of all our local and municipal institutions. "The principle of unity (of London) has already been established under the pressure of necessity as a matter which could not be resisted. It has been established in the Metropolitan Board of Works.... There can be no doubt we have established a principle of unity, and that we have found it satisfactory. "The supply of water and the supply of gas ... two of the most elementary among the purposes of municipal government, have been handed over to private Corporations for the purpose of private profit because you have not chosen to create a complete municipality for the metropolis. "And that is not all. "The defects of the present system are admitted.... Surely if there are these great and intolerable defects they ought to be remedied by the action of some genuine popular local authority. But we have got no genuine popular local authority.... "London, large as it is, is a natural unit--united by common features, united by common approximation, by common neighbourhood, by common dangers--depending upon common supplies, having common wants and common conveniences. "... Unity of Government in the metropolis is the only method on which we can proceed for producing municipal reform." The Bill was strongly opposed in Parliament, and was withdrawn at a late period of the Session, "but its introduction and discussion had done much to awaken interest and mature opinion on the question of the practicability of the government of London by a single municipality."[162] Up to this time, though overcrowding had occupied so prominent a position in the great health problem of London, no returns of the amount of overcrowding actually existing had been obtained, nor had any estimate even been attempted. The reports of the Medical Officers of Health showed in many graphic descriptions that overcrowding was prevalent in every part of London--more acutely so in some districts than in others--but as to the amount no information was available. The first reliable figures over a large area--a large central district of London--were collected by Mr. T. Marchant Williams, Inspector of Schools for the London School Board, and published in the _Times_ of February 22, 1884. He wrote giving some of the results of his recent investigations into the social conditions of the people residing in his district. "My sole desire," he wrote, "is to record facts. It will be my endeavour to show that these facts are sufficiently typical or representative of the social condition of the elementary school population of London to serve as a trustworthy basis for a fairly accurate estimate of the stupendous difficulties the School Board for London has to contend with." "The Division of Finsbury includes the following parishes:-- (1) St. Giles'-in-the-Fields { The whole population in { St. George-the-Martyr { 1881 was 503,851; number (2) { St. Andrew, Holborn { of children of school age, Clerkenwell { 3-13 == 91,128, 95 per St. Luke { cent. of whom have been Stoke Newington { scheduled by the Officers Islington { of the School Board." (1) In St. Giles'-in-the-Fields there were 9 efficient elementary schools, 4 churches, 6 chapels, 102 public-houses, 27 milk shops. He gave the number of families scheduled for elementary school purposes residing _in more than two rooms_ as 382, which represents about 14 per cent. of the whole number of scheduled families. 28 per cent. of the families lived each in 2 rooms only, and 58 " " " " " 1 room only. (2) In the parishes of Bloomsbury, St. George-the-Martyr, St. Andrew, Holborn, and part of St. Giles'. The number of families scheduled for elementary school purposes residing _in more than two rooms_ was 395, which is about 10 per cent. of the whole number of scheduled families. About 45 per cent. lived in 2 rooms only. " " " " 1 room only. (3) Lower Division of Clerkenwell and St. Luke's. The number of families scheduled for elementary school purposes residing _in more than two rooms_ was 3,886, which is about 37 per cent. of the whole number of scheduled families. 33 per cent. lived in 2 rooms only. 30 " " 1 room only. He gave similar information as regarded three other sub-districts, and then went on:-- "The foregoing statistics show that there were at the beginning of the present year, in the Finsbury division-- "10,490 families consisting of 41,044 persons, living, each, in _one_ room only, and 17,210 families consisting of 82,215 persons, living, each, in _two_ rooms only, a total of 123,259 persons living in one or two rooms. "For every efficient elementary school in the division there are more than 8 public-houses, for there are in the division 111 efficient schools, while the public-houses number 912; the grocers' shops, 682; bakers' shops, 409; dairies, 350; coffee shops, 427; churches, 74; chapels, 32; mission rooms, 47; registered lodging-houses, 101." And then he summarised his figures for the City Division: Number of children of school age == 6,986 " " churches and chapels == 71 " " public-houses == 408 Number of families living, each, _in more than two rooms_ was 1,972, which is about 33 per cent. of the scheduled families. About 43 per cent. live, each, in 2 rooms only, and nearly 24 " " " 1 room only. The _Times_ commented, in a leading article, on this information. "Everywhere, and by all sections not immediately affected, the scandal and almost the absurdity of the brutish degradation of an enormous number of habitations in the greatest and most opulent city in the world are thoroughly recognised.... Habits of life such as lodgings of the kind now common among London workmen foster and encourage are a positive danger to the whole of society. Only by one rank is the question treated as of no pressing importance. That happens to be the body of persons directly interested. "... No more instructive contribution has been offered towards a clear perception of the dimensions of the problem than those given by Mr. Marchant Williams.... "Incidentally the census, by the School Board, of the classes it was founded to teach, contains the precise materials for informing the public of the extent of the overcrowding which has been shocking the moral sense of the nation. Formerly, when instances of overcrowding were cited, it might have been fancied they were exceptions or exaggerations. Mr. Williams' report allows of no possibility of a doubt. * * * * * "The Finsbury educational division contained, in 1881, a population of 503,851. Of these, 41,044 live in single rooms, at an average rate of four a room; 82,215 occupy suites of two rooms, at a rate exceeding four persons and three-quarters for each. For a family of two to monopolise a whole room is a luxury, and to possess two rooms is a marvel. Some rooms are made to hold ten, and many to hold six or seven.... "A home partakes of the life of the dwellers in it. They mould and incorporate it with their being, and it helps to mould and fashion them. The 123,000 owners of an undivided and indivisible quarter of a hovel in Finsbury, and the other hundreds of thousands in like case elsewhere in the town, are curtailed of the essential parts of the rights of humanity by the miserable accident that their locality refuses them reasonable standing room. Family life is an impossibility for a whole family collected in the single room 12 to 15 feet by 6 to 10. In a multitude of instances those tenanting a single room are several families, not one. They have to distribute the floor by square inches, and grow up with less regard to decency than a cat or a dog." And in another letter written a few days later, Mr. Marchant Williams added:-- "It was only the other day that I discovered in one of these streets (near Fitzroy Square) a house containing nine rooms, each of which accommodates on an average eight persons! "... The rents in the most crowded parts of my district amount as a rule to about a third or fourth of the maximum wages earned by the tenants." He mentions a case, a riveter:-- "He had recently abandoned the room in which he, his wife, and six children had lived for two years." "I have more than once when going my rounds been accosted by a landlord in a state of abject terror, lest I might be arranging to rob him of some of his victims. The landlord's defence invariably is that he is obliged to levy high rents because the tenants frequently run away by night and leave no trace behind them of their whereabouts." More and more did the feeling grow that something must be done to ameliorate the conditions under which the working classes and poorer people were living, and on the 22nd of February, the Marquess of Salisbury, in the House of Lords, moved in an Address to Her Majesty for the appointment of a Royal Commission to inquire into the housing of the working classes.[163] "The attention of persons of every class, of every creed, and school of politics, has been turned to this question," he said. H.R.H. the Prince of Wales said:-- "I feel convinced that your lordships, in common with all classes of Her Majesty's subjects, will be gratified to learn that the noble Marquess has asked for a searching inquiry into this great and momentous question with regard to the housing and the amelioration of the dwellings of the poor and of the working classes, and that Her Majesty's Government have decided to issue a Royal Commission for that purpose. "As your Lordships know I take the keenest and liveliest interest in this question. "I can assure you, my Lords, that I am deeply flattered at having been appointed a member of this Royal Commission." The Government accepted the motion, and a Royal Commission was forthwith appointed and immediately began its work. While the great question of housing and overcrowding was under discussion and was being investigated, and efforts being made to deal with it, various other matters forming part of the general sanitary evolution of London were attracting attention, or gradually developing. In October, 1882, the limits of the Port of London were extended seawards, and in the following year the powers of the Port Sanitary Authority were extended.[164] Most of the powers of an Urban Sanitary Authority under the Public Health Act of 1875 were conferred upon it, and the Medical Officer of Health reported that he believed the legal powers of the Authority would be found "amply sufficient for the sanitary control and supervision of the Port." The Authority extended its attention now to the inspection of imported meat. It was a matter of the first importance to watch carefully the food supply of the people. The trade of frozen meat had been rapidly growing, and from time to time large quantities arrived in unsound condition, which it was most necessary should be prevented going on to the market. In connection with another very important article of food--namely, milk--action was also taken. The effect of the order made in 1879 by the Privy Council, as to dairies, cowsheds, and milkshops, had been very beneficial, and a marked change for the better in the conditions under which the milk trade was conducted was the result. That Order was revoked in 1885 by the Privy Council, and a new one passed extending the powers of local authorities in the matter, and prescribing further precautions to secure the sanitary condition of all dairies and cowsheds, and for the protection of milk against infection or contamination. Another beneficial sanitary improvement was effected in 1883, by the extension of the benefits of the infectious hospitals of the Metropolitan Asylums Board. The Royal Commission on Fever and Smallpox Hospitals, in 1882, stated that in their opinion it was of paramount importance that the hospitals of the Metropolitan Asylums Board, to which so many classes of persons might become liable to be removed, should be made as little unattractive as the nature of the case admitted, and they considered that the pauper character which attached to the hospitals of the Board, and which rendered them repulsive to all but the indigent, would disappear if the distinction between paupers and non-paupers were abolished. This suggestion was partially given effect to by the Diseases Prevention (Metropolis) Act of 1883, which enacted that, subject to certain arrangements, the admission of any person suffering from infectious disease into any hospital provided by the Metropolitan Asylums Board, or the maintenance of any such person therein, should not be considered to be parochial relief. The plan was only partly successful, but as years went on the hospitals were increasingly used by persons other than those of the legally recognised pauper class. In the years 1884 and 1885 the hospitals demonstrated their great utility. There was a severe epidemic of smallpox. From its outbreak in 1884, to its subsidence in the autumn of 1885, no less a number than 12,425 patients passed through the hospitals, hospital ships, and camps of the Metropolitan Asylums Board, and the arrangements for the removal to hospital of cases of infectious disease, from the whole of the metropolis, worked smoothly and satisfactorily. The gain to the community in thus removing infectious cases from its midst was immeasurable.[165] In 1885 the Report of the Royal Commission which had been inquiring into the Housing of the Working Classes was published. It presented to the general public a mass of facts of which previously they had taken but little heed, and the vast importance of which they had utterly failed to realise; and it brought into the forefront of social questions the vital question of the public health, and the imperative necessity of remedying evils which were eating into the very vitals of the community. The Royal Commissioners depicted the widely prevalent and dreadful overcrowding which existed, and which in certain localities was becoming more serious than ever, and they gave numerous instances of it. They described the fearsome condition of tenement-houses, and of the people living therein--the inadequacy of the water supply--the defective sanitary accommodation in houses--the lack of air space--the absence of ventilation--the use of cellars and underground rooms as dwelling-places--the limitless filth. And they pointed out the dreadful results of this condition of things--physical, moral, and material--the prevalence of disease, the heavy death-rate, the destruction of bodily health, the dreadful immorality resulting from overcrowding, the degradation to which masses were doomed, the incitement to drink, and depravity, and crime. They declared that:-- "Even statistics of actual disease consequent on overcrowding would not convey the whole truth as to the loss of health caused by it to the labouring classes.... "Nothing stronger could be said in describing the effect of overcrowding than that it is even more destructive to general health than conducive to the spread of epidemic and contagious diseases." And they pointed out that there was much legislation designed to meet these evils, yet that the existing laws were not put in force, some of them having remained a dead letter from the date when they first found place in the statute book. And they investigated the causes of many of these things--and they assigned the blame for some of them--and they passed in review the conduct of the local governing authorities--and they recapitulated the existing laws upon these various matters, and suggested certain alterations, and made various valuable recommendations. There was, in fact, placed on record a calm, unimpassioned, and unexaggerated statement of the evils which masses of the population of the great capital were enduring in the last quarter of the highly civilised and enlightened nineteenth century. It was a thorough confirmation of all the reports of the Medical Officers of Health, and of the facts set out, and pressed by them, year after year, upon the attention of the Vestries and District Boards, and which had so persistently been ignored by so many of those authorities. The Commissioners classified the-- "Unquestioned causes which produced the overcrowding and the generally lamentable condition of the homes of the labouring classes." The first was-- "The poverty of the inhabitants of the poorest quarters, or in other words the relation borne by the wages they received to the rent they had to pay." The next was the demolition, for various reasons, of houses inhabited by the working classes and poorer people, and the consequent displacement of the people. The third was the relation between the owners of property upon which the dwellings of the poor stood, and the tenants of those dwellings. "The other great remaining cause of the evil was the remissness of local authorities." From their very origin, these "authorities" were unsatisfactory instruments for the performance of the public duties. "But little interest was, as a rule, taken in the election of vestrymen by the inhabitants," instances having been known of vestrymen in populous parishes being returned by two votes, on a show of hands. Elsewhere it is reported they elected each other. The Commissioners referred to the "supineness" of many of these metropolitan local authorities in sanitary matters, and to the "laxity of administration of some of them." And still worse, to the self-interested action of vestrymen. Thus on the Vestry of Clerkenwell, they said, were-- "Thirteen or fourteen persons who are interested in bad or doubtful property, including several 'middlemen'; and ten publicans who, with the exception of one or two, had the reputation of working with the party who trade in insanitary property; and accordingly this party commands a working majority on the Vestry." "It is not surprising to find that the Sanitary Inspectors whose tenure of office and salary is subject to such a body should show indisposition to activity." "The state of the homes of the working classes in Clerkenwell, the overcrowding, and other evils, which act and react on one another, must be attributed in a large measure to the default of the responsible local authority." "Clerkenwell does not stand alone: from various parts of London the same complaints are heard of insanitary property being owned by members of the Vestries and District Boards, and of sanitary inspection being inefficiently done, because many of the persons whose duty it is to see that a better state of things should exist, are those who are interested in keeping things as they are." And in another part of their report they wrote:-- "It is evident that the remedies which legislation has provided for sanitary evils have been imperfectly applied in the metropolis, and that this failure has been due to negligence in many cases of the existing local authorities." The part of the evidence which was of greatest value and interest was that which laid bare the responsibility for the dreadful conditions under which such masses of the people lived. Apart from the measure of responsibility which fell on Parliament itself, and it was no light one, it is clear that those conditions were due (1) in part to the various classes of "owners," (2) in part to the people themselves, and (3) in part to the local authorities. As regarded _owners_, there were first the ground landlords, who themselves, or whose predecessors had leased their land for building purposes, or with houses thereon to a tenant. It would appear clear that these ground landlords or freeholders, or lessors, had power to enforce against the person who held directly from them the repairing clauses of leases. But the existing condition of things showed that they did not do so. One of the witnesses, giving evidence about a particular property, said:-- "By the terms of even the old leases the tenant was supposed to keep the place in proper repair.... The property has gradually deteriorated in consequence of neglect." And Lord Salisbury, who asked:-- "I suppose it is practically impossible for the ground landlord to see that the conditions are kept?" Was told in reply:-- "The only way in which it is possible for him to do that is to keep a very active supervision over his property. "If that was done by ground landlords, and had always been done by them, you would have personal supervision carried out by a sufficient number of people to ensure the conditions being kept." Any idea of property having its duties as well as its rights appears to have been non-existent. Next to the land-owner was the numerous and varied class of house "owners," from the man who leased the land from the landlord and built the house, or who had leased the house and had sub-leased it to some one else. And often there were sub-lessees, until in some cases there was a chain of persons holding different interests in the same house. And there was the class of persons who take a house and break it up into tenement-rooms, and who were known as "house-knackers," or house jobbers, or house farmers, or as "middlemen," these last being defined as any one who stands between the freeholder and the one who occupies. Some interesting descriptions of some of these "middlemen" were given. One of the largest in Clerkenwell was a Mr. Decimus Ball, and there was also a Mr. Ross--both of whom were on the Vestry. The witness stated that these men had neglected the houses, and in many cases were very extortionate in their demands against the occupants. Mr. Ball had many houses which were inhabited by families in single rooms, but which up to a short time previously were inhabited by whole families to a house. Mr. Ball's profit is "perfectly enormous if he does not do any repairs." And he made very few; and if the rent were not paid on the Monday morning, he threatened to raise it. Probably the most notorious "middleman" was a certain Mr. Flight. "He must have been the owner of thousands and thousands of houses in the metropolis." (18,000, it was said.) "He owned property in every part of London, and the squalid nature of that property, the wretched condition in which it has been kept, the avoidance of all decent rules by which habitations are governed, was something very fearful." "Middlemen," it was stated, sometimes appeared to be making 150 per cent. per annum, but they assert that repairs have to come out of that. Repairs, however, were only executed once in three or four years, and in the others they get their 150 per cent. "If the house-farmers do no repairs for years the profits are large.... They collect their rents very sharply. "The middleman makes the tenant pay an excessive rent because he insists upon making an excessive profit." The great work which the Commission did was in the enlightenment of the public, and the material they afforded for the formation of public opinion in the right direction. Subsequent experience showed that the recommendations made--excellent and helpful as so many of them were--did not by a long way cut deep enough to extirpate the more serious evils. "It is evident," wrote the Commissioners, "that the 35th Section of the Sanitary Act of 1866 (dealing with tenement-houses) which contains a remedy for some of the evils which have been described is likely to remain a dead letter in many districts of the metropolis until some improved means be devised for putting it into action." They recommended that the local authorities who had not already made and enforced bye-laws under the section "should proceed to do so." But no compulsion was suggested to make them do so, or for the only effective alternative, the provision of other machinery to act in their default, and so the local authorities were in this matter allowed to remain in their position of complete independence and to continue their policy of inactivity--if not obstruction. As to inspection, and the inadequacy of a sanitary staff, much evidence had been given, but, they remarked:-- "It is evident that where work is performed according to the custom of certain districts of the metropolis it really does not matter whether the staff of inspectors be large or small." They summed up their general view in the following passage:-- "Without entering upon questions of policy of far wider application than the more immediate subject-matter of the present inquiry, Your Majesty's Commissioners are clearly of opinion that there has been failure in administration rather than in legislation, although the latter is no doubt capable of improvement. What at the present time is specially required is some motive power, and probably there can be no stronger motive power than public opinion." And with that view they recommended that inquiries should be held as to the immediate sanitary requirements of different districts, and the reports be presented to Parliament. Public opinion, however, is hard to move, and usually slow in moving; and when it has at last decided on definite action Parliament is slow in giving effect to the decision, and, when Parliament at last acts, the legislation itself is frequently defective. And so the outlook was rather hopeless. Various other more concrete amendments were, however, suggested in the various Housing Acts to render them more effective for their purpose. And, as a result, in the session of Parliament of 1885 a Bill was introduced dealing with the "Housing of the Working Classes." Lord Salisbury, in moving the second reading, said[166]:-- The Bill he introduced was to a certain extent "a compromise." "No one need expect to find that it contains any magic formula which will cure all the evils of which this House and the public have heard a great deal, and there is nothing startling, sensational or extreme in its provisions. We are hoping to cure these evils by slow and gradual steps, by the application of remedies apparently not far-reaching in their character, but still judiciously directed to the precise difficulties which arose in each department of our inquiry." The Bill duly passed (48 & 49 Vic. cap. 72). Most of the reforms embodied in it were of a trifling character and such as could have only the most limited and gradual effect. This Act extended generally the operation of the Labouring Classes Lodging Houses Acts of 1851 and 1867, and substituted the Metropolitan Board of Works for the Vestries and District Boards as the authority under the Act. A really useful plan was authorised by it, namely, the sale, at a fair market price, to the Metropolitan Board of certain prison sites in London for housing purposes. And one other good thing done was depriving the owner of insanitary premises, which had been pulled down by order of the local authority, of the power to require the local authority to purchase such premises. But merely again to declare-- "That it shall be the duty of every local authority entrusted with the laws relating to public health and local government to put in force the powers with which they are invested so as to secure the proper sanitary condition of all premises within the area under their control"--was futile, considering that the authorities in question had steadily ignored the same direction, made nineteen years previously, in the Act of 1866. Lord Salisbury wound up his speech with the following abnegation of Parliamentary power:-- "We must not imagine that it is anything we can do in this House, or in the House of Commons, that will remove all these evils. It must be done by that stirring up of public opinion which these investigations cause; it is to this that we must look for any real reform, it must be from the people themselves, from the owners, builders, and occupiers, when their attention is drawn to the enormous evils which past negligence has caused, it is from them that the cure of the sanitary evils which have so largely increased the death-rate must come." Considering, however, the accumulated mass of evidence which had shown beyond all question that it was the owners and builders who were mainly responsible for those "enormous evils," and who were still hard at work adding to them and perpetuating them, it was rather hopeless to expect "the cure of the sanitary evils" to come from that quarter. Unfortunately two general elections, and the heated discussion of great political questions, threw even these great health questions into the background, and not so much immediate benefit as was to be hoped followed the inquiry of the Royal Commissioners. It is an awful handicap to the welfare of a community, and of a nation, when those who should take a principal share in the duty of raising the physical, social, and moral condition of the people over whom they can exercise influence, and who are more or less under their control, not alone stand idly aside, but absolutely exploit the misery and helplessness and ignorance of masses of the people. The Imperial Government may make most excellent laws, but the physical and sanitary welfare of the people cannot be secured by a local governing authority alone, nor their moral and religious welfare by the Churches alone. There is a great sphere of life where those who stand in the relation of land-owners or house-owners to tenants could exercise an enormous influence for good, and where nobody else could exercise it so effectually or so easily. But the disaster has been that in the great metropolis--the greatest of all cities--a vast proportion of those who ought to have been active in using this influence, have never made the slightest effort to use it, whilst others have used their position, and the dependence of the people upon them, solely to wring from them the last farthing that could be extracted. And these were the men who made the loudest protests and outcry against legislation and against administration which was to make them do that which the vital interests of the community and of the State required to be done. The root of the evil connected with the housing of the people in London lay with the disregard of "owners" for the condition of their tenants. Many "owners" appeared to be under the impression that their investment in house property was to be as free from trouble or labour as money invested in the national funds is; and so long as they got the rent they expected, they did not trouble themselves about the state of the houses or of the people living therein. They were loth to spend money on them, as that curtailed their income, and the argument was constantly used that it was useless spending money to put the property in order, when anything they did to it would be promptly destroyed. And they cared not who were their tenants so long as a high rent was obtainable from them. Some declared that the people were so sunken, so degraded, so filthy, and depraved, and destructive, that nothing they could do could secure their property being kept in a sanitary or decent condition. Doubtless in many districts and many cases the conduct of the tenants was as bad as bad could be. As one of the Medical Officers of Health wrote in 1883:-- "It must be borne in mind that many of the occupants of tenement property are careless and filthy in their habits; and in addition are very destructive; fittings put up one day are pulled down and destroyed the next; ash-bin covers, closet doors, and even flooring boards, share the same fate." And many were the "owners" of various degree who endeavoured to justify their neglect on this ground. Were such an argument admitted, the owner could claim to be exonerated from the duty of keeping his property in proper order, and the evil conditions and consequences resulting from his neglect would go on increasing indefinitely, until a state of things destructive to the community was ultimately reached. Viewed broadly, and impartially, there was much truth as regarded the misconduct and uncleanliness of great numbers of tenants, but the central fact was that the "owner" was the person mainly interested in, and benefited by possession of the property, and therefore primarily responsible for maintaining it in a condition which should not endanger the health of the community. If, through the neglect and indifference of his predecessors, the property had fallen into a bad state, the consequences equitably fell upon him, just as the consequences of any other bad investment by his predecessor would have done. He had inherited something which was not worth as much as he anticipated--that was all; but the consequences must not be shifted on to the community, nor must his tenants be made the victims. And if he allowed his property to become a danger to his tenants, and through them