!!^'l
THE SPRINGFIELD SURVEY
Shelby M. Harrison, Director
I
THE SCHOOLS OF SPRINGFIELD, ILLINOIS.
Leonard P. Ayres, E*h.D., Director, Division of Education, Russell Sage
Foundation.
II
RECREATION IN SPRINGFIELD, ILLINOIS.
Lee F. Hanmer, Director, and Clarence Arthur Perry, Associate Director,
Department of Recreation, Russell Sage Foundation.
Ill
HOUSING IN SPRINGFIELD, ILLINOIS.
John Ihlder, Field Secretary, National Housing Association.
IV
CARE OF MENTAL DEFECTIVES, THE INSANE, AND ALCOHOLICS
IN SPRINGFIELD, ILLINOIS.
Walter M. Treadway, M.D., Assistant Surgeon, U. S. Public Health Service
for National Committee for Mental Hygiene.
V
PUBLIC HEALTH IN SPRINGFIELD, ILLINOIS.
Franz Schneider, Jr., Sanitarian, Department of Surveys and Exhibits,
Russell Sage Foundation.
VI
THE CORRECTIONAL SYSTEM OF SPRINGFIELD, ILLINOIS.
Zenas L. Potter, Department of Surveys and Exhibits, Russell Sage Founda-
tion.
VII
THE CHARITIES OF SPRINGFIELD, ILLINOIS.
Francis H. McLean, General Secretary, American Association of Societies for
Organizing Charity.
VIII
INDUSTRIAL CONDITIONS IN SPRINGFIELD, ILLINOIS.
Louise C. Odencrantz, Committee on Women's Work, and Zenas L. Potter,
Department of Surveys and Exhibits, Russell Sage Foundation,
IX
CITY AND COUNTY ADMINISTRATION IN SPRINGFIELD, ILLINOIS.
D. O. Decker, Civic Commissioner, Commerce Club, St. Joseph, Missouri,
and Shelby M. Harrison, Director, Department of Surveys and Exhibits,
Russell Sage Foundation.
X
SPRINGFIELD: THE SURVEY SUMMED UP.
Shelby M. Harrison, Director, Department of Surveys and Exhibits, Russell
Sage Foundation.
SPRINGFIELD SURVEY EXHIBITION:
Findings and recommendations of the Survey were presented in an Exhibition
in Springfield, under the direction of E. G. Routzahn, Associate Director, De-
partment of Surveys and Exhibits; Mary Swain Routzahn, Exhibition Di-
rector; and Walter Storey, Director of Design and Construction.
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SE14
PUBLIC HEALTH IN
SPRINGFIELD, ILLINOIS
A SURVEY BY THE DEPARTMENT OF SURVEYS AND
EXHIBITS, RUSSELL SAGE FOUNDATION
FRANZ SCHNEIDER, JR.
R-S
•F-
THE SPRINGFIELD SURVEY
PUBLIC HEALTH SECTION
Department of Surveys and Exhibits
Russell Sage Foundation
New York City
May, 1915
"■lOLtHflP.
PUBUC
h£aith
LIBRAJRY
Copyright, 1915, by
The Russell Sage Fol^ndatiox
PRESS OF WM. F. FELL CO.
PHILADELPHL\
FOREWORD
The aim of the analysis of Springfield's vital sta-
tistics contained in this report has been sufficiently
different from that of common practice to require
a word of explanation and emphasis. It has seemed
better to portray to Springfield its life and health
losses in terms of its own people, rather than to com-
pute rates of mortality based on all registered
deaths and compare these rates with those occur-
ring in other cities. To this end deaths of non-
residents have been excluded from the tables and
text except at places where the contrary is specifi-
cally stated. Springfield's losses thus stated con-
vey to the citizens a more accurate and conservative
picture of the city's public health problem, and are
of themselves amply serious to justify any of the
preventive procedures advocated in this report.
The reader must be warned, however, against com-
paring the rates here given for Springfield with
those published for other cities, unless it is specifi-
cally stated that the latter do not include deaths
of non-residents. Otherwise such comparisons
would show Springfield to an unfair advantage.
The present report is the result of field investiga-
tions carried on by the author in Springfield in the
nine weeks between March 23 and May 26, 19 14,
supplemented by co-operative efforts by city and
state officials and local volunteer workers. With-
out the generous co-operation of Dr. B. B. Griffith,
superintendent of health, the enumeration of the
wells and privies — a task requiring the services of
the three sanitary inspectors for the better part of
two months — would not have been possible. Sim-
v
41584
FOREWORD
ilarly, the survey owes the investigation of the
dairy farms largely to the interest and energy of Dr.
C. St. Clair Drake, executive secretary of the
Illinois State Board of Health. Thanks are also
due to the National Association for the Study and
Prevention of Tuberculosis, whose field secretary,
Dixon Van Blarcom, made the investigation of the
local tuberculosis situation; to Dr. Edward Bar-
tow and Prof. Paul Hansen of the State Water Sur-
vey and to city commissioners W. J. Spaulding and
Frank Hamilton for much valuable information
regarding the city water supply and sewer system ;
to the State Food Commission for access to its
Springfield records; and to W. J. V. Deacon for
his analysis of the city's mortality statistics for 1910
and 1913.
The author also wishes to make acknowledgment
to Dr. George Thomas Palmer, former superin-
tendent of health, and Paul L. Skoog, former act-
ing superintendent of health, for generous contribu-
tions of information and time; and to Dr. Charles
V. Chapin and Prof. Selskar M. Gunn for their
courtesy in criticising parts of the manuscript.
Finally, acknowledgment must be made of the very
considerable assistance received from Springfield
volunteer workers, and in particular to Mrs.
Francis P. Ide, Mrs. H. L. Morrison, Miss Mary
Johnson, and Miss Henrietta Converse. The
names of many other volunteer workers will be
found on the back page of this report.
VI
TABLE OF CONTENTS
PAGE
Foreword v
List of Illustrations ix
List of Maps and Diagrams xi
List of Tables xiii
I. Life Wastage in Springfield i
II. Fundamental Facts Regarding Springfield 5
III. Infant ^Mortality 11
IV. Contagious Diseases of Children 25
V. The Springfield Tuberculosis Situation. By Dixon Van Blarcom 37
1. Extent of Tuberculosis in Springfield 38
2. Existing Agencies for the Control of the Disease 43
3. Suggestions for an Adequate Campaign 46
4. Where the Responsibility Lies 55
VI. Typhoid Fever 58
VII. The Venereal Diseases 65
VIII. City W^ater Supply 72
IX. Sewerage and Sewage Disposal 82
X. Wells and Privies 86
XI. Milk Supply 96
XII. Food Supply 103
XIII. Other Sanitary Conditions no
XIV. Springfield's Public Health Service 116
XV. Summary and Conclusion 128
APPENDICES
A. Selected Mortality and Morbidity Statistics by Year and Ward,
Springfield, 1908-1913 139
B. An Analysis of Springfield's Death Rate for 1910 and 1913. By
W. J. V. Deacon 142
C. Tuberculosis Death Rates 143
D. Population Statistics by Ward, Springfield 144
E. Estimates of Gross and Net Acreage, Springfield 145
F. Bacteriological Examinations of City Water 146
Index 147
VI 1
LIST OF ILLUSTRATIONS
PAGE
Baby-saving Work in Montclair, New Jersey 22
An Infant Welfare Station in New York 22
The Tuberculosis Association Dispensary 49
Present Type of City Water Supply Development 74
Testing a Drive Well 76
The New Pumping Station 77
Some Springfield Sewer Outlets 85
Springfield's Well and Privy Menace 92
Well and Privies Used by Three Families 94
One of Springfield's Poor Dairies 97
Somewhat Better 97
In One of Springfield's Good Dairies 99
The Small Middleman loi
A Good Milk House 102
A Springfield Bakery 104
Dough Kneader in Bakery^ 105
Toilet Facilities in Food-handling Places 106
A Meat Market Privy 107
Meat Market Interior 107
In the Rear of a Meat Market 109
Physical Examination of Children in Springfield's Schools no
Where Flies Breed 113
Another Example of Springfield's Manure Problem 113
The City Refuse Incinerator 114
How Smallpox Spreads 120
The Contagious Disease Hospital 123
IX
LIST OF MAPS AND DIAGRAMS
PAGE
Topography of Springfield and Vicinity Frontispiece
Leading Causes of Death, Springfield, 1913 3
Ward Map of Springfield, 19 14 6
Growth of Population in Springfield and State of Illinois, 1840-1910. ... 7
Distribution of Population in Springfield 8
Negroes in Springfield by Wards 10
Foreign-born Whites in Springfield by Wards 10
Births in Springfield, 1913 13
Birth Rate by Wards, Springfield 15
Deaths of Infants Under One, Springfield, 1908-1913 17
Deaths of Infants Under Two from Diarrhea and Enteritis, Springfield,
1908-1913 19
Diarrhea and Enteritis — Infants Under Two, Springfield 21
Cases of Scarlet Fever Reported to the Health Department, Springfield,
1909-1913 27
Contagious Diseases of Children, Springfield 28
Diphtheria in Springfield. Ward Death Rates per 100,000 Children —
Ages 6 to 20 years 30
Diphtheria in Springfield. Deaths per Hundred Cases Reported — By
Wards 30
Cases of Diphtheria Reported to the Health Department, Springfield,
1909-1913 32
Death Rates from Certain Preventable Causes by Year, Springfield, 1908-
1913 35
Tuberculosis in Springfield 38
Deaths from Tuberculosis, Springfield, 1908-1913 40
Tuberculosis Death Rates by Color and Year, Springfield, 1909-19 13 56
Typhoid Fever in Springfield. Ward Death Rates per 100,000 Population 59
Typhoid Fever in Springfield. Deaths per Hundred Cases Reported — By 59
W'ards 59
Pneumonia in Springfield. Ward Death Rates per 100,000 Population. . . 68
Pneumonia in Springfield. Deaths of Residents under Fifty-five Years
of Age, 1908-1913 69
Why Springfield Must not Pump from the River 73
Built-up Areas without City W^ater and without Sewers 79
Built-up Areas with Either No City Water or No Sewers; and Areas with-
out Both 80
xi
LIST OF MAPS AND DIAGRAMS
PAGE
Private Wells in Springfield, 1914 (insert) 86-87
Comparison of the Numbers of Wells and Privies Found^in 19 10 and 19 14. 88
Privies in Springfield by Wards 90
Private Wells in Springfield by Wards 91
Privies in Springfield, 1914 (insert) 92-93
Manure Accumulations in Springfield, 19 14 112
Smallpox in Springfield no
Sanitary Conditions in Springfield Wards 130
Social Statistics of Springfield Wards 132
Preventable Mortality in Springfield Wards ^ 133
Xll
LIST OF TABLES
TAbLE PAGE
1. Preventable deaths, Springfield, 1908-1913 (Residents only) 4
2. Population by color and nativity, Springfield, Illinois, 1850-1910 7
3. Density of population by ward, Springfield, 1910 9
4. Deaths of infants under one year of age, Springfield, 1908-19 13 (Resi-
dents only) II
5. Registration of births, Springfield, 19 13 14
6. Birth statistics by ward, Springfield, 19 13 15
7. Mortality of infants under one year of age by ward, Springfield (Resi-
dents only) 18
8. Infant mortality from principal preventable causes by ward, Spring-
field, 1908-1913 20
9. Deaths of infants under one year of age from diarrhea andenteritis
by ward, Springfield, 1908-1913 (Residents only) 21
10. Mortality from contagious diseases of children, Springfield, 1908-19 13
(Residents only) 25
11. Mortality from contagious diseases of children by ward, Springfield,
1908-1913 26
12. Case fatality from diphtheria and scarlet fever by ward, Springfield,
1909-1913 28
13. Death and fatality rates by year, contagious diseases of children,
Springfield (Residents only) 29
14. Mortality from tuberculosis, Springfield, 1909-1913 (Residents only) . 39
15. Tuberculosis cases treated by 49 Springfield physicians. May, 1914 ... 41
16. Results of sputum examinations made in the bacteriological laboratory
of the Illinois State Board of Health, during 1910-1913 42
17. Results of sputum examinations made at St. John's Hospital, May,
1912, to May, 1914 43
18. Death and fatality rates, typhoid fever, Springfield, 1908-1913 (Resi-
dents only) 58
19. Wells, privies, and typhoid fever by ward, Springfield 60
20. Examples of return cases of typhoid fever, Springfield 62
21. Cases of venereal disease treated by 49 Springfield doctors. May, 1914 . 65
22. Deaths from syphilis as certified in Springfield, 1908-1913 (Residents
only) 67
23. Estimates of ward populations not served with city water, Spring-
field, 1914 78
24. Estimates of ward populations not served by sewers, Springfield, 1914. 83
25. Data regarding Springfield sewer outlets 84
xiii
LIST OF TABLES
TABLE PAGE
26. Wells and privies in Springfield, 1910 and 1914 87
27. Changes in numbers of wells and privies by ward between 19 10 and
19 14, Springfield 87
28. Wells and privies by ward, Springfield, 1914 89
29. Unnecessary wells by ward, Springfield, 1914 90
30. Unnecessary privies by ward, Springfield, 1914 91
31. Dairy farms according to scores on prime essentials, Springfield, 1914 . 98
32. Milk producers according to amount produced, Springfield, 1914 99
33. Milk producers according to manner of sale, Springfield, 1914 100
34. Results of inspection of various food-handling places, Springfield,
1914 103
35. Work of city meat inspector, Springfield, January i to May i, 1914 . . . 108
36. Health department appropriation, Springfield, Illinois. Fiscal year
ending February 28, 1915 125
XIV
LIFE WASTAGE IX SPRINGFIELD
Health and life are primary human possessions whose infinite
value flashes upon us only when we are in danger of losing them.
Disease and death are sources of i^sery and economic loss.
These statements seem almost too obvious to set down; yet
their full force is constantly lost sight of and their fruitful appli-
cation is neglected. And this despite the fact that with the
great advances in sanitary science public health is becoming
more and more purchasable.
Disease is a subtle and industrious enemy. It comes into the
home by an unseen door; it knows no cessation of hostilities
by night or day; and with every new mode of human activity
it finds a new line of attack. It is this insinuating though unre-
lenting nature of disease that makes it inconspicuous and of
underrated significance. Only by standing off and viewing the
extent of the ravages worked by the disease cohorts in a con-
siderable period of time may we discover their destructive reality
and judge what forces must be marshalled against them for
effective prevention.
To count the tally of a city's disease and death record is not
of negative value, but should lay the foundation for constructive
action. In making a public health survey of Springfield, our
task, therefore, in general terms is to examine her death and sick-
ness records and her sanitary conditions, and to determine what
losses she is suffering and in what ways these losses may be pre-
vented.
The most definite index of Springfield's health history is to be
found, of course, in her death records. A common method of
treating this material is to compare the number of deaths regis-
tered in a year with the number of inhabitants; in other words,
to compute the death rate. This operation, and the comparison
I I
TlHE SPRINGFIELD SURVEY
of the city's death rate with those of other communities, is,
however, fraught with opportunities for error.
In general practice, the number of deaths registered in a city
includes all persons dying within the city limits, whether resi-
dents of that city or not. If the city is the hospital center for
the surrounding country, it will consequently be charged with
many deaths for which it has no responsibility, and an erroneous
impression will be created. Similarly, if the city has an unusual
proportion of infants or old persons, both of which classes have
high death rates, its general death rate will be raised out of all
proportion to its inherent healthfulness or unhealthfulness.
To illustrate the first condition : according to the report of the
city health department 994 persons died in Springfield in 1913;
of these, 185, or 18.6 per cent, were non-residents. Including the
non-residents, the city's death rate was 17.6 per thousand in-
habitants; excluding them, it drops to the more respectable
figure of 14.3. A certain though smaller number of Springfield
residents, on the other hand, died outside the city, their deaths
being registered in other communities. No universal method of
keeping track of these transfers between communities exists
as yet, so that the number of deaths added to or subtracted from
a city's record is in most instances indeterminate. For these
reasons comparisons of general (''crude") death rates are of ex-
tremely doubtful value.*
In the present survey attention will be restricted to deaths of
Springfield residents, the causes of these deaths, and their dis-
tribution throughout the city. On this basis the questions
naturally arise as to what are the leading causes of death in
Springfield and in w^hat degree they are preventable. The
diagram opposite gives the primary facts for a discussion of these
questions.
Striking indeed is the fact that the leading cause in Spring-
field's death list, tuberculosis, is a preventable disease; and that
the second, pneumonia, — whose active agent is also a micro-
organism,— is to a considerable degree preventable. With the
* See Appendix B, p. 142, for an analysis of Springfield's death rate on the
basis of residence and age. A general statement of the statistical methods
used in this report appears in Appendix A, p. 139.
2
PUBLIC HEALTH IN SPRINGFIELD
third and fourth causes, heart disease and Bright's disease, the
health authorities can do little of a direct nature; but the fifth,
diarrhea and enteritis among infants under two, offers great op-
portunities for life saving. Other opportunities for prevention
may also be noted in the records of typhoid fever, syphilis, the
contagious diseases of children, and a part of the accidents and
premature births. Altogether, the number of preventable deaths
constitute at least a fourth and quite possibly a third of all
Tuberculosis
86 1
Pneumonia
73 1
Organic heart disease
69 1
Bright's disease
58
Diarrhea and enteritis under 2
54
Cancer
40
Accident
38
Premature birth
29
Old age
28
Apoplexy
27
Suicide
18
Whooping cough
16
Congenital debility
16
Meningitis
15
Paralysis
15
Diphtheria
13
Syphilis
13
Measles
13
Alcoholism
13
Typhoid fever
10
Murder
10
Leading Causes of Death, Springfield, 19 13
Residents only
the deaths. Summarizing the city's record with respect to the
principal preventable causes for the last six years, 1908-1913,
the totals are impressive, as will be seen in Table i.
This list is conservative. It omits deaths from pneumonia
among old persons; deaths of infants certified under such titles
as premature birth, marasmus, and inanition; deaths from men-
ingitis and puerperal septicemia; and a number of other causes
where modern medicine argues that some saving can be made.
Yet the six-year total from preventable diseases reaches 1,218, a
3
THE SPRINGFIELD SURVEY
figure that about equals an entire year's addition to the commu-
nity through births. Nor is this loss among the old and halt;
it is among the young and the productive. Tuberculosis, for ex-
ample, responsible for 490 deaths during the period, strikes in
between the ages of twenty-five and fifty. And it must be re-
membered also that for each person dying from these diseases
there must be counted several cases of non-fatal illness.
table i. — preventable deaths, springfield, i908-i913
(residents only)
Deaths
Diseases
Tuberculosis 490
Diarrhea and enteritis under 2 years 228
Pneumonias under 55 years 227
Typhoid fever 84
Diphtheria 61
Whooping cough 44
Measles 31
Syphilis 30
Scarlet fever 23
Total 1,218
Accidents
Railroad 49
Coal mine 13
Other 125
Total 187
The multiplication of misery, suffering, and economic loss
thus involved makes it evident that health and life wastage in
Springfield is of a magnitude that demands the community's
businesslike attention. Obviously the city should study the ways
in which this wastage manifests itself and the ways in which
it may be restricted. The more specific questions are : Wherein
Springfield do the preventable diseases manifest themselves?
What conditions favor their spread? What is the city's equip-
ment to cope with the problem? What new measures should be
undertaken?
II
FUNDAMENTAL FACTS REGARDING SPRINGFIELD
The city of Springfield proper occupies about eight and one-
half square miles on the level prairie about four miles to the
south of a meander in the Sangamon River. Its surface, as
may be seen from the frontispiece, is very flat, the difference in
elevation between the highest and lowest points of land within
the city limits being only about 70 feet, and for about four-fifths
of the city's area the difference being less than 20 feet. The
city lies between two parallel creeks which flow in a north-
easterly direction to the Sangamon. Spring Creek, to the north-
west, receives about three-fourths of the city's drainage; Sugar
Creek, to the southeast, carries off the rest. The deepest de-
pressions within the city occur to the north and west, the principal
one being caused by the Old Town Branch, a tributary of Spring
Creek, whose drainage area extends from beyond the Wabash
railroad yards on South Tenth Street, and which flows through
the center of the city in a northwesterly direction, passing be-
tween the capitol and the court house and out along Salome
Avenue. This stream is the city's principal drain and has been
covered over and converted into a sewer.
Six railroads, exclusive of the Interurban Electric Line, enter
Springfield. Although these roads pierce the city limits at
some 13 points, but three lines of track actually cut through the
city. Two of these enter at the south and pass up Third and
Tenth Streets to the north, finally veering off to the east. The
other crosses in an east and west direction along Madison Street,
a little to the north of the center of the city. The railroads are of
social importance in influencing living conditions along their
lines and in establishing lines of division between parts of the
community. Thus the ward lines running north and south are
based on the railroads, the territory between Third and Tenth
5
THE SPRINGFIELD SURVEY
The Springfield Survey,
Springfield, Illinois
Ward Map of Springfield, 19 14
For a general description of the ward populations see page 9
PUBLIC HEALTH IX SPRINGFIELD
Streets forming three of the city's seven wards. The ward di-
visions are shown on page 6.
TABLE 2. — POPULATION BY COLOR AND NATIVITY, SPRINGFIELD,
ILLINOIS, 185O-I9IO
Year
Total
population
Negroes
Number I Per cent
Foreign-born whites
Number 1 Per cent
1850
4,533
171
3.77
a
a
1860
9,320
203
2.18
a
a
1870
17,364
808
4-65
4,456
25-7
1880
19,743
1,328
6.73
4,284
21.7
1890
24,963
1,806
7.24
4,796
19.2
1900
34,159
2,227
6.52
4,654
13-6
1910
51,678
2,961
5-73
6,900
13-4
a Information not available.
Springfield's growth in population on the whole has been
normal, showing no extraordinary nor sudden increases or de-
creases; and for the most part has followed the same general
State
populations
6.000,000
5,000.000
4,000,000
3,000,000
2,000,000
1,000,000
City .
populations
60,000
50,000
40,000
30,000
20,000
10,000
1840 1850 1860 1870 1880 1890 1900 1910
Growth of Populatiox ix Springfield and State of Illinois, 1840-1910
Broken line represents state figures; solid lines those for the city
Upward trend for the last 60 years as that of the state of Illi-
nois. The details are set forth In the diagram shown above and
in Table 2. The number of foreign-born whites has increased
7
THE SPRINGFIELD SUR\TY
but slightly since 1870, while their proportion of the whole has
undergone an uninterrupted decrease. Similarly the number of
Negroes has remained relatively small, while their proportion of
the total has also in the last twenty years shown a decline. Race
and color are not, therefore, the important factors in Springfield
that they are in the southern and eastern parts of our country.
The clustering of these elements in certain districts, which will
be brought out in the examination of ward statistics, has, never-
theless, a distinctly impor-
tant bearing on the city's
public health problem.
The distribution of popu-
lation is an important feature
to be noted in this study of
public health, not so much
on account of possible over-
crowding, which is at a mini-
mum in a city of homes such
as Springfield, but because it
furnishes the basis for com-
paring the amounts of disease
discovered in different dis-
tricts and the adequacy of
the city water and sewerage
services. The accompanying
diagram shows the distribu-
tion according to the 42 dis-
tricts used in the United
States census of 19 10. Each
spot represents 20 persons. Evidently the population is rather
evenly distributed, the density being, as might be expected,
greater near the center of the city. The densest section is in
the neighborhood of the court house, probably on account of the
number of lodging houses and apartments there.
The densities of population in the several wards, based first
on gross and second on net, or built-up,* acreage, are indicated
* The net acreage here used excludes parks and blocks not built up for
habitation.
K
Distribution of Population in
Springfield
According to the United States Census
of 1910
Each spot represents 20 persons
PUBLIC HEALTH IN SPRINGFIELD
in Table 3. The impression is much the same as that obtained
from the map — fairly even distribution, with somewhat closer
conditions in ward seven. The range of variation among the
42 enumeration districts of 19 lO was from 3.6 to 26.4 persons
per acre of gross area and from 6.4 to 28.9 persons per acre of net,
or built-up, area. In considering these figures it should be re-
membered that the densities observed in the great cities run up
into the hundreds.
TABLE 3. — DENSITY OF POPULATION BY WARD, SPRINGFIELD, I9IO
n A '. ; Net density
,,^ J I Gross density / ■ .
Vi^rd I rnersons ner acre) i (persons per acre of
(persons per acrej built-up land)
1 9.1 14.5
2 10.2 16. 1
3 9.1 12.4
4 9.6 14.3
5 10.6 13.8
6 8.9 12.2
7 20.0 21.2
Whole cit>- 9.7 13.9
The different character of the population in different parts of
the city is a matter of considerable sanitary significance. Thus
while Negroes and foreign-born whites do not form a large pro-
portion of Springfield's total population, 19. i per cent in 19 lo,
these two components together made up 36 per cent of the popula-
tion in ward one, and 24 per cent of that in ward six. The
comparable figures for wards four and five were, on the other
hand, 11 and 10 per cent respectively. Similarly the per-
centages of "illiterates" in wards one and six were 11.2 and 7.4,
as against 1.8 and 1.3 in the fourth and fifth wards.
Such differences in the composition of the population tend to
make the public health problem increasingly difficult in certain
districts and demand special activity on the part of the health
authorities in such districts. The first and sixth wards, or the
east side, have, in addition to a large percentage of Negroes
and foreign-born whites, the larger proportions of children of
school age ; and the evidence also indicates that the birth rate is
9
THE SPRINGFIELD SURVEY
higher in these sections. The eastern and northern parts of the
city contain, in short, the younger, poorer, and more foreign
NEGROES IN SPRINGFIELD, ILL.
PER CENT OF WARD POPUl-ATION
U.5 CENSUS 1910
J_l
1 £ 3 ■♦ 5 6 T
WARDS
□ LOWEST
HIGHEST
WARD RANKINGlS
THE JPflWCriELO Sl/f!^£y-IS/-t
parts of the population and most of the Negroes, while the south-
western section is more purely native white, is older, and its
people are more comfortably situated. Ward seven, embracing
the district around the court house, is somewhat peculiar, having
an excess of males, a markedly lower proportion of infants and
FOREIGN-BORN WHITES IN SPRINGFIELD
PER CEMT OF WARD POPULATION
■US CENSUS I9IO
NA/ A R D
n LOWEST ^ MIC1.ME31
WARD RANKINGS
r/i£ sp/!WGr/£LP su/fi^Er-zai-*
children of school age, and rather more than the average of
foreign born and illiterates. These differences are illustrated
in the accompanying diagrams.
