Chapter 18

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:

If weak and nervous, we shall look like this before taking exercise:

And like this after gymnasium exercise:

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.

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.

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.