to the community at large, the community had an absolute right to protect itself by insisting that he should be prevented from so doing. The only way in which, in the interests of the public, abuses can be prevented is by holding the person responsible for them who has the power of preventing them. And that was just what in this case the "owners" did not like. Building constituted an important part of the housing problem. The Medical Officer of Health for Lambeth, in his report for 1887, gave an interesting account of the process of building in London which shows how even the amended Building Acts had failed to secure those conditions of air and space which are essential for health. "In proximity to the centres of business every available plot of garden or recreation ground has been converted into building sites. Houses constructed from materials of the poorest quality and by workmen employed only for the cheapness of their labour, have been hurried into occupation. "The system of close building, at first confined in its application to the consolidation of the inner zone, has been adopted in the outer, and with the demand for shelter, which increases in a progressive ratio with the growth of the population, the once open suburbs must ere long become indistinguishable in the monotony of house row and pavement. "The art of close building appears a progressive one. In its infancy, twenty years ago, the art has now arrived at a stage nearly approaching perfection. In the earlier examples the space allotted to garden land was larger than that built on. Then the size of the two quantities reached an equality--then the covered ground becomes a larger quantity than the uncovered land, until the final stage of development is attained when the extreme limit of encroachment permitted by the Building Act is reached, and garden land is represented by a yard 100 superficial feet in area." Extraordinary loopholes in the sanitary laws, moreover, were constantly being discovered which almost neutralised the original enactment. Thus the Medical Officer of Health for Camberwell remarked in his report for 1888:-- "It has been long known to the Sanitary Committee that there has never been any efficient supervision of the drainage and other sanitary arrangements of houses in course of construction.... It is true that every builder has been required before constructing his private drains and connecting them with the public sewers, to send in a plan of his proposed drainage for the sanction of the Surveyor. But there has been no machinery by which builders could be compelled to carry out their private works in accordance with the plans submitted, and to ensure that the details of their works had been carried out in a workmanlike or efficient manner. The inspections of houses even recently built have shown that sanitary nuisances complained of have been largely due to scandalous neglect of duty on the part of those concerned in carrying out the drainage works, and that in most cases the plans sent in have not accorded with the arrangements finally adopted." Various, indeed, were matters connected with the public health which unexpectedly came cropping up; sometimes matters thought to have been disposed of but only partly so, sometimes, wholly new origins and ramifications of insanitation. Thus in 1886 the Medical Officer of Health for the south part of Poplar District drew special attention to a grievance long previously complained of and for many years endured. "A greater scandal cannot well be shown in matters vital to health than that in spite of abundant evidence of the magnitude of the evil, thousands and tens of thousands of families living in houses, the rates of which are payable by the landlords, may at any moment, without a particle of fault of their own, be suddenly denied one of the first necessaries of life--water--through the neglect and wilfulness of others." The main remedy open to the water companies to recover rates from defaulting non-resident owners of tenement-houses was the simple expedient of discontinuing the supply of water. This course was open to a double objection--first, tenants who had paid their rent were deprived of that for which they had constructively paid; and secondly, a tenement-house deprived of water might speedily become a focus of disease. "That disease and death are directly traceable to this want," wrote the Medical Officer of Health, "no one acquainted with sanitary work in London can doubt. Take this instance. Water cut off, drains stopped, opening up of ground and drains, removal of filth accumulations, horrid stench, diphtheria, death. "In Hanbury Place--having six houses--there was no water supply for twenty-six days, and families numbering each seven, nine, two of six, and others had to exist in May, 1885, with choked drains, yard flooded with sewage, and no water--and all because of non-payment of rates by the landlord." In 1887 Parliament happily dealt with this evil, and by an Act passed in that year-- "Water companies were prohibited from cutting off the water supply from any dwelling-house for non-payment of water rate, if such rate were payable by the owner and not the occupier of the premises...." In the middle of this decade, too, anxiety revived, owing to the state of the Thames, a matter which it was hoped had been finally disposed of. The discharge of sewage at the new outfalls make the river in those parts much what it had previously been in London. A Royal Commission was appointed to inquire into the subject. They reported that they found a condition of things which they "must denounce as a disgrace to the metropolis and to civilisation." They said that in 1884 "the sewage water from the outfalls manifestly reached London Bridge." "At Greenwich Pier the water was very black, and the smell exceedingly strong." "At Woolwich the river for its whole width was black, putrid, sewage--looking as if unmixed and unalloyed. The stench was intolerable." "We are of opinion that it is neither necessary nor justifiable to discharge the sewage of the metropolis in its crude state into any part of the Thames." This evil was surmounted by the adoption by the Metropolitan Board of Works of a system of treatment of the crude sewage. Chemical precipitation was effected by adding to the sewage certain proportions of lime and protosulphate of iron, and allowing it to remain for an hour or two in settling tanks. The effluent water was let flow into the river, and the sludge was carried down the river in barges and cast into the sea. The public interest evoked by the inquiries made by the Royal Commissioners on Housing, and the publication of their Report, certainly quickened the activity of many of the local authorities. In several of the parishes and districts the Regulations under the Sanitary Acts of 1866 and 1874 were being more readily adopted, and being put into force on a slightly more extended scale; and in every case it was reported that the results had been satisfactory, a great improvement taking place in the houses which were registered. A report of the Inspector of such houses, for Bermondsey, describes this well:-- "108 were placed on Register by Vestry. The majority of these houses are situated in the lowest and most densely populated parts of the parish. They are occupied by the very poor, costermongers, dock and waterside labourers, &c. They contain 509 rooms, occupied by 386 families, numbering 1,434 persons. 285 rooms were overcrowded. With three exceptions the overcrowding has been abated. Previous to registration the number in each house was 13, present average 9." "The sanitary condition of the said houses has been greatly improved. Staircases, &c., are now regularly swept and washed. In 85 houses the walls have been stripped and whitewashed. Many of the walls had 15 layers of paper, thus hiding filth and harbouring vermin. Ventilation in them is also improved. Many owners rendered much assistance." Several inquiries of the sort suggested by the Royal Commissioners were held in the course of the ensuing years and reports presented to Parliament, but it is much to be doubted whether they had any effect in so inciting public opinion as to make it insist on the recalcitrant local authorities carrying the laws into effect. Clerkenwell, Mile-End-Old-Town, Bethnal Green, and Rotherhithe, were inquired into, and reported on. The tale was much the same as that set forth time after time, and year after year, by various Medical Officers of Health--want of adequate sanitary supervision, numerous neglects by the Vestries, especially the neglect to make, or, if made, to enforce Regulations under the Sanitary Acts of 1866 and 1874. The initiative of dealing with the existing condition of things rested with the Vestries. It was forcibly pointed out that complaints could hardly be expected either from the owners of insanitary houses, on whom the cost of the improvements would fall, or from tenants who are too often indifferent to considerations of health and cleanliness, and who in any case would fear to offend their landlords by complaining. Rotherhithe came in for the strongest condemnation. Of it the Commissioners reported:-- "It is, in fact, no exaggeration to say that the results of lax administration abound in Rotherhithe, and especially in houses occupied by poor persons." The increase of the sanitary staff was recommended, but the obdurate Vestry resolved not to increase it. The absolute necessity of inspection was demonstrated every day of the year to every Vestry and District Board in the metropolis by the results of such exceedingly limited inspection as was carried out. In St. Luke, in 1890, of 1,348 houses inspected 296 were found "in fair sanitary condition." In Hackney, in 1887, 5,213 were inspected; 3,620 of them were found to be wanting in some sanitary requirement, or were so dirty as to necessitate orders being served for whitewashing and cleaning. In one street 111 houses were inspected, and in 97 nuisances were found. In St. Marylebone, in 1884, 2,136 orders were sent out for repairs and various sanitary improvements. In Hammersmith, 3,377 notices to abate nuisances were served in 1886. In Westminster, 1,609 notices served for sanitary defects. The Medical Officer of Health for St. Saviour, Southwark, reported (1890-1):-- "The importance of house-to-house inspection may be estimated by the fact that of 491 houses inspected, it was found necessary in nearly every instance to serve notice for the carrying out of urgent sanitary requirements." In Camberwell there were, in 1889, between 30,000 and 40,000 houses in the parish, "of which probably one-half should be inspected periodically." The Medical Officer of Health of Bethnal Green stated:-- "In my district we have a population of about 130,000, and about 18,000 houses, and we have two Inspectors. Of course there should be periodical inspection, that is to say, every house in the parish should be visited at least once a year by a Sanitary Inspector, but that with the present staff would be utterly impossible. In my district there is no house-to-house visitation; we simply attend to complaints as we receive them, and this completely fills up the time of the two Inspectors." And he further stated[167]:-- "In my district the Sanitary Inspectors are not under the control of the Medical Officer of Health." It is of course manifest that if houses had not been inspected, and the necessary sanitary improvements enforced, things would have gone on rapidly deteriorating, and with that deterioration would have come all those causes of disease which would endanger the lives of the occupants and create fresh centres for spreading disease broadcast. It might have been thought that the numerous inquiries into the condition of the working classes in factories and workshops would have laid bare nearly all there was to lay bare. A report to the Board of Trade on the Sweating System in the East End of London, by J. Burnett in 1887, rudely dispelled such an idea, and opened out to public view a new vista of causes, deleteriously affecting the public health, a new area of insanitation. Though the evils depicted had become acuter, they evidently had been going on for years. "The system may be defined as one under which sub-contractors undertake to do work in their own houses or small workshops, and employ others to do it, making a profit for themselves by the difference between the contract prices and the wages they pay their assistants. "The mass of those employed under the sweating system labour in workshops where much fewer than 20 are engaged, or in the houses which may be single rooms of the 'small sweaters.'" After referring to the numerous branches of the tailoring trade, he said:-- "Immense numbers of people of both sexes and all ages have rushed into the cheap tailoring trade as the readiest means of finding employment. The result has been an enormously overcrowded labour market, and a consequently fierce competition among the workers themselves, with all the attendant evils of such a state of things.... Matters have been rendered infinitely worse by an enormous influx of pauper foreigners from other European nations. The result has been to flood the labour market of the East End of London with cheap labour to such an extent as to reduce thousands of native workers to the verge of destitution...." "There are, of course, in addition many English workers employed in the same trade and in the same shops, but their number is gradually being reduced, owing to the severity of a competition in which those who can subsist on least are sure to be victorious. "The object of the sweater being his own gain, the inevitable tendency of such a system is to grind the workers down to the lowest possible level.... "The character of the workshops, or places used as workshops, varies considerably. The smaller sweaters use part of their dwelling accommodation, and in the vast majority of cases work is carried on under conditions in the highest degree filthy and unsanitary." "In small rooms, not more than nine or ten feet square, heated by a coke fire for the pressers' irons, and at night lighted by flaring gas jets, six, eight, ten, or even a dozen workers may be crowded. "The conditions of the Public Health Acts, and of the Factory and Workshop Regulation Acts, are utterly disregarded, and existing systems of inspection are entirely inadequate to enforce their provisions even if no divided authority tended to weaken the hands of the Inspectors. "Some of the shops are hidden in garrets and back rooms of the worst kinds of East End tenements, and a third of them cannot be known to the Factory Inspectors. "It is in regulating the hours of the women that factory inspection should be of most service, but how can two or three Inspectors keep in check the multitude of sweating dens of East London? Basements, garrets, backyards, wash-houses, and all sorts of unlooked for and unsuspected places are the abodes of the sweater." Early in the following year Lord Dunraven, in the House of Lords, moved for the appointment of a Select Committee to inquire into the sweating system. "The evils which existed there were caused by natural laws which were not by any means of necessity unwholesome in any degree.... But his belief was that though the causes were perfectly natural in themselves they had been allowed to run riot, and had not been put under proper control, and had thus produced the present terrible state of things.... "Large workshops were the exception. In the 'dens' of the sweaters there was not the slightest attempt at decency; men and women worked together for many consecutive hours, penned up in small rooms and basements, garrets, backyards, wash-houses, and all sorts of unlikely places, were the abodes of the sweaters." And he quoted the Chief Inspector of Factories and Workshops:-- "To add to the evils of overwork pursued by these people, we must note the overcrowded, ill-ventilated, and excessively hot state of the workrooms; ... it is surprising how such people can live under such conditions. "... It was," he said, "a ridiculous and scandalous thing that Parliament should pass Factory and Sanitary Acts regulating the hours of labour of women and children, and that those Acts should be grossly violated." Lord Sandhurst said:-- "It might appear to their Lordships almost incredible that within three or four miles of that House a state of things, involving so much human misery, could possibly exist as was to be found at the East End of London." The Select Committee was appointed. The results of its inquiries are stated in the next chapter. In 1888 the local government of London underwent a most notable change. In the early part of 1887 various rumours gained currency as to questionable dealings in connection with the lettings of land owned by the Metropolitan Board. Certain officials of the Board were mentioned. The details do not fall within the history of the sanitary evolution of London, except so far as they affected the central governing authority of London. The allegations made received increasing confirmation, and early in 1888 a Royal Commission was appointed to inquire into and thoroughly sift them, and early in May the Commission held its first sitting, the Metropolitan Board affording every facility for the thorough investigation of the matter. Before that time, however--namely, in March--the Government had introduced into the House of Commons its proposals as regarded the local government of England and Wales generally; and the opportunity was taken to deal with the great problem of London government which had so long vexed and perplexed successive governments, and which was becoming more and more insistent as years went on, and London was accordingly included in the general scheme. By the measure now introduced London was to be created--not a Corporation, nor a Municipality, but a County--with a Council as the governing authority of the County. Mr. Ritchie, introducing the Bill into the House of Commons, said[168]:-- "We cannot shut our eyes to the fact that whereas every other borough in the country possesses a body directly representing the ratepayers, no such body exists in London. "There is no one elected by, or responsible to the ratepayers. "We propose to take London, as defined under the Metropolis Management Act, out of the counties of Middlesex, Surrey, and Kent, and we propose to create it a County of London by itself, with a Lord Lieutenant, a Bench of Magistrates, and a County Council of its own. "We propose that the Council shall be directly elected by the ratepayers, as in all other counties and boroughs--that the franchise shall be the same--and that it shall consist, as in all other cases, of elected and selected members; the elected members sitting for three years, the selected for six years (one-half of their number retiring every three years). "It will take over the licensing powers and all the duties of the Metropolitan Board of Works, which will cease to exist." The "City" of London was to be allowed to retain its separate existence within the new County, together with its ancient privileges and immunities for the most part unaltered and untouched. The Bill developed into an Act, which created a new central authority for London, under the title of the London County Council. The area of the new "Administrative County" of London was made co-extensive with that of the former district of the Metropolitan Board of Works. And to the new Authority was transferred the powers, duties, and liabilities of the Metropolitan Board of Works; and to those were added functions much wider and more extensive than those of that Board. The Act also conferred upon the Council the power of appointing a Medical Officer of Health for the County, and additional powers of making bye-laws. It did not, however, materially interfere with the Vestries and District Boards, nor did it alter their relation to the Central Authority. Practically it left them untouched. The Council was to consist of 137 members, of whom 118 were to be elected triennially by direct election in the various metropolitan constituencies, and 19 to be elected by the Council itself as Aldermen. Finally, the Act set a limit to the existence of the Metropolitan Board of Works. While the Bill was going through Parliament the Royal Commission had been pursuing its inquiry into the allegations made against that Board, and had ascertained that several of the officials had been carrying on-- "... A nefarious course of proceeding by which they had been able to obtain for themselves large sums of money out of dealings with the Board's land." And that-- "... Two of the members of the Board in the architectural profession had availed themselves of their representative position to make personal profit out of some of the business which came before them." Under the growing disfavour with which public authorities were regarded who were only indirectly elected, and so not amenable to the influence or control of the electorate, it is improbable that the existence of the Metropolitan Board of Works would have been much prolonged. But it was an unfortunate ending to a great public body which had done really great service to London. Its own final words[169] may be quoted in its defence:-- "It has been a source of pain and sorrow to the Board that, at the close of thirty-three years' administration of the local affairs of London, which has been attended with at least some measure of success, and in the course of which the Board has carried out some of the greatest works of public utility of which any city can boast, its good name has during the last year of its existence been sullied by iniquitous proceedings of which, though carried on in its midst, its members as a body were entirely without knowledge. It is some satisfaction to remember, however, that a body of Commissioners, who in a judicial spirit made the most searching inquiry into the Board's proceedings, were able, while exposing the wrong-doings which were revealed to them, and justly distributing the blame, to speak of the Board, as they do in their report, in the following terms:-- "'It has had a multitude of duties to perform, and very great works have been constructed by it, which have transformed the face of some of the most important thoroughfares of the metropolis. And there has hitherto been no evidence that corruption or malpractice has affected or marred the greater part of the work which it has accomplished. The same may be said, too, in relation to the conduct of the vast majority of the members of the Board. We have received very numerous communications, some anonymous, some bearing the signature of the writers, impugning the action of the Board and certain of its members, but against the vast majority of them not even a suspicion of corruption or misconduct has been breathed. We believe that many members of the Board have cheerfully given for the public good much valuable time, and have rendered most important public services.'" The change in the constitution, nature, and character of the central authority of London effected by the Act was momentous and far-reaching. Instead of an indirectly elected body such as the Metropolitan Board of Works, over which the inhabitants of London had practically no control, there was brought into being a body directly chosen by an electorate of nearly half a million of the ratepayers of the metropolis, responsive to the views and desires of the electorate, endowed with the great authority derived from its representative character, and entrusted with the carrying out of the views and policy of London as one great city. London had been unified and welded together into one whole by the constitution of its new central authority; for the first time in his history it had been given a voice--the voice of one great city--and though much remained to be done before its entrance into its full rights as one city--and that the greatest which has ever existed in the world--the idea had been born, and had been embodied in the statutes of the realm that London was one great city, and not a mere conglomeration of petty jarring authorities. The first election of councillors took place on January 17, 1889. The first meeting of the Council took place on the 21st of March, when the Earl of Rosebery was elected Chairman, and the Council entered energetically on the work lying before it. The sanitary evolution of London was vitally involved in the change, but it was at once discovered that the powers of the Council relating to the public health of London were of a very limited and unsatisfactory nature. Matters concerning it were regulated by the Metropolis London Management Act and a large number of other Acts, the execution of which was in the hands of the Vestries and District Boards. These bodies were practically uncontrolled, and no machinery existed for securing any uniformity of administration in the different parts of the county. And even the Metropolitan Board had not used certain powers it possessed of making bye-laws for certain sanitary purposes. "We cannot," reported the Sanitary Committee of the Council, "too strongly emphasise our opinion that the London County Council should be empowered to frame bye-laws for the proper sanitary government of London, that the new or existing local bodies should put them in force, and that the County Council should be the supervising body to see that they are properly carried out." A somewhat similar report was made by the Housing of the Working Classes Committee. "The Committee," they said, "feels that until the law is strengthened, and fuller powers to enforce the law are placed in the hands of the Council, its action in dealing with insanitary areas will be of an imperfect character." The question of the housing of the poor in London was at once energetically taken up by the new body. Representations were made to the Government as to the necessity of the Acts relating to the housing of the working classes being consolidated and amended. Consequent upon this, the Government introduced a Bill which was passed--"The Housing of the Working Classes Act, 1890,"[170] which repealed and codified fourteen enactments, all having for their object the improvement of the dwellings of the artizan and labouring classes, and the clearing away of unhealthy areas. Very large powers were placed in the hands of the Council and of the district authorities to secure the better housing of the working classes. And the Act may be said to mark a new era in the history of reform in the matter of insanitary areas, giving full power to the Council as a central authority to enforce its provisions. Before the end of this decade Parliament passed two other Acts of great advantage to the health of London. One was, "The Infectious Diseases Notification Act, 1889," making the notification of certain specified diseases compulsory in London--smallpox, cholera, diphtheria, membraneous croup, erysipelas, scarlet fever, typhus, and other fevers. In accordance with well-worn usage London had been left behind in this matter. Other cities and even towns had, by means of local Acts, secured the advantages of such legislation long before. So far back as 1874, indeed, machinery had been in existence in London for the notification of infectious disease in houses let in lodgings. But owing to the neglect of the majority of the Vestries and District Boards to make or enforce regulations under the Sanitary Act of 1866, that machinery was left unused to the great detriment of the people of London. Thousands of lives must have been sacrificed by this neglect, and innumerable cases of preventable disease not prevented. It was not until a general Act was passed that London became possessed of the advantages resulting from such notification. In London, indeed, the health of cattle was better looked after in this respect than that of the people, for cases of infectious disease in cattle had to be notified to the Sanitary Authorities. By this Act it was made compulsory on medical attendants to certify, and on householders to notify, the existence of any of these diseases. Hitherto information as to infectious illness only reached the Medical Officer of Health after a sufficient time had elapsed to allow of the spread of the infection. The results of the Act of 1889 were soon found to be very beneficial in checking the spread of disease. The receipt of the notices of infectious diseases led to the more prompt and general disinfection of premises where infectious diseases prevailed, and led also to the discovery of sanitary defects which might not otherwise have been discovered. The information, moreover, kept the Medical Officers of Health informed of the progress of disease not only in their own districts, but also in contiguous ones, and so assisted them to take prompt measures for the eradication of disease in their respective districts. The other measure which passed the legislature in this same year contained provisions of the highest importance as affecting the metropolis. This was "the Poor Law Act, 1889." Until 1889 patients could be admitted only to the infectious hospitals of the Metropolitan Asylums Board on the order of the Relieving Officer and District Medical Officer, so, except in certain cases, the hospitals were only open to Poor Law cases. This measure made practical concession of two principles. Free admission to the hospitals of the Metropolitan Asylums Board of sick persons in need of isolation, and devolution upon the Metropolitan Poor Fund of all charges incurred in the maintenance of the sick in those hospitals. The Managers were, therefore, enabled to admit other than pauper patients reasonably believed to be suffering from fever, smallpox, or diphtheria. The system was attended with the happiest results in reducing the amount of infectious disease in the metropolis, and proved a great boon to all classes of the community. The Board in its annual report wrote:-- "The Managers are now, for the first time since the establishment of the Board in 1867, virtually recognised as the Metropolitan Authority for the provision of accommodation for the isolation and treatment of infectious disease--both pauper and non-pauper--and are now empowered to legally perform duties which the Legislature had imposed on the District Sanitary Authorities, but which the Managers had hitherto been called upon to perform in consequence of the failure of most of such Authorities to provide accommodation for non-pauper patients." The Managers by this date had increased the accommodation for patients afflicted with any of these infectious diseases. There were six fever hospitals, 2,463 beds; 350 beds in smallpox hospital ships; and 800 beds in the hospital for convalescing smallpox patients. One other Act[171] deserves mention before the close of this decade as it contained an unique section which required the Medical Officer of Health, on notice from the owner of property in which there are separate dwellings let for 7s. 6d. or less a week, to visit them and examine all their sanitary arrangements, &c., so as to be able to certify or not-- "That the house is so constructed as to afford suitable accommodation for each of the families or persons inhabiting it, and that due provision is made for their sanitary requirements." The certificate, if granted, was to be handed to the owner, who was then able to obtain the remission of the inhabited house duty. The owner, therefore, obtained a remission of taxes to which he was justly liable, because the dwelling which he lets was in a sanitary condition! In many ways, then, the sanitary evolution of the great city was developing satisfactorily, though by no means so rapidly as was to be desired, or as it might have developed if local governing authorities had done their duty. "The war of the community against individuals for the public good," which had now lasted for over thirty years, and the war against disease in its most dangerous forms, was being waged with good effect; and though an immensity remained to be done, a great deal had been accomplished. Larger numbers of all classes were beginning to grasp the idea and to realise that the necessity of securing and guarding the public health was not a craze or form of mental aberration, but was of absolutely vital consequence, not merely to certain classes but to the great community of the metropolis and to the nation itself, and that the future welfare and power, even the very existence, of the nation are dependent upon it. Larger numbers, too, were beginning to see who really were responsible for the widely prevalent evils, and who really were obstructing progress towards a higher standard of public health, and how little claim they had to consideration, either from the hands of the Legislature or of local administrators. The reports of the Medical Officers of Health of the latter part of this decade were distinctly more hopeful in tone, and recorded more progress than ever before. The catalogue of things in which improvement had taken place had lengthened--sewerage, water supply, the removal of refuse, paving, the regulation of offensive businesses, of cowhouses, dairies, and bakehouses, the provision of open spaces, the better disinfection of houses and of infected articles, the erection of hospitals for the isolation of cases of infectious diseases--all of which things were elemental necessaries if the public health was to be assured. In some parishes, in place of the smaller class of houses, great blocks of artizans' dwellings had been erected. In others great blocks of flats. With the increased wealth of the population finer buildings had been erected in many districts. London had grown enormously in wealth, and the wealth showed itself in finer public buildings and private houses. The District Board of Westminster, for instance, said in their report for 1885-6:-- "Whether viewed as to its character, its statistics, its topography, or its sanitary condition, the change which Westminster has undergone in thirty years can only be described as a complete transformation." "In the St. Margaret's portion, whole streets of fine houses which were occupied by the nobility and the wealthy for residential purposes are now let out in offices for the transaction of legal, scientific, or mechanical business, while narrow streets, wretched courts, and melancholy homes of squalid poverty and misery have been replaced by 'mansions,' 'flats,' &c.; and on the other hand by huge blocks of artizans' dwellings, comprising upwards of 1,200 homes." The Education Act was indirectly producing some good results as regarded the health of the rising generation. A most marked improvement had come over the mortality of children at school ages. Mortality has lessened-- 5-10 years 30 per cent. 10-15 " 32 " 15-20 " 30 "[172] due to the fact that children had been gathered into the schools from their crowded and insanitary homes, and had thus escaped some of the perils of disease. And the Medical Officer of Health for Lambeth referred to this same subject in his report for 1886:-- "The children of the pauper and mendicant are withdrawn from the atmosphere of vice and intemperance to which their fathers had become acclimatised, and are placed under supervision in the schoolroom...." Some slight improvement there was also as regarded the mortality of children under five years, though in many parishes it was still fearfully high. In Mile-End-Old-Town, for instance, in 1890 the deaths under five years amounted to 51 per cent. of all deaths. In Deptford district in 1890-1 they amounted to 50 per cent. In Bermondsey in 1889 they amounted to 52 per cent. In St. Olave, Southwark, in 1888-9 to 49-1/2 per cent. In St. Mary, Newington, in 1890, very slightly under 50 per cent. Infantile mortality was becoming of greater concern than ever as the birth-rate was showing a decided diminution--that for 1889 being the lowest on record since 1849. Though the tables as to death-rate in many of the parishes were still more or less vitiated by various local circumstances, there was considerable unanimity that the death-rate was falling and the public health better. Some diseases which had previously claimed their victims by thousands, now only claimed them by hundreds. Death from tubercular disease had steadily fallen, and the mean death-rate from phthisis in London showed a very satisfactory decrease between 1861-70 and 1881-90.