PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS

CHAPTER XXVIIToC

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.

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:

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 XXVIIIToC

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:

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:

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!

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 XXIXToC

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.

Five elements of adequate machinery are generally lost sight of:

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.

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.

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."