10
Ill
INFANT MORTALITY
The perilous times of life are the extremities; the very young
and the very old suffer by far the greater chance of death. Thus
in the year 1910 there died in Springfield 140 to each thousand
infants under one year of age, 67 to each thousand persons over
sixty-five years of age, and only 7 to each thousand persons from
twenty-five to forty-four years of age.* The babies' chance of
dying was, in other words, 20 times as great as that of adults be-
tween the ages of twenty-five and forty-four. This high rate
of mortality among infants, taken with the fact that there are
of course more infants for an age period of given size than for
an age period of similar length in any other element of the popula-
tion, makes this one of the greatest contributing sources of
death. Nearly a fifth of all deaths are among infants under one,
and in the last six years 727 Springfield infants have been born
only to die in their first year of life, a figure which in its aggregate
is little short of appalling. The causes of this mortality have
their inception in the period before birth and are intimately
related to the care given the infant in its first few weeks and
months of life. In the six-year period mentioned the principal
causes certified were as follows:
TABLE 4. — DEATHS OF INFANTS UNDER ONE YEAR OF AGE, SPRING-
FIELD, 1908-19 13 (residents only)
Cause of death | Deaths
Premature birth 160
Pneumonias 80
Acute infections 75
Diarrhea and enteritis i79
All other causes 233
Total 727
* See Appendix B, p. 142, for a more complete statement of the mortality
at the several age groups in Springfield.
II
THE SPRINGFIELD SURVEY
In examining this list with an eye to Hfe saving, it may be con-
ceded that a considerable proportion of the premature births
are probably unavoidable, being due to constitutional defects.
Prenatal educational and nursing work among mothers should,
however, save many; but this is the newest field in baby saving,
and the prospects of success' cannot be spoken of with the same
assurance as in the case of some of the other causes in the list.
The large group formed by the pneumonias and diarrhea and
enteritis, for example, has in other cities yielded splendidly to
preventive efforts, and there is every prospect that similar results
could be obtained in Springfield. Deaths from these causes are
commonly the result of ignorance of the proper care and feeding
of the infants, and the problem of prevention is simply to reach
uninformed mothers. Public health nurses and infant welfare
stations are the usual means to this end. Such work is now
commonly carried on by city health authorities and is attended
by gratifying success. The acute infections, including whooping
cough, syphihs, measles, and the like, fall naturally within the
direct province of the health department, and should be re-
stricted by the department's regular activities, especially when
re-enforced by the employment of suitably trained public health
nurses.
Altogether it is certain that a considerable proportion of the
727 infants could have, and should have, been saved; to estimate
this proportion at a third of the total would probably be con-
servative.
The best index of the intensity of infant mortality is the ratio,
in a given year, of deaths of infants under one year of age to
births. An efficient registration of births is necessary, however,
for the computation of this rate, and it is an unfortunate fact
that this condition has not as yet been reached in Springfield.
Previous to the city's reaching 50,000 population, the law re-
quired that birth returns be made to the county clerk's office;
subsequent to that time (19 12) the city health office, as is pro-
vided for by the law, required that reports be returned to it.
Registration of births with the city department thus became a
legal obligation on the attending physician or other person having
the birth in charge. The reporting, nevertheless, has been in-
12
PUBLIC HEALTH IN SPRINGFIELD
The Springfield Survey,
Springfield, Illinois
'Qjhntai^^^
nan
□DDamQB
DPI ^QQannmn
□□□an
Births in Springfield, 19 13
Round dots indicate births registered at city or county offices
Stars indicate unregistered births located
13
THE SPRINGFIELD SURVEY
complete, and in 1913 a considerable proportion of the reports
(40.4 per cent of those registered) were still returned to the county
clerk's office. In his report for 1913 the acting superintendent
of health pointed out that in the two years, 1912 and 1913, only
1,373 births were registered with his department, and estimated
that this number represented only about two-thirds of those
actually born. Such violation of the law is unfair to the child
and most prejudicial to any organized endeavor to reduce infant
mortality. Complete and prompt registration of births is
essential to the computation of true infant death rates and to the
effective administration of preventive measures.
To get a more exact idea of the situation and of the improve-
ment which the city authorities have been able to effect, and to
get some basis for estimating the variations in infant mortality
throughout the city, a search was instituted during the present
survey for births not registered during the year 19 13. Church
christening records and those of infant deaths were compared
with the city and county records of births. The results are in-
dicated on the map on page 13 and in Table 5.
TABLE 5. REGISTRATION OF BIRTHS, SPRINGFIELD, I9I3
Registered at city or county offices, address adequate 890
Registered at city or county offices, address inadequate 15
Unregistered, exact address obtainable 234
Unregistered, exact address unobtainable 141
Total 1,280
Evidently at least a fifth and quite possibly a third of the
births were still unregistered, as errors in the search would
probably be on the side of omission rather than duplication.
The proportions of unregistered births for the several wards,
as well as the birth rates per thousand population based on the
combined numbers of those registered and unregistered, are
shown in Table 6. It must be emphasized again that the figures
are not to be regarded as representing the exact situation; they
probably are still more or less an understatement of the actual
facts.
14
PUBLIC HEALTH IN SPRINGFIELD
TABLE 6. BIRTH STATISTICS BY WARD, SPRINGFIELD, 19X3^
Number of
Birth rate
Per cent of
Ward
births
per 1,000
births
located
population
unregistered
1
203
22.2
24.1
2
126
19.1
18.3
3
172
18.5
16.9
4
184
17.2
24-5
5
79
12.7
20.3
6
310
27.7
20.0
7
50
14.9
20.0
a Including only births for which a definite address could be obtained.
The considerable proportion of unregistered births in some of
the best residential districts, 25 per cent in ward four and 20 per
cent in ward five, is one of the outstanding facts of this table.
Faulty birth registration in Springfield is evidently not merely
BIRTH RATE BY WARDS SPRINGFIELD, ILL.
PER THOUSAND POPULATION
RESIDENTS OMLY
Vv'ARD RATES
Q LOWEST g t-llGHEAT
WARD RANKINGS
7-/W JP/fWGr/£:LO JU/fl^f>^-/S/4-
a sin of the poor. Another fact of considerable interest is the
low birth rates existing in wards five and seven, a state of affairs
which checks up with their deficiency in children of school age
and with the general character of their populations, — some of the
best residence sections and the chief business district being in
these wards.
15
THE SPRINGFIELD SURVEY
Steps for the improvement of birth registration were being
taken by the superintendent of health at the time of the survey.
A new appeal was sent to physicians and one doctor was prose-
cuted for non-reporting. It is to be hoped that these efforts
will be continued in a vigorous manner, that they will receive
the hearty co-operation of the public and medical profession,
and that they will meet with success. One reason why Spring-
field must get her births fully and promptly reported is that the
record may be highly important to the child in later life. It
establishes parentage, legitimacy, and age, — facts which may be
necessary in connection with school attendance, the securing of
working papers, the right to marry or to vote, or in connection
with entering one of the government services, or in securing an
inheritance. Another reason why the birth report is necessary
is that it is needed for the study of the city's infant mortality
problem and for the administration of a program of prevention.
Without it the infant death rate cannot be computed, either for
the whole city or any of its parts, nor can the health department
know where its nurses are needed nor can it send them in time.
Such evidence as is available in the face of the incomplete
birth returns points to about the ordinary rate of infant mortality
for a city of Springfield's size. It must be pointed out, however,
that the ordinary rate is an undesirable one and that in certain
parts of Springfield the problem is acute. If the city's infant
death rate for 19 13 be figured against the number of births for
which any record could be found (including those for which no
definite address was obtainable) the rate is 114. i deaths per
thousand births; if only those births for which a definite address
could be obtained are used the rate is 129.9 P^^ thousand. As a
check on these figures, which are true infant death rates, the
average number of infant deaths per year during the years 1908-
19 13 may be compared with the number of infants under one
year of age,* the resulting rate being 127.4 deaths per thousand
infants. These figures, which indicate that about one-tenth of
Springfield's infants die in their first year of life, show that the
city's infant hygiene problem does not assume quite those de-
structive proportions found in parts of the South and some con-
* Estimated to January i, 191 1.
16
PUBLIC HEALTH IN SPRINGFIELD
gested metropolitan areas. In relation to Springfield's oppor-
tunities for life saving the problem is, however, of prime im-
portance.
In studying the infant mortality in particular districts of the
The Springfield
Survey
Springfield, Illinois
Deaths of Ixfants under One, Springfield, 1908-19 13
city, the difficulty due to lack of accurate birth returns is again
met; but some very suggestive evidence can, nevertheless, be
brought forward. In Table 7 three sets of figures have been pre-
pared, each of some value as an indication of infant welfare in the
several wards. The first set, true infant death rates for 1913,
2 17
THE SPRINGFIELD SURVEY
is not quite conclusive because of the already mentioned de-
ficiencies in birth reporting and because the numbers involved
are somewhat small for statistical 'purposes. Some eccentricities,
especially in the smaller wards, result. The second set, based
on the average number of infant deaths for the last six years and
the birth returns for 1913, escapes much of the objection on the
score of small numbers; it still includes the possible birth regis-
tration error, however, and has the additional defect of comparing
figures for dissimilar periods of time. The third set of figures
is considerably different from the other two, being based on the
average number of infant deaths for the last six years and the
number of children of school age according to the federal census
of 1910. The weak point in this set is the assumption that the
number of infants in the wards is approximately proportional
to the number of children of school age. While all three sets
of figures are therefore subject to error of one kind or another,
the errors are not of the same character and the figures may be
considered as mutually supplementary.
TABLE 7. MORTALITY OF INFANTS UNDER ONE YEAR OF AGE BY
WARD, SPRINGFIELD (RESIDENTS ONLY)
Infant deaths
Infant deaths
Infant deaths
1908-13,a per
Ward
per 1,000
1908-
-13,a per
1,000
10,000 chil-
births,b 1913
birthsb in 1913
dren c 6-20
years of age
1
187.2
142.0
1 16.3
2
47.6
56.8
43-3
3
87.2
101.7
74.5
4
65.2
86.1
63-3
5
202.5
101.3
64-5
6
164.5
128.0
129.8
7
160.0
83-3
72.7
Whole city
129.9
107.8
87.4
* Yearly average.
b Births for which a definite address was obtainable.
'^ Estimated as of January i, 191 1.
From an inspection of these figures it is evident that the rate
of infant mortality in wards two and four is always low and that
18
PUBLIC HEALTH IN SPRINGFIELD
in wards one and six always high. |The indications regarding
wards five and seven are conflicting, but it would appear that
they, as well as ward three, usually hold positions somewhere
between the other four.
The Springfield
Survey
Springfield,
Illinois
Deaths of Infants under Two from Diarrhea and Enteritis, Spring-
field, 1908-19 13
Note the preponderance in the east part of the city. This is one of the prin-
cipal preventable causes of infant mortality
The marked differences in the relative infant mortality in the
wards are paralleled by a significant difference in the character
of the diseases causing death. In those wards having the higher
rates of mortality the preventable diseases are responsible for
19
THE SPRINGFIELD SURVEY
a higher proportion of the deaths. Table 8, which gives the
proportion of infant deaths due to diarrhea and enteritis, the
pneumonias, and the acute infections during the last six years,
brings out this fact.
TABLE 8. — INFANT MORTALITY FROM PRINCIPAL PREVENTABLE
CAUSES BY WARD, SPRINGFIELD, I908-I9I3
Deaths of Infants under One Year of Age from Diarrhea and Enteritis,
Pneumonias, and Acute Infections (Residents only)
Ward Number of deaths
Per cent of
ward total
1
94
54-3
2
IS
34.9
3
39
37-1
4
29
30.5
5
21
43-8
6
122
51-3
7
14
56.0
Whole city
334
45-9
Here again the mortality for wards two and four is low while
that for wards one and six is high. The opportunity for im-
provement is plainly greater in the wards having the higher
rates of infant mortality from all causes, a fact which makes a
strong argument for the initiation of preventive work. Diarrhea
and enteritis being one of the most important causes of infant
mortality, and its prevention being typical of the general infant
hygiene problem, it is worth while to consider the situation with
regard to this disease in some detail.
The diagram on page 21 and Table 9 give figures indicating the
relative havoc played by this cause of death among the infants
in Springfield's several wards. It will be noted that more than
two-thirds of the entire mortality occurred in the first and sixth
wards and that the rates computed on both bases show excesses
in these districts. The sickness that gives rise to this mortality
occurs chiefly in the hot months of the summer, and is probably
due for the most part to infection by specific micro-organisms.
Flies may carry these microbes or they may find their way into
well water from privies. Another important factor in this mor-
20
PUBLIC HEALTH IN SPRINGFIELD
DIARRHOfA& ENTERITIS- 1 NrANT5 UNDER 2
SPRINGriELD. ILL
WARD DEATH RATES PER 100,000 POPULATION
AVERAGE 1906-I9I3 RtSlOENTS ONLV
WARD RATE 5
□ LOWEST
[H HIGHEST
WARD RANKINGS
EXC1_VD NG REOEMPTU
7JW spjewcf^/^LD sl//f^'e:r-l^/■4-
tality is improper care of the infants, as with regard to clothing
and feeding. In either case better sanitation is called for. The
city authorities should see that the people in these districts need
not rely on wells and privies, and the health department should
open infant welfare stations and send out public health nurses
to instruct uninformed mothers in the essentials of baby hygiene.
Substantial reductions in the mortality would certainly result.
table 9. deaths of infants under one year of age from
diarrhea ant) enteritis by ward, springfield, i908-
19 13 (residents only)
Ward
Number of deaths
Per cent of
ward total
58
6
14
15
10
67
9
33-5
14.0
15.8
20.8
28.2
36.0
Whole citv
179
24.6
To sum up, out of every loo infants born in Springfield about lo
die before becoming one year of age ; in certain parts of the city,
21
THE SPRINGFIELD SURVEY
Courtesy of C. H. Wells, Health Officer, Montdair
Baby-Saving Work in Montclair, New Jersey
A health department nurse instructing a mother in baby hygiene. Mont-
clair is only a little over half as large as Springfield but finds the employment
of such a nurse worth while. Similar work in Springfield would save many
babies who now die
Courtesy of New York Milk Committee
An Infant Welfare Station in New York
A doctor and nurses are in attendance and at stated hours parents may
bring their babies for examination and may themselves receive advice regard-
ing the care of their infants. Despite heavy losses, Springfield makes no
attempt to prevent her unnecessary infant mortality
22
PUBLIC HEALTH IN SPRINGFIELD
however, only about five die, while in certain other parts as many
as 20 do not live to reach their first birthday. The problem
centers chiefly in the first and sixth wards, in the eastern section,
although there is reason to believe that substantial improvement
can be accomplished in the third, fifth, and seventh wards. The
wards to the east of Tenth Street, which in 19 lo included 36.4
per cent of the population, were responsible for 45.6 per cent of
the births located in 1913, and for 6i.oper cent of the infant deaths
reported in that year. During the six years 1908-19 13 these
wards have been responsible for 57.5 per cent of the mortality.
The infant deaths in these districts are due, furthermore, in a
relatively high proportion of instances, to the diseases which
modern sanitation has learned to prevent.
No escape is possible from the conclusion that a steady and con-
siderable health and life wastage is constantly going on among
Springfield's infants. If during the last six years the other wards
had but equaled the record of ward two, only 383 infants under
one year of age would have died instead of 727. This would
represent a saving of about 57 babies a year, or a total of 344.*
In other words, the lives of nearly half of these victims might
have been saved by proper precautions.
To put an end to this terrible loss we may recommend to
Springfield methods which have proved successful elsewhere, as
follows :
1. Prompt and complete registration of births, already re-
quired by law but not secured up to the present year (1914).
This wuU require the co-operation of the public, medical profes-
sion, and midwives.
2. Registration, examination, and regulation of midwives.
3. The employment of public health nurses who are qualified
to visit homes and instruct mothers who would not ordinarily
receive proper advice regarding the care of infants ; this work to
be carried on in connection with one or more infant welfare or
consultation stations, where instruction and demonstrations may
* This statement is based on the average yearly number of infant deaths
1908-13 per 1,000 births in 1913, — the second column of rates in Table 7.
This basis gives a more conservative estimate of the saving possible than the
other two sets of rates in the table.
23
THE SPRINGFIELD SURVEY
be given mothers and at which a doctor shall be in attendance at
certain set hours and to which sick infants may be brought.
This work should be carried on by the city health department.
4. The improvement of sanitary conditions in certain parts of
the city, such as are discussed later in this report, and especially
as affecting the breeding places of flies and the abolition of in-
sanitary privies and dangerous wells.
5. The continuation and extension of the present efforts to
improve the city's milk supply, as outlined later in this report.
Of the above, probably the most important steps that can be
taken will be the employment of nurses and the opening of infant
welfare stations. These agencies are relatively inexpensive and
have been attended by splendid results in other cities. Ig-
norance is the babies' greatest enemy, and the measures outlined
above are chiefly those of education.
24
IV
CONTAGIOUS DISEASES OF CHILDREN
Four wellknown contagious diseases, diphtheria, scarlet fever,
whooping cough, and measles, are peculiarly children's scourges.
These diseases practically limit themselves to children, cases
among older persons being relatively rare. At the same time,
if tuberculosis be excepted, these diseases are probably the most
important contagions with which children, after escaping the
hazards of infant life, have to contend. Others, such as infant
paralysis and cerebro-spinal fever, show small totals when com-
pared with the other four mentioned, nor is their control as well
understood.
The four diseases first named are beyond peradventure con-
tagious and their control has long been recognized as one of the
chief functions of the health authorities. Their importance is
great, both as represented by the amounts of sickness and death
of which they are the immediate cause and by the injurious
effects which they have on the kidneys, respiratory organs,
and other parts of the body. Many of these last effects are over-
looked at the time of the illness but make themselves felt in later
life when the general vitality of the body begins to decrease.
The numbers of deaths from these diseases in Springfield during
the past six years, and the yearly death rates, appear in Table lo.
TABLE 10. — MORTALITY FROM CONTAGIOUS DISEASES OF CHIL-
DREN, SPRINGFIELD, I908-I913 (RESIDENTS ONLY)
Disease Deaths
Yearly deaths per
100,()()b population
19.2
13-9
9.8
Total 159 50-2
25
Diphtheria
61
Whooping cough
44
Measles
31
Scarlet fever
23
THE SPRINGFIELD SURVEY
"While it may be truthfully contended that Springfield has
no more cases of scarlet fever and diphtheria than most of the
other medium-sized cities of the middle west, it is none the less
true that we have too many such cases," These words appear
in the October, 1909, bulletin of the Springfield health depart-
ment and have continued to represent the situation fairly.
Assuredly the four diseases are of importance when causing some
26 deaths a year. It should also be noted that in the last five
years there have been reported a total of 1,441 cases of diphtheria
and scarlet fever alone. If one attempts to visualize the suffering
and loss attending this vast number of cases, and further realizes
that modern science tells us how the diseases are spread and how
they may be prevented, it will be evident that the city is here
confronted with an opportunity for service of the most useful
sort.
Additional light is thrown on the preventability of these
diseases and the problem of their suppression in Springfield by a
study of their distribution throughout the city. The facts are
indicated in the accompanying maps and charts and in Table
II.
TABLE 1 1 . — MORTALITY FROM CONTAGIOUS DISEASES OF CHILDREN
BY WARD, SPRINGFIELD, I908-I9I3
Deaths and Death Rates from Diphtheria, Scarlet Fever, Whooping Cough,
and Measles (Residents only)
Yearly deaths I Yearly deaths per
100,000 children
6-20 years of age
Ward I Deaths ! per 100,000
population
1
39
76.2
262.1
2
13
35-2
130.7
3
26
49.9
184.5
4
20
33.4
133-2
5
II
31.6
147.7
6
46
73-3
250.9
7
4
21.3
116.3
Whole city 159 50.2 191 -3
The rates given in the last column of the table and in the dia-
gram, being based on the number of children of school age in
26
PUBLIC HEALTH IN SPRINGFIELD
the several wards, are the more significant. Examining these
figures, it is evident that the variations are much the same as in
The Springfield
Survey
Springfield,
Illinois
Cases of Scarlet Fever Reported to the Health Department, Spring-
field, 1909-1913
The marked "clumping" of cases is characteristic of the contagious diseases.
The health department needs an epidemiologist to keep closer watch over the
spread of these diseases and to prevent contact infection
the case of infant mortality. Wards one and six are again high,
wards two and four again low, with wards three and five again
27
THE SPRINGFIELD SURVEY
in intermediary positions. Ward seven makes a more favorable
showing than before, having for these diseases the lowest rate of
all.
CONTAGIOUS DISEASES OF CHILDREN
SPRINQFIELD, ILL
(DIPHTHERIA, SCARLET FEVER, MEA5LE5, WHOOPING COUGH)
WARD DEATM RATES PER 100,000 CHILDREN-AGES 6-20YRS
AVERAOE I30a-i9l,i REilDENTi ONLY
WARD RATES
□ LOWEST
H HIGHEST
WARD RANKINGS
THE jp/f/Aiaf^/sto Jc/ft^ey-zs/-*-
The figures for case fatality, the ratio of deaths to cases re-
ported for any given disease, for diphtheria and scarlet fever,
given in Table 12, show much the same variations. Again the
TABLE 12. — CASE FATALITY FROM DIPHTHERIA AND SCARLET
FEVER BY WARD, SPRINGFIELD, I909-I913
Deaths per Hundred Cases Reported
Ward
Diphtheria
Scarlet fever
9-45
8.86
9.17
8.21
3-57
8.44
4.24
0.83
1. 14
4.69
Whole city
8.01
1.72
east side ratios are excessive, although those for diphtheria in
wards two, three, and four are also higher than should prevail.
The city's general case fatality rate from this disease, 8 per cent
28
PUBLIC HEALTH IN SPRINGFIELD
in the six-year period, while not an uncommon one, is too high
as judged by the better standards of modern hygiene. Either
treatment is bad, or, what is more likely, reporting of cases is
incomplete. The high fatality ratios in the east wards, while
thus not indicating greater prevalence of the diseases in those
districts, do indicate objectionable conditions, and so re-enforce
the conclusion to be drawn from the death rate figures.
That the situation has not tended to improve during the last
six years is shown by Table 13, which presents by year the death
rates from the four diseases under discussion and the fatality
rates for diphtheria and scarlet fever. On account of the ten-
dency of these contagions to become epidemic, the incidence of
each shows considerable variation year by year. It is the func-
tion of the health authorities, however, to prevent epidemics.
TABLE 13. — DEATH AND FATALITY RATES BY YEAR, CONTAGIOUS
DISEASES OF CHILDREN, SPRINGFIELD (RESIDENTS ONLY)
1908 1
1909
1910
1911
1912
1913
Deaths per 100,000
population from
Diphtheria
12.2
4.0
17-3
22.5
34-6
23.0
Scarlet fever
20.5
2.0
9.6
II. 2
1.8
Whooping cough
12.2
4.0
7-7
9-3
20.0
28.3
IMeasles
2.0
27.6
3-9
1.8
23.0
Total
46.9
37-6
38.5
43 -o
56-4
76.1
Deaths per 100 cases
from
Diphtheria
a
1.96
6.29
13.48
9-74
8.23
Scarlet fever
a
1.30
1-95
1.72
2.70
^ Information not available.
The best practice for the control of these diseases has under-
gone considerable change in recent years, primarily on account
of better understanding of the modes and sources of infection.
Whereas great emphasis was formerly given to desquamation
(peeling) and fumigation at the termination of the case, the
importance of these points is now minimized and the emphasis
is shifted to early recognition of cases, especially mild cases and
"carriers" (persons who harbor the disease organisms but show
29
THE SPRINGFIELD SURVEY
DIPHTHERIA IN 5 PRI NGFIELD, ILL.
WARD DEATH RATE5 PER 100,000 CHILDREN-ACES 6-20YR5
AVELRAGt I©00-19I3
RCaiDENTS OMUY
I
1 a i A 5 6 7
WARD RATES
□ LOWEST
m HIGHEST
WARD RANKINGS
TMF yPffwaF/£lO 3l//ft^£y-/S/-4-
none of the usual symptoms), and to the prompt and efficient
disinfection of the discharges which flow from infected persons.
All four diseases are similar in that the throat and nose appear
DIPHTHERIA IN SPRINGFIELDJLL.
DEATHS PER HUNDRED CA5E5 REPORTED - BY WARDS.
AVERAGE 1909-I9I3
RESIDENTS ONl_V.
WARD FATALITY RATES
Q LOWEST
HlGiHEST
WARD RANKINQS
me SP/fMGr/£LD ju^i^£y-isi-4
to be the chief sources of infectious matter, the problem of pre-
vention thus being to destroy the virus secreted in the nasal or
mouth discharges or to otherwise prevent it from reaching new
victims.
In diphtheria, whooping cough, and scarlet fever much can
30
PUBLIC HEALTH IN SPRINGFIELD
be accomplished by isolating patients with the earliest possible
approach to the first appearance of symptoms, and by searching
among "contacts" (persons who have been in contact with
cases) for mild and incipient cases and carriers. In measles,
however, the problem is more difficult, as the latest evidence
seems to show that a patient is infectious for as long as ten days
before the appearance of symptoms, a state of affairs which goes
far to explain the long-recognized difficulty in controlling the
disease. In the presence of measles the health authorities can,
however, do much to lessen the fatality of the disease by drawing
the attention of parents to the necessity for taking great care
of children for a considerable period after apparent recovery, a
precaution the importance of which is commonly overlooked.
The additional health department operations demanded by the
newer ideas include follow-up medical inspection of "contacts,"
better instruction of families as to the details of isolation, espe-
cially as regards the disinfection of discharges, and generous
reinspection of quarantined cases. The savings incidental to
the newer ideas include relief from the expense and annoyance
of fumigation and, in a considerable proportion of cases, a
material shortening of the period of quarantine. Thus in English
hospitals, where the date of discharge of scarlet fever patients is
regulated by the condition of the nose and throat instead of com-
plete desquamation, the usual period of isolation is about three
weeks, as against the five or six weeks customary in this country.
The results are fully as satisfactory. Similarly, fumigation after
contagious disease, except on request, has been omitted in
Providence, R. I., for some years without bad consequences;
while New York City fumigates only when the patient dies or is
removed from the premises at the height of the disease. Such
gains are, in the aggregate, large.
The procedures now employed in Springfield are such as have
been common in American cities of similar size, and such as are
dictated by the slender resources commonly placed at the dis-
posal of our American health departments. Reports to the
health department of infectious and contagious diseases are re-
quired by state law and city ordinance, telephone reports with-
out written confirmation being accepted. Cases of diphtheria
31
THE SPRINGFIELD SURVEY
and scarlet fever are quarantined by a sanitary inspector, who
merely placards the front and rear doors and leaves the state
The Springfield
Survey
Springfield, Illinois
Cases of Diphtheria Reported to the Health Department, Spring-
field, 1909-1913
Cases of diphtheria are now released from quarantine by the attending
physician. This is bad because there are usually a few physicians who will
release cases too early and so expose other children to infection. Release by
the health department only after negative cultures from the patient's throat
and nose is much to be preferred
board of health pamphlets regarding the care of these diseases.