[173] The _Lancet_ of January, 1887, stated that, measured by its recorded death-rate, London was healthier in 1887 than in any year on record. In the Strand in 1886:-- "The efforts that have been made by the Board and its officers have resulted in a marked and continuous improvement in the sanitary state of the district." In St. Pancras in 1888 the death-rate was "by far the lowest yet recorded." In Bermondsey, in the same year, "so few deaths have not occurred since 1865." These and similar reports from other districts showed that sanitary progress was being made. But, unfortunately, in the autumn of 1888 there was an epidemic of measles of exceptional severity, which raised the death-rate. And in 1890 there was a sudden increase from 18·4 per 1,000 to 21·4, a mortality which was higher than any since 1882. The increase served to show the great necessity there was for unceasing watchfulness and for steady perseverance in sanitary work. The forces of disease are ever on the watch for the opportunity to work their evil will, and there were still many weak places in the defences against them. The central government of London had been improved enormously, but the corrective was not extended to where it was most wanted, namely, the local Sanitary Authorities, the Vestries and District Boards. FOOTNOTES: [149] To the then existing population of London. The South Eastern Counties contributed close on 290,000 " South Midland " " " " 249,000 " Eastern " " " " 196,000 " South Western " " " " 168,000 " West Midland " " " " 95,000 [150] The report was made in 1887, but was as true in 1881 as it was in 1887. [151] See Report of Select Committee, 1882, p. v. [152] _Times_, 20th November, 1883. [153] See his speech in Parliament, Hansard, 1884, vol. ccxc., p. 529. [154] Robert Reid (a Surveyor), p. 805. [155] The regulations suggested by the Local Government Board laid down that the landlord or owner should not allow a greater number of persons to occupy a room than would admit of free air space for each of 300 cubic feet--if used exclusively as a sleeping room--or 400 feet if used day and night. He was to-- (1) Keep the drainage in good working order, to properly pave the yard, and provide sufficient sanitary accommodation. (2) Keep the cisterns clean and in proper order, and keep the structure of ashpit in proper order. (3) Cause the ceilings and walls of every room to be whitewashed and papered every April. (4) Provide all requisite means for the ventilation of every room, and of the common passages and staircases thereof. (5) To notify cases of infectious disease. [156] Royal Commission, 1884. [157] Hansard, 1884. [158] 1884 Royal Commission, vol. ii. p. 2938. [159] Ibid. p. 724. [160] Hansard, 1884, vol. cclxxxix. p. 41. [161] Hansard, 1884, vol. ccxc. p. 541. [162] See Report of Royal Commission on the Amalgamation of the City and County of London, 1894. [163] Hansard, 1884, vol. cclxxxiv. [164] By the Diseases Prevention (Metropolis) Act, 1883, 46 and 47 Vic. cap. 35. [165] The total net expenditure was £401,000 in 1885. [166] Hansard, vol. ccxxix. p. 889. [167] Lords' Committee on Sweating, P.P. 1890, vol. 17. [168] Hansard, p. 1663, March 19, 1888. [169] See the last Report of the Board. [170] 53 & 54 Vic., cap. 70. [171] The Customs and Inland Revenue Act, 1890, 53 & 54 Vic. cap. 8. [172] See speech by Sir L. Playfair in House of Commons, March 4, 1884.--Hansard, p. 529. [173] See Report from Royal Commission on Tuberculosis, 1898. CHAPTER VI 1891-1901 IN 1891 the census once more gave authoritative figures as to the population of the metropolis of London. The population had increased from 3,830,297 to 4,228,317. The increase had been in a somewhat lower ratio than the population of England and Wales as a whole, and the fact was notable inasmuch as it was the first time that such a phenomenon had presented itself, London having been found in every preceding intercensal period to have gained more or less in its proportions as compared with the country at large. The movements of population had followed very much the same lines as in the previous decade. In the central parts--under the pressure of the great economic forces--the population had increased. In the outer parts it had increased, but "the wide belt of suburbs was beginning to show some signs of repletion." Immigration into London had greatly diminished in the decade. Fewer immigrants had come from the various counties of England and Wales, and the proportion of the inhabitants of London who had been born elsewhere had fallen from 308 persons per 1,000 in 1881 to 283 in 1891. Thus the influx of country people, mostly in the prime of life, and the admixture of fresh country blood into the urban population of London was undergoing diminution--a circumstance which, in the long run, would materially influence the physique of the people. Three important facts came into view with the figures set out in the census, giving food for thoughtful minds as regarded the future of London. The first was that the rate of increase of the population had again slackened off. The flood tide of population was not now flowing so fast. The second was that the population was being affected by migration. The natural increase of the population had been 510,384, the actual increase 396,199--so that London had lost by the excess of emigration over immigration more than 114,000 persons. This was the first time such an event had happened. London's boundaries, however, were very arbitrary and haphazard, and this emigration was probably only to places immediately outside London for residence at night, whilst work was performed in London during the day--as illustrated by the "City" and the Strand, where huge differences existed between the day and night populations. The figures showed, however, a movement of population which was bound to have an effect upon the sanitary condition of the people. A third and portentous fact, ascertained correctly by aid of the census figures, was the decline of the birth-rate in London. This had fallen remarkably since 1881. It was then 34·7 per 1,000 living. It was now 31·9. Deducible from the census figures, reliable calculations could also be made as to the death-rate in the metropolis. In 1891 it was practically the same as in 1881, being 21·4 per 1,000. It might be inferred that these latter figures did not afford much testimony to the effects of sanitary administration and labours, but the pause in the steady decline was only a temporary one. The authoritative and accurate records thus afforded decennially by the census are invaluable in tracing some of the most important developments in the sanitary evolution of London. Another very noteworthy change was also brought into prominence by the census. This was the continued rapid growth of the population immediately outside the boundaries of the County of London. Between 1871 and 1881 it had increased 312,000. Between 1881 and 1891 it had increased by 469,000, and now in 1891 it stood at 1,405,000, having more than doubled since 1871. A passage in the report of the Medical Officer of Health for Islington in 1895 illustrates this so far as his own district was concerned:-- "The fact cannot be burked that many of the better classes have gone further into the country to live, induced to do so by the increased facilities for travelling that railways have provided.... The same facilities have also checked the influx of people to the same extent as formerly, so that now in northern London people are flocking to Hornsea and Hampstead and thereaway." The fact was that the metropolis had burst its boundaries, and just as it had grown up around the "City" so now the "outer ring," as it was called, was growing up around it. How little reliance could be placed on the intercensal estimates of Medical Officers of Health as to the number of inhabitants and the death-rate, is illustrated by the following passage from the report of the Medical Officer of Health for Islington in 1891:-- "There was an error amounting to nearly 50,000 in the estimated population of the parish in 1891; consequently all statistics based on the estimated figures during the decade 1881-91 are more or less erroneous." Also "the mortality returns were not kept in such a manner as to lead to accuracy, for while all deaths of non-residents were excluded, the deaths of residents dying outside the district in similar institutions were not included. "It is impossible to make an accurate statement as to the correct meaning of the mortality returns--the returns are erroneous." A similar miscalculation was made by the Vestry of St. George, Hanover Square. In their report for 1890-1 they stated that they had no reason to believe that the population was much different from what it was in 1871 and 1881. The census, however, showed that it had fallen over 11,000. In each successive census the number of inhabited houses in London was enumerated. In this one the number was 547,120--being an increase of nearly 60,000; but not much instruction was to be obtained from such general figures beyond the fact that houses were becoming more and more densely packed. The substitution of blocks of dwellings for small houses had also made considerable progress during the intercensal period.[174] The same reasons as to the diminution of the number of houses in the central parts of London continued to be given by Medical Officers of Health. In St. George-in-the-East it had been brought about "by the extension of warehouses and the demolition of insanitary property." In St. Martin-in-the-Fields it was "due to many former residents having removed to the country, and to the demolition of so many houses for improvements." In the Strand to the fact that the district was becoming like all the central parts of London, "a business, as distinguished from a residential district." The Vestry of St. James' reported that "buildings formerly occupied as dwellings were being replaced by warehouses and business premises commanding a higher rent. As the centre of trade extends, this condition of things must be expected to continue, just as the increasing volume of trade has converted the City of London at night from a populous place to little more than a city of caretakers," and they drew attention to the "enormous number of people engaged in business in the parish during the day time who resided elsewhere." On the south side of the river the same story was told. The Medical Officer of Health for Lambeth remarking in his report that-- "The displacement of population from the central districts of Lambeth, and the settlement of population in those districts which are situated in the outer ring, or on the circumference of the inner, is a part of a greater movement which affects the whole metropolitan area." The census of 1891 is specially memorable by the fact that for the first time a mass of most valuable information was obtained which was wholly new, and which threw a blaze of light upon the condition of the housing of the population of London. For the first time full details were obtained and published as to the numbers of the people living in tenements of less than five rooms and the numbers and character of the tenements they lived in. A tenement was defined as "any house or part of a house separately occupied either by the owner or by a tenant." These tenements were classified into those of one room, two rooms, three rooms, and four rooms; and the number of persons inhabiting each of these classes of tenements was given. The nearest approach to information of this sort had been given by Mr. Marchant Williams in 1884, but it was only for a particular area in London. The information now given related to the whole of London. The total number of tenements in London in 1891 was stated to be 937,606. Of these, 630,569 were tenements of less than five rooms. And of these-- 172,502 were tenements of one room. 189,707 " " two rooms. 153,189 " " three " 115,171 " " four " An examination of the detailed figures revealed some astounding facts. In the central group of parishes and districts, in the parish of St. Luke 21,937 persons, or over one-half of the population, lived in tenements of one or two rooms; in Clerkenwell, over 33,000 persons; and in Holborn, over 16,000--practically one-half. In the eastern group, in Whitechapel, close on 33,000 people, or over 44 per cent., lived in tenements of one or two rooms. In Shoreditch, over 50,000, or 40 per cent.; in Bethnal Green, 45,000 persons, or 38·4 per cent.; in St. George-in-the-East, 43 per cent. of the population. In the northern group, in St. Pancras 95,000, or over 40 per cent., lived in tenements of one or two rooms; and in one district of the Parish, namely Somerstown, 57 per cent. of the population were living in such tenements. In St. Marylebone over 58,000 lived in such tenements. In the western group over 173,000 persons lived in tenements of one or two rooms. And on the south side of the Thames, in Bermondsey close upon 24,000 lived in tenements of one or two rooms; in Camberwell, 30,000; in Lambeth, 61,000; in Newington, 31,000; in St. Saviour over 41 per cent., and in St. George-the-Martyr 26,000, or over 43 per cent. And examining the numbers of persons living in one-room tenements, it appeared that in Chelsea one-tenth of the population lived in such tenements; in St. Marylebone somewhat less than a sixth; in Holborn a fifth; and in St. George-in-the-East between a fourth and a fifth. These figures show how large a proportion of the population began, spent, and ended their existence within the four walls of a single-room tenement. The total result shown was that in the metropolis 1,063,000 persons, or one quarter of the population, lived in one- or two-room tenements, and 1,250,000 in three- or four-room tenements; making a total of over 2,310,000, or well over half of the population living in tenements of less than five rooms. Of still deeper interest and import was the information obtained as to that dreadful factor in London life--"overcrowding." An effort was now for the first time made to get reliable information upon this matter. Hitherto it was only by piecing together the statements made by some of the Medical Officers of Health as to overcrowding in their respective parishes that one could form even the crudest idea of what the sum total in London actually amounted to. Here, at last, was material enabling accurate calculations to be made, not only of overcrowding in each separate parish or district, but in London as a whole. The Census Commissioners laid down the principle-- "That ordinary tenements which have more than two occupants per room, bedrooms and sitting-rooms included, may be considered as unduly overcrowded. "We may," they wrote, "be tolerably certain that the rooms in tenements with less than five rooms will not in any but exceptional cases be of large size, and that ordinary tenements which have more than two occupants per room, bedrooms and sitting-rooms included, may safely be considered as unduly overcrowded." By using the information given in the tables, and excluding all one-roomed tenements with not more than two occupants, all two-roomed tenements with not more than four occupants, all three-roomed tenements with not more than six, and all four-roomed tenements with not more than eight occupants, the desired information would be obtained. And they added:-- "Each Sanitary Authority is now provided with the means of examining with much precision into the house accommodation of its district." Provided with the tables as to the occupants of tenements, the Medical Officer of Health for the London County Council, in his report for 1891, worked out the figures for the metropolis. The result showed that there were in London 145,513 tenements of less than five rooms apiece, in each of which there were more than two inhabitants per room, and each of which consequently was "overcrowded." But it is when one ascertains the number of persons living in these overcrowded tenements that one realises what the extent of overcrowding was. In round numbers, one-fifth of the entire population of London lived in these tenements. The total population was 4,200,000; the number of "overcrowded" persons was 830,000. A few illustrations of the overcrowding in certain parishes brings the meaning of these figures home still more. In Clerkenwell, 25,600 persons lived in overcrowded tenements; in St. Luke, 18,700 persons; in Shoreditch, 41,700; in Islington, 64,600; in Kensington, 28,700; in Lambeth, 43,600. The larger proportion of these lived in one- or two-room tenements. Figures are dry things to read and difficult to understand. To appreciate the true meaning and import of these, and to enable one who reads them to at all realise the conditions of existence of these hundreds of thousands of people, one must recall to mind the descriptions given by many of the Medical Officers of Health of tenement-houses; of all the misery, the filth, the sickness, the physical and moral degradation of life in tenement-rooms. These facts now for the first time revealed the full magnitude and momentous nature of the problem of the sanitary housing of the people. The year 1891 is memorable in the history of the sanitary evolution of London for "the Public Health (London) Act, 1891,"[175] which consolidated and amended the laws then existing in connection with the public health of the metropolis. The state of the law was recognised as very unsatisfactory, being scattered over some thirty statutes or more--a condition of things which was greatly to the disadvantage of the public health of London. Moreover, in accordance with the extraordinary custom, London, which on account of its huge population needed sanitary legislation almost more than any other place, had been excepted from much sanitary legislation which had been in operation for many years, with the most beneficial results, in the remainder of the country. Part of this legislation was at long last extended to London. Many amendments were made, recommendations of the Royal Commission of 1884 were given effect to, new provisions introduced, and the general result was a Sanitary Code for London--imperfect still in some important respects, but a great advance on anything which London had previously possessed. The Act came into operation on the 1st of January, 1892, and it applied to the Administrative County of London only; some few of the provisions extending to the "City." And for the first time the new Central Authority--the County Council--with extended powers, occupied a prominent place in this legislation. Once more did Parliament enact the oft-ignored direction that "it shall be the duty of every sanitary authority to cause to be made from time to time inspection of their district" for detection of nuisances--a duty so shamelessly neglected--and "to put in force the powers vested in them relating to public health and local government so as to secure the proper sanitary condition of all premises in their district." With a view to secure fit and proper persons as Medical Officers of Health and Sanitary Inspectors, their appointment was made subject to the regulations of the Local Government Board. The Act greatly strengthened the law both as to the prevention and definition of nuisances. It provided for the immediate abatement of a nuisance, not only where actually proved to be injurious or prejudicial to health, but also where it was dangerous to health. It gave to any person the right to give information of nuisances to the sanitary authority instead of that right being limited to the person affected by the nuisance; and it extended to a Sanitary Authority the power to take proceedings for the abatement of nuisances arising in the district of another authority should the nuisance injuriously affect the inhabitants of their own district. It transferred from the police to the local authority the enforcement of the provisions of the law against smoke nuisances. It dealt with the removal of refuse. It extended the previous laws as to the adulteration of food and drugs, and the inspection of articles intended for the food of man. It enacted that a newly-erected dwelling-house must not be occupied until a certificate had been obtained of the Sanitary Authority to the effect that a proper and sufficient supply of water exists; and made the provisions as to the occupation of underground rooms as dwellings more stringent and effective. The notification and prevention of the infectious and epidemic diseases, the provision of hospitals, ambulances, and many other branches of the great subject--the health of the public--were legislated upon. Additional duties were imposed on the Sanitary Authority in the matter of disinfection; the practical result of which was that the whole cost of disinfecting houses, and cleansing and disinfecting bedding, clothing, &c., was thrown upon the rates. In several matters the option given in previous legislation to local authorities to administer the law was taken away, and the duty made imperative. Parliament evidently had realised the hostility of many of the Vestries to administering some of the principal provisions of sanitary law, and the word "shall" figured much more frequently than ever before. The hitherto optional provision of mortuaries by the sanitary authorities was made compulsory, the need for suitable and convenient places for the reception of the dead during the time that bodies are awaiting burial having long been felt, particularly in the poorer districts, where bodies awaiting burial were of necessity frequently kept in living rooms under conditions dangerous to health, especially where the case was an infectious one. Among these "shalls" was that most important of all health subjects--overcrowding--and the condition of the tenement-houses of London. In this matter the local authorities had through a quarter of a century been tried in the balance and found wanting, and it was enacted (Sec. 94):-- "Every Sanitary Authority _shall_ make and enforce such bye-laws as are requisite for the following matters (that is to say): (_a_) for fixing the number of persons who may inhabit a house, or part of a house, which is let in lodgings; (_b_) for the registration of houses so let or occupied; (_c_) for the inspection of such houses; ... (_d_) for enforcing drainage for such houses, and for promoting cleanliness and ventilation in such houses; (_e_) for the cleansing and lime-washing at stated times of the premises; (_f_) for the taking of precautions in case of any infectious disease." In another matter, which the Vestries had long opposed, their hostility was overborne. They were now required to appoint "an adequate number of fit and proper persons as sanitary inspectors," and, in case of their failure to do so, the Local Government Board was enabled, on the complaint of the Council, to order the appointment of a proper number. The new Central Authority, directly representative of the whole of London, was not constituted the chief sanitary authority for London, nor even a sanitary authority. It was given power to make bye-laws for the prevention of nuisances of various sorts in London, except as regarded the "City," to license cow-houses, and slaughter-houses, to appoint Inspectors to inspect them, and also dairies and milkshops, and it could extend the number of infectious diseases to be notified. But most important of all was the power given to the County Council (by Section 100), which enacted, on it being proved to the satisfaction of the Council, that any Sanitary Authority (except the Commissioners of Sewers of the City) had made default in doing their duty under this Act with respect to the removal of any nuisance, the institution of any proceedings, or the enforcement of any bye-laws, the Council might institute any proceedings and do any act which the Authority might have instituted and done, such Authority being made liable to pay the Council's expenses in so doing. And, furthermore, Section 101 provided that "when complaint is made by the Council to the Local Government Board that a Sanitary Authority have made default in executing and enforcing any provision which it is their duty to execute or enforce under the Act, or of any bye-law made in pursuance thereof, the Local Government Board, if satisfied after due inquiry that the Sanitary Authority have been guilty of the alleged default, and that the complaint cannot be remedied under the other provisions of this Act, shall make an order limiting the time for the performance of the duty of such authority in the matter of such complaint. If such duty is not performed by the time limited in the order, the order may be enforced by writ of mandamus, or the Local Government Board may appoint the Council to perform such duty," and the expenses were to be paid by the Sanitary Authority in default. "It seems to me right and proper," said Mr. Ritchie in introducing the Bill, "that in regard to the great question of public health in London the County Council ought to be charged with the performance of duty, which in the opinion of the Local Government Board after inquiry, has not been adequately and properly performed by the local authority." These sections were strongly opposed by some of the prominent Vestries, being held to be "degrading and destructive of local self-government by completely subordinating the local to the central authority." The self-government which many people like is the being able to do exactly as they themselves like, regardless of everybody else's likes and rights. And it is the same with many local government authorities. Their idea of self-government too often is to govern for their own objects, and their own interests, regardless of the infinitely greater interests and rights of the great community around them; and when it is brought home to them that they are only a small integral part of a great community, that their sphere of self-government can only be a very limited one, and that they cannot be allowed either by action or neglect to injure the community, they resent it with no little outcry. The principle of self-government, however, was not one to which appeal could be made, for it had been dragged through the mire by too many of the local authorities. Once the unity of London assumed definite shapes, as it did in the new Central Authority representing the whole of London, Vestry self-government, except upon certain lines and within certain limitations, was doomed; for it would have to make way for a far larger system of self-government--the self-government of London by Londoners. Moreover, prolonged experience had proved that the Vestries could not be relied on to enforce the laws, and it was manifest that some effective provision must be devised for preventing them perpetually thwarting the intentions and defeating the imperative enactments of Parliament designed for the welfare of the community at large. It was unfortunate, however, for the sanitary welfare of great masses of the people of London that the principle thus recognised and adopted by Parliament was not given fuller effect to than it was, for it is the only principle upon which any really sound system of public health administration for London can be based. A few years later the principle was reaffirmed by Parliament. During the summer of 1892 the appearance of cholera on the west coast of Europe--particularly Hamburg--exposed London to the importation of cases of this disease. The unsatisfactory position of the Council with regard to London administration for the prevention of epidemic disease was at once made evident. In order to remove doubts as to the Council's responsibilities as to the administration of the law relating to epidemic diseases, a provision defining the Council's position was included in the Council's General Powers Bill, which was passed by Parliament in 1893. This provision was to the following effect:-- "The Local Government Board may assign to the Council any powers and duties under the epidemic regulations made in pursuance of Section 134 of the Public Health Act, 1875, which they may deem it desirable should be exercised and performed by the Council. "If the Local Government Board are of opinion that any sanitary authority in whose default the Council has power to proceed and act under the Public Health (London) Act, 