What the State and

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State and the Municipality Can do to Create an Environment Favorable to Health.

M. V. BALL, M. D.

WARREN, PA.

President Board of Health.

TAKE it that disease is a result of the failure of the organism to adapt itself to its surroundings. Life is a process of adjustment, and in so far as we fail to adjust ourselves to the continual changes in our environment, we degenerate and become the subject or host of parasites and the various organs of our body cease to functionate and die. To prevent disease, therefore, we have either to make our tissues resistant so as to repel invasion, or we must alter our surroundings so as to destroy the disease producing factors.

The efforts of medicine have been largely directed to the endeavor to make the individual disease resistant; or failing in this, to antagonize and neutralize and repair the effects of the evil. Some attention, too, has been given to the environment and measures, on a more or less extended scale, have been put in operation to destroy disease producing agents. Thus recently the active warfare in Havana against the mosquito, which is believed to be the most important disseminator of the yellow fever parasite. Likewise, the efforts of all boards of sanitation in removing nuisances and securing pure food and drink.

Since the investigation of Weissman and his followers, heredity as a cause of disease, has lost much of its importance. Where the structure of the organism is deficient in some of its elements at birth, due either to some interference in nutrition during the process of formation or some mechanical disturbance of the embryological process, the germ cells may become so altered as to reproduce this alteration in succeeding generations; but the greater number of diseases are such as attack the individual during his own lifetime, and do not influence that portion of his organism which transmits his physical characteristics to his children. We are concerned with heredity only in so far as we would avoid the breeding from degenerated stock, from parents who from birth are markedly defective. How much the environment has to do with the production of even such congenital defects, as idiocy and insanity, an environment surrounding the mother during the development of the fetus, no one has as yet thoroughly determined. Whatever seriously affects the nutrition of the mother during pregnancy must have an influence on the fetus. Thus, environment in its broader sense is an important factor in the causation of disease, and one which man has sufficiently under control to shape for good or evil. In the economic and social world, many of the natural and physical forces have been utilized or provided against, and from earliest times man has made himself master of some of them. Deaths still occur from cold and heat, earthquakes, floods and volcanic outbursts, wolves and other wild beasts still attack the habitations, and worst of all, war between man and

man has not ceased to claim its many victims, yet for the most part, civilized man lives in comparative safety, safe from famine, frost, fire and flood and the outbursts of wild animals and savage tribes. Thousands, however, die annually from diseases which are clearly preventable; thousands are killed annually in accidents which are clearly preventable. Indirectly, the individual is responsible himself, but more often the social group, be it city, state or nation, is the offender, at least it is in a position to prevent the disease when the individual alone is powerless.

With our present knowledge, what can an enlightened government do to prevent disease, when it seriously determines to utilize this knowledge?

HOUSING OF THE PEOPLE.

That disease is caused by living in crowded and poorly constructed tenements, municipalities are beginning to recognize and are enacting laws to control the construction of the larger tenements, and are destroying hovels and rookeries which have grown very unsanitary. There should, however, be laws which would require all living houses to be built on streets of ample width, never in courts and alleys. All streets to be provided with shade trees, and at regular intervals of not more than six blocks, an open square or breathing park. The pavement on such streets should be easily cleaned and noiseless. Horseless carriages which, no doubt, will soon become general, should have constructed for them special roadways leaving the regular pavements for the pedestrian solely. The houses themselves, whether tenement or private, should be approved of by a board of sanitary engineers, who shall see to it that each new house constructed shall be as sanitary as our knowledge warrants. The use of wall papers and carpets should be especially condemned, and all fittings and furniture that cannot be thoroughly and frequently cleaned. Whenever tenants remove from apartments, the apartments should be well disinfected before new tenants are allowed to use the same. Laws in regard to plumbing and fire escapes, ventilation and toilet facilities are embodied in the recent New York Tenement House law which has many other features worthy of imitation and which is a step in the right direction. Al houses which have become permeated with insects, vermin, mould and are poorly constructed, and so unhealthy as residences should be condemned, and if not possible to properly repair, should be destroyed as nuisances whether inhabited by the owner or tenants. Sanitary architects should be employed by the city to study up new designs and devices and supply the citizens with the plans in order to bring about not only a city of healthy houses, but also a beautiful city.