Other members of the family must live apart or stay in quarantine
32
PUBLIC HEALTH IN SPRINGFIELD
unless conditions assure satisfactory room isolation, in which
case the breadwinner may continue at work and live at home.
Notice of the case is sent to the library and the board of educa-
tion, and the family is directed not to return milk bottles. Un-
less a complaint is received, the health department does nothing
more until the attending physician notifies the department that
the case is ready for release. The inspector then returns, takes
down the card, and fumigates with formaldehyde.
In diphtheria the quarantine period is fourteen days, the case
being thereafter released at the word of the attending physician.
Cases are also released after ten days providing the attending
physician will certify in writing that two cultures taken from the
patient on separate days have proved negative. In scarlet
fever the minimum period of isolation is twenty-one days, release
being made thereafter on the word of the attending physician
that desquamation is complete. In another two weeks the
patient may return to school. In measles and whooping cough
the patient is simply excluded from school, other children in the
household being likewise excluded unless they have had the
disease or the patient is isolated.
These procedures, as has been suggested, are such as are
dictated by the older practice and lack of funds. A number of
important suggestions for improvement can be made, the adop-
tion of which would insure greater safety to the city's children.
For one thing, every case should be reported promptly. While
the reporting of diphtheria and scarlet fever has been relatively
good, there is evidence that at times and in certain districts it
has been distinctly not up to standard. Measles and whooping
cough are reported hardly at all. Prompt and full reports of
these diseases are the first requisite for the study and prevention
of their spread, and the responsibility for securing such reports
rests with the public and the medical profession. The conceal-
ment of a case of contagious disease in order to avoid the bother
of isolation is most unfair to the rest of the community, and it is
a mistaken kindness for a physician to lend himself to any such
attempt. Concealment in such cases means trifling with the
lives of others.
The manner in which isolation is at present initiated, main-
3 33
THE SPRINGFIELD SURVEY
tained, and terminated can also be greatly improved. The
present operations are directed largely against the house or at
least the patient's inanimate environment, whereas it is now be-
lieved that the points to be concentrated on are the patient and
his discharges. Thus the report of a case is now followed, as
we have seen, by the visit of an inspector to placard the house.
The inspector's chief forte is nuisance abatement work and he
has no special knowledge of the modes of infection and the details
of efficient bedside disinfection. The educational pamphlet
which he leaves is a step toward instruction of the family, but
something more is needed. The fumigation is probably a useless
operation and a waste of time and money.
In the quarantine the most important points are overlooked;
the family or attendant has not received adequate instruction in
the details of bedside disinfection, and reinspections have not
been made to see that such instructions are properly carried out
and that the other requirements of quarantine are being main-
tained.
The arrangements for release are, furthermore, open to
weighty objections, the decision as to when the case is ready
being left to the attending physician. This feature is a bad one
because there are always some physicians who are willing to
release cases early and who get business on this basis. The
recommendation to "Have Dr. So-and-so; he'll get you out of it
easy," is a great friend of contagion. Release on inspection by
the health department, on the other hand, makes for uniformity
of practice and safety, and relieves the conscientious physician
from pressure by mistaken or unscrupulous families.
It is also recommended that in release greater attention be
paid to the condition of the nose and throat as compared with
desquamation, and that in diphtheria the sole criterion for re-
lease be negative cultures from both throat and nose, at least
two sets of cultures being taken on separate days. These cul-
tures should be examined, furthermore, by an established
laboratory having the endorsement of the health department,
as the laboratory diagnosis of diphtheria is an operation requiring
special training and practice. In this connection the city is
fortunate in being the home of the state board of health diagnostic
34
PUBLIC HEALTH IN SPRINGFIELD
laboratory, this making release by cultures easily practicable.
The presence of the state laboratory also ensures a reliable
supply of antitoxin ready at hand, and every effort should be
made to take full advantage of this circumstance by seeing that
sufferers from diphtheria receive the serum at the earliest possible
100
90
80
70
60
2 50
40
-.A
u
Q
y
/
7^
s^
V
U
^
\
\.
//
\
■^
f
^^^
Sj^— ^
/
^s
J-OO^^^
/■
\
^
....><
>..v
^» *^
/
• •^^
*>s..
-•>-^
/
Diarrhea and
enteritis
under 2
Pneumonia
under 55
Four conta-
gious diseases
of children
30
20
10
0
1908
Whooping
cough
Diphtheria
Measles
Typhoid
^■. 1 ••••<r^ I Scarlet fever
1909
1910
1911
1912
1913
Death Rates from Certain Preventable Causes by Year, Springfield,
1 908-19 1 3. Residents only
Typhoid fever is the only disease that really has shown an encouraging de-
cline in the period. Scarlet fever has shown some diminution, but taken as a
whole the four contagious diseases of children show a steady increase in the
last five years. The need for improvement in the city health department's
supervision of the communicable diseases is beyond question. The reader is
referred to the chart on page 56 showing the death rate from tuberculosis by
years
moment. The efftcacy of the treatment is directly proportional
to the earliness of administration and the health department
should provide a physician who will stand ready to administer
the antitoxin promptly among the poor on the call of any phy-
sician.
The local situation regarding the contagious diseases of chil-
35
THE SPRINGFIELD SURVEY
dren may be summed up about as follows. Serious amounts of
these diseases occur in the city, 159 children having died in the
last six years while several thousand were made ill. Marked
excesses occur in certain districts, notably that part of the city
east of Tenth Street. The records of the last six years show no
improvement in the situation, but rather the reverse. In the
face of these facts it is significant that the methods of control
have been only the usual ones adopted by health departments in
small cities such as are handicapped by lack of funds, and that
there are opportunities for radical improvement in the service
offered. The chief improvements that should be instituted are:
1. Prompter and fuller reporting of cases. It is suggested that
the health department furnish physicians with sets of post card
forms for this purpose and that written confirmation of tele-
phonic reports be required.
2. More detailed investigation of cases and of the possible
relation between cases, accompanied by examination of persons
who have been in contact with the case to discover mild and
incipient cases and carriers. This would naturally require more
complete history cards, the preparation of maps showing the
distribution and spread of diseases, and the like.
3. Closer supervision of cases of diphtheria and scarlet fever,
including a prompt initial visit by a medical inspector, or spe-
cially trained nurse, employed by the health department to issue
detailed instructions as to the maintenance of the patient and
the disinfection of his discharges; reinspections to follow at
frequent intervals to see that instructions are being followed,
with release only after a final inspection by a medical repre-
sentative of the health department. In the case of diphtheria,
release only after two successive negative cultures from the
throat and nose.
4. The visitation of cases of measles and whooping cough to
instruct the responsible parties as to the management of the
patient and the disinfection of his discharges.
5. Transference of the present emphasis on fumigation at
the termination of the case to bedside disinfection of discharges
during the activity of the disease and general cleaning at its
termination.
36
V
THE SPRINGFIELD TUBERCULOSIS SITUATION
Dixon Van Blarcom
Field Secretary National Association for the Study and Prevention of
Tuberculosis
A public informed of the prevalence, nature, prevention, and
cure of tuberculosis furnishes the surest basis for an adequate
campaign against the disease. Any effective movement to
suppress this preventable, and at the same time, most destroying
of all diseases, must be as thorough and far-reaching as our sys-
tem of public school education and must be conducted on as
firm a basis as our successful mercantile enterprises. Halfway
measures can not be depended on to yield results against this
enemy which has been deep rooted in civilized races for centuries.
The responsibility for the control of this disease is public and
for all practical purposes entirely local. That private individuals
have generally awakened to the situation in advance of public
officials does not relieve the latter of their responsibility. Tu-
berculosis is essentially a public health problem and should not
be confused with poverty or pauperism.
The investigation on which this report is based was made
during the first two weeks in April, 1914, and comments herein
apply at that time. Opportunity was not afforded for an in-
tensive study of the situation but information was secured which
may serve as a safe basis for future activities.
The main points considered are:
1. Extent of tuberculosis in Springfield.
2. Existing measures for its control.
3. Suggestions for an adequate campaign.
4. Where the responsibility lies.
37
THE SPRINGFIELD SURVEY
1. EXTENT OF TUBERCULOSIS IN SPRINGFIELD
During the five-year period 1909-1913, 346 whites and 72
Negroes, or a total of 418 resident men, women, and children,
died in Springfield from all forms of tuberculosis. This is an
annual average of more than 83. The diagram below and the
map on page 40 show the distribution of deaths from tuberculosis
throughout the city.
The tuberculosis death rate per 100,000 population during
this time was 137.3 for whites and 470.0 for Negroes, making the
TUBERCULOSIS IN SPRINGFIELD. ILL
WARD DEATH RATES PER 100.000 POPULATION
AVERAGE I90e)-I9l3
RESIDE-NTS O N UY
WARD RATES
□ lowest
HIGHEST
WARD RANKINGS
■THE spffiNcr/eiD 3u/f^£r-i9i4-
rate for the whole city 156.3. This rate is about the average for
the entire country during the same period.
The ratio of white to Negro population in the city is 16.4 to i.
The ratio of white to Negro deaths from tuberculosis is 4.8 to i.
About 30 non-residents died from tuberculosis in the city
during this period. On the other hand, about 30 persons died
of tuberculosis within one year after leaving the city either for
their health or for a new permanent residence. While it would
be fair to charge the latter group of deaths to Springfield, only
residents who died in the city have been included. The number
of deaths from tuberculosis and the estimated populations are
given in Table 14 by years, for whites, Negroes, and the whole
38
PUBLIC HEALTH IX SPRINGFIELD
city. The corresponding death rates appear in the chart on
page 56.
table 14.— mortality from tuberculosis, springfield, i909-
19 13 (residents only)^
Year
Whites
Negroes
Total
Population
Deaths
Population
Deaths
Population
Deaths
1909 47,583
1910 48,992
1911 50,401
1912 51,810
1913 53,220
60
88
71
53
74
2,894
2,979
3,064
3,149
3,235
21
10
14
15
12
50,494
51,989
53,484
54,979
56,476
81
98
85
68
86
Total
346
72
418
Yearly average
Yearly deaths ]
per 100,000 ■
population ,
69.2
137.3
14.4
470.0
83.6
156.3
a The title "tuberculosis" here includes all forms of the disease. The popu-
lation figures for 1910, 191 1, 1912, and 1913 are as estimated by the United
States Bureau of the Census; those for 1909 were computed by deducting on
the same basis. The total population includes a few Chinese and Indians.
The variation from year to year of the white and Negro death
rates, and in consequence the variation in the city rate, is not
unusual in restricted areas such as Springfield. It is worthy of
note that an upward or downward trend of the white death rate
in any year is accompanied by an opposite move of the Negro
rate.
The Negro rate has varied from i .9 times greater than the rate
for whites in 1910 to 4.7 times greater in 1912, and 5.8 times
greater in 1909. For the five-year period it was 3.4 times greater.
The Negro rate, which is much higher throughout the country
than the rate for whites, is generally explained by the personal
habits and insanitary manner of living of the Negro. He pre-
sents an acute problem which is accentuated by the possibility of
his spreading the disease to persons other than of his own race.
Having considered the number of deaths caused by this pre-
ventable disease, the question naturally arises as to the probable
number of living cases. No attempt is made to detail the misery
39
THE SPRINGFIELD SURVEY
and suffering accompanying these cases, the poverty which often
results where the breadwinner is incapacitated, and the large
number of children, one or both of whose parents have died of
tuberculosis, forced into orphan asylums.
The Springfield
Survey
Springfield,
Illinois
Deaths from Tuberculosis, Springfield, 1908-1913
Tuberculosis has killed 490 Springfield residents in the last six years. It
is one of the most important of the preventable diseases but receives little or
no attention from the health department
The number of living cases of tuberculosis in a community may
be conservatively estimated at five times the number of deaths
from the disease during the previous year. Cleveland, Ohio,
and sections of New York state have proved this estimate none
too high. Using the average number of Springfield deaths for
40
PUBLIC HEALTH IN SPRINGFIELD
the last five years (69 whites and 14 Negroes) there are probably
at least 345 white and 70 Negro living cases in the city continu-
ously,— approximately 415 in all.
The application of this estimate to Springfield is warranted by
facts obtained from the local physicians. Letters were sent to
the physicians asking the number of tuberculosis cases under
their supervision at present and during 19 13. Replies were re-
ceived from about three-fourths of those addressed, the results
of the inquiry appearing in Table 15.
TABLE 15. — TUBERCULOSIS CASES TREATED BY 49 SPRINGFIELD
PHYSICIANS, MAY, I9I4
Incipient
cases
Advanced
cases
Total
Under treatment " at present " 117 iii 228
Under treatment "during 1913" 300 246 546
These figures do not include cases under the care of physicians
not reporting, those persons who have no physician, and the
probably very considerable number of incipient and moderately
advanced cases who are unaware that they are afflicted. On
the other hand, it is probable that some of the cases reported in
the lower line of the table changed physicians during the year and
consequently were reported more than once, and again both lists
probably contain a negligible number of non-resident cases.
Further light is shed on the matter by the figures of sputum
examinations made for the city and county physicians by the
state board of health during the past four years. The figures are
especially interesting because of the comment made on them by
Dr. G. F. Sorgatz, state bacteriologist. They do not give an
accurate idea of the prevalence of the disease, as some doctors
make their own sputum examinations, and many cases do not
need this diagnosis. And again, a negative sputum test is not
proof of the absence of the disease.
During the four-year period, 1910-1913, 61 city physicians
submitted 1,105 specimens for examination, of which 284 were
positive and 821 negative; and 24 county physicians submitted
41
THE SPRINGFIELD SURVEY
147 specimens, of which 27 were positive and 120 negative; mak-
ing a total of 85 different physicians submitting 1,252 specimens,
of which 311 were positive and 941 negative; that is, 311 speci-
mens were found to contain the tubercle bacillus.
TABLE 16. RESULTS OF SPUTUM EXAMINATIONS MADE IN THE
BACTERIOLOGICAL LABORATORY OF THE ILLINOIS STATE
BOARD OF HEALTH, DURING I9IO-I9I3
Specimens sub- Specimens sub-
mitted by 61 , mitted by 24 t t 1
Springfield i Sangamon County ^ ^
physicians I physicians
1910 / Positive 47
[ Negative 162
1911 / Positive 85
\ Negative 223
1912 / -Posit^^^ 92
\ Negative 242
1913 / Positive 60
\ Negative 194
four I Pps^twe f 4
years l^^g^^i^^ ^^^
9
56
39
201
7
92
34
257
9
lOI
16
258
2
62
31
225
27
311
120
941
Total 1,105 147 1,252
Dr. G. F. Sorgatz, who prepared the above figures, makes the
following comment on them:
"Examination of this report shows that there were not as many specimens
examined in the year 1913 as in the previous years. It will also be noted
that the percentage of specimens with positive findings is less in 19 13 than
in any of the other years reported. These findings are similar to those of
the specimens from the entire State of Illinois.
"The reason for this is explained by an examination of the case histories
received with specimens. These histories show that the percentage of sputa
from early cases, or from cases in which no diagnosis has been made, is in-
creasing until it has become rather infrequent to receive a specimen from a
case of more than a year's duration.
"The specimens themselves show that a change has taken place. A few
years ago, it was not at all uncommon to find a sputum that contained from
a hundred to a thousand tubercle bacilli in each microscopic field. Within
42
PUBLIC HEALTH IN SPRINGFIELD
the past year, such a specimen has not been seen more than two or three
times.
"These facts, together with personal observation of the handh'ng of sus-
pected cases, lead me to believe that the physicians of this vicinity are mak-
ing the diagnosis, or attempting to do so in the early cases, and that they are
instituting a method of treatment which prevents the early cases from be-
coming hopeless. That they are making good use of the laboratory of the
Illinois State Board of Health is obvious, and we find that most of the physi-
cians are not satisfied with a single negative examination, frequently send-
ing in specimens, at intervals of a few days, until the diagnosis of tubercu-
losis can be confirmed or with reasonable certainty excluded."
Dr. W. G. Bain has submitted the following figures for sputum
examinations made at St. John's Hospital for the two years May,
1912, to May, 1914. The figures differentiate between specimens
taken from patients in the hospital and those sent in by outside
physicians.
TABLE 17. — RESULTS OF SPUTUM EXAMINATIONS MADE AT
ST. John's hospital, may, 1912, to may, 1914
Specimens from
hospital cases
Specimens from
outside cases
Total
Positive
Negative
46
249
19
53
65
302
Total
295
72
367
Even a conservative view of the foregoing facts, including the
estimates based on the annual number of deaths, the reports of
the physicians, and the sputum examinations, must convince the
most skeptical of the wide prevalence of the disease in Spring-
field and the pressing necessity for controlling measures. It is
gratifying to find evidence that diagnosis of the disease in its
earlier stages is increasing, as early recognition greatly increases
the chance of successful treatment.
2. EXISTING AGENCIES FOR THE CONTROL OF THE DISEASE
But what is being done in the city to check the Inroads of this
disease, and through what agencies?
43
THE SPRINGFIELD SURVEY
A. The City
The municipality of Springfield, upon which rests the re-
sponsibility for the control of the disease, practically ignores the
problem. The municipality's efforts in this direction may be
summarized as follows:
Fumigates (at best of doubtful value) only on request; dis-
tributes a limited amount of literature; fails to enforce an anti-
spitting ordinance.
B. The Springfield Tuberculosis Association
Fortunately for the citizens of the city, during the past few
years the Springfield Tuberculosis Association has been conduct-
ing a campaign against the disease, which may be summed up at
present as follows:
Maintains one visiting nurse (two in 19 12 and part of 19 13)
who also does general nursing; operates one free dispensary;
bears part of the expense of treatment of a few patients at the
Open Air Colony; conducts a limited educational campaign.
A recent report of the association says regarding the nursing
service :*
During the year 1913, there were 2,389 calls made by the visiting nurses.
Of these, 1,536 were made at the homes of the tuberculous; 734 were made
in rendering assistance to those sick of other or general diseases and 119
were special calls made in the interest of patients.
Of the dispensary service the report says:
During 1913, there have been 135 patients received at the Dispensary
and at the present time the average attendance of clinics is about fifteen.
The report of the treasurer of the association, not included in
the published annual report, for the calendar year 19 13 shows
that the total receipts from the sale of Red Cross seals, member-
ships, and so forth, amounted to $3,714.43. These funds were
expended as follows: Nursing, $1,127.50; patients at Colony
(from July i), $1,149.20; patients at lodging houses, $411.35;
* From a report of the work of the Springfield Tuberculosis Association for
the year 1913.
44
PUBLIC HEALTH IX SPRINGFIELD
miscellaneous items, including rent, stenographer, and inci-
dentals, $1,015.51; leaving cash balance of $10.87.
From July i, 1913, to July i, 1914, the association expended
$2,108.55 in part payment for the care of 18 patients at the Open
Air Colony and the county contributed the balance. Each
patient was cared for on an average of fourteen weeks at an
average cost to the association of about $8.40 per week.
The work of the association has reached the point where the
policy of caring for a few patients at considerable cost might well
be modified. It is a sound and well recognized principle of the
tuberculosis campaign that the small sums which are raised by
anti-tuberculosis societies may be spent to the best advantage in
ways which will lead to more permanent and general relief of the
situation by public authorities.
While the tendency to spend small sums for the immediate
relief of a few patients in an institution is perhaps natural, a
more farsighted policy would devote at least a part of this money
to a campaign to secure from the city and county appropriations
to build and maintain a permanent public tuberculosis hospital,
to a thorough campaign of education, and to the immediate care
of a greater number by means of increased nursing service and
open-air schools.
The number of new cases received at the dispensary and those
called on by the nurse; how these cases were discovered; the
number of deaths and apparent cures; something of the home
conditions of the patients; reference to the Negroes; together
with a complete financial statement, are not included in the
association's 1913 report, though they may normally be expected
to appear in the report of an organization of this character.
C. Hospitals
The two general hospitals in Springfield are averse to accepting
tuberculosis patients, according to the general custom of similar
hospitals which have no special provision for them. The Spring-
field Hospital can not be criticised for strict adherence to this
policy, but on the other hand St. John's Hospital deserves a word
of praise for its liberal policy of accepting a number of these cases
in the past.
45
THE SPRINGFIELD SURVEY
The Open Air Colony, a private sanatorium of 24 beds for in-
cipient cases, has cared for a few of the city's needy cases, the
county and the Springfield Tuberculosis Association sharing the
expense. The county almshouse has no adequate provision for
the tuberculosis inmates, but it is understood that an appro-
priation has been made for a special pavilion which should be
completed at once.
At the present time there is no public institution where the
citizens of the city of Springfield and the county of Sangamon
afflicted with tuberculosis may receive care and treatment.
Such an institution with special provision for children is not only
desirable but necessary.
D. Springfield's Physicians
The physicians of the city are showing an increasing and com-
mendable disposition to co-operate in the campaign against tu-
berculosis, which is necessary for its success.
3. SUGGESTIONS FOR AN ADEQUATE CAMPAIGN
What more can be done to prevent this preventable disease?
The measures recommended in the following program for
eliminating tuberculosis in Springfield have received general
approval throughout the country. Some of them are already
partly in force in the city.
A. An adequate campaign of education.
B. Institutional provision for adults and children.
C. Free dispensary service.
D. Adequate nursing service.
E. Reporting of cases and disinfection of premises.
F. Open-air schools.
G. Partial Reorganization of the Springfield Tuberculosis Asso-
ciation.
In general, every living case should be known to the health
authorities and under proper supervision either in an institution
or at home. Bovine tuberculosis undoubtedly has some influence
on the prevalence of the disease, especially among children, which
makes a strong argument for the improvement of the milk supply
46
PUBLIC HEALTH IN SPRINGFIELD
and for pasteurization — measures which are discussed in the milk
section of the present pubHc health survey. For the safety of
children in particular, milk should either come from cows dem-
onstrated to be free from tuberculosis or should be pasteurized.
Bearing in mind that prevention of the disease should claim
precedence over cure, let us take up in detail the measures out-
lined above.
A. An Adequate Campaign of Education
As education must of necessity mark not only the beginning
but the progress of the campaign against tuberculosis, some edu-
cational methods are outlined.
The entire school population should be reached about once
every two years through lectures, preferably by a nurse and in
connection with a small exhibit which may be secured at a rea-
sonable cost. The board of education might well adopt the plan
followed in an increasing number of cities of making instruction
concerning tuberculosis part of the regular curriculum.
Meetings of women's clubs, labor, fraternal, social and other
organizations, and gatherings of all kinds offer opportunities for
short talks.
Sunday night stereoptlcon lectures in the churches would
reach effectively a large number of people. In this connection
the special celebration of Tuberculosis Sunday is urged.
There are several good motion-picture reels on tuberculosis
and other health subjects w^hich may be shown in the motion-
picture houses either at special performances or on the regular
bill and preferably with a lecturer to explain the details of the
story. Most of these reels can be secured through the regular
exchanges at no additional cost to the motion-picture houses.
Local physicians should be invited to assist in giving the re-
peated talks which are necessary to the campaign.
Literature of a substantial and easily read nature should be
distributed at the various lectures given. Pamphlets printed in
large type with numerous illustrations are most effective, while
cheap literature is a waste of money.
The Red Cross seal campaign offers unlimited opportunities
47
THE SPRINGFIELD SURVEY
for the dissemination of information concerning tuberculosis and
the campaign for its control.
An adequate educational campaign should include exposure of
alleged "cures" for tuberculosis, of which "Nature's Creation,"*
widely exploited in Springfield, may be taken as an example.
It cannot be stated too emphatically that medicine in bottles
will not cure tuberculosis. Fresh air, good food, and plenty of
rest under proper supervision is the only remedy known.
B. Institutional Provision
The hospital is designed to prevent infection as well as to cure.
Besides receiving expert care and treatment, the patient is taught
the danger of spreading the disease and the precautions necessary
to prevent his infecting those with whom he comes in contact.
A hospital for patients from the entire county is to be preferred
to one that would accept patients only from the city. All pa-
tients should be received and treated on an equal basis, each
patient paying in whole or in part for his treatment or not at all,
according to his ability. It must be kept in mind that the hos-
pital should furnish care and treatment for the sick of a character
which will attract and hold them. Any discrimination or lack of
reasonable provision for comfort which would tend to prevent
full use of the institution by those afflicted must be studiously
avoided. Again, it should be remembered that those patients
who voluntarily isolate themselves in an institution and thereby
decrease the chance of spreading infection, perform a service to
* In a pamphlet entitled Consumption Cure Fakes, reprinted from the
Journal of the American Medical Association, February 4, 191 1, this fraudulent
"cure" is exposed at some length. Concerning testimonials the pamphlet
says:
" No 'consumption cure' is complete without its testimonials. The worth-
lessness of such testimony, from a scientific standpoint, has repeatedly been
shown, and this, too, without assuming that the letters are fraudulent. That
many of the letters published by fake medical concerns are documentarily
genuine there is no doubt; that is to say, the letters were actually written.
How valueless they are is made evident by looking into the cases of the indi-
viduals giving them. On investigating 'consumption cure' testimonials, one
of two things is practically always found: Either the writer of the testimonial
did not have tuberculosis and recovered from his indisposition in spite of the
nostrum, rather than because of it; or, the poor victim, in the first fiush of
optimism that comes whenever a new remedy is tried, deluded himself into
believing that the stuff actually helped him."
48
PUBLIC HEALTH IX SPRINGFIELD
the public which is no less than the benefit rendered to the patient
by the public in caring for him.
A campaign to secure such a hospital, to be maintained by
public funds, is the urgent need of the present situation and should
be undertaken without dela}^
An institution of lOO beds, with additional provision for chil-
dren, is necessary to meet the needs of the county. It would
cost from $750 to $1,000 a bed for site, building, and equipment,
depending largely on the cost of the site. Preferably this should
be at the center of population and near transportation facilities.
The cost of maintenance would run in the neighborhood of $1.35
to $1.50 per day per patient.
The Tuberculosis Association Dispensary
The Springfield Tuberculosis Association now maintains a dispensary and
visiting nurse. This is work of the right type, but to adequately meet the
city's problem it should be considerably extended and should be re-enforced by
a county sanatorium. The city health department should be built up so that
it could take charge of the anti-tuberculosis campaign
C. Free Dispensary Service
One important step toward the control of tuberculosis is the
discovery of patients before they have advanced too far for prob-
able recovery, or recovery possible at anything short of great
expense. One of the functions of the dispensary is to meet this
4 49
THE SPRINGFIELD SURVEY
need. The usefulness of the dispensary might be increased by
urging people, through the educational campaign and the visit-
ing nurses, to voluntarily come for examination at the slightest
symptom of the disease and at intervals when no striking symp-
toms are present.