1891, is making or is likely to make default in the execution of the said regulations, they may by order assign to the Council, for such time as may be specified in the order, such powers and duties of the sanitary authority under the regulations as they may think fit." Parliament thus once more emphasised the policy of the local sanitary authorities being subordinated to the Central Authority. The new Central Authority--representative of the people of London--gave early evidence of vitality and energy. The heir had come into his property, with high ideals as to its government, and as to the welfare of the people. A new power had suddenly been brought into London life--an unknown but vigorous force. A capable staff was at once organised, and a Medical Officer and Assistant Medical Officer of Health appointed. Inquiries and investigations into the various matters most concerning the welfare of the citizens of London were at once undertaken, and conclusions arrived at, and action taken, with a thoroughness and a rapidity hitherto unknown in the administration of London affairs. Bye-laws were made to regulate and unify the administration of sanitary laws by local authorities. Several of the water companies were induced to give a constant supply of water to an increased extent. And great efforts were made to utilise the powers conferred upon the Council by the recently passed Acts--the Housing of the Working Classes Act of 1890, and the Public Health (London) Act of 1891. It was at once felt that the problem which first faced the Council was the housing of the people, and the Council determined to attack it on every side. In the belief that facilities of communication between the working centres of London and residences in healthier localities would help considerably to alleviate some of the worst effects of overcrowding, and towards the successful treatment of the great housing problem, action was taken to turn the Cheap Trains Act of 1883 to greater account, and to secure greater numbers of workmen's trains and more moderate fares; so as to enable workmen to travel cheaply between more distant homes and their places of employment. That Act, which gave a large remission in the amount of passenger duty paid by railway companies, if the companies would provide a service of workmen's trains, and would convey workmen at less than the usual fares, had so far not been made much use of. On investigation it was found that the facilities afforded to workmen, particularly on certain railways, were very inadequate. There were no workmen's trains at all on one important line--on another only one such train was run, whilst on several others the number of trains run was very small. Representations were made to the Board of Trade and negotiations carried on with the Railway Companies, and by degrees a considerable extension of the facilities for the conveyance of workmen was secured. The Council gave its immediate and more anxious attention to those breeding-places and forcing-pits of disease and misery, the insanitary areas in London. The Housing Act of 1890 (by Part I.) constituted the Council the authority for preparing and carrying into effect schemes for the clearance and improvement of insanitary areas which were of such size, and situation, and character, as to render their clearance and reconstruction of general importance to the County. The tremendous task of dealing with them was rendered more difficult and costly by the obligation imposed by Parliament of providing housing accommodation for the persons displaced; for in the lack of easy means of communication with the outer parts of London it was held to be necessary to re-house the greater number of them in the same locality. The Metropolitan Board of Works had simply acquired and cleared the properties, and disposed of the sites to companies or individuals, placing on them the obligation to erect houses for the working classes. Now, however, the Council determined itself to erect, let, and maintain, the necessary dwellings. The chief reason for the change was the difficulty experienced in finding companies or persons who were willing to undertake the erection of dwellings on some of the sites. The Council had to complete several schemes which it inherited in an unfinished condition from the Metropolitan Board of Works, but it at once initiated many itself, and carried them through to a successful conclusion. And as one after another of the insanitary areas was investigated, so again and again was revealed to public view the appalling condition in which thousands of people--in the very heart of London--dragged out an existence more bestial than human; horrors piled on horrors--a state of things all the more awful because it had been existing for an indefinite number of years--levying annually the heaviest of tolls on those who came within its deadly sphere, and scattering its poison abroad among the community at large. There was the Clare Market (Strand) Scheme, some 3-1/2 acres--3-1/2 acres of human wretchedness and disease and misery and filth. In one sub-area there were upwards of 800 persons to the acre. Here the death-rate was 41·32 per 1,000 in 1894; in another sub-area, the death-rate had been 50·52 per 1,000 in 1893; the death-rate for the whole area having been 39·03 in 1894. And in addition to this was the unknown sick-rate. There was the Webber Row Scheme in St. George-the-Martyr, Southwark--close upon 5 acres in extent, with a death-rate of 30·5 per 1,000. There were the Roby Street and Baltic Street areas in St. Luke, areas which "have about the worst reputation of any in London." The largest scheme which the Council undertook was that known as "the Boundary Street Area" in Bethnal Green. Here some fifteen acres of old, dilapidated, crowded dwellings--dwellings so insanitary that the death-rate in them was over 40 per 1,000--were swept away, entailing the displacement of 5,719 persons; and the ground so cleared was laid out with wider streets, and a large open space and excellent buildings were erected thereon to contain 5,524 persons without crowding. The Prince of Wales once more testified his deep interest in the welfare of the poorer classes of London by opening the new buildings--a ceremony which took place on the 3rd of March, 1900--and delivering an impressive speech. A summary of the work accomplished by the Council up to this time showed that the Council had provided, or was engaged in providing, accommodation for 35,950 persons at a total outlay of close upon £2,000,000, an amount of building operations which, if conducted at one spot, would have resulted in the formation of a town of nearly 36,000 inhabitants.[176] The cost of this work was enormously heavy, owing to the fact that the arbitrator could and did award commercial value for the land; but, as was pointed out by the Medical Officer of Health for the London County Council[177]:-- "The primary object of Part I. of the Act is not to provide artizans' dwellings, but to secure the removal from the midst of the community of houses which are unfit for habitation, and the faults of which are in large degree due to bad arrangement. Where houses are thus situated, and are in a number of ownerships, rearrangement can only be carried out by vesting the property in one ownership, that of a public authority, who can then, by the making of new streets and by complete rearrangement of the area, ensure that the conditions which in future will exist are such as are needed for the health of the inhabitants. The chief value of the Act is, therefore, not so much the provision of house accommodation which is fit for habitation, as the abolition of houses which are dangerous to health. Part I. is not, therefore, in itself so much a Housing Act as an Act for the removal of nuisances on a large scale." But another reflection also suggests itself, namely, why should the ratepayers of London have been obliged to pay these high sums for property which, by the culpable neglect of the owners and their predecessors, had been allowed to sink into a condition not alone exceptionally dangerous to the lives of its inhabitants, but a constant danger to neighbouring districts--even to London itself. Surely in common fairness, those who had let it fall into such a state should have paid the penalty therefor, and not the public of London, who had had no part in bringing the property into such an evil condition. Part II. of the Act was mostly a consolidation of Torrens' Acts, 1868 and 1882, with amendments. It enabled the Vestries or District Boards to take proceedings before a magistrate for the clearing and demolition of single houses unfit for human habitation, and obstructive buildings, and empowered them and the County Council to undertake schemes for the improvement of areas too small to be dealt with by the Council. The owner might elect to retain the site after the demolition of the building, and in that case received compensation for the building only. If the Vestry or District Board acquired the site the same procedure as to compensation had to be followed as under Part I. A few schemes were undertaken by Vestries under this Part of the Act, the Council making a contribution to the cost, and a few by the Council. Thus in St. George-in-the-East, from November, 1890, to the end of 1894, 224 houses were "represented" as unfit for habitation--gruesome pictures of dirt, dilapidation, and insanitation of every form and variety, and this, too, after nearly forty years of sanitary work by the Vestry. Many were closed by order of the magistrate, some by the owner, some pulled down, some repaired and re-let. Part III. of the Act embodied the idea, originally started by Lord Shaftesbury in 1851, as to the erection of labouring classes' lodging-houses by the local authorities, and grafted several amendments thereon. Power was given for the acquisition by the Council of land for the purpose of erecting lodging-houses thereon. Such land, however, was to be within the Council's jurisdiction. Under this part of the Act the Council erected a common lodging-house in Parker Street for the accommodation of over 300 persons. It also acquired several sites, including the Millbank estate, upon which it proceeded to build houses; and one of 38 acres at Lower Tooting for the erection of cottages thereon. Altogether the work performed under the Act was considerable, and the housing for the accommodation of the working classes made sensible progress, the sites sold by the Metropolitan Board of Works to trusts, and public companies, and private persons, having been built upon and covered with artizans' dwellings. Private building was proceeding at considerable pace, and in many parts of London the ground was becoming more overcrowded than ever with houses. The older parts of London were being rapidly re-built, and open spaces at the rear of buildings were being gradually covered by buildings. Of St. Pancras the Medical Officer of Health wrote (1896):-- "... There is a prospect that in course of time the whole of the open space about buildings may disappear.... Old houses possessing yards, areas, open spaces, in some form at the front or back or both, are being re-built in such a manner as to entirely cover the whole ground area two or three storeys up--leaving not a particle of open space." The restrictions imposed by the Building Acts were of the most illusory character, and as the Acts were mostly future in their operation, and not retrospective, their effect was also limited. Any "owner" was entitled to re-build on "old foundations," no matter how crowded the houses were on the spot, so new buildings were usually only a resurrection in huger and more perpetual and objectionable form of the evils which ought, as far as possible, to have been eradicated. During the year 1894 the London Building Law was consolidated and amended. The Act recognised, for the first time in London, the principle that, in addition to the height of the building being proportionate to the width of the street on which it abuts, the amount of open space about the rear of a building should also be proportionate to its height, and hence the future crowding of buildings on area was put under limitation. But how small was the limitation, how small the concessions exacted from "owners" in this matter, and how miserably late they came in the history of London building operations. The tendency of house construction in London was to ever larger size, to greater height. To how great an extent this had been carried on in the "City" was described by the Medical Officer of Health in 1894:-- "It would be a fair and moderate estimate to put the superficial area (of the City) at _four square miles_ instead of one. We have only to point to the construction of business premises--the piling of one floor over another for many storeys high, each floor being occupied by separate occupiers, forming in itself a distinct tenancy, having all the rights and privileges of an independent building, and claiming as much attention from every branch of our municipal system as if it stood alone.... We have, in fact, to deal with about 28,000 separate tenancies, with a day population of 301,384." In some of the more well-to-do parts of the metropolis great blocks of buildings were built and let out in flats, most of them with the minimum of light and air prescribed by narrow laws. In other districts of London considerable numbers of small houses were removed, and large blocks of artizans' dwellings erected in their stead. Thus, in the parish of St. Luke, nearly one-fifth of the entire population resided in the ten blocks of artizans' dwellings which existed there. In the earlier stages of the reform of the housing of London such buildings had been acclaimed as great improvements, as indeed they were. The later opinions of Medical Officers of Health were not so laudatory. Thus, in 1891, the Medical Officer of Health for Whitechapel, after stating that there were in his district 27 buildings having 3,127 apartments containing 12,279 persons, added that he was "not enlisted amongst the enthusiasts of this method of providing for the housing of the working classes." In 1896 he wrote: "All model dwellings are not equally models of good sanitary houses." And in 1897:-- "The increased population are housed in huge barrack buildings which sometimes are constructed so as to allow light and air to permeate the rooms and sometimes not. The effect of this modern invention is to increase the density of population to a damaging degree.... "That the direct influence of these barrack buildings upon the health of their occupants--more especially the children--is adverse, I have not the slightest doubt." The Vestry of Shoreditch reported in 1892-3:-- "'Model Artizans' Dwellings' do not appear to have been quite what their title implied. At Norfolk Buildings, Shoreditch, on the Medical Officer of Health causing them to be examined for a certificate for exemption from the inhabited house duty, the whole system of drainage was found to be in a most defective and dangerous state. A number of cases of typhoid, diphtheria, and other infectious illness had occurred on the premises." And a couple of years later the Chief Sanitary Inspector submitted to his Vestry a report on some so-called "model dwellings": "These blocks of buildings, 50 feet high, are packed together so as to exclude light and air, and four rooms occupy the site of two: evil conditions which the architect and owner were not only privileged to create, but also, and very practically, in so doing were they privileged to condemn unborn generations of people, whose necessities condemn them to live in these tenements, to endure the evils of their creation." The Medical Officer of Health for St. James' wrote:-- "Block dwellings in such an area as St. James' do not provide the conditions in which healthy children can be reared, nor in which there can be a family life comparable with that possible in the open suburbs of London." The Medical Officer of Health for St. Olave gave a description of Barnham Buildings:-- "Many of the rooms, &c., on the ground and first floor are generally very dark, and the buildings have not been maintained in a sanitary condition, notwithstanding the hundreds of notices that have been served the past five years. The average death-rate of the past five years of the unhealthy tenements was at least 49·6 per 1,000 and of the remainder at least 29·1." The Medical Officer of Health for St. Marylebone gave an interesting explanation of the condition of this class of houses:-- "The following is a list of applications, under the Customs and Inland Revenue Act, 1891, from which it will be gathered that it is quite exceptional for a block of artizans' dwellings of even recent construction to be in a tolerable sanitary condition. The reason for this anomalous state of things is, that in the building of these dwellings the Sanitary Authority seems to have no power; a dwelling must be occupied before it comes under supervision." In spite of these and many other drawbacks, however, many of these buildings afforded accommodation far superior to that which had previously existed on the spots where they were erected, and provided residence for large numbers of people who otherwise might have been doomed to living in the worst class of tenement-house. Closely connected with the Public Health Act of 1891 was another Act passed in the same year--"The Factory and Workshop Act." The Select Committee of the House of Lords on the Sweating System had finished their inquiry and reported in 1890. The evidence given before it was, as regarded factories, workshops, and workplaces, very much a repetition of that which for thirty-five years had been detailed by Medical Officers of Health as regarded the dwellings of the people, but now obtaining greater publicity attracted more attention. Overcrowding and insanitation of almost every conceivable kind pursued large numbers of the unfortunate workers from their overcrowded and insanitary tenements to their overcrowded and insanitary workplaces, and with the same disastrous results. And as regarded domestic workshops the conditions were even worse, workers spending their days and nights often in the one room--sometimes with extra workers brought in. Want of light and air and overcrowding in workshops and factories are quite as serious matters as they are in inhabited houses. The Select Committee, in their conclusions and recommendations, said:-- "The sanitary conditions under which the work is conducted are not only injurious to the health of the persons employed, but are dangerous to the public, especially in the case of the trades concerned in making clothes, as infectious diseases are spread by the sale of garments made in rooms inhabited by persons suffering from smallpox and other diseases. Three or four gas jets may be flaring in the room, a coke fire burning in the wretched fireplace, sinks untrapped, closets without water, and altogether the sanitary condition abominable." "A witness told us that in a double room, perhaps nine by fifteen feet, a man, his wife, and six children slept, and in the same room ten men were usually employed, so that at night eighteen persons would be in that one room." "In nine cases out of ten the windows are broken and filled up with canvas; ventilation is impossible and light insufficient--the workshops are miserable dens. We are of opinion that all workplaces included in the above description should be required to be kept in a cleanly state, to be lime-washed or washed throughout at stated intervals, to be kept free from noxious effluvia, and not to be overcrowded--in other words, to be treated for sanitary purposes as factories are treated under the factory law." Lord Kenry, Chairman of the Committee, in his draft report, said:-- "It has been shown that the dwellings or shops in which the sweated class live and work are too often places in which all the conditions of health, comfort, and decency are violated or ignored.... Sanitary inspection is totally inadequate, and the local bodies have seldom done their duty effectually. At the East End of London generally the sanitary state of homes and shops could not possibly be much worse than it is." And Mr. Lakeman (Government Inspector under the Factories and Workshops Act) said, in reference to workshops: "I think that the evidence given your Lordships upon the insanitary state of those places is not at all too black." Once more the necessity of inspection was insisted upon. "On no point," wrote the Chairman, "was the unanimity of witnesses more emphatic than with reference to the necessity of more efficient sanitary inspection, not only of workshops, but of the dwellings of the poor." And just as it was as regarded tenement-houses, inspection here was lamentably deficient, if not absolutely non-existent. "The inspection at present carried on is totally inadequate, and nothing was more clearly proved before us than the fact that satisfactory results cannot be looked for from the system as it now stands."[178] "Even when an unmistakable cause of unhealthiness is discovered, and steps are taken to remove it, the process of applying the remedy is slow and uncertain. The Local Board meets once a week or fortnight ... the landlord is allowed a fortnight to carry out the work; three weeks may elapse before the inspector can go and see it, then perhaps nothing has been done; the summons, &c., takes time. In any case much valuable time is lost, and smallpox or fever is allowed to pursue its ravages with the source of the disease daily aggravated in intensity. "At present the inspectors under the Factory and Workshop Act of 1878 have no power to deal with any nuisance which lies within the district over which the local authorities preside. On the other hand, the local inspector cannot interfere should he discover any breach of the Factory Act." The Home Secretary, in moving the second reading of the Bill, explained its scope. He said:-- "The design and object of this Bill is to bring all workshops and all factories up to the same sanitary level, and to require the same conditions as to ventilation, overcrowding, lime-washing, and cleanliness to be applied to all kinds of workshops in which men alone, or women, children, and young persons are employed. The Bill does not deal with 'domestic workshops.' The President of the Local Government Board will introduce a Bill dealing with the public health, and the House may rest content with leaving what is called 'the domestic workshop'--that is to say, the working-man's home in which he works with the members of his family--subject to the provisions of the law of public health alone. It is obvious that in the domestic workshop you have not got the presence of the employer and the employé. You have the members of the same family ... and it seems to me that we may allow him and his family to work in a place which is sufficiently good so far as sanitary conditions are concerned for him and his family to live in. Now that we are extending the sanitary provisions of the Factory Act to all workshops throughout the country, of whatever kind they may be except the domestic workshop, so that every cobbler's shop, every blacksmith's shop, every tailor's shop, will come under the provisions of the sanitary law, it seems to me foolish not to take advantage of the existing machinery provided by the local authorities, and the enforcement of the sanitary provisions, so far as workshops are concerned, is by this Bill given to the local authorities." The passing of the Factory and Workshops Act (1891) and of the Public Health (London) Act of 1891 made the sanitary authorities primarily responsible for enforcing many new provisions. Those authorities were charged with the duty of securing the maintenance of the "workshops" in a sanitary condition, of preventing overcrowding in them, and of enforcing cleanliness, ventilation, lime-washing, and freedom from effluvia, and securing the provision of sufficient sanitary accommodation. Added to this was the sanitary supervision of the places of "outworkers."[179] It would appear, however, that only in exceptional instances was any systematic attempt made in 1892 to carry out the new duties imposed by the Legislature upon the Vestries and District Boards. In several instances the Medical Officers of Health drew attention to the impossibility of undertaking workshop inspection with their existing staff. Thus the Medical Officer of Health of Hackney:-- "Inquiry has revealed the presence of something like 2,000 workshops and dwellings of outworkers which, under this Act and Order, should be inspected to ascertain the presence or otherwise of any insanitary condition. With the present staff it is impossible that this can be attempted." In St. Marylebone the Medical Officer of Health stated, in 1894, that the number of workshops and workplaces in his parish amounted to 3,550. And in 1895 he wrote: "The workplaces are so numerous in the parish that it is not practicable for them all to be inspected regularly with the present staff." "Increased duties," wrote the Medical Officer of Health for Fulham in 1893, "having been placed on the sanitary staff by the 'Factory and Workshop Act' of 1891, relating to outworkers; but with the existing number of inspectors it is not possible to attend to them thoroughly, so that the Act in Fulham is almost 'a dead letter.'" "In Islington," reported the Medical Officer of Health in 1895, "neither the factories nor workshops in the district, nor the smoke nuisances receive any attention worth mentioning, and so far as this district is concerned they may be said to have been entirely neglected. "I look upon the inspection of factories and workshops as one of the greatest necessities of the present day, not only from a health point of view, but also from the social aspect." The manifest solution of this difficulty was the appointment of additional inspectors, but the local authorities had a sort of horror of such appointments, though by this time they must have known that the benefit to workers and to the community generally would have been very great. A report in 1892 of the Medical Officer of Health of St. George-the-Martyr shows the grievous need there was for inspection of one very important class of workshop:-- "I have inspected sixty-three retail bakehouses within the parish, and found them (with few exceptions) to be in a filthy and unwholesome state, dangerous alike to the health of the journeyman baker, who makes the bread, and to the public who eat it. Twenty-one were completely underground.... In times of heavy rainfall sewage forces itself through the draintraps of these cellars, soiling the sacks containing flour, and fouling the atmosphere." Parliament again legislated about factories and workshops in 1895. Under the Act a minimum space was required in each room of a factory or workshop of 250 cubic feet for each person employed. For the prevention of the infection of clothing, the occupier of a factory, &c., was prohibited from causing wearing apparel to be made or cleaned in a dwelling-house having an inmate suffering from scarlet fever or smallpox. An important step was also taken in extending the provisions of the Factory Acts to laundries, of which there were a great number in London, and where the workers stood in great need of improved conditions of work, and of public supervision. Lamentable as were the results of the non-protection of the workers in workshops, still more lamentable and disastrous were they as regarded the 2,310,000 dwellers in the 630,569 tenements of less than five rooms. Up to 1889 regulations under the Sanitary Acts of 1866 and 1874 had been adopted in 31 of the 40 London sanitary districts. In only nine of these was any considerable use made of them. Had these regulations been put into force a great amount of overcrowding would have been prevented and the houses kept in a fairly clean and sanitary condition. In the whole of London, with its 547,000 houses, only 7,713 tenement-houses were on the register in 1897, of which more than a half were in four parishes, namely: 1,500 in Kensington, 1,190 in Westminster, 840 in Hampstead, and 610 in St. Giles'; leaving 3,573 in the whole of the rest of London--a mere fraction of the tenement-houses of London. In Bethnal Green (1894), "76·1 per cent. of the population lived in tenements of less than five rooms. No houses had been registered." In Lambeth over one-half of the population lived in tenements of less than five rooms, and of these nearly one-third lived under conditions of overcrowding. There was one Sanitary Inspector to about 60,000 people. The inadequacy of the staff had been pressed upon the Vestry by the Medical Officer of Health from time to time for a number of years. Considerable ingenuity was in many cases exercised by the opponents of the regulation of tenements in the working of the bye-laws which resulted practically in rendering them inoperative. In some cases all houses were to be exempted where the rent was higher than certain specified weekly sums. The result was that the "owners" promptly raised the rent above these sums, and so secured their exemption, at the same time getting an increased rent. In others, the bye-laws gave the Vestry power to decide what houses should be registered, and thus enabled the Vestry to evade the necessity of registering any at all. In others, notices were to be given to the "owner" before a house was registered--the notice was not sent. And so, in one way or another, the imperative "shall" of Parliament was evaded by the largest proportion of the Vestries and District Boards. As regarded the Vestries and District Boards who made a show of putting the regulations in force, the Medical Officers explained that, owing to the inadequacy of the staff of Sanitary Inspectors, it was "impossible" to inspect the houses regularly. In other parishes and districts the number registered and inspected was but a fraction of the houses which ought to have been registered. In Bow (in Poplar) where none were registered, the Medical Officer of Health wrote in 1891: "I should say 4,000 houses require registration." In St. Mary, Newington: "At least 80 per cent. of the houses are occupied by members of more than one family." But as yet none were registered. And this same Medical Officer of Health pointed out how in his parish--"The indisposition that has hitherto been shown on the part of the Vestry to put into force the bye-laws for houses let in lodgings has led to great license in house-farming and house-crowding." Where really put into operation the regulations had an excellent effect. Thus the District Board of St. Giles' said: "The advantage of these regulations has been very great." And in Paddington the Medical Officer of Health stated: "The work done ... has had an excellent effect." Of some streets where houses were registered (1897-8)--"The whitewashing and cleansing has without doubt had a good effect. The streets have been freer from infectious diseases than they have been for several years past." The advantages of the regulations in the administration of the health laws were time after time pointed out and insisted upon by many Medical Officers of Health. The Medical Officer of Health for Westminster, where nearly 1,000 houses were registered, wrote (1899):-- "The great advantage in legal procedure lies in the fact that a breach of them is a finable offence with a further daily penalty after written notice, and is not a nuisance subject to abatement within a certain time. "If the conditions imposed by the bye-laws are carried out, no doubt one of the best methods for preventing overcrowding is thus achieved." The advantage of this quicker procedure was manifest, for, under the other Public Health or Sanitary Acts, the whole process of dealing with, or getting a nuisance abated, took "a long time--a very long time," but the advantages did not appeal to people who did not want to use them. Thus there was a most grievous neglect of duty on the part of the great majority of the Vestries and District Boards, with the inevitable result of the most disastrous consequences to the working and poorer classes all over London. It must have appeared strange, in view of this glaring and scandalous neglect of duty by the Vestries in enforcing the regulations, that the London County Council as the Central Authority did not use the powers which they were supposed to possess of acting in the default of the local authorities, or of making representation to the Local Government Board of the neglect of those authorities. The explanation was, that in the administration of this, absolutely the most important of all branches of the housing problem of London, the London County Council, had been left entirely out--had not even been given a voice in the framing of the bye-laws or regulations, and therefore had no legal power to act. Regulations or bye-laws, drafted by the Local Government Board as "models" for adoption by the local authorities, suggested "exemptions" to what Parliament had directed--though there was not a single word in the 94th Section or in any part of the Act to justify such a suggestion--or suggested phrases in them which actually placed the enforcement or non-enforcement of the Act in the discretion of those authorities, this, too, though Parliament had made the explicit imperative enactment that these local authorities should make and enforce regulations. Most of the Vestries made bye-laws under Section 94 of the Act, nearly all containing exemption or elusive clauses as suggested; some even avowedly reserving to themselves the option of registering or not registering houses, as they thought fit. The London County Council was not in a position to act in their default, as these authorities could shelter themselves under the option contained in the terms of the regulations, and a representation to the Local Government Board would have been useless, as the same defence would be effectively made by the local authorities if called to account. Thus, the deliberate enactment of Parliament was frustrated; the Act was prevented being a remedy for overcrowding, or even a protection against it, and except in a few parishes or districts where the great advantages of the Act were appreciated, all the dreadful evils of overcrowding were given free play, and allowed to flourish on as gigantic a scale as ever. The effects of the inaction of the Vestries and District Boards were unfortunately not confined to the moment. A legacy of suffering, of misery, and physical deterioration was left to subsequent generations. Once more might hundreds of thousands of voices of the victims and sufferers have cried out: "While you remain inactive, death and disease do not."