THE AIR.

That the air we breathe is very often a conveyor of disease, the laboratory experiments in bacteriology have repeatedly shown. The air is laden with disease germs, not only of tuberculosis, but of pneumonia and influenza, diseases which are responsible for many thousands of deaths annually. The dust, too, of the streets contains germs and spores derived from the manure of the lower animals, and how many intestinal diseases, especially of children are due to the entrance of these germs, con

veyed from the dust to food, and so into the body, it is not possible to say. Wounds suppurate from the action of air-borne bacteria. Again, the air is rendered heavy and impure by the smoke of many factories and engines. All factories and locomotives should be compelled to use smoke consuming devices. The streets should be carefully swept and kept clean continually, and in every way possible should the accumulation of dust be prevented. That the dust and dirt of a big city is a frequent source of disease, causing among other things, catarrhal affections of the nasal passages, no physician can deny. In this respect the cities of Germany are exemplary.

FOOD AND DRINK.

Improper food and drink are very important factors in the causation of disease. Governments attempt to prevent adulteration of food and the sale of meat from diseased animals, and regulate the sale of milk. There are laws, too, in some states, preventing the pollution of streams used for drinking purposes, but these latter laws are not strictly enforced. Milk is an uncertain article of diet. It is unknown whether or not milk from a tuberculous cow will give rise to tuberculous in man. There is, however, a strong presumption that milk from such a cow is dangerous to human beings, and especially infants. That milk from healthy cows speedily undergoes changes and becomes contaminated with myriads of bacteria if not handled in a very careful manner, is a matter well and commonly known. Government regulation of the dairies and handling of milk is of course, in vogue in many places, but everywhere does the law fall short of obtaining a healthy and safe supply of this very important and nutritious article. Under direct municipal ownership we think a better condition of the dairies would be assured. First.-The herd should be under constant surveillance of the veterinarian and all supsicious animals should be removed. Second.-The milking should be done under strictly aseptic precautions. The milk should, if possible, be obtained without the use of the hands and in rooms thoroughly clean. The milk should then be sterilized and bottled and consumers advised to use the milk in original containers only. The peddling of milk in bulk should be strictly interdicted, nor should any one but municipal employes be allowed to dispense it.

Water for drinking purposes should be obtained from springs which can be protected from pollution. Its bacterial analysis should be taken frequently and regularly.

Public markets under municipal control and subject to sanitary inspection should be built in convenient portions of the city where meat, fish and fruit are to be found for sale, and at no other place should meat be exposed. Here all such food should be inspected and of course a preliminary inspection should be made at the slaughter-houses. Paris and Berlin have such markets. Too much care cannot be taken with such articles of food as meat and fish

The use of preservatives like borax, formaldehyde and salicylic acid must certainly be considered dangerous to health. First, because it would

be impossible to say how much deterioration had taken place before the chemical was used, and thus poisonous products may have been formed that the preservative would not counteract. Second.-The dose of the chemical could not well be regulated, and though small amounts of the same may not be unhealthy, larger amounts and taken for a long period of time would undoubtedly bring about serious changes in the human organism.

SCHOOL LIFE.