The physician in charge of the dispensary should receive com-
pensation for his services. The city might assume this expense
at once as well as that for additional nurses.
Complete medical and social information concerning all pa-
tients who visit the dispensary or who are visited in their homes
by the nurses must be obtained and fully recorded. This is
essential to a first class service.
D. Adequate Nursing Service
The visiting nurse must be depended on to visit the afiflicted
in the home, follow up discharged institutional patients, and
bring suspected cases to the dispensary for examination.
An increase of the nursing service is undoubtedly necessary in
view of the lack of hospital facilities, and especially if the sugges-
tion is adopted of broadening the field of the Springfield Tubercu-
losis Association's work to include the entire county. A supervis-
ing nurse could look after the details of administration; namely,
arrange for the lectures previously mentioned, give some of
them herself, and secure lecturers for the balance; take care of
the correspondence of the association; assist in the membership
campaign and the sale of Christmas seals; co-operate with the
various sub-committees; supervise the work of the other nurses;
and devote any balance of time to actual nursing. The other
nurses would devote their entire time to the visitation of the
sick in their homes. While no definite estimate may be made of
the number of nurses needed, it can be safely stated that at least
two assistant nurses for the city and one for the county outside
the city are required to meet the need at the present time.
E. Reporting of Cases and Disinfection of Premises
In order that all patients may receive proper care and neces-
sary preventive measures be taken, all living cases must be
known to the health authorities. Physicians should report not
50
PUBLIC HEALTH IN SPRINGFIELD
only the living cases but the recovery, death, or change of resi-
dence of any patient. When reporting a case the physician
should state whether or not he is willing and able to give the
patient the necessary care and instruction, and whether or not
he wishes a nurse to assist him by visits to the home under his
direction.
Surface disinfection with suitable liquids, and at times thor-
ough cleansing, after the death or removal of a. patient, is ob-
viously necessary to prevent the spread of infection.
The least the municipality can do at the present time is to
pass ordinances requiring the reporting of all cases of tuberculosis
to the health department; requiring the disinfection, and when
necessary the thorough cleansing, of all premises after the death
or removal of a patient; and abolishing the common drinking
cup and towel. It must also enforce the anti-spitting ordinance.
The attitude of the physicians of the city toward the first two
of these recommendations is sufficient comment upon their de-
sirability. The physicians were asked for their opinions as to
the desirability of regulations requiring the reporting of cases of
tuberculosis, and of disinfection of the premises after the death
or removal of a patient. Forty-eight physicians replied.
To the question of w^hether there should be an ordinance re-
quiring the reporting of cases of tuberculosis, the replies were as
follows: Yes, 40; no, 4; for advanced cases only, 2 ; undecided,
2; total, 48.
Answers to the question whether there should be an ordinance
requiring the disinfection of premises after the death or removal
of a patient were as follows: Yes, 45; no, 3; total, 48.
F. Open-air Schools
Among the most encouraging features of the campaign against
tuberculosis are the results obtained in open-air schools and fresh-
air classes for tuberculous, predisposed, and physically subnormal
children. Of the necessity for these measures in Springfield
there can be no doubt.
Open-air classes may be conducted either with or without
feeding, but experience has demonstrated that with feeding the
children respond more readily. The board of education ordi-
51
THE SPRINGFIELD SURVEY
narily supplies the teachers and paraphernaUa for these schools
and classes, and if possible the food, special clothing, and carfare
for children who live at a considerable distance. These latter
three items may have to be supplied by some other city depart-
ment or by the Springfield Tuberculosis Association.
With the permission of the superintendent of schools an exami-
nation was made of children in the Palmer public school with
special reference to glands, tonsils, adenoids, anemia, and sus-
picion of tuberculosis. Dr. George T. Palmer, who made the
examination, reports as follows:
The Palmer School cannot be regarded as representative of the schools of
Springfield. To a greater extent than any other, its student body is made
up of foreigners and Negroes, and home conditions are not up to the general
average. However, prosperity and even luxury of surroundings do not
immunize children to the common physical defects, nor do they ensure sane
and hygienic living. Tuberculosis is in no sense a disease of the poor, al-
though it is a most potent poverty producer. Hence, while the findings in
this study cannot be taken as an absolute index, they probably give a fair
idea of conditions to be found among the children of Springfield.
To ascertain that a large percentage of the 456 children in the Palmer
School were physically below par, and to classify the physical defects found
by inspection, was in no sense difiicult. To determine the extent of tubercu-
losis infection, however, was another and a different thing. The diagnosis
of the disease in its incipient stages, always a delicate matter, is especially
difficult among children. And in the present instance this difficulty was
compounded because, to avoid any possible criticism, the useful tuberculin
test was not appUed nor was even an attempt made at a complete physical
examination of the children.
The diagnosis of tuberculosis referred to in this report must therefore be
regarded as merely a matter of diagnostic opinion based upon general physi-
cal conditions and comparatively fragmentary history. However, we are
coming more and more to recognize that tuberculous infection among chil-
dren is exceedingly common. Some authorities have gone so far as to hold
that primary tuberculous infection almost invariably takes place before the
sixth year of life and that later disease is due to the lighting up of this dor-
mant child infection. It should also be borne in mind that the common con-
ception that tuberculosis is always an acute and virulent disease is entirely
erroneous. Many cases are never recognized and others doubtless manifest
themselves only in enfeebled general health.
52
PUBLIC HEALTH IN SPRINGFIELD
In the actual inspection a visit was made to each room in the school and
the children who appeared below par were selected for more detailed exami-
nation.* To these were added all those among whom the school nurse had
observed physical defects in her routine work. It is quite certain that in
such a casual inspection many were omitted who possessed definite ailments
and defects. However, the process adopted brought 182 of the 456 pupils
to the examining room in the school.
As a means of rapid classification, the general nutrition was graded into
three groups indicated by the numerals ''i," "2," and "3," and a similar
grading was employed for the general condition as determined by the his-
tory and physical examination. In this grouping, the class described "Nu-
trition I ; General Condition i " included the best physical types, while
"Nutrition 3; General Condition 3" would indicate the poorest. By this
plan, the children were classified into nine different groups, as follows:
Nutrition i
Nutrition i
Nutrition i
Nutrition 2
Nutrition 2
Nutrition 2
Nutrition 3
Nutrition 3
Nutrition 3
General Condition i 25
General Condition 2 37
General Condition 3 8
General Condition i 20
General Condition 2 48
General Condition 3 10
General Condition i i
General Condition 2 12
General Condition 3 21
Total 182
A relatively complete history of the immediate family was obtained by the
nurses and this, with a record of the recent illnesses of the individual, were
of assistance in reaching the tentative diagnoses of tuberculosis.
It is my conviction that all of the children rated below as suspected tu-
berculous cases would respond to the accepted tests for the disease, and I
am under the impression that many others whose general condition and
history would not w^arrant a tentative diagnosis, would give ready response
to the von Pirquet test, which, in those of the lower grades at least, may be
accepted as reasonably definite evidence of infection.
It will be borne in mind, of course, that all of these children had been
selected as apparently below grade and that even the best were not normal.
* The inspection was carried on with the assistance of Mary J. Heitman,
the school nurse employed by the board of education, Mrs. Eleanor Vining,
supervising nurse of the Springfield Tuberculosis Association, and several
volunteer workers of the Springfield Survey.
53
THE SPRINGFIELD SURVEY
The following suggestive physical conditions were brought out in this ex-
amination of 182 children:
Enlarged tonsils 141
Adenoids 91
Enlarged cervical glands 140
Enlarged sub-maxillary glands 122
Apparent anemia* 139
Discharging ears (history or present) 43
Elevated temperature (above one degree) 63
Suspected tuberculosis 27
To those who hold the popular conception of tuberculosis and in whose
minds the disease exists only as a devastating and virulent disease, the state-
ment that 27 of the 456 children in this one Springfield school are probably
tuberculous will come as a distinct shock. If, on the other hand, we accept
the doctrine that 90 per cent of all persons acquire tuberculous infection,
and that infection usually takes place in childhood, and then recall that one
death in every eight is due to tuberculosis, we see that there is nothing sensa-
tional or improbable in the estimate. Those who recognize the decided ten-
dency of tuberculosis to spontaneous recovery will, I believe, accept these
figures as extremely conservative.
The following table shows the number of pupils in each grade, the num-
ber selected from each grade as presumably below par, and the condition
found upon examination.
Grades 12 3 4 5 6 7 8 Total
Number of pupils 83 74 87 46 75 39 33 19 456
Number examined 26 20 41 21 35 16 15 8 182
Enlarged tonsils 22 15 32 14 27 14 11 6 141
Adenoids 13 11 23 9 15 10 7 3 91
Enlarged cervical glands 25 17 36 17 28 6 8 3 140
Enlarged sub-maxillary glands 18 7 23 11 28 16 14 5 122
Apparent anemia 24 17 32 12 28 11 11 4 139
Discharging ears 991246.. 2 i 43
Elevated temperature 9 721 411 4 5 2 63
Suspected tuberculosis 93723.. 21 27
That many of these children will "outgrow" their defects is, of course,
certain. That others will never be seriously handicapped by them is like-
* As the examination did not go beyond the general inspection of the child,
the examination of the throat, and the taking of pulse and temperature, the
presence of anemia could not be verified, and its existence was deduced by the
general appearance and that of the conjunctivae and mucous membranes.
54
PUBLIC HEALTH IX SPRINGFIELD
wise certain. There can be no question, however, but that some will show
the results of the neglect of these ailments in physical and intellectual de-
ficiency and perhaps in serious, prolonged illness and premature death.
There are two main conclusions to be drawn from this little study: First,
the need for discovering the physical defects in our school children; second,
the need for remedial measures. The first may be met by the thorough
medical inspection of all school children. A factor in meeting the second
would be fresh-air classes and open-air schools for the anemic and those pre-
disposed to or suspected of tuberculosis.
G. Partial Reorganization of the Springfield Tubercu-
losis Association
As prospects point to the immediate burden of the campaign
against tuberculosis in Springfield falling upon the Springfield
Tuberculosis Association, a partial reorganization of this body is
suggested.
The county, including both urban and rural population, is
generally considered a more desirable unit for activity. Conse-
quently a first and most commendable step on the part of the
association would be to broaden its field of activities to include
the entire county of Sangamon.
The work of the association may be facilitated by division
among sub-committees somewhat as follows: Finance, hospital,
nursing, dispensary, open-air schools, education and publicity,
research, one of physicians, and one of Negroes.
4. WHERE THE RESPONSIBILITY LIES
Tuberculosis is essentially a problem in public health and as
such the responsibility for its control rests upon public officials.
Hospitals, nurses, dispensaries, and other institutions for its
suppression should be supported by public funds. There can
be no permanent evasion of the responsibility, as tuberculosis is
a preventable disease and must be stamped out. The question
facing each community, therefore, is how soon it will take proper
measures to achieve this end. The effective carrying on of this
work by the public points to the necessity for a full-time paid
health officer.
55
THE SPRINGFIELD SURVEY
A tuberculosis association with proper ideals will endeavor as
rapidly as possible to place the responsibility where it belongs.
State appropriations in sufficient amount to furnish adequate
provision for even the incipient cases can hardly be expected, and
still less can we hope for adequate state provision for the ad-
vanced cases which more particularly need institutional care and
treatment. Local hospitals for advanced cases, near centers of
population and which are within easy reach of patients and their
families, seem to be the most desirable. Theory points to the
advisability of these local hospitals, and experience is tending to
indicate that they are the most practical in handling the situation.
800
700
600
500
2 400
300
200
100
Negroes
Total for city
\\Tiite3
1909 1910 1911 1912 1913
Tuberculosis Death Rates by Color and Year, Springfield, 1909-1913
Residents only
CONCLUSION
The foregoing suggestions are in no wise radical or experi-
mental, but represent the best practice as developed so far in
this country. The question of the expense involved must be
settled on the basis of dollars versus human lives.
56
PUBLIC HEALTH IN SPRINGFIELD
Tuberculosis is preventable, and curable especially in its early
stages. These facts cannot be questioned. If true, why does
Springfield permit the disease to persist and destroy so many of
its people? In other words, w^hy is this preventable disease not
prevented? A decided beginning toward this prevention has
been made in the city. It remains to broaden and intensify the
work.
57
VI
TYPHOID FEVER
Typhoid fever is one of the best understood and most pre-
ventable of the communicable diseases. Caused by a specific
microbe, which dies rapidly outside the body of its victim, the
disease may be eliminated by simply keeping the bowel and
bladder discharges of infected persons from entering the mouths
of other persons. This would certainly seem a fairly simple
undertaking; and it has been well said that the disease is pre-
eminently one of defective sanitation and that its presence is a
civic disgrace.
Springfield has suffered severely from typhoid in the past,
even as compared with other American cities, which are in this
respect notoriously worse than those of Europe. Thus in 1907
Springfield's rate of mortality was, according to the health de-
partment reports, 81.7 per 100,000 population, an exceedingly
high rate; and in 1910, taking only deaths of residents, the rate
reached 40.4. In the last six years, 84 of the city's residents
have been killed by typhoid, and probably several hundred more
have been made ill. The situation has shown a tendency to
improve during this period, both as to prevalence and case fa-
tality, the latter of which is in this instance probably a rather
accurate criterion of completeness of reporting. But the city
has no cause to be satisfied with the present situation, or with
any other short of practical eradication.
TABLE 18. — DEATH AND FATALITY RATES, TYPHOID FEVER,
SPRINGFIELD, I908-I9I3 (RESIDENTS ONLY)
^ j Deaths per 100,000 I Deaths per 100
I population | cases reported
1908 32.7
1909 29.7 ..^
1910 40.4 21.4
1911 18.7 19.2
1912 21.8 15.0
1913 17.7 II. 2
^Information not available.
58
PUBLIC HEALTH IN SPRINGFIELD
The distribution of the disease throughout the city, which is
indicated by the accompanying death rate chart, is of consider-
TYPHOID FEVER IN SPRINGFIELD. ILL
WARD DEATH RATES PER lOO^OOOPOPULATION
AVERAGE — ISOS-l9lv3
RESIDENTS ONLY
WARD
RATE^
□ LOWEST
I HIGHEST
\A/ARD RANKINGS
TM£ JP/f//iaF/£LD sd/i^ey'/s/^
able significance with regard to the manner in which the disease
is spread and the measures that should be adopted for its control.
Evidently the east side has fared badly again, but so has the
TYPHOID FEVER IN SPRINGFIELD, ILL
DEATHS PER HUnDRED CASES REPORTED - BY WARDS
AVERAae- i9io-i9ie)
RESIDENTS ONLY
14^
29.6
l'^-" ■10.6
1 1 1^^
22.e
1
WARD FATALITY RATES
WARD •'<ANKINGS
TH£ SP/f/AJGn£LD ■3Upye-r-i9/4
whole city with the exception of the fourth and fifth wards, and
the fourth ward's record is none too good. Such a general dis-
tribution would suggest suspicion of the city water supply were
59
THE SPRINGFIELD SURVEY
it not that wards four and five, which are the most completely
supplied with city water, make the best showings, and that the
facts as to the distribution of wells and privies give a contrary
indication. While city water may have caused part of the city's
typhoid in years past when extensive use was made of raw river
water, and while the general decline in the prevalence of the dis-
ease may have been related to the diminishing use of river water,
there is no real evidence discoverable that tends to implicate the
city supply during the past few years. Such evidence as exists
exonerates the public water supply, which is probably one of the
city's best weapons against typhoid, as long as the intake from the
river is not used. A more detailed discussion of the city water
supply will be found elsewhere in this report.*
TABLE 19. — WELLS, PRIVIES, AND TYPHOID FEVER BY WARD,
SPRINGFIELD
Ward
Wells and privies per
1,000 population,
1914 a
Wells
Privies
Yearly deaths
from typhoid per
100,000 popula-
tion, 1908-13
1
180
183
2
103
lOI
3
126
128
4
97
86
5
67
56
6
202
206
7
39
42
29-3
32.5
28.8
20.0
8.6
33-4
32.0
a There is reason to believe that little actual change has occurred during the
past six years in the ratios of wells and privies to population. See the discus-
sion on page 87.
Comparison of the distribution of the last six years' typhoid
with that of wells and privies, such as appears in Table 19, cer-
tainly indicates that privies and wells play an important part in
the spread of the disease. A general correlation between a high
proportion of wells and privies and a high typhoid rate is mani-
fest, a relation that is commonly recognized. Typhoid urine or
feces deposited in a common privy are freely accessible to flies,
who can carry the infection directly to fresh victims ; or the ma-
* See p. 72 ff.
60
PUBLIC HEALTH IN SPRINGFIELD
terial may percolate rapidly through the ground and infect wells,
thus securing another quick and easy entrance to new mouths.
Some 7,000 wells and 7,000 privies standing side by side in an
area of eight and a half square miles, with especially thick clus-
terings in some districts, as in Springfield, is simply bad sanita-
tion. At some time or other infection is certain to be carried
from the privies by flies and some of the wells are certain to be
polluted.
The general correlation between wells and privies and typhoid
is not absolute, as is indicated by a close examination of the
Springfield figures. Ward seven, for example, has a high typhoid
death rate but the lowest proportion of wells and privies. The
truth of the matter is that the disease is spread in another very
important way — by "contact"; that is, through personal con-
tact between infected persons and their attendants or others
coming into their immediate environment. The discharges of a
person having the disease are highly infectious and minute par-
ticles from these discharges passing the lips of another person are
sufficient to cause the disease. The discharges may be infectious
even before the development of marked symptoms and are com-
monly so during convalescence. If the persons around the
patient do not understand the importance and method of ef-
ficiently disinfecting the patient's discharges it is very easy for
them to infect their fingers, either directly when handling the
patient or disposing of his discharges, or indirectly by handling
articles which have become infected; and fingers all too often
reach the mouth or touch objects that enter the mouth.
In fact, there is a general lack of appreciation of the contagious-
ness of typhoid fever, and once an initial case occurs in a family
or neighborhood it is lamentably common to find secondary
cases appearing in about the incubation period of the disease —
usually ten days or two weeks. The disease will thus smolder
through a neighborhood in a manner less spectacular than that
of the ''epidemic" but in a w^ay no less deadly.
The reporting of cases in Springfield, unfortunately, has not
been complete enough nor has the information elicited been full
enough to permit an intensive study of this phase of typhoid
transmission. Some significant information is, however, avail-
61
THE SPRINGFIELD SURVEY
able, and the data in Table 20, taken almost at random from the
case records as reported to the health department, shed light on
the subject.
TABLE 20. — EXAMPLES
OF RETURN CASES OF TYPHOID
SPRINGFIELD
FEVER,
Address
Dates of reporting
Year
i
1st case 2d case 3d case i
4th-6th
cases
1910
1912
1913
208 W. Pine
1 501 S. College
200 W. Pine
545 Elliott
1124 N. Rutledge
1709 E. Clay
926 Patton
900 N. 12th
153s E. Capitol
210 W. Jackson
216 W. Jackson
204 W. Jackson
June
28
July
6
June
29
July
6
Aug.
4
Aug.
8
July
27
Aug.
8
Aug.
I
Aug.
8
Aug.
5
Aug.
10
Aug.
26
Sept.
20
Aug.
a
Sept.
15
Sept.
25
Oct.
8
July
15
Aug.
6b
Aug.
12
Aug.
12
Aug.
22
July 27
Sept. 20 Sept. 20
^ Exact date not available.
b A child who had stayed at 210 W. Jackson.
It will be noted that the average time between the return
cases listed is about two weeks and that in only two instances is
the interval less than one week. The West Jackson Street cases
illustrate the spread of the disease through a neighborhood.
Bearing in mind that no general epidemic was present in the city
at any of the times covered by the above list, the suggestion is
strong that we are dealing here with secondary cases. And
indeed, considering the nature of the disease, the character of the
attention it receives from the health department, and the ex-
perience of other cities, it would be surprising if secondary in-
fection were not an important contributory factor in the causa-
tion of Springfield's typhoid.
The recommendations which may be made for the reduction
of the city's typhoid, aside from the elimination of wells and
privies and total abstinence from the use of unpurified river
water, relate chiefly to administrative measures by the city health
62
PUBLIC HEALTH IN SPRINGFIELD
department. In the first place, as in the other communicable
diseases, the department should receive a prompt report of every
case. Efforts in this direction have already been made by the
department and reporting has improved, but up to 1914, when
this investigation was made, there was still room for further im-
provement in parts of the city. The ward differences in case
fatality for the six years previous are illustrated in the chart on
page 59, and in examining them it should be borne in mind that
with complete reporting the fatality seldom exceeds 10 per cent.
Good reporting is required by law and is the absolute first es-
sential to effective methods of control. Doctors should not har-
bor the idea that the case report is simply a matter of record with
the department and that it may be sent in late or never ; while if
the department is alive to its opportunities the doctor will not
be able to make such an excuse for delinquency in this duty.
Receipt of a case report by the health department now results
in a visit to the patient's home by an inspector who leaves a copy
of the state board of health circular regarding the disease and
who attempts to learn the source of infection. Instructions are
given that the family and milkman shall not take or deliver milk
bottles, and that articles shall not be taken from the patient's
room during the course of the disease. An attempt is also made
to get a history of the case from the attending physician by tele-
phone, usually without much success.
Criticism similar to that made of the procedures employed
against the contagious diseases of children can be made of this
system of visitation and instruction by untrained inspectors.
Efficient bedside disinfection of discharges is the prime point in
preventing secondary typhoid and it is doubtful whether the
ordinary inspector, no matter how capable he may be in the
matter of nuisance abatement or enforcement of the sanitary
ordinances, is properly equipped to give instruction in the man-
agement of the patient. It is exceedingly doubtful whether the
inspectors themselves, without special training, would be con-
sidered competent to look after a typhoid patient by the authori-
ties of a first class hospital. Similarly the history taking and
study of the origin and relation between cases (epidemiology)
is a matter for a person of special training or ability. This work
63
THE SPRINGFIELD SURVEY
calls for an understanding of the principles of statistics and the
modes of infection such as may not be expected of persons who
have not made a special study of such matters. The recommen-
dations for improvement of the health department service are
thus much the same as in the case of the contagious diseases of
children : better reporting of cases ; prompt visitation of cases by
a medical inspector or specially trained nurse employed by the
health department, with revisitation, or removal of cases if
necessar}^; and more thorough epidemiological work.
In summing up the typhoid fever situation it may be said that
Springfield has suffered unduly from the disease, and that al-
though there has been a general improvement in recent years, too
much typhoid still occurs. As to causation, the evidence is that
since the use of unpurified river water has been abandoned the
city water supply has been free from blame. The distribution
of the disease throughout the city shows the fourth and fifth
w^ards to a decided advantage, a distribution that corresponds
in a general way to that of wells and privies, which assuredly
play an important part in keeping up the death rate. Contact
infection directly from person to person is, however, probably
responsible for much of the trouble, a fact which calls for improved
procedures of study and control on the part of the health depart-
ment. Such improvements require some money and consider-
able skill, but the results would surely be well worth while, as
typhoid killed 84 Springfield residents in the six years studied
and is, at the same time, one of the most certainly preventable
of the communicable diseases.
64
VII
THE VENEREAL DISEASES
Springfield's death rate from syphilis in 1913, 23.0 per 100,000,
was greater than its death rate from typhoid fever. And this
despite the fact that syphilis is seldom certified as a cause of
death when any other can be substituted. The truth is that the
number of deaths certified under this title is probably far short
of the actual number. Similarly, we do not know the actual
number of cases of syphilis in Springfield because the disease
receives no official cognizance. It is entirely probable, however,
that the same number of cases of typhoid fever, or scarlet fever,
or diphtheria, would cause great public agitation and an insistent
demand for action by the authorities.
Yet syphilis is only one of three communicable venereal dis-
eases, the consequences of which are quite possibly much more
important than some of the diseases mentioned and on account
of which rigorous measures are commonly taken. This extra-
ordinary and irrational state of affairs is partly due to the fact
that those afflicted take pains to conceal these diseases, so that
the public gets little idea of their prevalence, and partly to the
fact that the public does not realize their contagiousness and
their exceedingly serious after-effects.
To get some idea of the actual amount of venereal disease in
Springfield, letters were sent to the physicians, requesting a state-
ment of the number of cases under treatment during the past
year and at the present time. Replies were received from 49
individuals, or about three-fourths of those addressed, and the
results are as tabulated below.
TABLE 21. — CASES OF VENEREAL DISEASE TREATED BY 49 SPRING-
FIELD DOCTORS, MAY, I914
• c^ , .,. i Chan- Conor- ^ , ,
Syphilis ^^^-^ ^^^^ Total
Under treatment ''at present" 147 39 160 346
Under treatment "during 1913" 398 212 654 1,264
5 6.S
THE SPRINGFIELD SURVEY
As this list does not include all cases treated by physicians, nor
those treated by "specialists," nor untreated cases, it is evident
that there is ample basis for a statement that these are the com-
monest communicable diseases in the community. An accurate
idea of the damage actually done cannot be obtained, partly be-
cause of the tendency to certify other causes as responsible for
death and partly because a large part of the damage is manifested
indirectly.
Thus, syphilis can produce immediate suffering and injury of
the most serious character; but it may also run a mild course, or
be apparently cured, only to have the victim break down in
middle age with paralysis or softening of the brain. A very
large proportion of the cases of paresis and locomotor ataxia are
caused, according to the best medical opinion, by antecedent
syphilis. Similarly, in gonorrhea the local symptoms at the time
of the attack may be mild and the patient may apparently make
a complete recovery; yet the microbe of the disease can lie dor-
mant in such an individual for years, retaining its power to in-
fect others, who may be wholly innocent of any immorality. It
is claimed that a large proportion of surgical operations among
women are necessitated by gonococcus infections innocently
obtained from their husbands. Gonorrhea seldom kills, but it
blinds children and maims women. It is strictly true that the
more we know of the venereal diseases the more we have reason
to fear them.
The only information regarding these diseases that can be
gathered from the local vital statistics relates to syphilis. In the
past six years the deaths of 30 residents have been recorded as
due to this disease, besides 19 due to locomotor ataxia and paresis.
While these figures probably do not represent the situation ade-
quately, it is interesting to note the distribution of the deaths
throughout the city, and by age and year. From Table 22 it
will be seen that the majority of the deaths have been among
infants and that all the wards have had a share of the mortality.
A factor in the sixth ward's excess is the presence of the Redemp-
tion Home, which receives a number of girls and infants having
the disease. The marked increase in deaths during 19 13 may be
real or due simply to more accurate certification.