[180] A special census of the population of London was taken on March 29, 1896, which showed that the population had increased to 4,443,018 persons, being an increase of 200,900; and the number of inhabited houses from 547,120 to 553,119. As years had gone by, and the necessity and importance of sanitation had become more widely recognised, and as London had grown in size and increased in population, the duties of the Vestries had grown heavier, and the tendency of legislation was to broaden the basis of their action. The mileage of public streets to be paved, lighted, cleansed, and watered, had multiplied two, three, and four times since 1855; the number of houses in many districts had more than doubled; the drainage work had increased proportionally; the scavenging and removing of refuse also. Nominal duties had become real ones, and new duties had been added--the disinfection of infected houses and infected clothes, the inspection of food, the working of the Food and Drugs Act--these, with numerous smaller matters, meant a very considerable amount of work, expense, and responsibility. But all these were what one of the Vestries in their Report described as "well-worn grooves of familiar routine." In addition thereto, and now more than ever of primary importance, was the great duty of inspection--inspection of houses, and of rooms in houses, and of workshops, and often the consequent proceedings for the abatement of nuisances, or the punishment of offenders. "House-to-house inspection," wrote the Medical Officer of Health for Islington in 1893, "is the only efficient remedy for extensive sanitary evils. It is the life and soul of sanitary work." House-to-house inspection of their districts was the most necessary of all sanitary work--as it was the means by which most sanitary defects and malpractices were detected--but it was the first to be sacrificed under the increased pressure of work, and the last for which adequate provision was made. "A house-to-house inspection has been attempted more than once," wrote the Medical Officer of Health for Islington in 1893, "but it has never yet been brought to a complete and satisfactory finish." In fact the main breakdown of the Vestry administration in London was their antipathy to inspection, and their refusal to appoint a sufficient number of inspectors. "The subject of overcrowding alone," wrote one Medical Officer of Health, "if properly attended to, would pretty well occupy the whole of the time of the present staff." The complaints of the Medical Officers of Health were frequent and insistent on the inadequacy of the inspectorate. Thus the Medical Officer of Health for Fulham wrote:-- "The Vestry must clearly understand that the present staff of Sanitary Inspectors is quite inadequate to properly perform the duties devolving upon the Sanitary Authority. There is only one Sanitary Inspector to every 35,000 inhabitants. Should the Vestry persist in their refusal to employ an adequate staff, the inference will be unavoidable that they are unwilling that the Acts--for the faithful administration of which, in the interests of the public health, they as Sanitary Authority are responsible--should be properly carried out." Interesting light is often to be found in the reports sometimes of the Vestries, and oftener of the Medical Officers of Health, upon various aspects of the great housing problem. Sometimes a sentence enables so much else to be understood. Thus, in 1892, a Medical Officer of Health wrote:-- "Many persons think the Public Health Act an innovation on their privileges." Describing the insanitary condition of 230 houses in Provost Street, Shoreditch, the Sanitary Inspector wrote in 1892:-- "The difficulty of dealing with these houses has been greatly increased by the circumstance that the leases will expire in a very few years. There was, therefore, a very natural objection on the part of many of the leaseholders to execute substantial works, of which the freeholder would in a few years reap the benefit, and without contributing anything to the expense of the improvements." This "very natural objection" entailed, of necessity, sickness and death upon a considerable number of persons. The Vestry of St. Pancras wrote in 1893:-- "The primary cause of houses and buildings becoming insanitary is the neglect of freeholders to compel lessees to comply with the terms and conditions of their leases. If the Vestry were empowered (where freeholders are negligent) to compel freeholders to cause lessees to carry into effect the covenants of the leases, the houses inhabited by the poorer classes would not become so wretchedly dilapidated and a scandal, but might be maintained in a fairly habitable condition." The Medical Officer of Health for Bethnal Green exonerated some property owners, whilst fixing the blame on others. "... As a rule it is the professional insanitary property owner who has to be summoned time after time, and who exhausts every technicality and raises every possible objection, well knowing that in the usual way only an order costing some few shillings will be made against him." Others, however, went further. The Medical Officer of Health for Islington wrote in 1893:-- "Since 1891 there has been a steady forward movement, and ... one now constantly hears of the persecution of the 'poor property owner.' "That owner who for long years had everything his own way, and who did as little as he could to make things healthy for his tenants, knowing well that there were plenty of persons ready to occupy any or every house. Property has rights, but so has flesh and blood; and if it be right that property should be protected from unnecessary exactions, it is surely righteous that the health and lives of human beings should be safeguarded in every way." And in the following year, writing about some insanitary bakehouses, he said: "It has always seemed to me a very absurd argument that because a place has been allowed to be occupied for a long series of years to the detriment of the health of the people working therein that therefore it must not be now abolished. "If those insanitary places have been occupied for such a long time, surely they have more than recouped their owners for the money that has been originally spent on their erection?" The Medical Officer of Health for St. James', after twenty-five years' work as Medical Officer of Health, declared in 1898:-- "The only practical course is to saddle the landlord with full responsibility for the neglect or misconduct of the tenants whom he harbours, at large rents, for his own profit." In 1894 Parliament passed "The Local Government (England and Wales) Act," which included London in its scope, and which introduced great changes as to the electorate, the mode of election, and the qualification of vestrymen. A new electorate on almost the widest basis was created, all persons, male or female, on the Parliamentary or County Council Register, including lodgers and service voters, and married women, who were themselves tenants of property, being made parochial electors; and the Vestry was to be elected under the provisions of the Ballot Act of 1872. Thus the scandals hitherto associated with Vestry elections were for the future obviated, and greater publicity--that safeguard of all public bodies--was assured. Additional powers were also obtainable under the Act by the Vestries on application to the Local Government Board, who could transfer to the Vestry the powers and properties of the Library Commissioners, the Baths Commissioners, and the Burial Board; the power of appointing the Overseers of the Poor, and some other powers and duties of more or less importance, possessed or possessable by Parish Councils. The elections were held on December 15, 1894. The new Vestries, however, did not mend the ways of their predecessors as regarded "inspection." Of Bethnal Green the Chief Sanitary Inspector said (1897): "With the existing staff (five Inspectors) and having regard to other work, it would take five years to visit all the houses in the parish--about 17,000." The Medical Officer of Health for Kensington wrote (1898): "The staff is quite inadequate for the discharge of the duties devolving upon your Vestry as Sanitary Authority." And the Medical Officer of Health for Hammersmith wrote in 1899: "The house-to-house inspection of the district is now nearly completed, and has taken six years to accomplish. The result of the inspection is in the highest degree satisfactory ... nevertheless it cannot be contended that inspecting the district once in six years is properly carrying out the 1st Section of the Public Health (London) Act, 1891." A series of investigations was made by the Medical Officer of Health of the London County Council, or by his assistant, into the sanitary condition of various parishes or districts, and an instructive light thrown upon the administration of their affairs by their respective local governing authorities. Almost uniformly, so far as they were concerned, it was found that bye-laws as to houses let in lodgings were not enforced, and no, or practically no inspection of workshops, of which there were thousands, nor of "outworkers" had been carried out, and that the sanitary staff was quite inadequate for the work. Though much was thus most unsatisfactory, yet in many other important matters which vitally affected the public health, considerable progress was being made. In the matter of water supply a steady but slow improvement had, under public pressure, taken place. In 1892 a Royal Commission was appointed to inquire as to whether the existing sources of supply were adequate, and it reported in the following year. "We are strongly of opinion," they said, "that the water as supplied to the consumer in London is of a very high standard of excellence and of purity, and that it is suitable in quality for all household purposes. We are well aware that a certain prejudice exists against the use of drinking water derived from the Thames and the Lea, because these rivers are liable to pollution, however perfect the subsequent purification by natural or artificial means may be; but having regard to the experience of London during the last thirty years, and to the evidence given us on the subject, we do not believe that any danger exists of the spread of disease by the use of this water, provided that there is adequate storage, and that the water is efficiently filtered before delivery to the consumers." This statement was to a certain extent satisfactory, but the fact remained that both the Thames and Lea still received sewage effluents above the intakes, and considerable pollution from other causes; and that diseases might still be water-borne and water-distributed by them. The thoroughness of the filtration also was often open to doubt. Improvement was gradually being effected in the system of removal or disposal of filth and refuse of all sorts and kinds; the sweepings of the streets, the refuse from houses. According to the general practice of the local authorities the great bulk of this stuff was first brought to yards or places, the property of the authorities, and there sorted or sifted and sent down the river or along the canals in barges, or sometimes even by rail to the country. But the system was costly and insanitary and inefficient, and as was pointed out--"it could not be deemed satisfactory when large metropolitan districts inflict their filth upon smaller communities in urban districts." A system of destroying much of this filth by fire had been devised, and gradually was adopted by the local authorities. It was found that with a properly constructed and efficient destructor no nuisance need result, and this method of disposing of house refuse was much more desirable from a sanitary point of view than that usually adopted by London Sanitary Authorities. A certain number of local authorities adopted this method to the great advantage of the community, and though there is still much to be done in this direction, the change, so far as it has gone, has undoubtedly minimised a great evil. Both numerous and various are the measures which have to be taken for the protection of the public from disease. One of the most essential of these was disinfection--the disinfection of rooms where there had been infectious or contagious disease, and the disinfection or destruction of clothing or articles used by the person suffering from the disease. The process of disinfection originally was of the most primitive character and doubtful efficacy, but the progress of science had elaborated really effective methods. In 1866 the local authorities had been given power to provide a proper place with all necessary apparatus, &c., for the disinfection of infected clothing, &c., free of charge, and to give compensation for articles destroyed. Thus every inducement was given to the public to get infected articles disinfected. But many years were to pass before provision by the Vestries was extensively made. By the Public Health London Act, 1891, this provision was made imperative on the local authorities. Disinfection by steam was considered practically the only efficient system. By 1895 twenty-four sanitary authorities had provided themselves with this apparatus, six with an apparatus whereby disinfection was effected by dry heat, and eight had arranged with a contractor. When it is a fact that a few infected rags could let loose disease of the worst type upon a community, the advantages to the public of the general practice of disinfection were incalculable. And in London the advantages were specially great. In almost every district hundreds of houses were disinfected every year, and thousands--even tens of thousands--of articles. The system of the compulsory notification of infectious diseases facilitated greatly the work of disinfection, for by informing the authorities where cases of such disease occurred it enabled them to scotch disease in its breeding-places, and so it was of the greatest benefit to the community. How great may be gathered from the following figures. The number of cases of Infectious Diseases in London notified under the Act of 1889 were:-- 29,795 in 1890 46,074 " 1892 67,485 " 1893 49,699 " 1896 42,344 " 1899 Of those in 1893:-- 36,901 were cases of Scarlet Fever 3,633 " " Enteric " 22 " " Typhus 13,026 " " Diphtheria 2,813 " " Smallpox Great work was being done in the prevention of the spread of infectious disease in London by the Metropolitan Asylums Board, in whose hospitals thousands of persons suffering from such disease were isolated. Dr. G. Buchanan, Chief Medical Officer to the Local Government Board, wrote in 1892:-- "In regard to some infectious cases, notably those of scarlet fever and diphtheria, there are no means at all to be compared to isolation in hospital for preventing the spread of a limited number of cases into a formidable epidemic. "And the wonderful and repeated checks to small outbreaks of smallpox in the metropolis in the course of the past seven years bears overwhelming evidence to the truth of this dictum." As the population of the metropolis increased in density it became more and more necessary in the interests of the people as a whole to make proper and sufficient provision for the prompt isolation of those of its inhabitants who might be smitten with infectious disorders. Home isolation in London was difficult even under the best circumstances, but in the smaller tenements it was impossible. "The removal to hospital of so many of the cases (of scarlet fever) is a vast blessing to this neighbourhood," wrote the Medical Officer for St. Mary, Newington, in 1897. For some time a growing tendency on the part of the public to accept hospital treatment for infectious cases had been evinced. "The 'depauperisation' of the Hospitals had led to a great increase in the admissions, so that the public are on the whole very willing to take advantage of the facilities offered for having their infectious sick cared for in hospital, whereby the other members of the patient's family can follow their avocations without hindrance and without risk to the public generally." The Chief Sanitary Inspector for Bethnal Green gives information as to the numbers who from his parish availed themselves of the hospitals. "A satisfactory feature, and of the greatest assistance in dealing with infectious disease, is the large number of patients now sent to hospital. This year nearly two-thirds of the cases notified were removed. The importance of this either to the patients themselves or to the public can hardly be overestimated." By the Public Health London Act, 1891, every inhabitant of London suffering from any dangerous infectious disease was entitled to free treatment at one of these hospitals.[181] On receipt of notice an ambulance was at once sent for his removal. Year by year greater use was made of the Board's hospitals, and at times there was not sufficient room in the Metropolitan Asylums hospitals to receive all the cases. In 1892 the total number of patients received amounted to over 13,000, there being at one time 4,389 patients suffering from all classes of fever or diphtheria receiving treatment in the hospitals, whilst in 1893 the admissions amounted to 20,316. By 1895 the Board had eight fever hospitals, including diphtheria, with 3,384 beds; three ships for smallpox cases with 300 beds; and a large hospital for convalescents with 1,200 beds. By 1898 the accommodation had reached the large total of about 6,000. The Chairman of the Metropolitan Asylums Board, reviewing in 1897 the thirty years' work of the Board, said:-- "Whilst, during the first twenty years of the Board's experience, London was again and again visited with epidemics of smallpox, during the past seven years it has, thanks to the action of the managers in having removed to and isolated at Long Reach all cases of the disease, been practically non-existent as a health disturbing factor. "The percentage mortality of smallpox cases treated by the Board decreased from 20·81 in 1871 to 4·0 in 1896, and the annual mortality from 2·42 to practically zero." The rate of death from diphtheria also showed a continuous fall, and this fall had been coincident with the introduction and increasing use of the anti-toxic serum treatment of the disease. A valuable criticism on the existing machinery for the sanitary government of London was given in a report of the Metropolitan Asylums Board Statistical Committee in June, 1892:-- "Although London possesses an ambulance service and a system of hospitals admittedly unrivalled, yet it has no central authority charged with the duties of tracing out an outbreak of this infectious disease (smallpox), and of taking concerted action towards stamping it out by measures of disinfection and vaccination and re-vaccination. "These matters still remain in the hands partly of the 41 local sanitary authorities, partly of the Local Government Board, and partly of the London County Council. "Clearly the present arrangements are not only cumbrous and incapable of that rapid action essential to success in dealing with infectious disease, but they are also excessively expensive." In connection with hospital accommodation there were two other factors in the sanitary evolution of London. One of these was the provision made by the Poor Law for the treatment and care of the sick poor.[182] Previous to 1867 the accommodation provided by the Poor Law for the sick was in the sick wards of the workhouses. The Act of that year, which had established the Metropolitan Asylums Board, laid the basis for the removal to separate hospitals of paupers suffering from the worst forms of infectious disease. The same Act authorised the building and establishment of Poor Law infirmaries, thus removing most of the sick from the workhouse wards, giving them better treatment and better prospect of recovery. In 1892 the number of new infirmaries was 24, containing 12,445 beds; but a large proportion of the sick were still kept in the workhouses, the returns for 1890 showing about 4,000 occupied beds in them. And, in addition to these institutions, there were Poor Law dispensaries. The establishment of these dated from 1870, and by 1890 there were 44 of them. The immense amount of work they did is shown by the following figures: "In 1890 nearly 120,000 orders were given to Medical Officers for attendance on patients, 53,572 being seen at their own homes, and 59,149 at the dispensaries. It is calculated that there are about eight attendances on each order. Favourable opinions were expressed as to the quality of the treatment afforded at them." There is no means of even forming an estimate of the results of these great remedial agencies, but that they were an immense advance on previous arrangements for the treatment of the sick poor is a well-established fact. The Lords Select Committee reported that:-- "The evidence on the whole appears to indicate a general recognition of the high standard of efficiency attained by the best of the new infirmaries. "The poor do not generally regard the infirmary as they do the workhouse; they look upon it rather as a State-supported hospital; they come to the infirmary, are cared for, cured, and go out again without feeling that they are tainted with pauperism." The other great factor in the sanitary evolution of London was the group of great hospitals--general and special--supported, not by the State nor by aid from the local rates, but by the charitable public, and governed and managed and worked not by officials, paid either by the central or local authorities, but by men--lay and medical--who, from the highest and most public-spirited motives, devoted themselves to this responsible work. The general hospitals in 1890 numbered nineteen--some of them great institutions, such as St. Bartholomew's, St. Thomas's, Guy's, the London Hospital; and the number of special hospitals--many of them small--was stated to be 67 in 1890. "The total number of beds in the general and special hospitals in London combined was stated by Dr. Steele to be 8,500, of which 6,500 are continually employed. But according to Mr. Burdett--8,094 and 6,143." "The vast numbers of persons who are treated in out-patients' departments of hospitals, the number treated at the eleven hospitals with schools, were estimated by one witness at over half a million." Here, again, no precise estimate can be formed of the part these great institutions have taken in the sanitary evolution of London. That their part has been a really great one is evident without figures--proved not only by the millions restored to health and capable citizenship, but even more by their adopting and reducing to practice, and placing within the reach of the whole community, the vast benefits following the great scientific discoveries of recent times. Among the many causes of insanitation, and all its miserable accompaniments, one of the most hopeless and most difficult to deal with has always been intemperance or "drink." Statistics give no means of estimating its disastrous consequences, but these consequences always have been, and still are, of the most deplorable kind. The overcrowded dwellings and bad sanitary arrangements constantly tended to increase the habit of intemperance, and the moral degradation caused by drink made people indifferent to their housing, and lead to the poverty which increased overcrowding and insanitation. In London the facilities for obtaining drink are practically unlimited. In the evidence given before the Royal Commission on Liquor Licensing Laws, which was appointed in 1896, it was stated that:-- "In Soho District, in an area of a quarter of a square mile, there were 1950 inhabited houses and 116 public-houses. In another district, a little over half a square mile in extent, there were 259 public-houses (excluding restaurants and private hotels)." Down one mile of Whitechapel Road there were 45 public-houses. "The streets branching off, the hinterland, are also thickly supplied; some exactly opposite each other." "In one street in St. George-in-the-East so crowded are the public-houses that there are 27 licensed houses out of 215 houses." And these facilities are intensified by the great number of hours during the day in which licensed houses keep their doors open to all comers. Parliament has done but little to mitigate this terrible evil. Happily, however, other influences are at work. The Royal Commissioners in their Report in 1899 said:-- "Most persons who have studied the question are of opinion that actual drunkenness has materially diminished in all classes of society in the last twenty-five or thirty years. Many causes have contributed to this. The zealous labour of countless workers in the temperance cause counts for much. Education has opened avenues to innumerable studies which interest the rising generation. The taste for reading has multiplied manyfold within a comparatively brief period. The passion for games and athletics, which has been so remarkably stimulated during the past quarter of a century, has served as a powerful rival to 'boozing,' which was at one time almost the only excitement open to working men." And then followed this weighty statement: "Yet it is undeniable that a gigantic evil remains to be remedied, and hardly any sacrifice would be too great which would result in a marked diminution of this national degradation." And the Chairman of the Commission (Viscount Peel), the Archbishop of Canterbury, and seven Commissioners in a Minority Report stated that-- "The broad facts remain unchallenged of the prevalence of the evil arising from drink." That drink and insanitary housing constitute a vicious circle should by no means deter the most vigorous efforts being continued to improve the conditions of housing and to raise the standard of the public health. There was widespread testimony through the latter half of the decade that the public health in London was improving. Thus the Medical Officer of Health for the Bow District in Poplar wrote in 1895: "We have only to remember what London used to be, and consolation can be found in the comparison. Epidemics are not so frequent, disease is not so virulent, and those attacked stand greater chances of recovery through better and more skilful treatment." And the Medical Officer of Health for Paddington in 1896: "There has been a steady diminution in water-borne disease since efficiently-filtered Thames water has been substituted for the numerous wells and pumps of former days." The Medical Officer of Health for the Strand reported in 1897: "The Strand District (as to health) compares favourably with other years. The result of your labours is a steady improvement in the health of the inhabitants." And the Medical Officer of Health for Islington in 1897 reported the death-rate as 15·80--the lowest since registration was introduced in 1837. In Whitechapel "the policy of your Board has resulted in a considerable saving of human life." The death-rate for the district in 1879 was 26·0 per 1,000, and in 1899 it was 19·3 per 1,000. In Battersea the death-rate was 26·8 in 1871, and 17·6 in 1901. But infantile mortality did not show a similar rate of improvement. In many parishes there was a decided improvement. In many, however, infantile mortality remained at a very high rate. In Bethnal Green, in 1893, nearly half the total deaths were of children under five years of age--a figure which drew from the Medical Officer of Health the remark: "The ignorance of women of the working classes on the subject of infant feeding is colossal." In 1896 it was 51·5 per cent., and in 1898 it was 49·7 per cent. In Poplar the Medical Officer of Health wrote, in 1895: "I think it my duty to point out the terribly high rate of infant mortality...." In Of 1,000 Births in 1895 Died under 1 Year. Bow 179 Shoreditch 199 St. George's-in-the-East 196 Limehouse 202 "It is an awful state of affairs that so many young children die every year." In Shoreditch, in 1896, 49·1 per cent. of the total deaths were of children under five; in Islington, in 1896, 42·4 per cent.; in Hackney, in 1898, 40·9 per cent.; in Fulham, in 1896, 51 per cent. On the south side of the river--in St. George-the-Martyr, in 1894, it was 58 per cent. of the total deaths; in St. Olave, Southwark, 48·6 per cent. in 1896. A most hopeful sign was the greater public interest taken in matters pertaining to the public health. The Medical Officer of Health for Islington wrote in 1892:-- "With the advance of education the public and Parliament appreciate the importance of more and more safeguarding the public health." In 1895:-- "They (middle class) will not tolerate the sanitation of a few years ago; indeed, they expect that the houses they live in will at least be rendered safe against the entrance of sewer gas, and themselves safeguarded against infectious disease." And the Medical Officer of Health for the "City" in 1894:-- "Attention has been more particularly directed to premises and dwellings of the better class, the occupants of which are becoming more and more exacting owing to the increased knowledge acquired by the public on all sanitary questions. Some of these premises are of great size and employ many hundreds of persons, and many enormous insurance, banking, and gigantic commercial establishments." And that there is a community of interest in a healthy London was becoming more widely realised. That the fact should have taken so long to be grasped is extraordinary as it was so manifest a one. Over and over again it had been proved that disease was not restrained by the paper boundaries of parishes, and that once set alight anywhere no limit could be put to its widespread devastations. An unhealthy area in any part of the metropolis constituted a danger to the whole. Nor was disease a respecter of classes. All were interested in keeping it away. And, after many painful lessons, people were realising much more than formerly that disease was a most costly infliction. The Medical Officer of Health for St. James', Westminster, in his report for 1893, set out the business aspect of it:-- "The position of St. James', as the shopping centre for the best retail trade of the West-end of London, makes the district more and more a city of luxurious shops, hotels, clubs, and lodging-houses. Increasing facilities for travel to the suburbs, and the increasing value of premises, necessitate its utilisation for business purposes during the day, and its comparative desertion at night.... Its resident population of 25,000 persons is therefore an inadequate exponent of the activity of its daily life, of the importance of its retail trade, and of the necessity for active sanitation. An outbreak of smallpox or of cholera would at once so damage the trade of the district as to inflict upon its ratepayers a thousand times the cost which is now incurred by their preventive sanitary service, and by the prompt removal of infectious cases to suburban hospitals as is now done." But that was only a single and a limited case. The industrial classes realised to a greater extent than ever before the disastrous results to themselves and their families of sickness and ill-health; the prolonged suffering, the loss of work and wages, the ensuing hardships. And it was upon them more than on others that the effects of disease fell most heavily. In most matters the interests of the various parts of London, and of the various classes, are one and the same, but in none to anything like the same extent as in the vital matter of public health. Here they are one and indivisible. But neither Parliament nor the Government had got so far as to recognise that yet, and London--the great metropolis--with its four-and-a-half millions of people, was left for its protection against disease to a number of semi-independent local sanitary authorities who had no authority beyond their own area, and who could take no action for the safety of London as a whole. One thing was absolutely certain--and that was that the civic life of London had within the decade been lifted to altogether a higher plane. The publicity of the proceedings of the central representative authority--whether of its meetings in the Council Chamber, or of its constant applications to Parliament for legislation embodying far-reaching civic reforms in London--the triennial elections, when the area of discussion was shifted from the Council Chamber to the constituencies, quickened the interest and awoke the dormant masses of the people to the importance of civic administration and of civic laws. In this remarkable change the subject of the public health strode to the front. Men began to realise how it entered into every branch or part of their own lives and of their families, how its ramifications invaded every part of their existence, how much their welfare and comfort and even their existence depended upon it. And the people had a great load lifted off them--the load of despair begotten by the hopelessness of any amelioration of the conditions of life which so long had weighed them down. They felt now that there was some one to whom they could complain, some public authority who would see that things would be righted, if they could be righted, and hope was born in their lives. In 1899 another change was made in the system of local government in London. The Act of 1888, while dealing with the central government of London, had practically not touched the local areas. The work was felt to be incomplete, and in 1893 Commissioners were appointed "to consider the proper conditions under which the amalgamation of the City and the County of London can be effected, and to make specific and practical proposals for that purpose." They reported in August, 1894. Their general conclusion was contained in the following paragraph.