Although it is true that the average child in America spends but four years in school, yet a great many children attend school for at least ten years, and spend a large part of their waking hours in the school-house. How very necessary is it then that the school house should in every way be sanitary. Since the school age of a child is, next to its infancy, the most important from the health standpoint, a State, careful of the lives of its citizens and desirous of preventing disease, will do its utmost to safeguard its school children, especially as they are for the time being its wards. As a rule, modern school houses are well built, though too often they have no grounds around them. A school-house should have plenty of play-ground. A city square would be none too small a space for, every school-house. Plenty of shade and plenty of sunlight. The gymnasium and swimming pool should not be wanting. Most important, however, is the health history of every child. A careful physical examination should be made of every child on entering its school life-eyes, ears, throat, urine and blood not excluded. Once a week its temperature and its weight should be taken and recorded. Every day the school's medical officer should inspect every child. The school should have its own physician; a teacher in physiology, and perhaps director of the gymnasium might be some of his other duties. He should study each child as if it were a patient in a hospital, in order that the slightest deviation in health might be detected promptly and speedy action taken to avert disease. The physician should be trained in a new mental science, a new psychology, and he should endeavor to direct the education of each child in the field best suited to it. The study periods must be short-the hand and eye and ear should receive more special training, yes not even neglecting the legs. No child should be allowed to leave school under 18 years of age. Out of 22,000,000 children of school age in the United States, only a very small precentage ever obtain a high school education. The greater majority are obliged to enter the shop and store and mine before they are 14 years of age. Children employed often at hard and always at lengthy labor at a most important period of their lives, namely, the period of puberty, are certainly liable to be dwarfed in body as they are in mind. No country can well afford to make slaves of its children, to confine them in factories for eight, ten and twelve hours a day, at work that is often dangerous and never healthful. Sooner or later, this practice must result in a nation of deteriorated men and women.

It is not my purpose here to show the economic necessity for doing away with child labor, but I believe that every argument against the labor of children under twleve holds equally good against the labor of children

up to eighteen, and most certainly the law considers such persons children.

No child can learn well, who is not efficiently nourished. To expect children who have had nothing but a bit of dried bread and a cup of coffee for their breakfast, and perhaps a dinner equally unnutritious, to acquire healthy knowledge, or to acquire knowledge and remain in health, is one of the absurdities of our times. We experiment unceasingly to keep our soldiers well nourished both in peace and war. Soldiers are the policemen who defend our wealth, but the school children whom we take under our care and spend millions every year to educate, compel even to acquire an education, these we have no concern about if they are fed well or ill, or not fed at all, if they are clothed poorly or go naked.

If it is our business to prevent illness we will see to it that the school kitchens and dining-rooms shall be one of the most important departments of our educational system. In them shall be cooked and served at least one meal a day that should be nutritious and suited to the nature of the child. The food problem shall here be worked out on a scientific basis, and at least as much attention should be paid to the commissary department of the school army as is paid to that of the regular army. Înasmuch, however, as children are more delicate than men and their bodies are being formed, and it is our purpose to create a race of healthy individuals, I maintain that this department should have the utmost consideration shown to it. My attention was called to a recent news item, that in one of the continental cities, the superintendent of schools forbade girls the use of corsets. I would urge the state to furnish to children for use during school hours, suitable uniforms that would allow the limbs and chest to be unhampered in their movements, and that would be in accordance with the most approved hygienic garments. We uniform our soldiers, why not our scholars? Children then would not remain away from school, because they had no shoes to wear, or would not be obliged to come in tattered clothing and insufficient to keep out the cold.

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THE WORKERS.

Our young men and women now enter another period of their lives. They become workers. We are not concerning ourselves with a Utopia, but merely with such practical measures which any city could put in use at once if it cared to. We will take it for granted that the greater number young men and women will be employed in large factories. This is an age of concentration and specialization; the factories grow larger and combine, and are more and more united under one management, therefore it is easier for general measures to be introduced-general methods as to book-keeping, buying, etc., and so general methods looking to the health and safety of the employes will be found in the end to pay. But even if the corporation is short-sighted, the state or municipality must not be, and knowing or learning that one case of sickness prevented is worth more than the attempt to cure a dozen, it will provide more and more for the health of the workers.

First of all, no person under 18 years will be employed, all such will be in school; and no one over sixty should be employed. Some corpora