66
PUBLIC HEALTH IN SPRINGFIELD
table 22. — deaths from syphilis as certified in springfield,
1908-1913 (residents only)
Deaths
by
year
Dea
ths by
ward
Deaths by
age
Year
Deaths
I
Ward
1
Deaths
5
Age at death
Deaths
1908
Under i
18
1909
6
2
I
I to 2
2
1910
3
3
6
Adults
10
1911
2
4
2
1912
5 r
5
3
1913
13
6
7
II
2
Total
30
Whole
city
30
Total
30
Granting the magnitude and importance of the venereal dis-
ease problem the question arises as to what can be done. The
three diseases are each caused by a specific micro-organism with
whose characteristics the bacteriologist is familiar. Given the
same privileges as in typhoid, diphtheria, and other infections,
the health department could undoubtedly reduce the prevalence
of these diseases to a considerable extent. The "conspiracy of
silence," however, that is, the unwillingness to speak of these dis-
eases, is a factor that makes the complete reporting of individual
cases and the institution of such preventive procedures imprac-
ticable. It even hinders the dissemination of educational ma-
terial, and it is a condition which any plan of campaign must
take into account.
The city can, nevertheless, undertake several things that are
valuable. It can, through its health department, require the
reporting of cases by number instead of name, the residence by
district also to be given. This is the necessary first step toward
acquiring an idea of the prevalence and distribution of infection.
It can also, preferably through its health department, see that
indigent cases are promptly treated and cured, thus eliminating
these sources of infection. Such work would coordinate well with
the health department dispensary and health department nurses
advocated elsewhere in this report. The city can also see that
there is adequate provision for the hospital care of cases of these
diseases and can arrange for free laboratory diagnosis of samples
67
THE SPRINGFIELD SURVEY
of blood and discharges, this service to be offered freely to physi-
cians. Finally the city can, through its health department,
educate the public, telling how the diseases are contracted, how
avoided and cured, and what precautions should be taken by
patients to avoid infecting others.
The city can, in other words, make a beginning, and should
do so, imitating those procedures which have been instituted
by progressive health departments in other cities. The general
taboo placed on this subject by society is a heavy handicap to
progress, just as was the case at the inception of the tuberculosis
movement, but a good deal can be done even in the face of this
handicap, while efforts meanwhile should be made to remove
its most unreasonable aspects. Certainly the venereal diseases
are of vast importance in the community and certainly a start
should be made on their prevention.
SUMMARY OF THE PREVENTABLE DISEASE SITUATION
IN SPRINGFIELD
Enough has been said to show what a very serious life and
health wastage is constantly going on in Springfield, — to be ex-
plicit in a conservative way, something like the loss of 1,218
lives and a much greater number of cases of non-fatal illness in
the last six years. The diseases most active in this telling ravage
PNEUMONIA IN 5PRINGriELD, ILL
WARD DEATH RATES PER 100,000 POPULATION
AVERAQE I90a-I9l3
UNDER. iJ YEARi or AGE RESIDENT,! ONLV
WARD RATE.5
Q LOWEST
B HIGHEST
WARD RANKINGS
TH£ 3PXWaF/£LO Sl/f!l^£Y/9/-4-
68
PUBLIC HEALTH IN SPRINGFIELD
are tuberculosis, those of infants — especially diarrhea and enter-
itis, the venereal diseases, the contagious diseases of children,
and typhoid fever. Other preventable infections occur, but their
The Springfield
Survey
Springfield, Illinois
Pneumonia in Springfield
Deaths of residents under fifty-five years of age, 1908-19 13. Pneumonia
is another one of the important infectious diseases, and study of it by the health
department, especially as related to the deaths it causes among infants, would
probably be well repaid
extent is relatively small and they will be controlled in much the
same manner and by the same administrative machinery as those
specifically mentioned.
69
THE SPRIN'GFIELD SURVEY
The variation in the amounts of preventable sickness and
death in different parts of the city is of interest as re-emphasizing
the preventability of the diseases and indicating the locaHties
that call for special activity by the health department. In almost
every particular the district to the east of Tenth Street, including
the first and sixth wards, has come off badly in the comparisons.
Here occur excesses of typhoid, tuberculosis, infant mortality,
and contagious diseases of children; and here also are relatively
the largest number of wells and privies. It is likewise significant
that this district contains most of the Negroes, a large part of the
foreign-born whites, and most of the illiterates. The east side
is also, with the more northerl}^ part of the city, the place of abode
of the younger and more distinctly laboring part of the city's
population. The public health problem clearly centers in these
districts.
The underlying causes of the excesses of preventable disease
are ignorance, insanitary conditions, and inadequate city health
service. Although the detailed discussion of sanitary conditions
in Springfield appears later in this report, it is not out of place
to note here the deleterious effects of the existing wells and
privies as indicated by the ward vital statistics. Similarly it is
evident that the health department equipment needs augment-
ing, more especially in the form of public health nurses and of
expert service as applied to isolation and epidemiology. These
two agencies, working hand in hand and extending out to com-
bat infection at that important contact point, the home, should,
at very reasonable expense, accomplish great things.
70
PUBLIC HEALTH IX SPRINGFIELD
SPRINGFIELD AS A SANITARY ENVIRONMENT
Man's environment may be defined as everything that sur-
rounds him and exerts an influence on him. It thus includes the
earth he treads, the air he breathes, the buildings he inhabits, the
plants and animals about him, and — the rest of humanity.
From the standpoint of infection, and so of public health, it is
convenient to emphasize the difference between the human and
non-human parts of this environment. On such a basis man's
environment has two great components — first, all his fellow men,
and second, everything else. This distinction is useful in public
health work because while man may contract infection from both
these parts of his environment, the modes of transmission and
the methods of control are in the two cases materially different.
In discussing infection this report has dealt so far chiefly with
the ways in which disease spreads directly from person to person
and the ways in which this mode of infection may be combated.
Attention will now be given to the principal sanitary influences
in Springfield's non-human, or inanimate, environment. This
group of influences, to be specific, includes the city water supply,
sewer system, milk supply, food supply, w^ells and privies, and
a few others. Two important parts of the sanitary environment,
those surrounding children at school and workers in industrial
establishments, are not treated in this report, as they are dis-
cussed in the sections of the survey dealing specifically with
those subjects.*
* Ayres, Leonard P.: The Public Schools of Springfield, Illinois. (The
Springfield Survey.)
Odencrantz, Louise C, and Potter, Zenas L.: Industrial Conditions in
Springfield, Illinois. (The Springfield Survey.)
71
VIII
CITY WATER SUPPLY*
''Health requires pure water. Civic health requires faithful
public service." These words appear on an inscription tablet at
the new pumping station, and they are indeed well chosen. The
relation between an impure water supply and high death rates
from typhoid fever and other intestinal diseases is well known ;
and a considerable body of evidence has been collected which
tends to show that impure water may even cause excesses of
diseases formerly thought quite outside its range of influence.
The Springfield water works are situated at a point on the south
bank of the Sangamon River about two miles from the northern
edge of the city and four miles from its center. The first works
were built at this point in 1867, water being pumped direct from
the river to the city through a 15-inch pipe. River water proved
so dirty, however, that in 1884 a large circular brick well, 60
feet in diameter and 53 feet deep, was constructed near the river's
edge. A supply of ground water was secured from this well, but
the yield was not sufficient to meet the demand and in 1888 an
infiltration gallery was constructed running southeast from the
large well. This gallery was laid in a gravel deposit about 26
feet below the surface of the ground, was constructed of elm
planking, and was four feet broad, five feet high and 1,000 feet
long. The supply still being insufficient a direct connection
was made with the river in 1890, while increases were also made
in the gallery system so that by 1900 some 2,735 ^^^^ were in use.
Further attempts to find an adequate supply of ground water
took a new form in 1902, four tubular wells being driven. No
* Much of the material in this section is drawn from Hansen, Paul, and
Stromquist, W. G.: Report on the PubHc Water Supply of Springfield, State
Water Survey, April 5, 1913. For a discussion of the supply from the stand-
point of fire protection, reference should be made to the 85th Report of the
Committee on Fire Prevention, National Board of Fire Underwriters, Decem-
ber, 1908.
72
PUBLIC HEALTH IN SPRINGFIELD
adequate test of these wells seems to have been made, however,
until 1911, possibly because filtration projects were in favor
during the intervening period. The tests, when finally made,
were encouraging, and in 19 12 and 19 13 new wells were driven,
flllPat^N URBPM
.SMtLBTVlLLt
ScALC or Ml
.ITCnfltLD
J
Why Springfield must not Pump from the River
The heavy black Hne marks the limits of the drainage area of the Sangamon
River above the city water works. This area was inhabited in 19 10 by some
191,000 persons, of whom 110,000 resided in places of over 1,000 population.
The river at Springfield is seriously polluted by the sewage of Decatur and parts
of Springfield's own sewage, and water from it should not be used in an un-
purified condition
the results being again satisfactory. Meanwhile, for over two
decades, unpurified river water made up a considerable part of
the supply, and even in 1914, although only for a few days at its
very close, it was found necessary to pump from the river and
advise citizens to boil the water.
73
THE SPRINGFIELD SURVEY
The present water-gathering equipment consists then of the
old galleries and six tubular well units. The old large well is
still in use, but as a receiving cistern for the other developments.
The tubular units each consist of a central pit about 20 feet deep
Present Type of City Water Supply Development
One of the six tubular well units making up part of Springfield's supply.
The well house covers a pit about 20 feet deep containing an electrically driven
centrifugal pump. The latter pumps water from the several driven wells
making up the unit to the receiving well at the main pumping station
and eight feet in diameter at the bottom of which is an electrically
driven centrifugal pump surmounting a 12-inch tubular well,
with suction lines running to supplementary lo-inch wells about
50 feet distant. All the tubular wells penetrate the alluvium
of the river bank to a depth of 45 to 55 feet, reaching hard-pan.
74
PUBLIC HEALTH IN SPRINGFIELD
The yield of these well units is stated to average i ,000,000 gallons
per day, the total capacity thus being 6,000,000 gallons. Com-
l^ared with the average daily consumption of 5,500,000 gallons
this yield would seem fairly adequate, but as the maximum rate
of demand reached 8,500,000 gallons in the year ending February
28, 19 14, and as the system has practically no storage reserve
against possible conflagrations, and as the city is constantly grow-
ing, it is evident that the development, and experiments to de-
termine the limitations of the possible development, should be
pushed. The fact that during the summer of 1914, despite un-
usual drought, sufficient ground water was had is encouraging,
and the city should be liberal in its allowances for further experi-
ments and development, the need of which is conclusively shown
by the shortage experienced at the very end of 19 14.
The important need is that the supply be made entirely inde-
pendent of the river. The Sangamon above Springfield drains
an area of about 2,710 square miles, which was inhabited in 1910
by about 191,000 persons of whom about 1 10,000 resided in places
of over 1,000 population. Decatur, with a population of about
37,000, discharges its sewage directly into the Sangamon, and
in time of flood fecal material from this source could reach the
Springfield intake in about ten hours. Pollution of the river and
the possibility of its infection is thus assured. The tubular well
system should be developed to a point where the possible need of
river water will be precluded, and the river intake should be elimi-
nated because of possibility of leakage in the gate valve or of its
being left partially open.
This need is emphasized by a long series of analyses made by
the State Water Survey, which show that the quality of the water
supplied in the past has varied widely in accordance with varia-
tions in pumpage from the river. A tabulation from these analy-
tical records, giving an idea of the extent of these variations and
the general tendencies of the last few years, may be found in Ap-
pendix F, page 146. While the number of samples has not been
large enough nor the taking of them sufficiently systematic to
allow of conclusive judgment, it would appear that the supply has
improved in the past few years, as might be expected from the
decreased use of raw river water.
75
THE SPRINGFIELD SURVEY
Our discussion of the city water supply has so far dealt with
the question of securing an adequate supply of pure water. The
question that remains from the standpoint of sanitation is how
thoroughly the water is distributed throughout the city. The
adequacy of the pumping machinery and of the size of the mains
is of the first importance in connection with fire risks, and is
Testing a Drive Well
Test wells have been driven on the Sangamon River bank around the pump-
ing station to determine the amount of ground water available and the best
locations for permanent wells. There is need for more of this experimental
work, as the yield from the present wells is not adequate in the face of long
continued drought and does not insure sufficient reserve for possible conflagra-
tions or the future growth of the city
discussed on that basis in the Municipal Efficiency section of the
survey* and in the report of the National Board of Fire Under-
writers. The sanitary need is met, however, if the capacity of
the machinery and pipes is sufficient to give consumers satis-
* Decker, D. O.: City and County Administration in Springfield, Illinois.
(The Springfield Survey.)
76
PUBLIC HEALTH IN SPRINGFIELD
factory service and if the mains are distributed so that all persons
in built-up sections may receive the water.
For these ordinary demands the present pumping equipment
is entirely adequate, a new pump of modern design with a ca-
pacity greater than the maximum rate of demand experienced
in the last two years having been installed in 19 13. The old
pumps, with at least equal capacity, are held in reserve. The
The New Pumping Station
Built in 19 13 at an expense of $55,000, it contains a new pump costing
$52,000. To follow up this creditable improvement Springfield should now
increase the force main capacity to the city and should extend the smaller
mains to serve a number of parts of the city which cannot at present obtain
city water. The location of the water works is shown in the frontispiece
distribution system is not so satisfactory. The force mains to
the city, a 15-inch pipe laid in 1867 and a 24-inch pipe laid in
1892, are inadequate in size and, being laid over coal workings,
are liable to disturbance and consequent impairment of the
service. Such interruptions, resulting in a cutting off or fall in
pressure of the water and marked increases in turbidity, are
objectionable from a sanitary standpoint because they force
77
THE SPRINGFIELD SURVEY
many to make temporary use of shallow wells and prejudice
others against using the supply at all. The need for additional
force main provision is beyond question, and the engineers of the
National Board of Fire Underwriters in 1908 recommended the
immediate construction of two additional 24-inch mains, while
the commissioner of public property for the past year advocated
the construction of a 36-inch main. The estimated cost of the
latter project is $150,000; and whatever the necessary expense
it should be granted.
Perhaps the most important part of the distribution problem
is to see that the water is available to all persons living in built-up
parts of the city. If city water is not available, that is, if there
is no main in the street, persons must rely on wells, which in
built-up districts are always liable to pollution and infection.
The illustration on page 79 shows in black the built-up areas
not served in 19 14 by the city mains, the information on the
latter point being supplied through the courtesy of the com-
missioner of public property. It is evident that the east and
northwest sections (wards one, three, and six) are the poorest
served, a conclusion borne out by Table 23, which gives estimates
of the populations not served.
TABLE 23. ESTIMATES OF WARD POPULATIONS NOT SERVED WITH
CITY WATER, SPRINGFIELD, 19X4'^
Ward Persons
Per cent of ward
population
1 2,510 30.0
2 340 5-6
3 783 9.2
4 . 394 4.0
5 166 2.9
6 2,090 20.4
7 75 24
Whole city 6,358 12.3
a Based on present location of mains, but population of 1910.
The above estimates were arrived at by multiplying the num-
ber of houses listed in the 19 12 city directory in the unserved
78
PUBLIC HEALTH IN SPRINGFIELD
areas by the average number of persons per house in the corre-
sponding ward according to the census of 1910. The resulting
figures, while not strictly accurate, are sufficiently significant
for the purpose at hand. That 30 per cent of the people in ward
one and 20 per cent of the people in ward six cannot use city water
are facts of serious sanitary import, and make a strong argument
for a policy of liberal extension of the mains of the city, which
should go hand in hand with one of well condemnation and com-
BuiLT-up Areas without City Water and without Sewers
The map to the left shows in black inhabited areas without city water mains
in the street; the map to the right shows similar areas without sewers in the
street. Approximately 12 per cent of the population do not have city water
available, while 17 per cent are without sewers. The deficiencies are evidently
more marked in the eastern parts of the city
pulsory connection.* The small householder should be given
every inducement to connect, as is done by the present arrange-
ment whereby the water department will install a service connec-
tion from the street main to the house for $20, payable $5.00 in
advance, the balance in instalments of one dollar a month. It
is stated that requests for extension of mains exceed in the ratio
* On November 16, 1914, the city commissioners voted to authorize a
number of new mains in certain parts of the city.
79
THE SPRINGFIELD SURVEY
of four to one the additions permitted by the funds available,
and it is evident that the cost of these extensions and of the new
force main service needed will require that very considerable
funds be placed at the disposal of the water department. Such
funds should be made available, as pure water for the whole city
is a sanitary and commercial necessity.
To sum up the situation: Springfield, after enduring for many
years a supply more or less polluted with river water, has within
recent years succeeded in locating a supply of pure ground water
■■'l' 1
-^
III
Built-up Areas with Either No City Water or No Sewers; and Areas
WITHOUT Both
To the left, map showing inhabited areas lacking one or both of the services;
to the right, map showing similar areas lacking both services
and a method of collection that promise to give satisfactory
results for years to come. Further experiments should be made,
however, to determine the ultimate possibility of development,
and further development should be undertaken to assure a greater
margin of reserve than now exists. Means should be devised
whereby the supply of ground water will be suf^cient to meet any
possible demands, even in the face of large fires, and the river
intake should, as has been recommended by the State Water
Survey, be done away with. The present pumping equipment
80
PUBLIC HEALTH IN SPRINGFIELD
is amply adequate for any normal demands, but the present force
mains to the city should be supplemented by one or more new
mains to preclude the possibility of interruptions in the service
on account of breaks in the existing mains and to prevent exces-
sive velocities in them such as give rise to objectionable turbidity.
Finally, there is much need for new distribution mains in the
eastern part of the city. At the time of the survey 30 per cent
of the population in ward one and 20 per cent of the population
in ward six had no mains in the streets, a serious situation in
view of the dangers attending the use of wells and privies in built-
up districts. The city is to be congratulated on the improve-
ments which have been made in the source of the supply and the
equipment at the pumping station, but there is real need for
further development.
81
IX
SEWERAGE AND SEWAGE DISPOSAL*
A detailed investigation of the design, construction, and
maintenance of Springfield's sewer system has been impossible
in the present survey owing to limitations as to time and funds.
Some significant information is available, however, and there are
prospects that a detailed survey may be undertaken by the city
authorities at the instance of the State Water Survey. The
information that can be presented here relates to the distribution
of sewers throughout the city, and to the location of sewer out-
lets and the condition of streams into which they discharge.
Springfield's sewerage is of the "combined" type; that is, one
set of sewers cares for both house sew^age and storm water.
The inadequacies in distribution of the existing sewers are
brought out in the illustration on page 79, w^hich shows in black
the built-up areas having no sewers in the streets. The deficien-
cies are obviously similar to those in the case of the city water
system ; but the sewerage situation over the entire city is some-
what worse. This fact is brought out in Table 24, which gives
estimates of the populations without sewers for the several wards,
prepared on the same basis as the estimates on page 78 for city
water. Here the estimates indicate that 17.5 per cent of the
city's population cannot connect with sewers, as against 12.3
per cent in the case of the w^ater mains. The east side again
fares badly while the showings of wards two and three are ma-
terially worse than in the case of the city water system. The
showing of ward five is again of the best.
* The reader is referred also to: Hansen, Paul, and Stromquist, W. G.:
Report on the Public Water Supply of Springfield, April 5, 1913; and Hansen,
Paul, and Norbury, Garm: Report on Inspection of Streams Into Which Sew-
age of Springfield Is Discharged, October 10, 19 13. Information regarding
the present location of sewers was available through the courtesy of the city
engineer's office.
82
PUBLIC HEALTH IX SPRINGFIELD
TABLE 24. — ESTIMATES OF WARD POPULATIONS NOT SERVED BY
SEWERS, SPRINGFIELD, 19X4^
Ward
Persons
Per cent of ward
population
1 2,226 27.1
2 I1063 17.6
3 1,664 19-5
4 1,171 ii-Q
5 254 4.5
6 2,307 22.5
" 333 T0.8
Whole city 9;058 17.5
^ Based on present location of sewers but on population of 19 10.
The presence of these very considerable unsewered areas is of
prime sanitary importance. Lack of sewers compels the privy
system, which in turn greatly increases the opportunities for fly
infection. The city should undertake without delay a thorough
survey of its present sewerage equipment and should utilize the
results in formulating a plan for the rapid extension of the system
to serve all built-up districts. Such a program should of course
be attended by a policy of privy condemnation and city water
main extension.
Springfield now discharges her sewage in a more or less hap-
hazard manner at some twelve points either within or a short
distance outside her boundaries. The location of these outfalls
is shown in the frontispiece, while the particulars as to their size
and construction appear in Table 25. Most of the sewage flows
to the northwest and reaches Spring Creek; the remainder goes
ofi to the southeast into Sugar Creek. None of the sewage is
treated in any way, and according to the report of inspections
made by the State Water Survey during August of 19 13 serious
pollution attended with nuisance occurs in the streams receiving
the sewage, more especially that part of Spring Creek between
the Old Town Branch and Camp Lincoln. The nuisance is ob-
jectionable to householders in certain places and with the growth
of the city is sure to become worse. The volume of flow in some
of the creeks manifestly is not large enough to assimilate the
83
THE SPRINGFIELD SURVEY
amounts of sewage they receive. Aside from the nuisance
caused in these streams by putrefaction of the sewage there is
the added danger that must attend the discharge through popu-
lated districts of raw sewage which may at any time contain in-
fectious matter.
TABLE 25. — DATA REGARDING SPRINGFIELD SEWER OUTLETS^
Outlet
number
Material
Size
Stream
reached
1
Concrete and brick
10' X 12' rectangular
Spring Creek
2
Brick
7' circular
Spring Creek
3
Brick
2' circular
Spring Creek
4
Brick
5' circular
Spring Creek
5
Brick
4' circular
Spring Creek
6
Brick
4>^' circular
Sugar Creek
/
Brick
2)14' circular
Sugar Creek
8
Brick
6' circular
Sugar Creek
9
Several tile sewers
Stream to be
covered
Spring Creek
10
Brick
3' circular
Spring Creek
11
Brick
5' circular
Spring Creek
12
Concrete
3' circular
Spring Creek
a From the State Water Survey reoort on the Springfield Public Water
Supply, April, 19 13. See frontispiece for location of above outlets.
Under the circumstances, Springfield must be prepared to
grapple not only with the question of adequate sewers within her
boundaries but with the question of disposing of her sewage with-
out nuisance and danger to herself or others. To quote from the
State Water Survey report, ''There can be no doubt but that if
the present rapid growth of Springfield continues it will soon
become necessary to install sewage treatment works."
The ultimate necessity for treatment has an important bear-
ing on the selection of any sewer plan for the whole city, and
should be given careful consideration in a thorough-going survey
of the sewerage situation such as the city should make. The
construction and maintenance charges for treatment works will
be less with separate collection of sanitary sewage and storm
water and with a single treatment plant.
In studying her sewage problem Springfield will do well to in-
vest in the best engineering assistance, as the economies inciden-
84
PUBLIC HEALTH IN SPRINGFIELD
Some Springfield Sewer Outlets
Springfield discharges her sewage in a haphazard manner at twelve different
points along her borders. The creeks which receive the sewage are seriously
polluted at a number of places. In the illustration the upper picture is of the
main drain of the city (sewer No. i in Table 25) which consists of a creek, the
Old Town Branch, covered over. Below to the left is outfall No. 2; to the
right, outfall No. 8. There is need for a careful engineering study of the city's
sewerage problem, which should take into account the possible ultimate neces-
sity for disposal works
tal to Starting with the right plan are Hkely to be very great.
The work of bringing sewers into the unsewered sections should
proceed with a minimum of delay, as should a study of the whole
situation as regards existing and needed trunk sewers and a dis-
posal system.
85
X
WELLS AND PRIVIES
In 1910 Dr. George Thomas Palmer, superintendent of health,
undertook a sanitary survey to determine the number and loca-
tion of all private wells, privies, cesspools, and premises other-
wise insanitary. A house to house canvass was made and a large
map was prepared representing in different colors the various
conditions found. Extensive publicity was given the findings in
this and other ways. An ordinance was passed requiring all per-
sons building, or rebuilding, to make proper sewer and water con-
nections if within 100 feet of a sewer and a water main, an^ re-
quiring all wells and vaults to be abandoned within 30 days of
such connection. Owners of wells and privies not affected by
this ordinance were at the same time strongly advised to abandon
these appurtenances and connect with the city water and sewer
facilities wherever possible. In commenting on the findings of
this survey in his annual report for 19 10 Dr. Palmer expressed
himself as follows :
1. There are 7,000 shallow wells in the city and the pollution of these is
insured by 6,000 privy vaults.
2. There are 9,000 homes in the city, 6,000 of which are not connected
with city sewers or water mains for sanitary purposes. The sewer and water
systems of Springfield have cost the taxpayers approximately $4,000,000.
This means that the public expenditure of $4,000,000 for sanitary purposes
is utilized by but one-third of the population and the benefits which should
be derived by the community are lost.
Four years having elapsed since the publication of Dr. Palmer's
findings it was thought desirable to make a re-survey of the well
and privy situation, and such an investigation was made possible
through the generous co-operation of Dr. B. B. Griffith, present
superintendent of health. The new canvass was made by the
three regular health department inspectors during the summer of
19 14, watch being kept for manure accumulations as well as for
86
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PUBLIC HEALTH IN SPRINGFIELD
wells and privies. Although an exact comparison of the situation
in 1914 with that in 1910 cannot be made, because certain parts
of the city were omitted from the 1910 survey, a fairly good idea
of what has happened may be obtained from the tables below and
the accompanying diagrams.
TABLE 26. — WELLS AND PRIVIES IN SPRINGFIELD, I9IO AND I9I4
Wells
Privies
Number actually enumerated in 19 10
Number estimated in 1910
Number enumerated in 19 14
Increase over 19 10 enumeration
Increase over 19 10 estimates
Per cent increase over 19 10 enumeration
Per cent increase over 19 10 estimates
5,869
5,498
7,000
6,000
7,530
7,431
1,661
1,933
530
1,431
28.3
35-2
7.6
23-9
It is apparent that the number of wells and privies has in-
creased, both as compared with the actual count in 1910 and the
estimates made in that year. The actual increases are probably
smaller in both cases than indicated by comparisons of the enum-
eration figures, and smaller in the case of the privies than indi-
cated by comparison of the present number with the estimate of
1910. Slight decreases have occurred in some parts of the city,
more especially in the case of wells, and the location of these
areas is indicated in the accompanying diagrams. Table 27
TABLE 27. CHANGES IN NUMBERS OF WELLS AND PRIVIES BY
WARD BETWEEN 1 9 10 AND I9I4, SPRINGFIELD
Ward
Wells
Privies
Increase
Decrease
Increase
Decrease
1
445
418
2
, ,
62
24
3
412
. .
487
4
175
. .