[183] "A consideration of the evidence we have received confirms the opinion suggested by the course of previous inquiries and of legislation, or, in other words, by the historic development of the metropolis, that the government of London must be entrusted to one body, exercising certain functions throughout all the areas covered by the name, and to a number of local bodies exercising certain other functions within the local areas which collectively make up London, the central body and the local bodies deriving their authority as representative bodies by direct election, and the functions assigned to each being determined so as to secure complete independence and responsibility to every member of the system." In February, 1899, Mr. Balfour introduced in the House of Commons a "London Government Bill."[184] He referred to the Act of 1888 which created the London County Council as effecting a change "so much in consonance with the traditions of English municipal government that it is likely to be permanent," and said:-- "We recognise to the full that there must be a great central authority in London." "Broadly speaking," he said, "the administrative Vestry and the District Board exist now as they were framed in 1855." "It is with these administrative Vestries and District Boards that the present Bill proposes to deal. It is with the subordinate area, not with the central area, that we are now concerned. "We do not propose to touch the City of London. "We have determined that, by the appointed day it would be desirable that all London should be divided into areas for local government, and that every area should be simultaneously provided with all the necessary machinery for government of its local affairs." He mentioned the areas. "The constitution of the governing bodies in these areas shall be practically identical with the constitution which our great municipal boroughs already possess.... "We propose that there should be mayor, councillors, and aldermen. "As regards their powers--the Vestries already possess (except as to police) the great urban powers possessed by other municipalities. Certain powers agreed upon between the Vestries and the London County Council at certain recent conferences will be added, and there would be transferred to them the powers relating to baths and wash-houses, libraries, and burial boards." "On an appointed day every elective Vestry and District Board in the County of London is to cease to exist. He hoped the plan would come into operation in November, 1900." The Bill became an Act--"The London Government Act"--in 1899. The new municipal boroughs numbered twenty-nine--"the City of London" and twenty-eight others; sixteen of them consisting of single parishes, and the remaining twelve of several amalgamated parishes. A few extra duties were cast upon them. Among them the duty of enforcing within their borough the bye-laws and regulations with respect to dairies and milk, slaughter-houses, and offensive businesses; and in some respects their powers were enlarged, the principal addition being the power to adopt and use the provisions of Part III. of the Housing of the Working Classes Act, 1890, within their borough. All preparations for the change were completed by the autumn of 1899; the new Municipal Councils were elected on the 4th of November, the forty-three Vestries and District Boards ceased to exist, and London entered upon a new stage of her career. Here, at the close of 1900, the Vestries and the District Boards of London came to their decreed end, and disappeared from the scene of London civic life. That end was not regretted by the general public, whose opinion may be gauged from the fact that the name "Vestry" had become almost synonymous with incapacity, mismanagement, neglect, sometimes even of graver transgressions, though in later years the Vestries did something towards removing from themselves that reproach. They certainly had done much useful work, and even at the outset of their existence were a great improvement upon their predecessors. They had found their parishes and districts forty-five years previously in the state described in the first and second chapters of this work--a chaos of filth, a slough of insanitation and deadly disease, and the great mass of the people living in misery indescribable--and the task before them was one which might have daunted the stoutest heart. In many ways they did their work well; local sewerage and house drainage were effectually carried out; the refuse of the great city was regularly removed; the paving, and lighting, and cleansing of the streets were greatly improved. But in many parts of London, and by many Vestries and District Boards, the larger, graver problems with which they were confronted were scarcely dealt with at all. Powers entrusted to them by Parliament were not used, vitally important duties imposed upon them by Parliament were ignored or neglected. Had this been pure incapacity it would have been deplorable, but upon many of the Vestries were men who either were themselves interested in continuing existing evils and abuses, or whose friends were, and so laws which should have removed or mitigated the evils were not administered. And the result was the non-prevention of diseases which led to deaths, and the continuance of miseries (consequent on disease) which might have been warded off, and the sowing of the seeds of evils of which we are still reaping the crop. As years went by the pressure of public opinion upon them became more insistent, and their administration improved, but even to the end many of them grievously failed to fulfil the responsibilities of their position. One class of workers under them must, however, be excluded from such blame, namely, the Medical Officers of Health. It is not too much to say that the greater part of the sanitary progress which was made all through the period of Vestry rule was directly due to the unceasing labour, the courageous efforts, the insistence of many of these officers. Their recommendations were often ignored, their requests constantly denied, their opinions made light of; but in spite of such discouragement they persevered. And not alone did they bravely stand between disease and the people, but they were ever striving to drive it back, and to destroy its prolific sources and its power; ever urging upon their employers the necessity for action to relieve the people from the worst of the evils they were suffering under. The description given in 1856 by one of them that their work was "a war of the community against individuals for the public good" had been proved to be absolutely true. And in that war, of them generally, it is to be said that there were no sturdier fighters on the side of the community than they proved to be. In 1885 Dr. J. Liddle, "a pioneer of reform," died after thirty years of "unflinching adherence to duty" as Medical Officer of Health for Whitechapel. In 1889 Dr. N. Vinen died after thirty-four years' service as Medical Officer of Health for St. Olave, Southwark.[185] In 1895 Dr. J. S. Bristowe passed away after forty years of service as Medical Officer of Health for Camberwell. And there are still in the service men whose labours have extended over prolonged periods. Such men as these, and others of them who gave their best to the service of the community, have indeed a claim to the lasting gratitude of the citizens of London. FOOTNOTES: [174] See General Report of Census Commissioners, P.P. 1904, vol. cviii. [175] See speech of the President of the Local Government Board, Mr. Ritchie, in introducing the Bill in April. Hansard, 1891, vol. ccclii. [176] Statement by the Clerk of the London County Council. [177] See his Report for 1899, p. 63. [178] P.P. 1890, vol. xvii. See fifth Report from the Select Committee of the House of Lords on the Sweating System. [179] See the Order made by the Home Secretary in November, 1892, as to "outworkers." [180] Not much interest appears to have been taken in the proceedings of some of the Vestries. Thus, in 1891, the Vestry of Westminster complained of the lack of public interest in the record of their proceedings. "Only eleven ratepayers out of 8,800 have purchased copies (price 2d.) of the Reports of the Vestry in each of the last three years." (A few years later they reduced their Reports to a few pages.) And in 1896 the Vestry of Kensington complained of the limited demand for their Annual Report, though it only cost 2d. [181] See 3rd Report from Select Committee of the House of Lords on Metropolitan Hospitals, 1891. [182] See the Report of Select Committee of House of Lords on Hospitals, P.P. 1892, vol. xiii. [183] See Report of Royal Commissioners on the Amalgamation of the City and County of London, 1894. [184] See Hansard, 1899, vol. lxvii. p. 354. [185] In his last report he recorded the death of J. Munro, who had been Inspector of Nuisances for thirty-three years, so for that long period they had worked together. CHAPTER VII 1901-1906 ONCE more the census placed on record the actual population of the great metropolis, no longer divided, so far as local government was concerned, into parishes and districts, but now into a smaller number of municipal boroughs. The figures of this census are the last available for reliable deductions as to numerous important matters forming part of that comprehensive subject, the sanitary evolution of London. The enumerated population of London had reached the great number of 4,536,541, and showed an increase of 308,224 during the ten years 1891 to 1901. The rate of increase, however, continued to show a decline, having fallen from 10·4 to 7·3 per cent. during the intercensal period. The same movement of the population noted in previous censuses was recorded in this one. In the City of London and six of the central metropolitan boroughs the enumerated population showed an actual decline of over 67,000 in the ten years, notwithstanding that the recorded excess of births over deaths in that period amounted approximately to 70,000. In all the other boroughs there had been increases. In the Eastern group the increases had been very small, with the exception of Stepney, where, owing to the immigration of aliens, the population had increased 13,484. In the Northern group the greatest increase had been in Hackney (19,666). In the Western group Fulham showed the highest increase, namely, 45,500; whilst on the south side of the river, Wandsworth had increased 76,500, and several others showed large increases. Outside the boundaries of the county the "outer ring" had attained to a population of 2,044,553 persons--an increase of 639,000. If the metropolis and this "outer ring" were regarded as one city--and in many matters it is hard to consider them apart--the total population in 1901 was 6,581,372. The information as to the birthplaces of the people showed that of the 4,536,541 persons, 3,016,580 were natives of London. The proportion of natives of London had increased; the proportion from the rest of the United Kingdom had decreased; whilst there had been an increase of 40,000 foreigners, the number having considerably more than doubled since 1881. Of every 1,000 inhabitants, 668 were born in London, and 332 elsewhere, as against 653 and 347 respectively in 1891. Once again the arrivals and departures by the gates of life and death were recorded. In the ten years from the 1st of April, 1891, to the 31st of March, 1901, 1,329,428 births had been registered, and 838,454 deaths. The excess of births over deaths, therefore, was 490,974; and as the increase of population was 309,228, it followed that 181,746 persons had migrated. As the migration had only been 114,000 in 1891, it was manifest that migration to outside the County of London was increasing. The total number of inhabited houses was 571,768, as against 547,146 in 1891; but owing to a variation in the manner of collecting the information, the figures have little value for comparative purposes. The accurate figures given of the population of London enabled the death-rate to be calculated on facts instead of upon estimates. The death-rate was 17·1 per 1,000 living in 1901, a decrease from 18·6 in the previous year, and from 21·0 in 1891. But to be set against this was the portentous fact that the birth-rate had declined from 31·8 per 1,000 in 1891 to 29·0 per 1,000 persons living in 1901, the lowest recorded in London since civil registration began. The public health of London was now altogether on a better level than it had been before, but in the course of the year 1901 some cases of smallpox appeared in various parts of London, and in 1902 there was the most severe outbreak of it--with the possible exception of 1884-5--since 1871, nearly 9,000 cases being admitted to the hospitals of the Metropolitan Asylums Board between September, 1901, and July, 1902. Ninety-three patients were removed to hospital in one day, and on one day (March 11th) 1,604 cases were under treatment. Over 1,300 persons died of it in the year. The cost of disease to the community has often been referred to in previous chapters. The Metropolitan Asylums Board stated that so far as it was concerned, the cost for 1901-2 might be put at £500,000--equal to about a threepenny rate--a sum which was wholly apart from loss of wages to the individual, and various other expenses, and apart from the charge upon the rates of those who were pauperised by the death of the breadwinner of the family. 1903 was "a year of comparatively very slight prevalence of infectious disorders." In 1904 there was "a marked absence of undue activity amongst the infectious diseases of the metropolis." And 1905 was the healthiest year in the records of London since registration, the death-rate being 15·1 per 1,000. In the five years which have passed since the census of 1901, Parliament has passed three Acts of the utmost consequence to the sanitary condition of the people of London, marking, in their respective spheres, definite stages in the sanitary evolution of the metropolis. The sanitary evils to which many of the people were subject might, as has already been stated, be roughly divided into two classes--those of their dwellings at night, and those of their workplaces in the day. "The Factory and Workshop Act" of 1901 dealt with the latter. It was the amendment and final codification of a mass of piecemeal legislation which had been spread over a period of years. In 1878, previous enactments on the subject had been consolidated into one Act. That Act was amended in 1883, 1891, and 1895. All were now finally embodied in this Act of 1901 with several additions and amendments. Additional sanitary provisions were made as to the ventilation of factories and workshops, and as to the drainage of floors. Bakehouses came within the scope of the Act, and the law was made much more stringent as to them. After January 1, 1904, it would be unlawful to use any underground bakehouse unless certified by the Borough Council to be suitable. A register of workshops was to be kept, and the Medical Officer of Health was, in his annual report, to report specifically on the administration of the Act in workshops and workplaces--a direction which ensured publicity as to the action of the local authorities. The powers of the sanitary authorities were extended by the Act, and certain duties necessary for efficient administration imposed upon them. The Act also ensured the inspection of dwelling-houses where there were outworkers. The work imposed on the Sanitary Authorities was very considerable as a very large number of premises came under their supervision, and every workroom in each workshop had to be measured in order that its cubic space might be ascertained; and when the subsequent routine inspection of the premises, and of outworkers' premises, remedying of defects and other duties, were taken into consideration, the magnitude of the work, and the necessity of an adequate staff of officers, were evident. The records show that at the end of 1904, 34,488 workshops in London were under the supervision of the local authorities. The necessity of inspection was demonstrated by the fact that 18,922 conditions required remedying. Improvement was testified to by the Medical Officers of Health, overcrowding was diminished, and it was further stated that "employers are found to co-operate willingly with the local authorities in the remedy of faulty conditions." Altogether, then, when a comparison is made between the conditions of the factories and workshops, and workplaces in which the people worked in the middle of the last century and now, the contrast is remarkable. The worst of the evils have been swept away, and healthy conditions of work have taken their place. And the limitations put upon the labour of children and young persons and women have all been to the good of those subjected to them. And the public health of London, so far as this very large and very valuable portion of the population is concerned, has been immensely the gainer. The second of the three Acts since 1900, which had a vital bearing on the sanitary condition of the people of London, was "The Metropolis Water Act" of 1902. That the water supply should be under the control and management of the municipality had long been advocated, but though hundreds of County and Municipal Authorities in Great Britain--many of them not the hundredth part of the size of London--had a Municipal Water Supply, that great boon was denied to London. The reform was vigorously pressed by the central representative body of London--the London County Council--and after several Royal Commissions of Inquiry, Parliament dealt with the subject in 1902. But the manner of dealing with it was unfortunate and retrograde. A new public Board--the Metropolitan Water Board--was established for the purpose of acquiring, by purchase, for the inhabitants of London, and of certain areas outside London, the undertakings of the eight Metropolitan Water Companies, and for managing and carrying on the supply of water. The great bulk of the purchase money was to be provided by the ratepayers of London, and the great bulk of the debt to be a charge on the rateable property of London. The Board was to consist of 66 members, 14 of whom were to be nominated by the London County Council, 31 by the Metropolitan Borough Councils and the City Corporation, and the remaining 21 by the authorities of localities outside London hitherto supplied by the Companies. The Board, therefore, was not a representative body directly elected by the ratepayers or electors of London, but was constructed, on the discredited precedent of the Metropolitan Board of Works, of delegated instead of elected members; and though the people of London were emancipated from the control of trading Water Companies, they got in their place a body over which they can exercise no direct, and therefore very little actual, control. The new Board was constituted in the spring of 1903, and took over the undertakings of the Water Companies on the 24th of June, 1904, at the cost to the ratepayers of London of not much less than £40,000,000, a sum immensely higher than that at which they could have been acquired many years before. And inasmuch as the Board can call upon the ratepayers of London to make good any deficiency of income resulting from their management, the unsatisfactory result is the establishment in London of a new indirectly-elected public body vested with enormous financial powers affecting the interests of the ratepayers of London, and yet but little responsible to public control. The third of the three important Acts, the Education London Act, was passed in 1903, and carried in its bosom possibilities of the most far-reaching benefits to the health and physical welfare of future generations. By this Act the London School Board was abolished, and its duties transferred to the London County Council, which was constituted the Education Authority for London. Though, indirectly, the schools of the Board were having considerable effect upon the physical well-being of the rising generation, it cannot be said that the School Board had utilised its vast opportunities for improving the general health. By instruction, by influence, it might have done so much, might have moulded the physical future of generations. But education was always much more in the minds of the Board than health, though the two might well have been considered together, and without health education is of little use. The Board in their "Final Report" endeavoured to offer an explanation of their inaction. "It has always been a question how far the Board are authorised to spend public money on the medical care of children. On the one hand suggestions have been made for the inspection of their teeth, and the treatment of cases of anæmic condition and arrested development. On the other hand a legal opinion has been expressed that the Board are not entitled to do anything, or to take any measures except such as spring from the fact that the attendance of the children is compulsory. On this account it has been thought right to take action only in those cases in which on account of contagious disease, it is necessary to exclude children from school."[186] Even the sanitary condition of the schools does not appear to have been well looked after. In January, 1890, one of the Committees submitted a report to the Board, on which the resolution was passed-- "That the Committee be authorised to thoroughly examine the whole of the drainage of any school of the Board where they may think it necessary," &c. The drainage was subsequently examined. In 181 schools the drainage was all right. In 292 of the schools re-drainage was required. For how long that fertile source of disease had been scattering its evil germs among the tens of thousands of children attending these insanitary schools, no information is available. In 1890, just twenty years after its formation, the Board appointed a Medical Officer, and he gave only a portion of his time to the work. "Before 1891 there was no attempt on the part of the Board to prevent the spread of infectious diseases by precautionary measures being adopted in the school."[187] In 1895 the Medical Officer of Health for Paddington wrote:-- "School teachers should be required to inform the Sanitary Authority of any special amount of illness which may occur among the scholars. Half a school may be away through sickness if the disease be not a notified one, but no information of such fact comes to the Sanitary Authority." And in 1896 he wrote:-- "The past year had emphasised the need of definite instructions to school teachers to keep the Medical Officers of Health informed of the existence of infectious disease among their pupils. It is surmised that there were upwards of 2,000 cases of measles in the parish in the earlier part of the year." And "measles is the most fatal disease of childhood." In evening schools "efforts were made between 1899 and 1903 to teach the simple laws of health.... Prior to 1898 gymnastics were taught in only a few schools."[188] In 1902 the Medical Officer resigned, and a new one was appointed who should give his whole time to the work. His first report (1903) is enlightening as to the methods of the School Board in matters pertaining to the health of the children attending the schools. He wrote:-- "The maintenance of sanitary conditions as regards heating, lighting, ventilation, and cleanliness both of the buildings and persons of the pupils, the detection of early cases of illness ... ill-health from many causes, school habits, and school work in their influence on health ... these ... come under the daily work of the teacher, and there is no requirement that any knowledge of such matters should be possessed by him. It is left to his own common-sense, and he muddles through. The definite requirement of hygienic knowledge as part of the equipment of every teacher is a necessity if a great part of the work of this department is not to be useless in result."[189] And in his Report of the following year he wrote:-- "The provision of medical oversight for school life is rapidly becoming a necessity. Five-sixths of the population spend a seventh part of their lives under the exceedingly artificial conditions of the schools, and during the plastic period of life. Their chief function in the earlier part of that period is to grow, and it is necessary that they should not only do this, but do it under favourable circumstances for development."[190] Soon after the transfer of the administration of the Education Acts to the London County Council, the medical work of the late School Board was amalgamated with that of the London County Council. The change is one which is likely to be of the greatest benefit to the children in the schools, and through them, as times go on, to the population of London as a whole. The great value of health will receive greater recognition than it has done hitherto, whilst greater facilities for instruction in health matters, and better physical training, cannot fail to have the most beneficial effect. The vast field for this work is evident when it is called to mind that nearly half a million of children are in average attendance at the London County Council Schools. Three other matters legislated upon by Parliament claim mention. In 1902 the Midwives Act was passed. It provided for the constitution of a Central Midwives Board with power to frame rules for the registration of midwives and for regulating and supervising the practice of midwives. After the 1st of April, 1905, no person might use the title of midwife without being certified under the Act. The London County Council was constituted the local supervising authority for London, and under its supervision much good has already been done. Also in 1902 the Cremation Act, which empowered burial authorities to provide and maintain crematoria, and empowered the Secretary of State to make regulations as to the conditions under which cremation might take place. And to complete the tale of sanitary legislation since 1900, a few reforms were secured by sections in the annual General Powers Acts which the London County Council obtained from Parliament. Among these was one rather important one. In 1894 the duty of supervising and regulating the common lodging-houses in London, which hitherto had been performed by the Commissioner of Police, was transferred to the London County Council. In that year 654 such houses were on the register, and the authorised number of lodgers was close upon 30,000 persons. In 1902 the Council obtained powers for the annual licensing of such houses. These larger powers enabled the Council to improve the sanitary condition of many of these houses. The supervision of these houses has been most satisfactorily carried out, and has been of immense value in securing sanitary abodes for the miserable people who frequent them, and in diminishing what would otherwise doubtless often be a source of infection to the community. The sanitary evolution of London having begun a little before the middle of the nineteenth century, the figures of the censuses of 1851 and 1901 afford the means for measuring many of the great changes which have taken place in the intervening period. And a comparison of the state of those things which most affect the public health at these two dates enables a reliable deduction to be drawn as to whether there has been evolution to a higher level of public health, or a retrogression; and, if the former, the progress which that evolution has made. In 1851 the population of London was 2,362,236. In 1901 it had reached 4,536,541. And when to this is added the fact that all through the intervening years so enormous a mass of people has been cooped up in an area of 117 square miles, and that at the present time there are over 4,500,000 within that small area, the multiplicity of the matters decisively influencing their health and physical well being, and the vastness of the issues at stake, come into vivid light. As has been often said, the very basis or foundation of the sanitation of a city is an efficient system of drainage. Without it sanitation is impossible. What the main drainage of London was up to 1858 has been described in the earlier chapters of this book. In effect, nothing less than an entire system had then to be designed and constructed to provide London with this first essential. This was done, and the result was of immediate and enormous benefit to London, and ever since then the maintenance and extension and improvement of this work has received the solicitous attention of the Central Authority. Originally designed for 3,500,000 people, it had, as London grew, to be considerably enlarged and extended, and as some of the districts outside the boundaries of London were allowed by Parliament to drain into the London sewers, still larger works had to be constructed. And now the system serves a resident population of, in round figures, 5,500,000 people spread over an area of about 140 square miles. It comprises close upon 90 miles of great intercepting and outfall sewers, 176 miles of main sewers, and 26 miles of large relief sewers, constructed for the special purpose of conveying storm-water away. This, however, was but part of the provision which had to be made. During the _régime_ of the Metropolitan Board of Works, more than 1,100 miles of new sewers were laid by Vestries and District Boards in their respective districts, and since the creation of the London County Council of 1888, further additions of 1,516 miles have been made, making a total of over 2,600 miles. All this work was essential to enable a proper system of house drainage to be carried out, and as the drainage of houses into the local sewers was compulsory, the general system of drainage was thus rounded off or completed. The change effected thereby in the conditions of life in London has been remarkable. There are no longer open ditch-sewers polluting the air with their pestilential abominations; no longer streets without sewers, and houses without the possibility of drainage. In the Report of the County Council for 1902-3, prepared by the Clerk of the Council, there is given a calculation of what these works annually accomplish. "The flow of sewage during the year, namely 87,556 million gallons, represents a canal 24 feet wide with a depth of 9 feet, running day and night at the rate of 2 feet per second; or it may be considered as equivalent to a lake of 44 square miles, or about one-third of the area of the county of London, with a depth of 11-1/5 feet." To the efficiency and thoroughness of the present system is primarily due the greatly improved condition of the public health of London as compared with 1855. Water was another of the absolute necessities of existence and of sanitation. An ample supply of good water is essential for health; and the numerous outbreaks of typhoid fever which in recent years have occurred in England with a heavy death-roll, testify to the dangers incurred by bad water, and the necessity for the utmost care being taken to secure its being pure and uncontaminated. The supply of water in the eighteen-fifties had been very limited in quantity, and, with the exception of that supplied by one company, abominable in quality. And progress to a better state of things was slow. Improvements were made most unwillingly and haltingly by the Water Companies, and only under Parliament's reluctant compulsion, whilst the inaction of most, and the obstruction of some, of the Vestries and District Boards, and the hostility of "owners" of houses to being put to expense for water fittings, still further impeded reform, and perpetuated the evils inflicted upon the inhabitants of London--suffering, disease, and death. The "slaughter wells" and the sewer-ditches were, however, filled up and those evil sources of supply ended. And a supply of water was gradually extended to the streets which were without any, and an increased supply to others which had but little; but it was not until 1899, the very end of the century, that the County of London was, for the first time, receiving a constant supply in accordance with the provisions of the Metropolis Water Act of 1871. And by slow degrees the sources of defilement of the water were reduced, and a larger proportion of the dirt ingredients filtered out, until at last some of the worst evils connected with the supply were rectified. And in 1891 it was enacted by Parliament[191] that a dwelling-house without a proper and sufficient supply should be a "nuisance" liable to be dealt with summarily. The main cause of all the grave disadvantages the people of London had so unceasingly suffered under in this matter arose from the fact that the interests of the Water Companies and the interests of the people of London ran directly counter to each other. London, in fact, had from the very outset been at the mercy of trading companies for its supply of this necessity of life, and bitter cause, indeed, had London to rue it. It is too soon to know what improvements will result in the supply of water to the people of London, but in the interests of the public health it is most unsatisfactory that the public should even now be debarred from that direct control which alone can secure them the fullest benefits. In another of the numerous branches of the great subject of the public health of London--the widening of the streets and thoroughfares--the improvements made in process of years was marked, and the better provision of light and air and breathing space has been considerable. The total gross cost of new streets and improvements carried out by the Metropolitan Board of Works had amounted to over £12,000,000,[192] whilst it had contributed another million and a half to the cost of smaller street improvements carried out by the "City" and other districts, which latter also expended considerable sums. The London County Council continued the policy of the Metropolitan Board of Works, and by the year 1904-5 it had carried out, or was in process of carrying out, improvements at an estimated gross cost of over £11,000,000,[193] the greatest and most costly of all being the new thoroughfare--Kingsway and Aldwych--connecting Holborn with the Strand, which swept away some of the most notorious and worst slums in London. In addition to these, many local improvements have been carried out by the "City" and by the Vestries and District Boards, and later by the Borough Councils. These were estimated to cost about £1,800,000. The total work accomplished, therefore, has been very considerable, but the cost has been huge; amounting in the whole to about £27,000,000. Of greater value to the health of the people has been the increase of the number of parks and open spaces in London, not merely in preventing land being built over, but in the opportunities afforded the people, and especially the younger portion of them, for exercise. Here considerable acquisitions have been made since the time of the Metropolitan Board of Works. Immediately after the creation of the London County Council two generous gifts were made to the citizens of London--Waterlow Park of 30 acres and Myatt's Fields--and the Council had acquired Hackney Marsh, with 337 acres; Brockwell Park, with 127 acres; and Avery Hill, 84 acres; and some distance from London, 803 acres of Hainault Forest. In addition to these several small pieces of ground were acquired and thrown open as public gardens and recreation grounds. The "City" had also acquired, outside the County of London, Epping Forest, about 5,560 acres in extent, Burnham Beeches, 375 acres; Coulsdon Common, 347 acres; and a few small open spaces in the "City" itself. And many acquisitions had been made by the Vestries and District Boards, and, since their supersession, by the Borough Councils. Purity of air was another of the important elements of a satisfactory health condition. Once that the Thames had ceased to be the main sewer of London, and once that the hundreds of thousands of cesspools were filled in and abolished, the most persistent and fruitful and worst of the causes of the impurity and unwholesomeness of the atmosphere were removed. Gradually too, but only too slowly--a slowness resulting in widespread loss of health and life--were the noxious trades in London made amenable to the law, and somewhat less noxious to those living in their immediate neighbourhood; this, too, without that ruin to trade and manufactures which was always predicted when any effort was made to prevent the prevalence of intolerable nuisances. The duty of administering the provisions of the law relating to the abatement of smoke nuisances rested with the police. Under their action a steady reduction had taken place in offences against the law. In 1882, 1,248 cases were reported, and there had been 162 convictions; and in 1890 the numbers had sunk to 702 reported cases and 46 convictions. In 1891, by the Public Health London Act, the duty was transferred to the Sanitary Authorities. Considerable use has been made by them of the Act. In many cases severe penalties were imposed, and the general result has been a very satisfactory improvement. Much, however, of the fouling of the atmosphere is caused by factories outside London, and consequently outside the control of the local authorities of London. And yet another of the great branches of the general subject of the public health is the food supply of the people. It would be difficult to give any approximate estimate even of the part which good or bad food has in its effect upon the public health, or to produce any statistics on the subject, but, undoubtedly, it is a very large part; and every now and then the outbreak of some serious illness and heavy loss of life, directly traceable to the consumption of bad food, shows how important it is to safeguard the people from such disasters. Thus in 1901 there was an outbreak of scarlet fever, in which some 300 persons were attacked, directly traced to an infective milk supply. Previous to the date of the Nuisances Removal Act of 1855 there was, so far as London was concerned, practically no control or supervision over the food sold to and consumed by the people. That Act contained a section providing for the inspection of food by the local sanitary authority, so the importance of securing wholesome food for the people was then recognised. Little, if any, use was made of the power thus given, and the Act was amended and extended; but even then it was almost a dead letter. As years advanced great scientific discoveries demonstrated the fact that some of the most dangerous diseases, such as typhoid and scarlet fever, could be conveyed in food of various sorts, and opened up a new vista of dangers as to the conveyance of disease.[194] And the huge size of London, and the vast numbers of its population, increased enormously the difficulty of safeguarding the public from the dangers of contaminated food. The first and greater portion of this work was done by the Corporation of the City of London. Its Committee, the Port Sanitary Authority, was able to prevent large quantities of bad meat which arrived by sea being put upon the markets; and the Corporation, which administered the principal markets of London--the cattle-markets at Deptford and Islington, the fish-market at Billingsgate, and the others at Smithfield and Leadenhall and Spitalfields--by a system of inspection, prevented large quantities of bad or diseased food being sold to the public. In 1905, 415,000 tons of meat reached the Central Smithfield Market, of which 2,128 tons were seized as being diseased and unsound. At Billingsgate, 211,600 tons of fish were delivered, of which 674 tons were condemned. And there were 28 wharves and warehouses in the City where tinned food and tinned meat and vegetables were received. 173 tons were seized. All these places were daily inspected. This, however, was only a portion of the food which reached London. The responsibility for inspecting food in other parts of the metropolis rested (under the Public Health (London) Act of 1891) with the various Sanitary Authorities, and the reports of the Medical Officers of Health contain accounts of inspections by them, and of the seizure of meat, fish, poultry, rabbits, tinned food, vegetables, eggs, and sweetmeats, and of prosecutions, and of a few convictions. And many other articles of food were, under the Food and Drugs Act of 1875-99, also liable to inspection so as to secure that they should not be adulterated; so that theoretically, and in a very great measure actually, provision exists for protecting the people of London from adulterated articles of food, and from food unfit for human consumption. All this is an immense advance upon the time when there were no laws against the sale of unsound or adulterated food. But there is great room for improvement, for the inspection and means of prevention are far from adequate to secure the protection of the public from this danger; indeed, the existing system of government for dealing successfully with this most important element in the well-being of the people is very defective. The experiences of the past sixty years or so in London have abundantly shown how great is the extent to which the public health is dependent upon the system of local government in existence at the time, and upon the administration of the laws relating to the public health by those authorities. The considerable changes which have taken place in the fifty years since the creation of a Central Authority, the Metropolitan Board of Works, have been described. So far as regarded the local authorities over the separate areas into which London was divided, the "City" remains practically as it was, with the exception of the addition to its sphere of action of the important duties of Port Sanitary Authority, and such further powers as the exigencies of the times required, and certain changes consequent upon the creation of the London County Council. In the metropolis the other local sanitary authorities instead of being Vestries and District Boards--43 in number--are now Municipal Borough Councils--28 in number--with some larger powers, including wide powers of rating. The Poor Law Guardians, also with wide powers of rating, have remained much as they were, their sphere of work being a definitely limited one. Various Commissioners, such as the Commissioners of Baths and Washhouses, Library Commissioners, and Burial Boards, have ceased to be; their powers being now exercised by the Borough Councils. The important changes in the local government of the metropolis have mainly been in the Central Authorities, whose sphere of duties extends over the whole area of London. The principal Central Authority, the London County Council, which superseded the Metropolitan Board of Works in 1889, instead of being indirectly elected as was that body, is a directly elected body, elected by and representative of the whole electorate of London. Its duties and powers have undergone extension and increase; the latest material addition to them being its appointment as the Education Authority for London. In 1867, owing to the default of the Vestries and District Boards to make provision of rate-supported hospitals for paupers suffering from infectious or contagious disease, a Central Authority--the Metropolitan Asylums Board--constituted on the indirectly elected system, with considerable powers to spend money which had to be provided out of the rates of the metropolis, was created to do that work. In 1870 another central body was created, the London School Board, to deal with the elementary education of the children of London, and though not a health authority, its work was closely associated with the public health. It also possessed the widest powers for spending money, which had to be provided out of the rates of the metropolis. It was a directly elected body, but elected on a system peculiar to itself, and one which in great measure removed it from any financial public control. By an Act of Parliament in 1903 the London County Council was made the Education Authority for London, and the work of the School Board was transferred to it. To the two existing central authorities was added, in 1903, another wholly gratuitous central local authority, the Metropolitan Water Board, an indirectly elected body with ultimate rating power over the metropolis. There is a third sphere of government in matters pertaining to the public health--namely, that occupied by the State. It is charged with many duties connected with the public health, and is in close relationship with the various central and local authorities in London. It has undergone large changes since the middle of the last century. At that time some of the powers possessed by the State Government in health matters were exercised by one of the Secretaries of State. Others, for some years, through the General Board of Health appointed by the Government. In 1858, when that Board ceased to exist, some of its powers were transferred to the Privy Council, others lapsed to the local sanitary authorities. So great, as time went on, was the development of local government throughout the country, and so essential was it to have some central government State supervision over the largely increased number of local sanitary authorities, that in 1871 a new Government Department, the Local Government Board, was created to perform this work. To it were transferred most of the powers in connection with sanitation and health matters possessed by the State Government, and the various authorities in London came more or less under its supervision. Since then, as the sanitary needs of the community grew, and as legislation became more voluminous, fresh duties have been constantly imposed upon that Board. Summing up these changes, and their broad effects, it is to be said that the machinery for the administration of the sanitary laws in London is undoubtedly far more potent and effective than it has been at any previous time. Instead of the Vestries and District Boards there are now the Borough Councils; instead of the Metropolitan Board of Works there is the London County Council; instead of the Privy Council and Board of Health there is the Local Government Board, whilst the Metropolitan Asylums Board and the Water Board had no predecessors. But on the other hand the system now in existence is very complex, and in many ways cumbersome, and in recent years there has been a most unfortunate tendency on the part of Parliament to revert to that which was the curse of London before the Act of 1855--the multiplicity of local authorities--all of them, too, with separate rating powers. So far, then, in the way of the machinery of local government has London come on its way to an improved condition of the public health. And Parliament, as has been narrated, had, since 1855, multiplied the health laws, which these bodies were charged with the administration of. Then, the passing of an Act dealing with matters affecting the public health was so rare as to constitute a remarkable event. Now Acts of Parliament and "Provisional Orders" as to health matters are quite common events. With such numerous laws covering so many phases of the public health, with so much larger and more powerful a machinery for their administration, the crucial point of all is the administration of those laws by the various authorities. It is obvious that the administration is much more searching and effective and wide-reaching than it has ever been before. The Central Authority, the London County Council, has done great work, as has already been shown, in extending and maintaining the efficiency of the drainage system of London, in the clearance of insanitary areas, and the erection of houses for the working classes; in the acquisition of open spaces, in great street improvements, in its efforts to help towards a solution of the great housing problem by the facilities of traffic it has created by its tramways, in the inquiries it has instituted into the insanitary condition of various districts in London, in the unifying of administration by the local sanitary authorities, and in many other ways too numerous to be recited. It has, in fact, vigorously used such powers as it possessed. The Metropolitan Asylums Board has also used its powers effectively, having erected hospitals, and having each year successfully isolated and treated many thousands of cases of infectious and contagious disease. The Water Board is still too young to have a record. The Poor Law Guardians had improved the workhouses and the infirmaries, and the dispensaries were continuing to do their useful work. The Metropolitan Borough Councils were grappling with their numerous duties. The perusal of the annual reports of these bodies shows their multiplicity. House-to-house inspection--the inspection of factories and workshops, and workplaces, and outworkers; of bakehouses, cowsheds, dairies, and milkshops; of food and the places where food is prepared; of offensive trades and slaughter-houses, and of houses let in lodgings; the management of baths and wash-houses, the removal of dust and filth, disinfection, proceedings under the Housing of the Working Classes Acts; measures for the prevention of disease, for the abatement of nuisances, and many other duties connected with sewerage, drainage, and paving and cleansing of streets--all and every one of which closely affect the health of the people. The amount of work done varied considerably. In a well-administered municipality the number of Sanitary Inspectors had been increased, the number of inspections was high, and the work continuous and heavy. In some, however, the work was less satisfactorily done, and the old Vestry antipathy to the expenditure of money upon Inspectors appeared to have been handed on. Much, nevertheless, was being done, and on the whole matters appeared to be progressing satisfactorily, and in many respects undoubtedly were doing so. But every now and then some revelation occurred of insanitary conditions under which large numbers of the people were living which showed a grievous omission somewhere, and for which some persons were responsible. Thus when, under the Education (London) Act of 1903, the County Council had to take over the non-provided schools in London, the schools were inspected, and it was found that their drains were generally in a very bad condition. No fewer than 342, or 78 per cent. of the school drains which were tested, were declared unsatisfactory. A most prolific source of disease and death was thus laid bare, a source which for years must have been working grave evil--and as in these schools there were about 135,000 children in attendance, the number of persons involved in danger was enormous. Again, some of the figures published by the Census Commissioners in 1902 disclosed a condition of things of the utmost gravity. Similar figures in the census of 1891 had passed almost unnoticed; these of 1901 reiterated the story, and as the evils they laid bare were on a somewhat smaller scale they were hailed more as a mark of progress and improvement, than as something portentous in themselves. Yet they go down to the very roots of the sanitary condition of the people of London, and show how great is the task to be accomplished before the sanitary condition can be considered satisfactory or even safe. They bring into sudden view the fact that the problem of the housing of the people is still unsolved. The census of 1901 had recorded that there were 4,536,541 persons in London. It also recorded that the total number of tenements was 1,019,546. It further showed that of these tenements no fewer than 672,030 were tenements of less than five rooms; and then going into details of these 672,030 tenements it showed that-- 149,524 were tenements of one room. 201,431 " " two rooms. 181,542 " " three " 139,533 " " four " Comparing these figures with those for 1891 it appeared that-- "A marked improvement had taken place in the manner in which persons occupying tenements of less than five rooms are housed in London. The shifting of the population in the ten years from the tenements of one or two rooms to the more ample accommodation provided in tenements of three or four rooms is conspicuous."[195] There had been a reduction in the number of one-room tenements, which are justly regarded as the worst of all from 172,503 in 1891, to 149,524 in 1901, whilst there had been an increase in the number of two, three, and four-room tenements. As to the numbers of persons living in these 672,030 tenements-- 304,874 persons lived in tenements of one room. 701,203 " " " two rooms. 752,221 " " " three " 691,491 " " " four " --------- Total 2,449,789 Still, therefore, well over half the population of London lived in tenements of less than five rooms; whilst over 1,000,000 lived in tenements of one or two rooms--and between one- and two-room tenements there is not much to differentiate. By further details given (as in 1891) each Sanitary Authority was "provided with the means of examining with much precision into the house accommodation of its district." The Medical Officer of Health for the Borough of Finsbury, utilising the figures for that Borough, deduced some most instructive conclusions as to the effect of the one-room and two-room tenements upon the death-rates. Forty-six per cent. of the population lived in such tenements; the death-rate in one-room tenements was 38·9 per 1,000; the death-rate in two-room tenements was 22·6 per 1,000. And the number of deaths occurring in them was 63 per cent. of all the deaths in the Borough. "The conditions of life obtaining in one-room tenements," he added, "are such as tend towards poor physique, disease, and death. The density of population is higher, the physical restrictions are greater, and there is less fresh air and more uncleanliness." The information thus given by the Census Commissioners as to tenements was striking enough, but of deeper interest and import even than these figures was the information as to "Overcrowding." The Medical Officer of Health for the London County Council, utilising the figures of the census, worked out the facts as regarded the overcrowded tenement population of London. There were 726,096 persons living in an overcrowded state in 124,773 tenements of less than five rooms. Of these-- 147,771 lived in 40,762 one-room tenements. 296,659 " 50,304 two " " 187,619 " 23,979 three " " 94,047 " 9,728 four " " ------- ------- 726,096 124,773 There had been a reduction of overcrowded tenements from 145,513 in 1891, containing 829,765 persons, to 124,773 in 1901, containing 726,096 persons. There would appear then to be some hope that the acme or climax of overcrowding has been passed. But even from the most sanguine point of view the improvement is not great, and many decades would have to elapse before "overcrowding" ceased to be a power for evil. A few illustrations show the dreadful condition of things in this respect in certain localities. In the Borough of Finsbury, over 35,000 persons lived in overcrowded tenements of less than five rooms; in Stepney, 99,000; in Islington, 56,000; in St. Pancras, 56,000; in Lambeth, a few short of 37,000; and in Southwark, over 46,000. And if some of the figures about overcrowding were looked into a little more minutely it was to be seen that in St. Marylebone there were 1,020 two-room tenements inhabited by five persons each, 685 by six persons each, 366 by seven persons each, and 170 by eight persons each. In Islington there were 1,253 such tenements with six persons each, 624 with seven persons, and 258 with eight persons. In St. Pancras there were 1,414 two-room tenements with six persons in each, 743 with seven persons in each, and 323 with eight in each. In Shoreditch there were 694 two-room tenements with six persons in each, 380 with seven in each, and 155 with eight in each. Stepney was the worst of all--with 1,126 two-room tenements with seven persons in each, 577 with eight persons in each, and 278 with nine persons in each; but this was the result of alien immigration. In Lambeth there were 699 tenements of two rooms with six people in each, and 322 similar tenements with seven each, and 118 with eight each. It must have come as a revelation to many of the Borough Councils to find such a condition of things existing in their municipality. These are the most recent reliable figures. Not much change can have taken place since then, and they may be regarded as presenting fairly well the existing condition of the housing of the people of London. The main fact emerging from them is that a population of 726,096 persons in London are living in 124,733 overcrowded tenements of less than five rooms. The accumulated testimony of the most experienced and capable observers during half a century is clear and precise that overcrowding is disastrous to the physical welfare of the individual. The conditions of life are not much better in one- and two-roomed tenements, and the conclusion is thus forced upon us that, speaking broadly, a fifth of the population of London are at present living in circumstances where physical well-being is impossible, and where even a moderate standard of public health is unattainable. For some time back, fears as to the physical deterioration of certain classes of the population have found public expression, and to such a point did these misgivings come that, in 1903, a Committee was appointed by the Lord President of the Council to inquire into the subject throughout the kingdom. The idea of physical deterioration being at work found expression sometimes in the reports of the Medical Officers of Health even far back. Thus, in 1869, the Medical Officer of Health for Paddington wrote:-- "In Paddington overcrowding in its worst forms cannot be said to exist, but there is an over-concentration of building which will some day be considered a disgrace to our civilisation. It may safely be predicted that besides a high infantile death-rate a concomitant deterioration of race will result.... This high (infantile) death-rate is not the only check to population. Another and more painful form of evil manifests itself in the sickly and puny race around us. Young men and young women are unable from low vitality to cope with their contemporaries in the labour market, where prolonged muscular exertion is required. We find in this class the seeds of debility and disease." In 1871 he gave a table with particulars of five hundred heads of families of the wage-earning class engaged in industrial occupations living in tenement-houses in certain streets near the Great Western Railway terminus. "Sixty-four per cent. were born in country places. This," he added, "confirms my statement in former reports that large numbers of men born in cities have poor constitutions and deficient vital stamina, who cannot cope with their competitors from the country, nor command the best labour markets of the world. In the struggles of town-life large numbers are prematurely crushed out at early periods of their existence." And he added: "This deterioration of race has for some time been recognised by Medical Officers of Health." Unfortunately the conditions of life conducive to deterioration did not cease to exist in 1871, as evidenced by the figures of the censuses of 1891 and 1901, of the population living in overcrowded tenements of less than five rooms. The Committee reported in 1904, but while both the Report and the evidence are of great interest, it cannot be said that they advanced the question much. The Committee stated that-- "There are no sufficient 'data' at present obtainable for a comparative estimate of the health and physique of the people." That being undoubtedly so, the best light obtainable on the subject must be sought for in a different way. Fortunately that way exists--and it is possibly the soundest of all--the method of inference from well-established facts. The reports of the Medical Officers of Health for London during the last half-century enable this method to be applied to London. In cases innumerable it has been demonstrated beyond dispute that the death-rate was highest in overcrowded houses or localities, that the sick-rate was proportionately higher, that disease assumed more virulent form in them, and left the victim in a more impaired condition. "It is almost an axiom that the greater the crowding, the greater the sickness and the higher the death-rate." That these conditions affect the health and stamina of persons of all ages, and more especially of the children who are to constitute the new generation, is a truism, and thus the health and stamina of a large proportion of the population is, of necessity, damaged and deteriorated, and a heritage of suffering and debility passes to a succeeding generation. Were these evils mere passing events like an epidemic of cholera which sweeps away its thousands of victims and is gone, the results