184
5
34
6
771
. .
846
7
46
26
Whole city
1,661
1,933
87
PUBLIC HEALTH IN SPRINGFIELD
wells and privies. Although an exact comparison of the situation
in 1 9 14 with that in 19 10 cannot be made, because certain parts
of the city were omitted from the 19 10 survey, a fairly good idea
of what has happened may be obtained from the tables below and
the accompanying diagrams.
TABLE 26. — WELLS AND PRIVIES IN SPRINGFIELD, I9IO AND I9I4
Wells
Privies
Number actually enumerated in 19 10
Number estimated in 1910
Number enumerated in 19 14
Increase over 1910 enumeration
Increase over 19 10 estimates
Per cent increase over 19 10 enumeration
Per cent increase over 19 10 estimates
5,869
5,498
7,000
6,000
7,530
7,431
1,661
1,933
530
1,431
28.3
35-2
7.6
23.9
It is apparent that the number of wells and privies has in-
creased, both as compared with the actual count in 1910 and the
estimates made in that year. The actual increases are probably
smaller in both cases than indicated by comparisons of the enum-
eration figures, and smaller in the case of the privies than indi-
cated by comparison of the present number with the estimate of
19 10. Slight decreases have occurred in some parts of the city,
more especially in the case of wells, and the location of these
areas is indicated in the accompanying diagrams. Table 27
TABLE 27. — CHANGES IN NUMBERS OF WELLS AND PRIVIES BY
WARD BETWEEN I9IO AND I9I4, SPRINGFIELD
Wells
Privies
Ward
1
Increase
Decrease
Increase
Decrease
1
445
418
2
, .
62
24
3
412
. .
487
4
175
184
5
. .
34
6
771
. .
846
7
46
26
Whole city
1,661
1,933
87
THE SPRINGFIELD SURVEY
sets forth the increases or decreases in the several wards as be-
tween the two enumerations. The decreases are evidently more
marked in the case of the wells, but in both instances are slight.
The actual increases which have taken place are probably due
to the erection of new buildings at points where sewers and city
water are not available, 400 cases of building or rebuilding at such
places occurring in 1910-1913 according to the annual report of the
Wells Privies
Comparison of the Numbers of Wells and Privies Found in 19 10 and
1914
According to the enumeration districts used by the United States Census of
19 10. Black areas indicate increases in the period; white areas decreases;
and shaded areas no change in number
Part of the increase is more apparent than real, as the survey of 19 10 omitted
certain sections near the city limits
Little actual change has taken place in the situation in the four years
health department for 19 13. The present situation is evidently
very much the same as in 1910; which is certainly discouraging,
and discreditable to the city, in view of the strenuous efforts
made by Dr. Palmer to do away with these rural appurtenances.
The distribution of wells and privies throughout the city is indi-
cated on the maps opposite pages 86 and 92 and their accompany-
ing diagrams. The largest numbers are manifestly in the sixth,
first, third, and fourth wards, in the order named. Over 50 per
PUBLIC HEALTH IN SPRINGFIFXD
cent of both wells and privies are located in the two wards east
of Tenth Street, the district occupied in 1910 by 36.4 per cent of
the population. Figuring the number of wells and privies to a
thousand of population the ranking is much the same as with
respect to the gross number; ward six again leads, followed by
wards one and three, but ward two instead of ward four is now
fourth in rank. The best showings from all standpoints are made
by wards five and seven. It is noticeable that the number of
wells shows a close correspondence with the number of privies
throughout the city, although there is a slight preponderance of
wells over privies in the fourth and fifth wards. Another signi-
ficant fact is that in ward six there is a well and a privy for every
five persons, which in conjunction with the fact that the census
of 1 9 10 showed 4.4 persons per dwelling in this ward, indicates
that over four-fifths of the people in the district rely on these
conveniences, in spite of the fact that over three-fourths can con-
nect with the city water and sewers. The situation in ward one
is nearly as bad.
TABLE 28. — WELLS AND PRIVIES BY WARD. SPRINGFIELD, I914'
Ward
Wells
Privies
Number
Percent P^'-lfO ^. ^ Per cent P^"- ''^
of total P°P"'^- dumber ^^ ^^^^^ popula-
tion
tion
1
1,689
22.4
180.1
1,714
23.1
182.8
2
697
9-3
103. 1
683
9.2
ioi;.i
3
1,206
16.0
126.2
1,219
16.4
127.6
4
1,058
14.1
96.5
947
12.7
86.3
0
424
5-6
66.5
357
4.8
56.0
6
2,321
30.8
201.8
2,368
31-9
205.9
y
135
1.8
39-3
143
1.9
41.6
Whole city 7,530 100. o 129.9
7,431
1 00.0
128.2
^ Enumeration made by inspectors of the city health department.
The entire lack of necessity for most of Springfield's wells and
privies is brought out in Tables 29 and 30 which give data with
reference to the availability of sewers and city water. Seventy-
eight per cent of the wells could be eliminated without any addi-
tions to the present city water mains, while 74 per cent of the
89
THE SPRINGFIELD SURVEY
PRIVIES I.N SPRINGFIELD BY WARDS
PER THOUSAND POPULATION
191-4-
E0i9
WV /K R D 5
Q LOWEST HI HIGHEST
WARD RANKIMGS
TH£ sp/fwcf^/eiD Jc/i^£y-/9/4
privies could be replaced by modern toilets without the construc-
tion of any new sewers. Nearly two-thirds of the privies are at
places where both sewers and city water are available.
Glancing at the figures for the different wards it is evident that
in general the highest proportions of unnecessary wells and privies
occur in the wards where wells and privies are least numerous,
these wards being the ones best equipped with sewers and water
mains. At the same time, even in those wards most poorly
equipped with the city services — wards one and six — most of the
wells and privies are unnecessary. Approximately two-thirds of
TABLE 29. UNNECESSARY WELLS BY WARD, SPRINGFIELD, I9I4
Wells at Places where City Water is Available
Ward
Number
Per cent of all
wells in ward
Per cent of all
unnecessary wells
in city
1
1,099
65.1
18.7
2
591
84.8
lO.I
3
1,023
84.8
17.4
4
937
88.6
iS-9
^
399
94.1
6.8
6
1,701
73-3
29.0
7
123
91. 1
2.1
Whole city
5,873
78.0
1 00.0
90
PUBLIC HEALTH IN SPRINGFIELD
PRIVATE WELLS IN SPRINGDELD BY WARDS
•PER THOUSAND POPULATION
1914-
Vy/^R. D S
n LOWEST
HlGMtST
WARD RANKINGS
mf ■5P/!iAiaF/£LO si//fi^£r-i9i-*
the wells in ward one are at places where city w^ater is available ;
while two-thirds of the privies in the ward are along sewer lines
and nearly a half are at places where both sewers and city water
are available. Ward six offers the greatest opportunity for the
reduction of numbers, nearly one- third of all the unnecessary wells
and privies in the city being in this ward. Ward one, the other
east ward, stands second in this respect.
TABLE 30. — UNNECESSARY PRIVIES BY WARD, SPRINGFIELD. I9I4
Privies with sewer
Privies with both sewer and
available
1
city
water available
Per cent
Ward
Per cent
Per cent
of all
privies
with
Per cent
of all
Number
ofaU
privies
Number
of all
privies
privies
with
in ward
in ward
sewer and
sewer
water
1
1,172
68.4
21.4
802
46.8
17-3
2
450
65-9
8.2
399
58.4
8.6
3
840
68.9
15.3
778
63.8
16.7 i
4
797
84.2
14.6
697
73-6
15.0
5
?>?>?>
93-3
6.1
321
89.9
6.9
6
1,767
74.6
32.3
io37
64.9
11'"^
7
117
81.8
2.1
114
70-7
2.4
Whole cit
y 5476
73-7
100. 0
4,648
62,6
lOO.O
91
THE SPRINGFIELD SURVEY
The reasons why wells and pri\ies in cities are objectionable
are not difficult to understand. Privies are dangerous because
they pollute the ground water and allow flies and other animals
free access to human excreta. The material which flies carry
from privies is probably in most cases merely filthy, and not neces-
sarily dangerous to health. When the material deposited in the
Springfield's Well and Privy Menace
A well with two privies about 25 feet distant. The conditions are favorable
for pollution of the well, both through the soil and the loose planking. The
privies were also quite open to flies. Springfield has approximately 7,500 wells
and 7,500 privies, many of which are as objectionable as those shown above.
privy comes from a person suffering from intestinal disturbances,
however, the danger becomes acute. The excreta of a person
coming down with typhoid fever, for instance, may be swarming
with the germs of the disease ; and a fly touching such material
may proceed directly into an adjoining house and infect food
about to be eaten. Thus a new victim is secured.
92
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PUBLIC HEALTH IN SPRINGFIELD
Many more persons are capable of discharging infectious matter
in privies than is generally realized. Thus, in typhoid the danger
is not limited to persons with a well-developed attack or to those
coming down with the disease; some persons continue to harbor
the germs and to discharge them in their urine and feces for years
after recovery, while others become infected and discharge the
germs without showing any symptoms of the disease whatever.
Then there are mild cases that escape recognition, the patient
excreting, nevertheless, the germs of the disease. These "car-
rier" cases, fortunately, are not relatively common, but their
occurrence greatly complicates the problem of communicable dis-
ease control and in the case of the intestinal diseases increases the
chances for privy infection. Altogether in a city of Springfield's
size and with roughly 7,500 privies there is ample opportunity for
some of the privies to contain infectious material from time to
time ; there is sure to be a supply of flies at hand at some of these
times ; and there is sure to be a supply of persons available for in-
fection. Thus in the long run more typhoid and other intestinal
disease is bound to arise from the privies. That such has actually
been the case is indicated by the distribution in the past of ty-
phoid and diarrheal diseases throughout the city.
The case for well pollution is very miifch the same. Some wells,
owing to the nature of the soil they penetrate and their disposi-
tion with respect to privies, w^ill probably never be polluted.
Others with less favorable soil and more closely hedged with
privies will be frequently polluted with human excreta. In the
course of time this pollution may become infectious; that is, may
come from an infected person, whereupon those drinking the
water will suffer. In rural districts where the soil is of favorable
quality and where it is merely a matter of protecting one's well
from one's own privy, the situation can be controlled, but in the
congested city, privies belonging to one's neighbors may be close
at hand, and the distances between the wells and the privies not
great enough and the pollution of the ground water too heavy for
the material to be cared for in the natural way. For this reason
wells in a city should always be regarded with suspicion, and al-
ways discarded when a pure supply of city water is at hand.
That there is ample reason for suspecting the shallow wells of
93
PUBLIC HEALTH IX SPRINGFIELD
Many more persons are capable of discharging infectious matter
in privies than is generally realized. Thus, in typhoid the danger
is not limited to persons with a well-developed attack or to those
coming down with the disease ; some persons continue to harbor
the germs and to discharge them in their urine and feces for years
after recovery, while others become infected and discharge the
germs without showing any symptoms of the disease whatever.
Then there are mild cases that escape recognition, the patient
excreting, nevertheless, the germs of the disease. These "car-
rier" cases, fortunately, are not relatively common, but their
occurrence greatly complicates the problem of communicable dis-
ease control and in the case of the intestinal diseases increases the
chances for privy infection. Altogether in a city of Springfield's
size and with roughly 7,500 privies there is ample opportunity for
some of the privies to contain infectious material from time to
time ; there is sure to be a supply of flies at hand at some of these
times ; and there is sure to be a supply of persons available for in-
fection. Thus in the long run more typhoid and other intestinal
disease is bound to arise from the privies. That such has actually
been the case is indicated by the distribution in the past of ty-
phoid and diarrheal diseases throughout the city.
The case for well pollution is very miAh the same. Some wells,
owing to the nature of the soil they penetrate and their disposi-
tion with respect to privies, will probably never be polluted.
Others with less favorable soil and more closely hedged with
privies will be frequently polluted with human excreta. In the
course of time this pollution may become infectious; that is, may
come from an infected person, whereupon those drinking the
water will suffer. In rural districts where the soil is of favorable
quality and where it is merely a matter of protecting one's well
from one's own privy, the situation can be controlled, but in the
congested city, privies belonging to one's neighbors may be close
at hand, and the distances between the wells and the privies not
great enough and the pollution of the ground water too heavy for
the material to be cared for in the natural way. For this reason
wells in a city should always be regarded with suspicion, and al-
ways discarded when a pure supply of city water is at hand.
That there is ample reason for suspecting the shallow wells of
93
THE SPRINGFIELD SURVEY
Springfield is indicated by the results of analyses made by the
State Water Survey of samples of Springfield well water. Several
hundred such samples have been examined in the past few years
and considerable amounts of pollution have been found in almost
every case.
To remedy the situation will be relatively simple if Springfield
decides to reform. Approximately three-fourths of the wells can
be eliminated without extension of the water mains and three-
fourths of the privies without new sewers. Public opinion
Well and Privies Used by Three Families
The well is only i8 feet from the nearer privy. These are located on a corner
lot and the well is said to be used freely by the public
should be strongly appealed to, and the city authorities should
apply firm, even if gentle, pressure in the line of well and privy
condemnation where city water and sewers are available. Cer-
tainly it is folly, as Dr. Palmer has pointed out, for the city to
spend millions on water and sewers and then neglect three-fourths
of the sanitary advantage. And the presence of the privies and
wells, with the incidental communicable disease, is not a matter
that affects merely the well and privy users. The presence of
typhoid or other diarrheal disease is a menace to all, even to per-
sons who have done away with their own wells and privies.
94
PUBLIC HEALTH IN SPRINGFIELD
Privies can be made sanitary by rigid regulations as to their con-
struction and screening; and, short of elimination, such measures
should certainly be taken. Such a program, however, involves
a considerable inspection system and an appreciable financial
burden, and it is probable that the troubles incidental to keeping
privies strictly sanitary would induce most people to abandon
them. At all events, Springfield should set about to become a
privy-less and well-less city, and should adopt a rational program
working to accomplish this purpose. Until she makes marked
progress on such a program she cannot hope to free herself of her
typhoid and her diarrheal disease.
95
XI
MILK SUPPLY
A valuable inspection of the dairy farms supplying milk to
Springfield was secured to the Survey through the generous
co-operation of the state board of health as represented by its
chief, Dr. C. St. Clair Drake, and the city health department as
represented by Dr. B. B. Griffith. Two inspectors, one from
each department, visited the farms together and scored them on
the modified government score card as used by the Chicago health
department. In the course of this work it appeared that Spring-
field is supplied by some loo producers owning about 1,055 cows
and producing about 2,355 gallons a day. Approximately a
fourth of the farmers, producing about a third of the city's supply,
peddle their own milk ; slightly more than half of them, producing
slightly less than half of the supply, sell to one large dairy com-
pany; and the remainder dispose of their milk to stores and
middlemen. The milk sold by the dairy company is pasteurized.
The results of the farm inspections were anything but favorable.
Thus the average scores of all farms were 49 per cent on equip-
ment and 44 per cent on methods. The average final score was
46 per cent, certainly a discreditable figure. To make the test
as fair to the farmers as possible, since the government score card
is somewhat severe on the small farmer who has little equipment.
Dr. Drake prepared a tabulation rating the producers with respect
only to those points on the score card that may be regarded as
absolutely essential; such points as relate to cleanliness in all
particulars, freedom from contaminating influences, cooling, and
methods of storage and transportation. Out of the entire 200
points 125 such were selected, and in Table 31 there appears the
classification of the farms with reference to good and bad show-
ings on these points. It is assumed that any dairy deficient less
than 10 per cent in prime essentials may be rated "very good,"
96
PUBLIC HEALTH IN SPRINGFIELD
One of SprinciFielu's Puur Dairies
Note the lack of provision for light and ventilation. In the inspection of
Springfield's dairies made for the Survey by the city and state health depart-
ments 102 out of 109 farms scored "bad" or "very bad." The city needs a
milk inspector
Somewhat Better
The concrete floor and deep gutter here shown are efforts in the right direc-
tion. The attempt to let in more light and to whitewash are also commend-
able. Reinspections of some of Springfield's dairies by the state health de-
partment a few months after the inspection for the Survey showed that 41
per cent of the orders for improvement, some of which called for radical
changes, had already been obeyed
7 97
THE SPRINGFIELD SURVEY
those deficient lo per cent and less than 20 per cent as "good,"
those deficient 20 per cent and less than 30 per cent as ''fair,"
those deficient 30 per cent and less than 50 per cent as "bad,"
and those deficient 50 per cent or more as "very bad."
TABLE 31. — DAIRY FARMS ACCORDING TO SCORES ON PRIME ES-
SENTIALS, SPRINGFIELD, I9I4
Classified as
Deficient in :
Number of
Per cent of
essential points
farms ^
total
Very good
Less than 10 per cent
I
0.9
Good
10 to 20 per cent
2
1.8
Fair
20 to 30 per cent
4
3-7
Bad
30 to 50 per cent
41
37-6
Very bad
Over 50 per cent
61
56.0
^ Includes nine farms not selling or selling cream only.
Comment on the above table is hardly necessary. Only three
of the farms, less than 3 per cent of the total, earn the classifica-
tion of "good," while over 90 per cent of them score "bad" or
worse. There would seem no room for doubt but that the city
needs to employ a milk inspector and to embark on a system of
frequent and systematic farm inspection. In this connection it
is encouraging to note that a reinspection of a number of the
farms made later in the summer showed that considerable im-
provements had been made.
Information as to Springfield's milk production and dairy
scores, classified according to the amount of milk produced and
the manner of disposal, appears in Tables 32 and 33. The figures
show that the small farmer is one of the serious problems met with
in seeking to secure a sanitary milk supply, a fact which is gen-
erally recognized. The man with three or four cows, kept largely
for supplying milk for the family and on account of their manure,
usually makes very little profit from his milk sales, can afford
very little in the way of equipment, and often would quit the
business rather than clean up. At the same time it should be
said that the public should be prepared to pay a fair price for clean
milk and that experience in many places indicates that 10 cents
a quart is not an excessive figure.
98
TABLE 32.
PUBLIC HEALTH IN SPRINGFIELD
-MILK PRODUCERS ACCORDING TO AMOUNT PRODUCED,
SPRINGFIELD, I914
Num-
Cows
Gallons
V
Average
scores
Percent
Producing
daily in
gallons
ber of
pro-
ducers
kept
(aver-
age)
pro-
duced
per day
Equip-
ment
Meth-
ods
Final
defi-
cient in
essen-
tial
28
•
37-3
points
0-10
4.6
207
41.8
34.6
55-2
11-20
31
8.7
488
44.4
41.7
42.8
50.6
21-50
33
12.9
1,093
54-0
50.6
5T-7
42.9
Over 50
8
2Q.O
562
67.4
61.8
6,3.6
32.9
Total
100
10.6
2,350
48.7
44-3
45-9
47-9
It is also evident from Table 33 that dairies selling direct to the
consumer made the best scores, that those selling to middlemen
were smaller and poorer, and that the poorest showing was made
by dairies selling to the large milk company, and to bakeries.
In One of Springfield's Good Dairies
Note provision for good light and ventilation, cement floor with deep gutter,
comfortable stanchions, and good receptacles for water and feed
99
THE SPRINGFIELD SURVEY
confectioneries, and the like. In choosing a milk supply, how-
ever, cleanliness at the farm is not the sole criterion, as efficient
pasteurization is highly desirable. Experience has abundantly
shown that despite great efforts to secure cleanliness supplies may
become infected, as by unrecognized "carriers" of communicable
disease. The accumulated evidence also indicates that the early
surmises that pasteurization can injure milk and cause rickets in
infants are entirely groundless. Many of the best pediatricians,
in fact, recommend boiled milk, — which is of course heated con-
siderably higher than in pasteurization, — for infant feeding when
a substitute for mother's milk must be employed. Clean milk is
certainly to be desired and striven for, but proper pasteurization
is the final essential for safety.
TABLE 33. MILK PRODUCERS ACCORDING TO MANNER OF SALE,
SPRINGFIELD, I9I4
Manner
of sale
Number Cows Gallons
of pro- kept produced
ducers (average) per day
Final
score
(average)
Average
deficiency
in essential
points
(per cent)
Directly to con-
sumer
26
14.0
828
59-0
34-5
To middlemen
Q
Q.6
201
45-3
48.0
To stores, etc.
10
7-4
229
42.0
50-3
To dairv Co.
"A"
5 5
0.7
I,OQ2
40.3
53-7
Total
100
10.6
2,350
45-0
47-9
Although the city has no regular system of milk analysis, a few
bacteriological examinations were made during the summer of
19 14 at the instance of Dr. Griffith. Thirty-two samples were
taken, all from delivery wagons. The results are as follows:
BACTERIA PER CUBIC
CENTIMETER
Over 1,000,000
500,000 to 1 ,000,000
100,000 to 500,000
Less than 100,000
Total
NUMBER OF
SAMPLES
I
3
14
14
32
100
PUBLIC HEALTH IX SPRINGFIFXD
The number of samples is too small to allow of judgment on the
character of milk being supplied the city, but such as it is the
showing is neither reassuring, — in view of the fact that all samples
were from wagons and not from stores and so were relatively
fresh, — nor alarming when compared with results in other cities.
Altogether it is entirely clear that the milk situation in Spring-
field needs attention. Dairy conditions were found to be bad
and there is no city inspection service such as is necessary to keep
track of the situation and secure the needed improvements. It
The Small Middleman
The milk house of a middleman who buys from farmers and bottles about 125
gallons a day. This place scored 50 per cent
may be stated emphatically that the city health department
should be given a full-time milk inspector, a man competent to
score dairies and examine milk. The activities of such an in-
spector should include the supervision of transportation and hand-
ling of milk and the making of tests of its temperature and bac-
terial content in transit and storage. The inspector should be
furnished with means of rapid travel from dairy to dairy and should
be paid a salary commensurate with the ability required. In-
cidentally it may be said that such a person will have little time
lOI
THE SPRINGFIELD SURVEY
for relaxation in adequately covering the situation in a city of
Springfield's size.
Granted an inspection system and a set of dairy rules, the other
prime requisite is adequate publicity for the results of inspections.
The health department should publish each month, or as often as
practicable, a list of the inspections and analyses made, giving the
particulars as to the name of the producer or dealer and whatever
explanatory comment seems necessary. These results should be
A Good Milk House
Separate from the barn and with proper equipment for milk-handling
published in a health department bulletin and in the daily papers.
Then every consumer will be able to know just what kind of place
his milk comes from and just how it compares w4th other milk on
sale. Such publicity is also a powerful stimulus to producers and
dealers to improve their standing and makes them much more
willing to listen to suggestions of the milk inspector. At the same
time we may reiterate that the public should be prepared to do its
part by paying a fair price for a more sanitary product.
102
XII
FOOD SUPPLY
The sanitary handling of the ordinary food products is a matter
that has received more attention in Springfield than the sanitary
production and handling of milk. The city has, for one thing,
employed a meat inspector, while representatives of the state
food commission have from time to time given more or less atten-
tion to conditions in the markets, groceries, bakeries, and the like.
During the spring of 1914 one of the state inspectors devoted con-
siderable time to Springfield, visiting some 134 places where food
was handled or sold. The results of these inspections were
placed at the disposal of the Survey through the courtesy of the
state food commissioner, and some of the more important findings*
are brought out in Table 34.
TABLE 34. — RESULTS OF INSPECTION OF VARIOUS FOOD-HANDLING
PLACES, SPRINGFIELD, I9I4
(The Information Presented below is Taken from the Original Records of
O. J. Lindstrom, State Food Inspector)
Grocer-
ies
Meat
markets
Restaur-
ants
C^^^y I Total
shops
Places inspected
55
Sanitary surroundings
Good
40
Fair
13
Poor or bad
2
Floors
Good
43
Fair
Q
Poor or bad
.S
Receptacles
Good
43
Fair
0
Poor or bad
,S
Implements
Good
43
Fair
Q
Poor or bad
3
Orders for improvement
issued
63
16
12
4
II
5
II
5
II
5
28
24
4
23
5
^2>
5
5
33
15
114
12
88
3
24
2
13
90
2
21
3
13
90
2
21
3
13
90
2
21
3
19
132
103
THE SPRINGFIELD SURVEY
It is reassuring to note that the general condition of the places
visited is good, the showing being much better than in the case of
the dairy farms, which are out of the consumer's sight and also
not subject to the same amount of inspection. At the same time
it is a fact that some dirt}' places exist in Springfield and that some
order for improvement was issued in a very considerable propor-
tion of the places visited. The conclusion is that while conditions
are in general good, a city inspection service which can keep the
A Springfield Bakery
Declared unfit by the state food inspector and ordered closed pending im-
provements. Mixing room to the right; bake room at the center of the pic-
ture. The last shed to the left is the privy
situation under more constant supervision than is possible for the
state authorities would be an advantage.
Perhaps the most serious conditions disclosed by an examina-
tion of the state inspector's records are those relating to the toilet
and washing facilities in these food-handling places. In a con-
siderable proportion of instances the ordinary privy was in use,
while many of the flush toilets found were either not enclosed or
lacked outside ventilation. In view of the abundance of flies
usually in the neighborhood of food-handling places and the
opportunities the common privy gives flies to pick up infectious
104
PUBLIC HEALTH IN SPRINGFIELD
material, it is not only reasonable but important to require such
places to make use of the city water and sewer services wherever
the latter are available. When privies must be used special
effort should be made to have them in a sanitary condition. The
accompanying illustrations give an idea of what some of the privies
now used by markets and bakeries are like.
The present city meat inspector is a practical butcher and de-
DOUGH KXEADER IN BaKERY ShOWN ON OPPOSITE PAGE
Photograph taken while the clean-up was going on. The city has no system-
atic inspection of such places
votes his time and efforts entirely to the inspection of meat, meat
markets, slaughter houses, and sausage factories. The super-
vision of seven slaughter houses on the outskirts of the cit}' and of
a certain amount of killing in the outlying country receive about
two-thirds of his official attention, the rest being devoted to the
supervision of some 75 meat markets. The inspector cannot, on
account of limitations of time and place, be present at all the
105
THE SPRINGFIELD SURVEY
Toilet Facilities in Food-haxdlixg Places
This privy is the sole toilet provision of a Springfield grocery store
On account of the dangers of fly infection a special responsibility rests on
food-handling places to be provided with sanitary toilets
killing operations; he tries, however, to see all the stock on the
hoof and requires any suspicious looking animals to be killed in
his presence. Some of the country-slaughtered meat is brought
into the city dressed and without previous inspection, which
makes it practically impossible to determine whether the animal
was healthy or diseased.
The inspector points out the advantages incidental to a central
municipal abattoir where all animals slaughtered could be in-
spected by him at the most important time — that of killing.