would not be so disastrous. But when to these clearly proved facts is added the awful fact that these evils have been unceasingly in active operation for considerably more than half a century, that the past is still exerting a powerful and pernicious effect upon the present, and that the seeds of evil then sown are still producing a deadly crop, it is a necessary and unavoidable conclusion that there has been a considerable deterioration of race. Counteracting these deadly forces have been those which have been described in this book:-- Efficient sewerage and drainage, water supply improved in quantity and quality, sounder food, wider thoroughfares, cleaner streets, open spaces, new dwellings, prevention of the defilement of the atmosphere, prevention of the spread of infection--all these, together with better knowledge of health matters, the vast advance in medical science, the better provision for the treatment of the sick, greater temperance, and the great work carried on by numerous philanthropic workers and organisations, have effected vast improvement--an improvement testified to in the fall in the death-rate of London from 23·38 per 1,000 in 1851 to 17·1 in 1901 since which year it has further decreased. Painfully and laboriously, and in the face of persistent obstruction and hostility, has the present sanitary position been attained. "Vested rights in filth and dirt" have offered a prolonged and dogged fight against reforms which curtailed their privileges. Hundreds of thousands of lives have been needlessly cast away, an uncountable number blighted and made useless by diseases which were preventable, and which were not prevented, and an incalculable injury inflicted upon the community. And the expense to the community has been enormous. Millions upon millions of money have had to be spent to make good--so far as could be made good--the ravages of past neglect and culpable management. Millions upon drainage, upon hospitals, upon houses for the working classes, upon open spaces--tens of millions upon water supply, and most unjustifiable and regrettable of all, millions to compensate slum owners for their iniquities. And even yet we have not arrived at our goal. What, then, are still the causes of failure? What the impediments? Where the shortcomings? The failure is in part due to a great omission by Parliament--in part to the non-administration of existing laws by local authorities--in part to a great defect in the system of local government. Parliament had, most unfortunately, omitted from all its enactments affecting London any provision for the supervision of the great movement in part economic, in part social, which has been going on in London for well-nigh two-thirds of a century--namely, the change of houses inhabited by one family into tenement-houses, or houses inhabited by several families. That movement with its appalling attendant evils was allowed to go on practically unregulated, uncontrolled, and unsupervised. The great evil of this movement was, that a house which had been structurally and sanitarily designed for one family was sanitarily unsuited for its altered career as the abode of several families. Nothing was done to obviate this evil. And so these houses became packed with people and families who had to live in one or two rooms in them without the primary necessities of a healthy existence--without ventilation--without an adequate supply of water--without facilities for cooking food--with the scantiest and filthiest sanitary accommodation--had to live under conditions which put a high premium upon dirt and insanitation, and which absolutely invited disease and death. Even the Sanitary Act of 1866, and its amending Act of 1874, did not deal with this crucial matter; and no legal obligation was created by Parliament to ensure that the houses undergoing such a change should be adapted to their altered circumstances. The Sanitary Act of 1866 only in part dealt with the evils inherent in such houses. It imposed on the Sanitary Authority the duty of making regulations which prescribed a standard of the air space for each person, and thus made an effort to prevent overcrowding; it imposed upon the "owner" the duty of maintaining a certain standard of cleanliness--the rooms were to be painted or lime-whitened every year--it laid upon the tenants certain duties also as to maintaining cleanliness. But even this imperfect legislation was completely brought to naught by the opposition of the Vestries and District Boards to such action as would have secured at any rate some degree of decent accommodation in the tenement-houses of London. By the Public Health Act, 1891, the London County Council was empowered to make bye-laws enforcing a certain standard of sanitary accommodation in them, and did make them. But in other respects nothing was done; and so the process still goes on, large numbers of houses hitherto occupied by one family are passing into the occupation of several families devoid of the primary necessaries of a healthy existence. The great movement has by no means spent its force; for long to come houses will be going through this transition, and until legislation deals definitely with this matter the inevitable evils attendant on the change will continue. The second main cause of failure lies at the door of the local authorities who would not and did not administer the existing laws. The local governing authorities are now more active than they have ever been before; the amount of work done in every branch of sanitation is far greater than ever before; the number of Sanitary Inspectors has been increased from 188 in 1893 to 313 in 1904. But the regulations or bye-laws under the Act of 1891 which Parliament had imperatively directed them to make and to use as regarded the tenement-houses in London, are very far from being enforced to the extent they should be. The total number of houses let in lodgings which were on the various registers in 1905 was 22,257. With only a few exceptions the Borough Councils, like their predecessors the Vestries, make comparatively little use of this power, though there is a concurrent mass of testimony as to the beneficial results following its use. Stepney, under the inrush of aliens, found the benefit of exercising the power, and heads the list with 2,672 houses on the register. Kensington has 2,107; Westminster 1,641; St. Pancras 2,192; Hammersmith 2,266; and Finsbury 1,169. These amount to 12,047, or 10 per cent. of all the inhabited houses in those six boroughs. In the whole of the rest of London with 451,596 inhabited houses, only 10,207 of the houses let in lodgings are registered: so that only 2-1/4 per cent. of the houses in them, as against 10 per cent. in the others, are registered. It is manifest, therefore, how imperfectly the greater number of even the present local authorities perform the duty which has been imperatively imposed upon them by Parliament. The Borough of Shoreditch, for instance, with 22,940 tenements of less than five rooms, of which 6,269 were overcrowded with 35,500 persons living in them, has only 283 of the houses let in lodgings on the register. The Borough of Lambeth with 44,495 tenements of less than five rooms, of which 6,548 were overcrowded with 36,900 people living in them, had only 372 houses on the register. The Borough of Bermondsey with over 25,000 persons living in overcrowded tenements had only 221 houses on the register. This, as has been explained (see p. 377), is not a matter in which the Central Authority, the London County Council, has any authority to interfere. The Borough Councils are their own masters in this matter, as were their predecessors the Vestries, and the responsibility as to administering or not administering in their areas the Act of Parliament rests entirely with them. The consequences of the non-administration of these bye-laws to the health and physical well-being of great masses of the people are disastrous. Various legal decisions in recent years have somewhat impeded the effective administration of the bye-laws in this matter, but the real impediment is the dislike to them of the Borough Councils. The condition of the vast tenement-house population in this great city is of such immeasurable consequence to the community at large that matters can only be allowed to continue in their present most unsatisfactory state at the most dire cost. The sooner it is thoroughly inquired into by Parliament and drastically dealt with the better; great evils will be stayed, great benefits will be secured. The third principal cause of failure to attain a higher level of the public health in London than at present enjoyed has been the want of a real central Health Authority. The Metropolitan Board of Works was never such. The London County Council is only such in a very limited way. A real central Health Authority for London is an absolute necessity--that is the great moral to be drawn from the history of the last half-century so far as local government in health matters in London is concerned. Disease recognises no boundaries, and in a great city like London it is essential that in so vital a matter as the public health full authority should, subject to Parliament, be vested in one supreme authority--a central authority which shall secure uniformity of administration; a central authority which shall be able to compel a local authority in London to do that which if it neglects is a danger to the community; a central authority which, in the event of such neglect, shall be authorised itself to undertake that work; a central authority which shall be able to act at once for London as a whole in presence of any sudden or great emergency--that is absolutely essential for the sanitary safety of this great city and of the millions who live in it. The want of such an authority has throughout the whole sanitary evolution of London been a disaster of the greatest magnitude, and is an ever-present peril to this great metropolis. The existence now of a central popularly elected representative body for the metropolis would render this reform quite a simple matter. Further measures are also required to aid in the removal of the worst of London evils. In 1903 a Royal Commission was appointed to inquire into the means of locomotion and transport in London. It reported in 1905, having done its work more thoroughly than even most Royal Commissions do their work. A great portion of its report deals directly or indirectly with the sanitary condition of the people of London. "The question of locomotion," said the Commissioners, "affects the health, comfort, and efficiency for work of the whole community.... "Witnesses who have special knowledge of the subject are of opinion that the remedy for overcrowding is to be found in the removal of the people to outside districts by providing additional facilities for locomotion, and in this opinion we agree.... "We have come to the conclusion that in order to relieve overcrowding means must be provided for taking the population into and out of London, not in one or two directions but in many directions, at rapid speed, frequent intervals, and cheap rates." To this recommendation of the Commission it should be added that means must be devised for preventing in "outer London" a repetition of those circumstances and conditions of life which, for more than half a century, entailed such sufferings and evils upon the people of London. * * * * * In reviewing the principal events, and studying the powerful underlying forces of the great movement of the sanitary evolution of London, the bitter experiences of the time gone by would indeed have been in vain if they did not point the way to an avoidance of past blunders and iniquities, and towards a better and happier future for the people. The lines upon which reform should move gradually become apparent as the events unroll themselves; and the measures now to be taken evolve and shape themselves from the successes and failures of the past. The reforms just suggested are undoubtedly those which are most imperatively necessary. The whole experience of the past justifies the belief that they would soon work a great change for the better in the physical, mental, and moral conditions of life of large masses of the people of London. And from improved and healthier homes would come to the people increased comforts and happiness, and more physical energy and greater strength to fulfil the duties of their lives, and to meet whatever demands the future may make upon them and upon our nation. The strength and even the existence of a nation depend upon the health of its masses. The stake at issue is a vital one to people and nation; and now more than ever is it necessary that the health and vigour of our race should be maintained at the highest possible attainable standard. FOOTNOTES: [186] Final Report of the School Board for London, p. 326. [187] See Report of Medical Officer of the late School Board for 1903-4. [188] Final Report, p. 297. [189] First Report of Medical Officer for year ended March 25, 1903, p. 24. [190] Second Annual Report to March 25, 1904. [191] In the Public Health (London) Act. [192] The recoupments arising from the sale of surplus lands reduced the actual or net cost to less than £8,000,000. [193] Here the net cost is estimated to be about £5,500,000. [194] The International Congress of Hygiene, held in Brussels in 1903, passed a resolution declaring meat to be unfit for human food when it was derived from animals attacked by bacterial anthrax, glanders, rabies, tetanus, tuberculosis, in certain cases, and several other diseases. [195] See Report of the Medical Officer of Health of the London County Council, 1902, p. 10. INDEX ADULTERATION OF FOOD ACT, 1860, 182-4 Aldwych, 413 Allison, Dr., evidence quoted, 28 Alteration of Food and Drink and Drugs Act, 1872, 238 Artizans' and Labourers' Dwellings Act, 1868, 212-3, 254-5, 282 Artizans' and Labourers' Dwellings Improvement Act, 1875, 256-8, 264 Amendment Act, 1879, 265, 292-5 Avery Hill, 414 BAKEHOUSES, 171-2, 275, 374, 381-2, 404 Bakehouse Regulation Act, 1863, 183, 275 Balfour, Rt. Hon. A. J., 396-7 Ball, Decimus, 323 Ballard, Dr., 252 Barnett, Canon, 294 Bateson, Dr. Henry, reports quoted, 150, 286-7 Baths and Wash-houses, 39, 126, 252 Baths and Wash-houses Act, 1846, 39, 252 Battersea, 98, 177, 203, 229, 284, 392 Beaconsfield, Lord, 287 Beale, James, 186 Bedfordbury, 259-60 Bermondsey, 17, 23, 98, 116, 144, 177, 188, 220, 250-1, 300, 309, 332-3, 347-8, 354, 431 Bethnal Green, 46-7, 74, 97, 103, 108, 120, 129, 138, 145, 177, 188, 190, 202, 219, 222, 268, 288, 291, 293, 303, 308-10, 333-4, 353, 364, 375, 383, 386-7, 393 Billingsgate Market, 416 Birth-rate, decline of, 350, 402-3 Bloomsbury, 314 Boundary Street Area, 364 Bow, 393 Bristowe, Dr. J. S., 400 Brockwell Park, 414 Bromley, 159 Building Act, 1844, 30, 164 Burial grounds, 35-7, 54-5, 64, 67, 231, 309-10 Burnett, J., report quoted, 335 Burnham Beeches, 414 CAMBERWELL, 98, 104, 137, 144, 155, 190, 219, 222, 267, 288, 291, 305, 309, 334, 354, 406 Census of 1851, 56, 410 of 1861, 155-7 of 1871, 221-2 of 1881, 288-9 of 1891, 349-52 of 1896, 379 of 1901, 401-2, 422 Central Health Authority needed, 195-6, 277-8, 431-2 Cesspools, 18, 51, 104, 128, 159, 229 Chadwick, Edwin, 47 Chamberlain, Rt. Hon. Joseph, 293, 308 Cheap Trains Act, 1863, 362 Chelsea, 98, 141, 197-8, 255, 267, 288, 354 Children's Employment, Commission on, 210-1 Cholera epidemics, of 1832, 2, 46 of 1848, 45-6 of 1849, 46-9, 63 of 1853, 72-5, 164 of 1866, 189-92 Chichester, Bishop of, speech in 1850, 66 "Christopher Court," Whitechapel, 28 "City," the, its commercial character, 7-9 its government, 9, 417 its sanitary condition, 50 its declining population, 94-5, 155, 222, 224, 288, 352, 401-2 construction of business premises, 367, 394 Amalgamation Committee, 396 Clare Market scheme, 364 Clerkenwell, 22, 74, 97, 102-3, 109, 115, 120, 124, 126, 185, 245, 261-2, 288, 303, 307-8, 314, 321, 323, 333, 353, 355 Common lodging houses, 67, 132, 145, 253 erected by L.C.C., 366, 410 Common Lodging Houses Act, 1851, 67, 132 Commons, acquisition of, 206, 282 Compulsory Vaccination Act, 1867, 208 Consumption, 146, 170 Contagious Diseases Animals Act, of 1869, 237 of 1878, 275-6 Coulsdon Common, 414 Cowhouses and dairies, 275, 318 Cremation Act, 1902, 409 Cripplegate, 165 Cross, Sir R. A., 256 Customs and Inland Revenue Act, 1890, 344-5 DENSITY OF BUILDING, 25, 28, 98, 203, 329-30 Deptford, 74, 347 Derby, Lord, 165 Dickens, Charles, on burial grounds, 36 speech in 1850, 65 Dilke, Sir Charles, 308 Diphtheria, 146, 386 Diseases Prevention Act, 1848, 79, 152 Diseases Prevention (Metropolis) Act, 1883, 318-9 Disinfection, 194, 248, 252, 358, 385 Dispensaries, 389 District Boards created, 83-9 inefficiency and inactivity, 183-7, 267-73, 301-8, 321-2, 398-9 abolition, 398-9 Drunkenness connected with overcrowding and insanitation, 130, 142-3, 157-8, 176, 263, 391-2 Dunraven, Lord, 336-7 EAST LONDON WATER CO., 106, 191-2 Education (London) Act, 1903, 406, 421 Elementary Education Act, 1870, 219, 346 Epping Forest, 414 FACTORIES, overcrowding in, 113, 173-4, 193, 334-7 Royal Commission of 1876, 274 need of inspection, 373-4 Factory Act of 1864, 183 of 1867, 210-1 of 1878, 274-5 of 1891, 370 of 1901, 403-4 Farr, Dr. W., 189 Fever, prevalence of, 4, 32-4 connection with cholera, 47 Finsbury, 16, 314-5, 423-4, 430 Finsbury Park, 206 Flight, 323-4 Forster, W. E., speech quoted, 242 Fulham, 98, 100-1, 112, 115, 131, 159-61, 166-7, 191, 204, 214, 219, 222, 226, 228, 252, 288, 307, 374, 380, 393, 401-2 GLADSTONE, W. E., 312 Godwin, George, 173, 181 Goulston Street scheme, 293 Grainger, Dr., evidence quoted, 48-9 Granville, Lord, 165 Gray's Inn Road, 295 Greenwich, 17, 74, 98, 101, 124, 222, 309, 332 Grey, Sir G., 70 Griffith, Dr. J., evidence quoted, 21-2 Grosvenor, Lord Robert, 66 HACKNEY, 17, 97, 100, 103, 117, 123, 136, 179, 190, 197-8, 222, 228, 230, 267, 288, 309, 334, 373, 393, 401 Hackney Marsh acquired, 414 Hainault Forest, 414 Hall, Sir Benjamin, 73 Hammersmith, 101, 204, 226, 383, 430 Hampstead, 97, 100, 125, 351, 375 Hampstead Heath acquired, 206 Harcourt, Sir William, 311 Hickson, W. E., evidence quoted, 26 Holborn, 97, 123, 127, 155, 164, 170, 255, 314, 353-4 Hornsey, 351 Hospitals for infectious diseases, 209-10, 283, 318-9, 387-8 Hospitals, voluntary, 390 Houses, defective building of, 227-9, 232, 273 Housing of the Working Classes Act of 1885, 325-6 of 1890, 342, 363-6, 398 Housing of the Working Classes Commission, 317, 319, 321-5 Hunter, Dr., 185-6 IMMIGRATION INTO LONDON, 156, 221, 225-6, 288-91, 336, 349, 402 Infectious and contagious diseases, 194, 208-9, 239-40, 263, 266, 276, 283, 318-9, 343-4, 357, 385-8, 403, 407-8 Infectious Diseases Notification Act, 1889, 342-3 Inspectors of Nuisances, 86, 91, 188-9, 193-4, 307-9, 324-5, 334-5, 358 their insufficient number, 379-80, 382-3 Islington, 97, 99, 108, 120, 127, 155, 177, 180, 188, 201, 222, 224-5, 279-80, 288, 351, 355, 374, 380-1, 392-3, 424 JACOB'S ISLAND, foul water in, 23 Jewish sanitary laws, 143, 146, 149 KENRY, LORD, 371 Kensington, 98-9, 105, 121, 188, 219, 222, 225, 230, 278-9, 288, 355, 375, 383, 430 Kingsway, 413 LABOURING CLASSES LODGING HOUSES ACT of 1851, 69-70, 326 of 1867, 326 Lakeman, 371 Lambeth, 12, 17, 30, 98, 103, 105, 116, 122-4, 155, 188, 203, 222, 251-2, 267, 300, 309, 352, 354-5, 375, 424-5, 431 Lambeth Water Company, 73 _Lancet, The_, description of the Thames, 77 Lankester, Dr., 189 Laundries, public, 126 Lea Conservancy Board, 208 Lewisham, 98, 102, 144 Liddle, Dr. J., 399 Limehouse, 97-8, 111, 120, 163, 188, 251, 258, 279, 393 Little Coram Street, Bloomsbury, 262-3 Local government of the "City," 9 of Greater London, 11-4 lack of central authority, 13 Act passed in 1855, 82 Local Government Board Act, 1871, 232-3, 419 Local Government (England and Wales) Act, 1894, 382 Locomotion, additional facilities needed, 432 London, Bishop of, speech in 1850, 64 London County Council created, 338-9 powers given by Public Health Act, 1891, 359-61 and by Housing Act, 1890, 363-6 constituted education authority, 406-9, 418 summary of its work, 420 London Fever Hospital Report, 1845, 32 London Government Act, 1899, 396-7 London Government Bill, 1884, 311-3 Lynch, Dr. J., 33-4, 261 MARYLEBONE. _See_ St. Marylebone Measles, 408 Meat, inspection of imported, 318 Medical Officers of Health, their duties, 86, 91, 96 their reports, 92-3 their treatment by local authorities, 189 their labours, 399-400 Metropolis Local Management Act, 1855, 82, 110, 185 Metropolis Turnpike Trusts Act, 1828, 24 Metropolis Water Act, 1852, 71, 160, 191 Metropolitan Asylums Board, 210, 418, 420 Metropolitan Board of Works constituted, 83-5 abolished, 337-41 Metropolitan Building Act of 1844, 24, 76 of 1855, 88, 164, 204, 231 Metropolitan Burials Act, 1852, 55 Metropolitan Gas Act, 1860, 184 Metropolitan Market Act, 1851, 247 Metropolitan Paving Act, 1817, 12, 24 Metropolitan Poor Act, 1867, 208-10 Metropolitan Sanitary Association, 106 Metropolitan Sewers Commission, evidence before, 18-9 Metropolitan Water Amendment Act, 1871, 233-5 Metropolitan Water Board, 405-6, 418, 420 Middlemen, 323-4 Midwives Act, 1902, 409 Mile-End-Old-Town, 97, 99, 131, 163, 166, 227, 278, 288, 309, 333, 347, 383 Milk trade, 275, 318 Millbank estate, 366 "Model dwellings," 368-70 Morpeth, Lord, 43-4 Mortality, in the fifties, 120-1, 129-30, 144-5, 148, 150 in the sixties, 153, 156, 176-8, 191, 219-20, 223 in the seventies, 263, 278-81, 283 in the eighties, 292, 346-8 in the nineties, 350-1, 364, 392-3, 402 Mortuaries, 252, 358 Municipal Corporations Act, 1835, 78 Municipal Councils, created, 397-8, 417 their work, 421 Munro, J., 400 NATIONAL ASSOCIATION FOR PROMOTING SOCIAL SCIENCE, 181 New Oxford Street formed, 29 New River Company, 20 Newington, 12, 98, 101, 115, 122, 124, 144, 155, 185, 190, 214, 220, 224, 248, 250, 285, 309, 347, 354, 376 Notting Dale, 121, 177 Noxious trades, 37-8, 53-4, 87, 114-7, 145-8, 246-7, 252, 415 Nuisances Act, 1846, 39-40, 45 Nuisances Removal and Diseases Prevention Act, 1855, 82-3, 86, 117, 415 OVERCROWDING, in the forties, 29-34 in the fifties, 55-6, 107-14, 119, 127, 133-4, 145 legislation against, 87, 147-9, 193-4, 197 in the sixties, 165-77, 198-200, 202-3 in the seventies, 224-5, 243-6 in the eighties, 313-6, 332-3 in the nineties, 354-6, 371, 375-6 in 1901, 422-6 PADDINGTON, 98, 100, 102, 123, 155, 163, 168, 180-1, 184, 188, 201, 203-4, 220, 222, 224, 226, 248-9, 252, 279, 288, 290, 309, 376, 407-8, 425-6 Palmerston, Lord, 75 Parks and recreation grounds, 122, 206, 282, 414 Pauperism, 139 Paving boards in middle of nineteenth century, 12 Peabody Trustees, 265, 296 Pear Tree Court, Clerkenwell, 261 Pennethorne, J., 28 Phillips, J., 19 Physical deterioration, 426-7 Plumstead, 98, 267 Poor Law Act of 1879, 283 of 1889, 344 Poor Law Guardians, 407 Poplar, 97, 120, 123, 126, 155, 190, 199, 222, 227, 230, 254, 279, 284, 288, 300, 309, 331, 376, 393 Population, growth of, 9-10, 80, 155-7, 221-5, 288-9, 349-52, 401-2, 410 Port of London Sanitary Authority, 239-41, 283, 317-8, 416 Printing works, 172-3 Privy Council, medical department of, 152, 171 Public Health Act of 1848, 51-2, 79 of 1858, 152 Public Health (London) Act, 1891, 356-60, 385, 408, 412-3, 415-6, 429-30 Purvis, W., 237-8 REDESDALE, LORD, 165 Registrar-General's Report after census of 1861, 154 Rendell, Dr. William, 142-50, 175, 186-7, 189 Ritchie, C. T., 338, 359 Rodwell, Hunter, 271 Rosebery, Earl of, 341 Rotherhithe, 17, 36, 74, 98, 101, 105, 108, 114, 116, 117, 144, 177, 206, 220, 252, 280-1, 333-4 Ross, 323 Russell, Lord John, 66 Russell Court, Drury Lane, burial ground in, 36 ST. GEORGE, Hanover Square, 98, 137, 188, 212, 288, 351 St. George-in-the-East, 102-3, 106, 120, 233, 253, 278, 288, 303, 352-4, 391, 393 St. Giles', 28, 68, 97, 99, 100, 105, 108-10, 113, 124, 130, 139, 168, 176, 178, 191, 199-200, 224, 250, 252, 255, 260, 262-3, 305, 313-4, 375-6 St. James', Westminster, 97-8, 102, 109, 125, 130, 155, 170, 179, 189-90, 222-3, 249-52, 256, 272, 288, 290, 352, 369, 394 St. Luke, 97, 108, 219, 231, 255, 293, 314, 334, 353, 355, 364, 368 St. Martin-in-the-Fields, 97, 102, 129, 155, 161, 214, 352 St. Marylebone, 30, 97, 100, 105, 124, 181, 188, 222, 225, 232, 250, 280, 288, 299, 309, 354, 369, 374 St. Pancras, 97, 108, 115, 125-6, 128-9, 132, 155, 164, 169, 175, 188, 256, 268, 273, 279, 299, 304, 309, 348, 353, 367, 424, 430 Salisbury, Marquess of, 317, 322, 325-6 Sandhurst, Lord, 337 Sanitary Act, 1866, 193, 199-202, 217-8, 254, 266, 300, 302, 324, 429 Sanitary Law Amendment Act, 1874, 266, 305, 429 Scarlet fever, 249, 386, 415 Schools, overcrowding in, 113-4, 174, 244-6 defective drainage in, 421-2 School Board for London, 283-4, 292, 313-5, 406-7, 418 Scrofula, 58, 170 Sewers, early statutes relating to, 14 glaring inefficiency in the forties, 15-7 in the City in the fifties, 50-1, 60 plan adopted by the M.B.W., 90-1 medical officers' reports in 1856, 100-3 attention paid by Vestries and District Boards, 123, 249-51 M.B.W.'s scheme carried out, 158-9, 281, 411 L.C.C.'s report, 411-2 Sewers, Commissioners of, before Act of 1848, their authority, 9, 11, 15 their incapacity, 15-7 after Act of 1848, 41-2 superseded, 84 Shaftesbury (Ashley), Lord, 32, 47, 64, 66, 165, 174, 176, 274, 307, 366 carries Act to regulate common lodging houses, 67-8 Labouring Classes Lodging Houses Act, 69 Shops, 172 Shoreditch, 37, 97, 105, 111-2, 120, 166, 188, 228, 251, 267, 288, 309, 353, 355, 368, 380-1, 393, 425, 430 Simon, Dr. John, 50-62, 120, 171, 192, 215-7, 248, 286 Simpson, W., 29 Slaughter-houses, 247 Smallpox, 38-9, 146, 150, 208, 235-6, 269, 319, 386, 403 Smith, Dr. Southwood, 4, 6, 25-6, 151 Smithfield Market, 416 Society for Establishing Public Baths and Washhouses, 126 Society for Improving the Condition of the Working Classes, 70 Soho, 391 Southwark, 17, 98, 111, 120, 128, 131, 135-6 parish of St. George-the-Martyr described, 142-52, 167, 189, 214-5, 222, 224, 228, 230, 267, 279, 284, 305-6, 334, 347, 354, 364, 369, 374, 375, 393, 400, 424 Southwark Water Company, 21, 73, 192 Spitalfields, 28, 161, 245-6, 253 Stanley, Lyulph, 295 Stepney, 401, 424-5, 430 Strand, 97, 100, 110, 112-3, 115, 117, 123, 128, 133, 140, 176, 212, 223-4, 259, 288-90, 347, 352, 364, 392 Street improvements, 29, 205-6, 413-4 Sutherland, Dr., 75 Sweating, Select Committee on, 337, 370-2 TENEMENT HOUSES, 313-6, 353-6, 358, 375, 422-5, 428-31 _See_ also "Overcrowding" Thames, the, sewers discharged into, 15-6, 21 source of water supply, 21-2 _The Lancet's_ description, 77 a Medical Officer's words in 1858, 117-8 Embankment constructed, 207, 282 Thames Purification Act passed, 207-8 scope of Conservancy Board extended, 208 Port of London regulations, 239-41, 283 new treatment of sewage adopted, 332 Torrens, Mr., 213 Towns Improvement Act, 1847, 79 Tramways Act, 1870, 219 Tremenheere, H. S., 171 Typhus, prevalence of in 1838, 4 in 1847, 43 in the "City" in the fifties, 58, 112, 147 VACCINATION ACT OF 1836, 208 of 1871, 237 Vestries created, 83-9 inefficiency and inaction, 183-7, 266-73, 301-8, 321-2, 398-9 abolition, 398-9 Victoria sewer, 76 Vinen, Dr. N., 400 Vulliamy, G., 229 WALES, THE PRINCE OF (now King Edward VII.), 317, 364 Wandsworth, 98, 100, 124, 155, 177, 219, 222, 228, 230, 250, 279, 289, 402 Water supply, disgraceful condition of, 20-3, 104-7, 160-2, 191-2 for the "City," 51-2 Act of Reform passed in 1852, 71 Act of 1871, 233-5 Act of 1887, 331 Royal Commission of 1892-3, 383-4 Act of 1902, 405-6 general survey, 412-3 Waterlow Park, 414 Webber Row scheme, 364 Westminster (_see_ also St. James), 16, 97-8, 108, 110, 115, 126, 161, 167, 177, 201, 222, 288, 300, 303, 346, 375, 377, 430 Whitechapel, 33, 97, 99, 103-4, 114, 117, 121, 126-7, 130-1, 153, 160-1, 166, 168-9, 178, 200-1, 219, 229, 231, 243, 245-6, 253, 278, 288, 290, 293-5, 353, 368, 391-2, 399 Williams, T. Marchant, 313-6 Window tax, 26 Woolwich, 98, 332 Workhouses and infirmaries, 209, 389-90 Workmen's trains, 296-7 Workshop Regulation Act, 1867, 211-2 ZYMOTIC DISEASES, 42-3, 118, 131, 163, 170, 260-1 UNWIN BROTHERS, LIMITED, THE GRESHAM PRESS, WOKING AND LONDON. * * * * * Transcriber's note: Minor typographical errors have been corrected but inconsistent accents and punctuation are as in the original text unless noted below. Archaic spellings have been left unchanged. * CORRECTIONS TO THE ORIGINAL TEXT The following misprints and other errors have been corrected: Page 42 - the text "was it a" changed to "it was a" ("but none the less it was a forward step towards a sounder and wiser system of government"). Page 96 - the text "it amounted it" changed to "it amounted to" ("And that is what, undoubtedly, it amounted to"). Page 121 - "61·3 of the total deaths." changed to "61·3 per cent. of the total deaths." Page 145 - the text "illness resulting difficult of cure" changed to "illness resulting in difficulty of cure" ("each from illness resulting in difficulty of cure, constantly recurring."). Page 199 - the text "precisely the powers which not last year only," changed to "precisely the powers which, not last year only," ("Section 35 gives precisely the powers which, not last year only, but every year since the constitution of the Board, the Medical Officer has demanded"). Page 203 - sentence changed from "And another example near Paddington Road--where 275 houses had been built, and the population was 493 to the acre; showing" to read "And another example near Paddington Road, where 275 houses had been built, and the population was 493 to the acre, showing--" Page 207 - the text "acccess of energy" changed to "excess of energy" ("The visitation of cholera was doubtless in the main accountable for the excess of energy displayed by Parliament about this period"). Page 219 - comma added after "50 per cent." ("the high rate, nearly 50 per cent., of infantile mortality"). Page 246 - the text "in the yards of some of them slaughter-houses" changed to "in the yards of some of them were slaughter-houses" ("indeed, in the yards of some of them were slaughter-houses, with all their unpleasant concomitants."). Page 304 - the text "for there many" changed to "for there were many" ("for there were many and considerable advantages in this form of procedure"). Page 314 - the text "was 382" changed to "as 382" ("He gave the number of families ... residing in more than two rooms as 382, ...."). Page 353 - "inhabitating" changed to "inhabiting" ("number of persons inhabiting each"). Page 357 - "prejudical" changed to "prejudicial" ("injurious or prejudicial to health"). Page 375 - the text "76·1 of the population" changed to "76·1 per cent. of the population" ('In Bethnal Green (1894), "76·1 per cent. of the population lived in tenements of less than five rooms. No houses had been registered."'). * OTHER CHANGES AND NOTES The following changes to the original text have been made for clarity or consistency: In CHAPTER I, the section numbers have been prefixed with the words "CHAPTER I, PART" for clarity. This means that the headings of the sections in this chapter are now-- CHAPTER I CHAPTER I, PART II CHAPTER I, PART III CHAPTER I, PART IV CHAPTER I, PART V The word "death roll" changed to "death-roll" throughout to match the more numerous instances of the latter form in the original text. Page 254 - reference to "The Artisans' and Labourers' Dwellings Act (Torrens) of 1868" changed to "The Artizans' and Labourers' Dwellings Act (Torrens) of 1868". Page 437 - reference in the Index to "Metropolitan Markets Act, 1851" changed to the correct title of "Metropolitan Market Act, 1851" as cited on page 247. Footnotes have been re-indexed using numbers and collected together at the end of each chapter. Where there were multiple references on a page to the same footnote, the second and subsequent reference is now sequentially numbered with its own footnote which says "Ibid." The following variations of a word or descriptive term are common in the original text and have been retained: "Common Lodging House", "lodging house" and "lodging-house" "back-yard" and "backyard" "cow-houses" and "cow houses" "lime-washed" and "limewashed" "over-crowded", "overcrowded" "over-crowding", "overcrowding" "re-built", "rebuilt" "re-build", "rebuild" "re-inspection" and "reinspection" "sub-soil" and "subsoil" "tenement-house" and "tenement house" "Wash-houses" and "Washhouses" "water-course" and "watercourse"