1 06
A Meat ATarket Privy
Another bad example
Meat Market Interior
This is the market maintaining the privy shown above
Conditions were poor but the proprietor was trying to make the improve-
ments demanded b>' the state food inspector
107
THE SPRINGFIELD SURVEY
With such a plan in operation the slaughter of animals elsewhere
in the city and the bringing in of country-slaughtered but unin-
spected meat would of course be forbidden. All meat shipped in
by railroad has been inspected by the federal government. The
details of the meat inspector's activities, taken from his reports
for the first four months of 19 14, are shown in Table 35.
TABLE 35. — WORK OF CITY MEAT INSPECTOR, SPRINGFIELD,
JANUARY I TO MAY I, I9I4
Animals Number inspected Number condemned
Cattle 1,177 3
Hogs 4,436 5
Sheep 406
v^aives
(507
D
Total
6,916
13
Dressed meats and fish
Pounds inspected
Pounds condemned
Beeves
6,267
Hogs
Sheep
Calves
5^520
2,452
2,029
Pork sausage
435
Liver
Hamburger steak
Spare ribs
Fish
135
40
225
50
540
360
70
90
435
135
40
225
50
Total 17,153 i>945
To sum up the situation, Springfield's markets and groceries
appear to be up to the average but open to improvement in a
number of instances and in a number of ways, more especially
with respect to toilet and lavatory facilities. Up to the present
the city has relied for its food protective service on the state food
inspectors and one meat inspector of its own. The latter is con-
fronted with an abundance of work in looking after local slaugh-
tering and meat in markets, and it is clear that there is need for
another food inspector to keep closer watch of the various food
shops, restaurants, and candy and ice cream shops and factories.
Such an inspector could co-operate with the milk inspector in his
108
PUBLIC HEALTH IN SPRINXiFIELD
supervision of the handling of milk within the city and could
relieve the meat inspector of much of the meat market and restau-
rant inspection that he must now attempt. It should also be
In the Rear of a Meat Market
Immediately behind the barrels is a smoke house which was in poor condi-
tion. The peak-roofed building behind the smoke house was used for slaugh-
tering and was in filthy condition, being littered with remains of animals that
had been some time killed. The place was drawing and feeding flies
noted that a central city slaughter house would greatly economize
the meat inspector's time, would allow of more efificient inspection
on his part, and would probably result in much cleaner slaughter-
ing conditions.
109
XIII
OTHER SANITARY CONDITIONS
As has already been pointed out, two important sets of sanitary
conditions, those surrounding children at school and workers in
industry, are discussed in other sections of the Survey dealing
specifically with the public schools and industrial conditions. At
Physical Examixatiox of Children in Springfield's Schools
The board of education now employs two nurses to make regular inspec-
tions of school children. This is work in the right direction; it should be ex-
tended, and the examinations made more intensive through the employment
of a physician
this point it is accordingly necessary merely to re-emphasize the
importance of these subjects. The supervision of work conditions
to ensure the proper guarding of dangerous machinery and the
absence of injurious fumes and dusts or other insanitary condi-
tions is delegated in Illinois, as is usual, to the state labor authori-
ties; and there is no reason to believe that this is not the proper
no
PUBLIC HEALTH IN SPRINGFIELD
method of administration. Still, such state authorities are com-
monly handicapped by inadequate resources and there is little
reason to doubt but that a wide-awake and properly equipped
local health department could do considerable that would be use-
ful in protecting its citizens engaged in industrial pursuits.
Similarly in the case of school hygiene it has in many places
seemed best to leave the administration of this work in the hands
of the school authorities, possibly partly because the latter are
usually better supplied with funds than the health authorities.
At all events the important question seems to be whether the
work is done well and not whether the one authority or the other
actually administers it. And certainly there should be the closest
and most complete co-operation between the two authorities. In
Springfield a start has been made on the school hygiene problem
by the employment of a school nurse by the board of education.
This is a step in the right direction but, as has been pointed out in
Dr. Ayres' report on the school system,* more nursing assistance
is needed, to be supplemented by the services of a physician. f
The possibility of the joint employment of such additional per-
sons by the board of education and the health department is well
worth consideration. The health department needs additional
medical assistance for the supervision of quarantine and might
find it possible to share a medical inspector with the school author-
ities. Similarly the school nurses might be employed during the
summer on infant hygiene work. Attention must also be drawn
to the fact that three-quarters of the children in the elementary
schools and a fifth of those in the high school are un vaccinated.
Smallpox has been in and out of Springfield fairly frequently (87
cases in the last five years) and the presence of so large an unvac-
cinated population is an element of risk. It is unnecessary to
comment on the unpleasant, embarrassing, and expensive aspects
of locking the barn after the horse has been stolen.
Another matter, and one that is of first-rate public health im-
portance, is the handling and disposal of manure. Without
privies and sick people the fly would not be dangerous, and with-
* Ayres, op. cit., p. 105.
t Subsequent to Dr. Ayres' investigation the board of education employed
a second school nurse.
Ill
THE SPRINGFIELD SURVEY
out horse manure it is probable that flies would be relatively few.
At all events manure is their favorite breeding material and in a
campaign against them is ordinarily the point to concentrate on.
The health department inspectors were instructed to keep watch
The Springfield
Survey
Springfield
Illinois
Manure Accumulations in Springfield, 19 14
Each black square represents a manure accumulation found by the city in-
spectors— 420 in all
for manure accumulations in their house-to-house canvass for wells
and privies, and 420 such accumulations were noted, distributed
as indicated on the accompanying map. The illustrations give
an idea of the way in which this material is to be found piled in
Springfield's alleys. The city should require tight containers for
112
PUBLIC HEALTH L\ SPRINGFIELD
Where Flies Breed
This picture and the one below give an idea of the manure accumulations to
be found in Springfield. Horse manure is the fly's favorite breeding place
Another Example of Springfield's Manure Problem
In order to prevent fly breeding the city should adopt and enforce regulations
prescribing how manure shall be kept and disposed of
113
THE SPRINGFIELD SURVEY
manure, and weekly removal. The way to swat the fly at its
source is to restrict its efforts to deposit eggs in manure and other
organic matter, and to keep any such eggs from hatching out, at
least within the city.
Two other subjects intimately related to civic decency and
having some public health bearings are garbage disposal and
housing. A general discussion of the housing situation in Spring-
field appears in a separate section of the Survey devoted to that
subject.* It is to be hoped that the city will see the wisdom of
The City Refuse Incinerator
Anyone may bring refuse material to the city incinerator and dispose of it
free of charge, but there is no general or compulsory system of collection such
as is essential for civic cleanliness. The collection and disposal of garbage and
other wastes are engineering matters and any attempt to meet these problems
should be preceded by careful engineering studies
adopting a housing code to insure itself against the construction
of unserviceable and indecent buildings, and that it will have its
building inspection service keep the situation under supervision.
It would seem best that such a service be concentrated, as far as
practicable, under the building department, as the latter must
pass on all buildings when first erected and is the department most
familiar with the various details of a housing law.
Similarly in the case of garbage and refuse disposal, although
the importance of garbage as a breeding place for flies and as a
* Ihlder, John: Housing in Springfield, Illinois. (The Springfield Survey.)
114
PUBLIC HEALTH IN SPRINGFIELD
source of all sorts of vague deleterious effects on health has been
the subject of even grotesque exaggeration, it must be acknowl-
edged that the city should stand for decency; and it is indecent to
tolerate alleys or yards littered with garbage, or haphazard sys-
tems of collection and disposal. The city of Springfield is at
present in the somewhat anomalous position of maintaining a
garbage incinerator but no collection system. Anyone may
bring his material to the city incinerator and there dispose of it
free of charge, but no one is under any compulsion to do so. The
result is poor collection and considerable complaint over condi-
tions throughout the city. It is also said that the lack of system
in collection results sometimes in the arrival at the incinerator of
greater quantities of material than the plant is capable of hand-
ling, w^hile at other times the plant may be standing idle. .
In considering this problem Springfield will do well to remem-
ber that the collection and disposal of garbage are engineering
matters and that investigation by competent engineers before
embarking on any plan is the part of wisdom. As in the case of
sewerage and sewage disposal, the proper type of refuse disposal
works depends to a certain degree on the type of collection sys-
tem, and vice versa; while both depend on the nature of the
material to be handled. The first thing for Springfield to do is to
make up her mind w^hat she really wants to accomplish in the way
of collection ; after that she should call in the engineers.
115
XIV
SPRINGFIELD'S PUBLIC HEALTH SERVICE
Having now considered the loss of life and health in Spring-
field from the preventable diseases, and the city as a sanitary
environment, the question that remains for discussion relates to
the machinery which the city government has created to cope
with its health problems; that is, the city health department.
Som.e discussion of the health department's activities has already
been given in the sections of this report dealing with the com-
municable disease problems. In the present chapter attention
will be given to the department as an organization, — to its staff,
financial resources, deficiencies, and the improvements needed.
THE PRESENT HEx^LTH DEPARTMENT
The staff of the city health department consists of a part-time
health officer, a secretary-clerk, a meat inspector, three sanitary
inspectors, and the matron of the contagious disease hospital.
The department's physical equipment consists of an office with a
small laboratory in the city hall, and the contagious disease hos-
pital situated beyond Oak Ridge Cemetery. An assistant super-
intendent of health was formerly employed at full time but when
he resigned during the summer of 19 14 the office was done away
with and a young woman appointed as secretary and clerk in-
stead. The health officer is appointed by the commissioner of
public safety for an indefinite period and may be removed by the
latter at pleasure. The scheme of organization is as shown in the
diagram below.
PRESENT ORGANIZATION OF THE HEALTH DEPARTMENT. SPRINGFIELD,
1914
Commissioner of Public Safety
Superintendent of Health
3 Sanitary Meat Clerk and Matron Contagious
Inspectors Inspector Secretary Disease Hospital
116
PUBLIC HEALTH IN SPRINGFIELD
The routine work of the department Is represented largely by
the activities of the three sanitary Inspectors, and consists prin-
cipally in placarding and fumigating reported cases of contagious
diseases and in abating nuisances. Most of this work Is of a
reflex character ; that is, in response to complaints; some original
work, however, is instituted. The work of the meat inspector
has already been described.* The isolation hospital receives
cases of the common contagious diseases and boards them free of
charge.
DEFECTS IN THE EXISTING ORGANIZATION
Most of the defects in the present organization relate to defici-
encies in the service rendered and may be considered more con-
veniently under that head. The most serious defect that is not
an out-and-out deficiency is the part-time employment of the
health officer. The part-time system is a relic of days when
health department work was regarded as merely an emergency
provision in the event of epidemics, on which occasions the health
officer could be called on for a heavy contribution of time. At
other times the health officer presumably would have nothing to
do. Since those days we have come to know that a great health
and life wastage is going on even in the absence of epidemics, and
that the health department can and must prevent this steady
wastage. We have also come to realize that health departments
should prevent epidemics and not merely curb them after they
are well established. These modern ideas of the health depart-
ment's usefulness and functions call for a continuous, ever-
watchful campaign against disease — and for the full-time health
officer. Of this there can be no doubt whatever.
Springfield finds it worth while to employ a full-time superin-
tendent of schools at a salary of $5,000 a year. If the city wishes
to take advantage of the developments of sanitary science and to
make a serious attempt to eliminate the 200 odd deaths a year
occurring from preventable diseases, It will do well to employ a
health officer on a similar basis. This is clearly one of the great-
est improvements that can be effected In Springfield's health
department.
* See page 105.
117
THE SPRINGFIELD SURVEY
Another detail in the present organization that offers possibili-
ties for detrimental results relates to the manner of the health
officer's appointment. This officer is now entirely subordinate to
the commissioner of public safety. The latter can remove the
health officer at will and can reverse that official's slightest de-
cision. It would seem that this condition would tend to make
the position unattractive to a man of the caliber needed, and
would, furthermore, seem likely to subject the health officer and
his decisions to political pressure. Many of the health officer's
orders are necessarily burdensome to the individuals affected, and
if any of these individuals should be influential politically and the
commissioner of public safety be susceptible to pressure, there is
a very real possibility that the health officer's ruling might be in-
terfered with. Such an occurrence would be fatal to the morale
of the health department. It is w^ell worth considering whether
it is preferable to weaken the health office in this way or whether
it would not be better to appoint the health officer for a definite
period and make him removable only for cause.
DEFICIENCIES IN THE PRESENT SERVICE
As has already been noted, important deficiencies exist in the
present city health service. Thus two of the most important
opportunities for life-saving, campaigns against infant mortality
and tuberculosis, are quite neglected, while the work to control
the common communicable diseases is open to radical improve-
ment. Emphatically, properly trained nurses should be em-
ployed and a beginning made on the infant and tuberculosis work.
If lack of funds absolutely prohibited this it would even be worth
while considering the substitution of nurses for one or more of the
present sanitary inspectors. Nuisance abatement is a practical
necessity, but it is not a matter of life and death like work for
infants. Some authorities, in fact, declare that nuisance abate-
ment is more properly a function of the police department. To
re-enforce the work of the nurses a free tuberculosis clinic, such as
is maintained by the Anti-Tuberculosis Association, and a free
baby consultation station* to which sick infants may be brought,
are necessary.
* See page 23.
118
PUBLIC HEALTH IN SPRINGFIELD
The need for an epidemiologist* (a person qualified to study
the progress of the communicable diseases and to check up on the
measures to be taken for their control) and for a milk inspector!
I
Smallpox in Springfield
Cases reported to the health department in 1909-1913. Smallpox Is one of
the most contagious of diseases and is extremely hard to control by ordmary
methods of isolation. Vaccination is by far the most effective barrier to the
disease
have been discussed elsewhere, and are real and urgent. A food
inspector to supplement the activities of the meat inspector would
* See page 63. t See page 1 01.
119
THE SPRINGFIELD SURVEY
also be a benefit; and it is probable that when all the work that
is recommended is under way the department will require a
laboratory man for the examination of milk and water and for the
laboratory diagnosis of the communicable diseases.
Another line of work which the department should develop is
that of health education and publicity. For its most effective
labors it is essential that the public have a sympathetic under-
standing of what the health department is trying to do, and that
How Smallpox Spreads
Houses at 1016 and 1008 East INIonroe Street, Springfield. The incubation
period of smallpox is usually about ten days to two weeks. On October 28,
191 1, a case was reported from the house numbered 1016; on November 12
six more cases were reported from the same house. On January 3, 1912, a
case was reported from number 1012, a house that stood back of and between
the two shown. On February 7, 1912, two cases were reported from 100839.
the second story of number 1008. \'accination would have prevented these
cases
the public receive advice on the best ways to avoid infection and
on other subjects of public health importance. To this end many
departments find it advantageous to distribute a bulletin, which
should be accurate, and simply and attractively prepared. It
should be made understandable to all, — and not merely a com-
pilation of unintelligible and insignificant statistics. The co-
operation of the newspapers should also be secured and they
should be furnished with interesting copy such as they would care
to use. Lectures and exhibits may be arranged, and moving
120
PUBLIC HEALTH IN SPRINGFIELD
pictures utilized. Some such efforts have been made in the past
by the Springfield health department; and they should be con-
tinued and extended.
The importance of an adequate annual report should also be
emphasized, the form preferably to follow in general one of the
excellent standard forms prepared by certain public health associ-
ations. In this connection a word of praise may be given to
some of the department's past reports, which are certainly credit-
able as compared with the department's resources and deserve
to be published w4th greater regularity and in fuller form.
The record keeping of the department has been rather better
than the average found in cities of similar size. Minor improve-
ments can be made in the manner of keeping and filing some of
the present records, but the most radical suggestions relate to new
and fuller records, as in the case histories of communicable dis-
ease. The keeping of these records is, how^ever, contingent on
the initiation of new" inspection work such as has been outlined
elsewhere in this report. The situation regarding the sanitary
code is somewhat similar. The old code is admittedly unsatis-
factory, and a new one has been drawn up, but had not been
passed on by the commission at the time this report was pre-
pared. It would seem, however, not so important to have a new
code complete in every particular (many provisions of which
could not be enforced with the present staff), as that the health
officer be able to have ordinances passed as needed authorizing
work he especially wishes to prosecute. The ordinances should
be printed as often as may be necessary for the convenience of
citizens.
The registration of vital statistics is another important branch
of the work in w^hich improvement should be made, although in
this case the responsibility rests more particularly with Spring-
field's physicians. In examining the death certificates on file it is
evident that there is a pronounced tendency to certify symptoms
as the cause of death, or to certify vague and indefinite causes.
There is also confusion as between the primary and contributory
causes of death, an all-too-common failure to grasp the fact that
by ''primary cause of death" the census office means the disease
primary in point of occurrence and causation. If a child ill with
121
THE SPRINGFIELD SURVEY
measles becomes greatly weakened and dies with pneumonia as
the final complication, measles and not pneumonia is the primary
cause of death. Similarly, to certify that an infant has died of in-
anition (lack of nourishment) or marasmus (wasting) is about as
illuminating as to say that death was due to shortness of breath.
If we are to get on with the prevention of deaths and an under-
standing of local situations we must get nearer the real cause of
death. There is no excuse for such examples of poor workman-
ship on the part of trained professional men, especially as the
census office has issued and distributed to all doctors convenient
vest pocket booklets setting forth just what is wanted and just
what constitutes bad certification. In fact, general directions as
to certification are printed on the back of every standard death
certificate signed by a doctor, but one must conclude that these
directions are far too seldom read. All of Springfield's physicians
should realize that the accurate certification of death is a matter
of first-rate public health importance, and the health department
should apply firm pressure to this end.
A word must also be said regarding the contagious disease hos-
pital. This institution, the appearance of which is shown in the
accompanying picture, is located northwest of the city near Oak
Ridge Cemetery and is maintained jointly by the city and county,
although only city patients are received. No charge is made.
The building has 14 rooms and is stated to have capacity for 12
smallpox patients and 20 cases of other diseases. The hospital
is under the immediate care of a matron and under the general
supervision of the health officer. No medical staff is in attend-
ance, reliance being placed on the patient's attending physician.
The medical equipment is slight. In considering the value of the
hospital it must be admitted that its location at such a distance
from the city is unfortunate. It might be called the Isolated
Hospital. This isolation means a longer ambulance ride for the
patient and greater difficulty in securing nursing and medical
service. A properly maintained contagious disease hospital is no
danger to its immediate neighborhood and should be centrally
located.
Taking the hospital as it is, there is need for renovating much
of the equipment and for making the surroundings more attrac-
122
PUBLIC HEALTH IN SPRINGFIELD
tive. With the above defects in mind it may be stated that the
hospital probably meets its present purpose — that of a boarding
house for persons with contagious disease — fairly well. While
this purpose does not realize the ideal of a contagious disease
hospital it does allow of useful service in taking infectious patients
out of homes where proper isolation cannot be maintained or
where the patients cannot ha\'e decent care.
The Contagious Disease Hospital
Maintained jointly by the city and county but taking only city patients.
Its isolated location (beyond Oak Ridge Cemetery) is a disadvantage both as
it affects the transportation of patients and the securing of medical service;
whereas a properly maintained contagious disease hospital is no danger to its
immediate neighborhood and should be centrally located. The needs of the
present hospital are for renovations in its equipment and for greater attractive-
ness in the building and its surroundings
The employment of nurses has been advocated a number of
times in this report, the particular work for which they were re-
commended being in connection with tuberculosis, infant mor-
tality, and the supervision of cases of contagious disease. Re-
commendations have also been made for the institution by the
city of free clinics for poor persons suffering from tuberculosis and
the venereal diseases, and for the dissemination of information
relating to baby hygiene. At this point it may not be amiss to
123
THE SPRINGFIELD SURVEY
point out the opportunity for the correlation of such work with
other work of a medical nature already performed by the city.
The work referred to is that now carried on by the city physician.
A considerable part of the latter's time is already taken up with
cases of communicable disease, such as syphilis, and in the course
of this work he acquires much information of public health signi-
ficance— information that would be of value to the health authori-
ties in their efforts to control infection. The suggestion is offered
that in addition to the clinics already specifically recommended
for the health department the latter establish a general medical
clinic for the indigent; in other words, that the health depart-
ment be given the administration of the medical poor relief now
carried on by the city physician. Under such an arrangement
the health department nurses would be available for home visit-
ing among the sick poor, as would the health department medical
man already recommended. This plan w^ould seem to offer better
treatment for the sick poor, more efficient administration of the
city's medical relief, and an advantage to the health department
in its efforts to discover sickness and contagion throughout the
city.*
One other point regarding the organization of health work in
Springfield may be noted — the possibility for advantageous co-
operation between the city and county. At present the county
carries on practically no public health work, which is a serious
disadvantage to county residents outside of Springfield and to
residents of the city itself. The county residents need protection
on their ow^n account, and many of them live just over the city
limits so that infection among them is a danger to residents of the
city proper. This last point is recognized by the city in setting
up its jurisdiction, as far as quarantining contagious diseases is
concerned, for a distance of a half mile beyond its borders. Under
similar conditions a number of American communities have
established joint city and county health departments. Such de-
partments are financed by both city and county and exercise equal
jurisdiction and supervision over both the city and the rest of the
* The reader is referred to the discussion of medical poor relief to be found in
a companion report, McLean, Francis H. : The Charities of Springfield, Illinois.
(The Springfield Survey.)
124
PUBLIC HEALTH IN SPRINGFIELD
county. The arrangement is desirable because it secures for the
county the nucleus for a strong service and for the city a stronger
department because of the additional funds available. The re-
sult is better health in both county and city. Springfield and
Sangamon County are of a size to make such an arrangement
economically desirable. The formation of a joint department
would very probably be advantageous to the community and
such a step is hereby suggested.
FINANCIAL TREATMENT OF THE HEALTH DEPARTMENT
The health department cannot, of course, be expected to carry
on the necessary work without adequate funds. For this reason
it is essential to examine the size of its appropriation and to com-
pare the latter with the amounts found necessary for proper ser-
vice in other cities. The details of the Springfield appropriation
for the year ending February 28, 1915, are given in Table 36.
TABLE 36. — HEALTH DEPARTMENT APPROPRIATION, SPRINGFIELD,
ILLINOIS
Fiscal Year ending February 28, 19 15
1,020.00
Salaries
Superintendent of health $1,200.00
Assistant superintendent (resigned)
Secretary
Meat inspector 1,000.00
Three sanitary inspectors 2,520.00
Matron, isolation hospital 720.00
Office supplies and incidentals S^S-oo
Fumigation and quarantine work 650.00
Dairy inspection 50.00
Milk investigation and laboratory supplies 475-oo
Isolation hospital
Supplies and repairs 150.00
Light 75-00
Transportation to hospital 150.00
Sanitary investigation 200.00
Educational work 30o-oo
Total $0,025.00
The total appropriation, $9,025, represents a yearly expendi-
ture of 15.6 cents for each inhabitant. This figure is much lower
125
THE SPRINGFIELD SURVEY
than is necessary for a well-rounded department, most authorities
recommending 50 cents to $1.00 per inhabitant as a proper figure.
The deficiencies which have been noted in the health depart-
ment's program must be considered in the light of this small
appropriation. In the same year Springfield allowed its police
department $56,630 and its fire department $99,758, expendi-
tures that are probably not excessive. It is not clear why the city
should be willing to spend 98 cents per person on police protection
and $1.72 on fire protection and yet stop short at about 16 cents
per person for the much-needed health protection. If the city
has simply acquired the habit of regarding 16 cents per person as
an adequate health department figure, it should make all haste to
disabuse its mind of any such pernicious and expensive delusion.
SUMMARY OF RECOMMENDATIONS REGARDING THE HEALTH
DEPARTMENT
The principal recommendations which are made for the im-
provement of the city health department may be summed up as
follows :
1. The employment of a full-time health officer. This is a
most important recommendation. The health officer should be
appointed for a term of years and should be given a free rein over
his department.
2. The employment of public health nurses to carry on work
against tuberculosis and infant mortality. This recommenda-
tion is hardly second to that for the employment of a full-time
health officer, and the employment of such nurses should take
precedence over that of any other additional persons, such as
inspectors.
3. The employment of an epidemiologist, w^ho might act also
as medical inspector in contagious diseases. This person along
with nurses to supervise isolation are the most necessary re-
enforcements to the present work against typhoid and the con-
tagious diseases of children.
4. The employment of a milk inspector and, somewhat less
urgently needed, a food inspector. The possibility for the ul-
timate need for a laboratory man should also be noted.
126
PUBLIC HEALTH IN SPRINGFIELD
5. The initiation of systematic efforts at health education and
pubHcity.
6. Greater insistence on more accurate certification of death by
physicians.
7. The shifting of emphasis in the control of the communicable
diseases from quarantine of the premises and fumigation to early
recognition of all cases and efficient bedside disinfection of the
patients' discharges. Also greater strictness in the matter of
release from quarantine, in diphtheria by the culture method
only, and in scarlet fever only after inspection of the patient by a
medical representative of the health department.
8. The initiation of work against the venereal diseases such
as has been instituted by progressive health departments in
other cities.
9. Renovation of considerable of the equipment at the con-
tagious disease hospital and the inception of measures to add to
the attractiveness of the place. A new hospital, centralh- lo-
cated, would be preferable if funds are available.
10. Finally, the increase of the present scanty appropriation of
the health' department sufffciently to permit the adoption and
proper administration of the measures recommended.
PROPOSED REORGANIZATION OF THE SPRINGFIELD HEALTH
DEPARTMENT
Proposed additions to the present staff appear in the lower line.
A full-time superintendent of health (health officer) and at least
three public health nurses for tuberculosis, infant mortality, and
contagious disease ^York, are the most important necessities.
Superintendent of Health
3 Sanitary Meat Clerk and ! Matron Contagious
Inspectors Inspector Secretary | Disease Hospital
Milk Labora- Epidemi- Public
Inspector tory Man ologist Health Nurses
127
XV
SUMMARY AND. CONXLUSIOX
LIFE WASTAGE IX SPRINGFIELD
Serious life and health wastage is constantly going on in Spring-
field. Thus in the last six years 1,218 residents died from the
more common communicable diseases and several thousand more
were made ill. At least a fourth of the deaths from all causes
ma}^ be laid to these preventable diseases.
The greatest single agent in this devastation is tuberculosis,
responsible for 490 deaths in the last six years and for 1 1 per cent
of all the deaths in 19 13, the year here studied in detail. The dis-
eases of infants form another great contributing group; 727 in-
fants under one year of age died in the last six years, deaths of
such infants amounting to 18 per cent of all deaths in 19 13.
Nearly half of these infant deaths are from the ordinary prevent-
able causes, such as diarrhea and enteritis, pneumonias, and
acute infections. Other important contributory factors in the
city's preventable mortality and morbidity are the contagious
diseases of children, typhoid fever, and the venereal diseases.
The toll exacted is much heavier in certain sections of the city
than in others. Thus the tuberculosis death rate in the wards
east of Tenth Street is over twice that in the two southwest wards.
Corresponding differences are found in the death rates for typhoid
fever, the contagious diseases of children, and infant mortality.
The east wards, which have these high death rates, are the ones
that contain the greater proportions of the city's Negroes, foreign-
born whites, and illiterates. They also have the highest birth
rates and the highest proportions of children and people of work-
ing age, and they are the districts which have called for the largest
amounts of poor relief. The city's public health problem centers
in these districts and it is here that the health department should
concentrate its attack against disease.
128
1
PUBLIC HEALTH IN SPRINGFIELD
SANITARY CONDITIONS IN SPRINGFIELD
Within Springfield's eight and a half square miles are to be
found 7,500 privies and 7,500 wells. This is probably the most
serious insanitary condition in the city. Most of the wells and
privies are unnecessary, three-fourths of them being along the
city water or sewer lines. The two east wards, which in 19 10
contained 36 per cent of the population, contain over half of the
wells and privies in the city and approximately a half of those
that are absolutely unnecessary. Wards four and five, to the
southwest, and ward seven, in the central business section, have
relatively the fewest wells and privies in proportion to their popu-
lation. The southeast ward (six) has five times as many wells
and privies per 1,000 population as the central ward (seven); it
has a well and privy for each five persons. This ward and its
11,500 odd inhabitants, in other words, depend almost entirely
on wells and privies, a situation w^hich puts this section of the
capital city of Illinois in a class with those small villages of the
state which still depend upon the insanitary makeshifts of pioneer
days.
The city is fairly well covered by public water mains and sewers,
estimates at the time of the Survey indicating that 88 per cent of
the people could connect with the former and 83 per cent with the
latter. The distribution of these services is, however, markedly
deficient in certain parts of the city, notably the east wards again.
In the northeast ward (one), for example, 30 per cent of the in-
habitants were unable to connect with the water system and 27
per cent with the sewer system.
The character of the public water supply has been improving
steadily during the past few 3^ears, but there is need for further
development of the tubular well system to insure a more adequate
reserve capacity and to eliminate all possibility of needing to
pump direct from the polluted Sangamon River, — as was the
case at the end of 19 14. Additional force main capacity from the
pumping station to the city is also a necessity.
The city disposes of its sewage in a haphazard way, the outfalls
being located at some 12 different points along the city's limits.
Serious stream pollution occurs at certain points. The city must
9 129
THE SPRINGFIELD SURVEY
Wells
Privies
* ' VII .
CLij I
jrr^\r.r^
M'J'
rLL I'
k
No City Water
Xo Sewers
Sanitary Conditions in Springfield Wards
The darker shadings in the smaller maps indicate higher proportions of
wells and privies per 100,000 population; the black areas in the larger maps
indicate built up districts without sewers and without city water. The
original diagrams from which the smaller maps are taken are to be found on
pages 90 and 91. The larger maps are described on page 79, Compare with
illustrations on pages 132 and 133
130
PUBLIC HKALTH IN SPRINGFIELD
look forward to the erection of sewage treatment works, both for
her own safety and self-respect and because of the possibility of
compulsion by the state authorities. In this event it will be a
distinct advantage if the sewage can be treated at a single point
and if separate sewers are provided for the collection of storm
water and house sew^age. Consequently this is the time for Spring-
field to make a thorough survey of her sewers and to formulate a
sewer plan for future developments.
Inspection of the dairy farms supplying the city showed them
to be in poor condition, less than 3 per cent scoring good or better.
A city milk inspector is clearly needed. The usefulness of such
an inspector is indicated by the fact that reinspection of a num-
ber of farms several months after the original inspection show^ed
that considerable improvements had been made.
Inspections of the groceries and markets showed them to be
generally in good condition. Many of these places make use,
however, of the common privy and have inadequate washing
facilities. Here again regular city inspection is desirable.
The manner in w^hich manure .is stored and disposed of is ob-
jectionable and the matter is important because this material is
the chief breeding place of flies. In the house-to-house canvass
the inspectors noted 420 open accumulations of manure, most of
them in the northeast part of the city. The city should require
tight bins and stable floors, and regular collection and disposal.
In this connection it may be noted that Springfield has a small
refuse incinerator but no system of collection. Regular and gen-
eral collection and proper disposal of refuse are certainly essential
for a clean city.
THE CITY HEALTH DEPARTMENT
The city health department has done creditable work w'ith the
resources at its command, but is very meagerly financed and,
probably as a consequence, ignores its greatest opportunities for
life-saving. The department does nothing to stop the heavy in-
roads upon infant life or to restrict the ravages of tuberculosis.
In the face of these vital losses Springfield allow^s its health de-
partment only a fraction of the funds needed for a well-rounded
and effective organization, and less than a sixth of the amount
131
THE SPRINGFIELD SURVEY
allowed the police department, and less than a tenth of that
allowed the fire department. Granting the importance of the
police and fire departments, which are largely for the protection
of property, Springfield should consider whether it will continue
to put such a relatively low value on its health department — the
service it has created more specifically for the protection of life
and health.
Negroes
Birth rate
Social Statistics of Springfield Wards
The darker shadings indicate higher proportions of Negroes and foreign
born whites, and higher birth rates. The east wards evidently have the higher
ratios. The original diagrams from which these maps are taken may be found
on pages lo and 15. Compare with illustrations on pages 130 and 133
The most urgent needs of the health department are a full-time
health otificer and nurses for baby-saving, tuberculosis work, and
the supervision of quarantine. Better methods for the study
and supervision of cases of typhoid and the contagious diseases
of children should be instituted and an epidemiologist should be
provided. These additions to the stafT, as well as a milk in-
spector, are of prime importance.
Moreover, the department should develop certain other new
lines of work, such as the prevention of venereal diseases and
better health education and publicity. It should also work for
improvement in the registration of vital statistics.
132
PUBLIC HEALTH IN SPRINGFIELD
CONCLUSION
Springfield has a well defined and clearly localized public health
problem. It has a combination of serious life wastage from pre-
Diarrhoea and enteritis
under 2 years
Diphtheria
Contagious Diseases
of Children
Pneumonia under 55 yrs. Tuberculosis
Preventable Mortality in Springfield Wards
The darker shadings indicate higher death rates. The rates on which the
rankings are based are per 100,000 population, except in the case of diphtheria
and the contagious diseases of children in which cases they are per 100,000
children of school age. The figures are for residents only. The original dia-
grams from which these maps are taken are to be found on pages 21, 28, 30,
38, 59, and 68. Co.npare with illustrations on pages 130 and 132
ventable diseases, fairly good sanitary conditions, except for the
presence of an extraordinary number of wells and privies, and a
poorly supported and weak health department. Certain parts of
133
THE SPRINGFIELD SURVEY
the city, notably the wards east of Tenth Street, have excessively
high rates of mortality from preventable causes, and it is in these
districts that sanitary conditions are specially bad. The plain
fact is that people are dying in parts of the city because they are
ignorant; because they are poor; because they are surrounded
by inferior sanitary conditions; and because the city does not
give them a proper health department service.
What is needed at once to meet Springfield's public health
problem is fairly obvious. The wells and privies should be done
away with, and the city should perfect its water supply and sewer-
age, and make the mains of both systems available to all. The
city should also see to it that the benefits of such improvements
are denied no one simply because he is too poor "to afford them.
This is to the advantage both of the individual and of the whole
city. Then the city should set to work, through its health de-
partment, to overcome popular ignorance with regard to sanitary
matters. Finally, the city should provide its health department
with proper equipment in the way of staff and funds so that the
department may adequately cope with the various administrative
phases of the needed preventive work.
The adoption of such a program of course raises the practical
question of cost. Where is the money coming from and how
much is needed? Also, if money enough for all measures cannot
be had, which are most important and which will give the great-
est return in lives saved and sickness prevented for a given
amount of money expended?
To the first question, where the money is coming from, Spring-
field and its city officials must find the answer. Similarly, the
city must rely on her engineers for estimates of the cost of the
various sanitary improvements needed. But it can be said here
emphatically, and should be promptly recognized, that her pres-
ent health department expenditure needs to be trebled or quad-
rupled. Even then it will be moderate as compared with health
department expenditures in more progressive cities and small as
compared with what Springfield now spends on its police and fire
departments.
It can also be said here that the investment in the health de-
partment will probably, dollar for dollar, save more lives than
will the investments for the various sanitary improvements.
134
PUBLIC HEALTH IX SPRINGFIELD
This is not to say that the other improvements, as in the water
supply and sewer system, should not be made; it means simply
that the health department need is most urgent and should be
met first.
The whole question of better health in Springfield is in no sense
limited to the realm of theory. It is a thoroughly practical mat-
ter and is squarely up to the citizens and the city administration.
That public health is purchasable is now a well recognized fact.
Springfield has a splendid opportunity to buy — to save 200 or
more lives a year and to prevent much additional sickness.
Realizing that the safety and welfare of the citizens are involved
to this extent, there ought to be no question of the city's willing-
ness and determination to find the funds needed and to buy
wisely.
135
APPENDICES
APPENDIX A
SELECTED MORTALITY AND MORBIDITY STATISTICS BY
YEAR AND WARD, SPRINGFIELD, 1908-1913
The general plan followed in the investigation of Springfield's vital statis-
tics was to study the mortality from all causes for two years, 1910 and 1913,
and to study the mortality from the preventable diseases for the last six
years, 1908 to 1913 inclusive. To this end a transcription was taken of the
certificates of all deaths occurring in Springfield in 1910 and 1913 and of all
deaths from preventable causes in the city in the other four years. The
transcription cards were then studied on the basis of residence and cause of
death. The results are to be found in the text and in Appendix B, prepared
by W. J. Y. Deacon, to whom thanks are due for the detailed studies of
1910 and 1913.
The six-year period was selected for the study of the preventable deaths
because it was desired to obviate as far as is practically possible erroneous
impressions arising from the fluctuations in mortality occurring from year
to year in a city of Springfield's size, and because it was desired to have a
larger base for computing ward rates than would be afforded by the figures
for a single year. It is hoped that the six-year period in large measure over-
comes the difficulty due to small numbers, as it makes the ward figure for
any disease approximately as reliable as the figure for that disease for the
whole city for a single year. It is realized, however, that even taking the
six-year period, the numbers are in some instances rather small for statistical
purposes, as for example in the death and fatality rates for the several con-
tagious diseases of children. But in this connection it should be remembered
that a small number of deaths from a communicable disease may be a positive
indication of satisfactory health conditions and not merely a sign of an in-
adequate base; and that the primary object of this report is to describe
local conditions in Springfield and not to add to our general knowledge of
sanitation. In some cases it is reahzed that larger numbers would be de-
sirable; but in these instances it has seemed wise to make the best of the
material at hand, taking care not to draw any unjustifiable conclusions from
such figures.
Mid-year populations are used in every case for the computation of yearly
death rates; and in the cases where an average yearly death rate is computed
139
THE SPRINGFIELD SURVEY
for a period of years the figure is obtained by dividing the number of deaths
in the whole period by the number of years in the period and referring this
quotient to the population as estimated for the middle of the period. Of
the estimates of population used, those for igio, 191 1, 191 2. and 1913 are
as furnished by the United States Bureau of the Census; in computing those
for 1908 and 1909 it is assumed that the annual increase in those years was
the same as estimated by the census office for the years subsequent to 1910.
Some further discussion of the statistical methods used in this report are
to be found in the foreword and the introductory discussion.
The ruhng of tables follows the statistical practice of the Russell Sage
Foundation.
deaths from certain causes by year, springfield, i908-i913
(residents only)
Disease
1908
1909
1910
1911
1912
1913
Total
Tuberculosis
Pneumonias under 55
72
81
98
85
68
86
490
years
Infants under i year (all
33
38
40
40
30
46
227
causes)
Diarrhea and enteritis
123
105
131
104
118
146
727
under 2 years
Typhoid fever
Diphtheria
Scarlet fever
37
16
6
10
34
IS
2
I
41
21
9
5
29
10
12
6
33
12
19
54
10
13
I
228
84
61
23
Whooping cough
Measles
6
I
2
14
4
2
5
II
I
16
13
44
31
deaths from certain causes by ward, springfield, i908-i913
(residents only)
Disease 1 2 3 4 5 I 6 7 Total
Tuberculosis
Pneumonias under 55
years
Infants under i year (all
causes)
Diarrhea and enteritis
under 2 years
Typhoid fever
Diphtheria
Scarlet fever
Whooping cough
Measles
^ Excluding six who died in the Redemption Home.
140
98
42
99
45
42
114
50
490
53
29
29
35
15
52
14
227
173
43
105
95
48
238
25
727
72
10
17
20
12
80 a
II
228
15
12
15
12
3
21
6
84
14
7
12
II
4
13
61
10
. .
I
I
II
23
9
I
8
6
3
16
I
44
6
5
5
3
3
6
3
31
APPENDIX
DEATHS FROM DIPHTHERIA AND SCARLET FEVER BY WARD, SPRING-
FIELD, 1909-1913 (residents only)
Disease
1
2
3
4
5
6
7
Total
Diphtheria
Scarlet fever
12
5
/
10
I
II
2
I
13
6
55
13
CASES OF certain COMMUNICABLE DISEASES BY YEAR, SPRING-
FIELD, 1909-1913 (residents only)
As reported to the city health department
Disease
1909
1910
1911
1912
1913
Total
Diphtheria
102
143
89
195
158
687
Scarlet fever
77
257
348
35
37
754
Typhoid fever
a
98
52
80
89
319
Smallpox
20
27
15
15
10
87
'* Informal ion not available.
CASES OF certain COMMUNICABLE DISEASES BY WARD, SPRING-
FIELD, 1909-1913 (residents only)
As reported to the city health department
Disease
1
2
3
4
5
6
7
Total
Diphtheria
127
70
109
134
56
154
28
687
Scarlet fever
118
80
120
165
&S
128
55
754
Typhoid fever
62
27
62
59
28
62
19
319
Smallpox
6
13
21
5
7
26
9
87
141
THE SPRINGFIELD SURVEY
APPENDIX B
AN ANALYSIS OF SPRINGFIELD'S DEATH RATE FOR 1910 AND
1913
By W. J. V. Deacon
State Registrar of Vital Statistics for Kansas
All populations as of July i, according to the estimates of the United
States Census Ofhce.
DEATHS AND DEATH RATES BY RESIDENCE AND COLOR
1910 1913
Deaths registered ^
Crude death rate
Deaths of non-residents
Deaths of residents
Death rate for residents only
Deaths of white residents
Deaths of Negro residents
Death rate for white residents
Death rate for Negro residents
86o
994
16.54
17.60
185
185
675
809
12.98
14-32
621
737
54
72
12.68
13.85
i8.n
22.26
^ According to the 19 13 report of the city heahh department.
DEATHS AND DEATH RATES BY AGE (RESIDENTS ONLY)
Age group
Population Deaths Death rates
1910 I 1913 1910 I 1913 1910 1913
Under i year
Q38
1,019
131
145
139-7
I to 4 years
3,846
4,178
41
70
10.7
5 to 14 years
8,974
9,748
26
34
2.9
15 to 24 years
9,893
10,747
46
54
4.6
25 to 44 years
17,471
18,979
130
133
7-4
45 to 64 years
8,314
9,031
136
173
16.4
65 years and over
2,467
2,680
165
200
66.9
All ages
51,989'^
56,476b
675
809
13.0
142.3
16.8
3-5
5-0
7.0
19.2
74.6
14-3
. '1 Includes 86 persons of unknown age.
b Includes 94 persons of unknown age.
Death rate corrected to standard milHon of population (England and
Wales in 1901) becomes 13.31 for 1910 and 14.76 for 1-913.
142
APPKXDIX
DEATHS AND DEATH RATES BY WARD (RESIDENTS ONLY)
Ward I —
Population
1910
1913
Deaths
1910 1913
Death rates
1910 1913
1
8,410
9,136
115
152
13-67
16.64
2
6,060
6,583
82
80
13-53
12.15
3
8,567
9,307
106
127
12.37
13-65
4
9,836
10,685
121
135
12.30
12.63
5
5Ji6
6,209
77
d>2
13-47
13.21
6
10,316
11,206
129
179
12.50
15-97
7
3,084
3,350
40
54
12.97
16.12
Ward unknown
Whole city 51 -989
56,476
67:
809
12.98 14.3.
APPENDIX C
TUBERCULOSIS DEATH RATES
tuberculosis death rates per 100,000 by year, springfield,
1909-19 1 3 (residents only)
Year
White
Negro
Total
1909
126. 1
725-6
160.4
1910
179.6
335-7
188.5
1911
140.9
456.9
158.9
1912
102.3
476.3
123-7
1913
130.0
370.9
152-3
These figures are represented graphically in the chart on page 56.
143
THE SPRINGFIELD SURVEY
APPENDIX D
POPULATION STATISTICS BY WARD, SPRINGFIELD
POPULATION OF WARDS BY SEX, AGE, AND ILLITERACY, SPRING-
FIELD
United States Census, April 15, 1910
Child!
6-20 y
Illiterates in
Total
Males
"en
ears
population
Ward
popula-
tion
over 10
years
Per
Per f
Per
Number
cent
Number
cent
Number
cent
1
8,360
4>432
53-0
2,430
29.1
723
IT. 2
2
6,o?4
2,866
47.6
1,624
27.0
133
• 2.6
3
8,516
4,153
48.8
2,301
27.0
150
2.1
4
Q^777
4,505
46.1
2,452
25-1
142
1.8
5
5,682
2,704
47.6
1,216
21.4
63
1-3
6
10,254
5,201
50.7
2.094
29.2
581
7-4
/
3^065
1.627
53-1
561
18.3
180
6.8
Whole cit>
' 51,678
25,488
4Q-3
13,578
26.3
1,981
4-7
FOREIGN BORN WHITES AND NEGROES BY WARDS, SPRINGFIELD
United States Census, April 15, 1910
Ward
F'orei.sfn-born whites born in
Germany Ireland Russia
All
countries
Negroes
1
439
193
575
1,858
1. 186
2
178
175
40
810
60
^
456
169
32
977
218
4
272
90
87
812
249
.">
T17
126
17
447
91
6
496
209
183
1,469
1,026
7
169
50
108
527
131
Whole city
2,127
1,012
1,051
6,900
2,961
144
APPENDIX
CHILDREN' 6 TO 20 YEARS INCLUSIVE, BY WARD, SPRINGFIELD,
I9IO AND I9I4
Ward
United States
Census 1910
School census
1914
Decrease
Number ' Per cent
1
2,430
2,336
94
3-9
2
1,624
1,604
20
1.2
3
2,301
2,222
79
3-4
4
2,452
2,356
96
3-9
^
1,216
1,031
185
15-2
6
2,994
2,822
172
5-7
7
561
518
43
7-7
Whole city
13,578
12,889
689
5-1
District
omitted
in 191C
53
Total
12,942
Note. — The figures from the school census of 19 14 were prepared by Mrs.
H. L. Morrison. It seems improbable that a decrease such as is indicated in
the above comparison has actually taken place; and it should be noted that
enumerations undertaken by school authorities do not in general approach
the accuracy of the federal census. The comparison is interesting in so far as
it indicates that no radical change has taken place in the distribution of chil-
dren throughout the city.
APPENDIX E
ESTIMATES OF GROSS AND NET ACREAGE, SPRINGFIELD
The information below is supplementary to that given in Table 3, page 9.
The areas are as of April 15, 1910, as are the population figures used in com-
puting the densities given in Table 3. The area figures were obtained by
planimetering the map of Springfield as revised and copyrighted by Frank
R. Simonds, 191 1. The gross acreage gives the entire area of the ward;
net acreage excludes areas not built up for habitation, such as parks and land
used for industrial purposes, but includes the ordinary street areas.
10
145
THE SPRINGFIELD SURVEY
ESTIMATES OF GROSS AND NET ACREAGE, BY WARD, SPRINGFIELD,
I9IO
Ward
Gross acreage
Net acreage
1
914-5
577-3
2
590.1
374-2
3
938.9
687.7
4
1,023.3
683.1
5
537-5
411. 2
6
1,152.4
842.0
7
153-2
144-8
\\'hole citv
5-309-9
3,720.3
APPENDIX F
BACTERIOLOGICAL EXAMINATIONS OF CITY WATER
RESULTS OF BACTERIOLOGICAL EXAMINATIONS OF SPRINGFIELD
CITY WATER, I907-I9I4
From the records of the State Water Survey
Fermentation in
Indol forma-
Num-
ber of
Per
dextrose broth b
tion c
Bacteria
cent of
Num-
\ear
sam-
ples
per c.c.a
(average)
counts
over
500
ber of Per
tubes cent
Num-
ber of
Per cent
positive
mocu- positive
tests
lated
1907
4
225
SS-S"^
8 25.0
1908
5
716
40.0
10 50.0
5
40.0
1909
18
593
22.2
16 75.0
17
88.2
1910
15
1,120
40.0
22 40.9
15
86.7
1911
7
160
i6.6d
14 35-7
7
100. 0
1912
12
1,120
41.7
24 33-3
12
50.0
1913
26
147
S.o
52 25.0
26
46.2
1914
22
243
IS.od
42 33-3
21
19.0
a On gelatine at 20° C.
b I c.c. of water inoculated.
c 10 c.c. of water inoculated in 10 c.c. of Dunham's solution; incubated for
72 hours at 37.5° C.
^ Result lost on one sample.
146
INDEX
INDEX
accidexts, 3
Aim of Study, i
Analyses: of city water, 146. See
Milk Supply
Annual Report: of health depart-
ment, 121
Anti-spitting Ordinance : in tuber-
culosis, 51
Antitoxin: administration of, by heahh
department, 35; in diphtheria, 35
Appropriation: fire department, 126;
health department, 125; health de-
partment, inadequate, 126; police de-
partment, 126
Area: estimates of gross and net
acreage by ward, 145
Ayres, Leonard P.: Pubhc Schools of
Springfield, Illinois, 71; recommends
more thorough physical examination,
III
Baby Hygiene. See Infant Mortality
Baix, Dr. W. G., 43
Birth: bad registration of, not con-
lined to the poor, 15; location of, 13;
medical profession and registration
of, 16; premature, 3, 11; prenatal
work against premature births, 12;
rate, 12, 15; recommendations for
improvement of registration of, 23;
registration, 12; registration, why
necessary, 16; steps for the improve-
ment of registration of, 16; test of
registration, 14; the public and regis-
tration of, 16; unregistered, 14, 15
Birth Rate. See Birth
Board of Education: and open-air
schools, 51; and school hygiene, iii;
Board of Education {Conlinu d)
and tuberculosis campaign, 47; co-
operation with health department, iii
Building Department: and housing
inspection, 114
Bulletin: health department, 120
Camp Lincoln: pollution of Spring
Creek near, 83
Carriers: and flies and privies, 93;
and milk supply, 100; in contagious
diseases, 29, 36
Case Fatality: in diphtheria and scar-
let fever by ward, 28; in diphtheria
and scarlet fever by year, 29; in
diphtheria by ward, 30; in typhoid
by ward, 59; in typhoid by year,
58; indications of high ratios of, 29
Cases: diphtheria, location of, 32;
scarlet fever, location of, 27; small-
pox, location of, 119
Causes of Death: leading, 3; pre-
ventable, 4; primary and contribu-
tory, 121, 122
Cerebro-spinal Meningitis: amounts
of, 25
Chancroid: cases treated by physi-
cians, 65
Chicago Health Departaiext: dairy
score card used by, 96
Children: and tuberculosis, 52. See
Contagious Diseases; School Hygiene
Children of School Age, 144, 145;
contagious disease death rates based
on, 26
Chinese: in Springfield, 39
149
INDEX
Churches :
paign, 47
and tuberculosis cam-
CiTY Physician: and health depart-
ment, 124; and medical poor relief,
124
City Water Supply. SeeWalcr Supply
Clerk and Secretary, See Health
Department, Slaf
Cleveland, Ohio: and estimates of
cases of tuberculosis, 40
Coal Workings: and city water
supply, 77
Code: of health department, 121
Communicable Diseases: recommen-
dations regarding, 127
Contact Infection: in contagious dis-
eases, 31; in typhoid fever 61
Contagious Diseases: breadwinner
in, 2)y, carriers in, 29, 36; case fa-
tality, 28, 29; concealment of cases,
2)2,', "contacts" in, 31; control of,
29, 31; death rate by year, 35; de-
fects in present isolation of, 34; des-
quamation, 29, 31, 34; disinfection
of discharges in, 3c, 31, 36; educa-
tional pamphlet, 34; extent of city's
jurisdiction, 124; fumigation, 29,
31 ) 2>2)^ 34) 36; health department
and, 36; in Springfield, 25; investi-
gation of cases, 36; isolation in, 2)2>\
isolation of , in Springfield, 31; medi-
cal inspector in, 36; medical profes-
sion and, 2)y> milk bottles in, 2>yi
mortahty by ward, 26, 2'i\; mortal-
ity by year, 29; mortality from, 25;
newer ideas in control of, 29; nose
and throat in, 34; opportunity for
prevention, 3; pubHc health nurses
in, 36; quarantine period, 33; recom-
mendations to meet situation, 36;
re-inspections of isolation, 34, 36;
release by health department, 34;
release from quarantine, 33, 34, 36;
reporting of, 29, 31, 33, 36; sanitary
inspector in, 32, 34; secondary etiects
of, 25; summary of situation, 36;
supervision of cases, 36; unscrupulous
families in, 34. See Contagious Dis-
ease Hospital; Diphtheria; Measles;
Scarlet Fever; Whooping Cough
Contagious Diseases of Children.
See Contagious Diseases
Contagious Disease Hospital: ca-
pacity, 122; isolation of, 122; loca-
tion, 122; needs of, 122; should be
centrally located, 122; value of, 123
County Almshouse : and tuberculosis,
46
County Clerk's Office: births re-
turnable to, 12
Cultures : release by, in diphtheria, 33,
36
Dairy Farms, 96. See Milk Supply
Deacon, W. J. v.: 142
Death Rate: analysis of, for 19 10 and
1913, 142; at age periods, 11; by
year from t\-phoid, contagious dis-
eases, diphtheria, scarlet fever, meas-
les, whooping cough, pneumonia, and
diarrhea and enteritis, 35; contagi-
ous disease, by year, 29, 35; crude, 2;
diarrhea and enteritis, by year, 35;
diphtheria, by ward, 30; doubtful
value of, 2; errors in method of com-
puting, 2; general, i; non-residents,
2; of Negroes from tuberculosis, 2'^.
39; of whites from tuberculosis, 2,^;
pneumonia, by year, 35; residents
only, 2; syphilis, 65; tuberculosis,
38, 39, 56, 143; typhoid fever, 35,
58, 59
Deaths, 139-141; of infants under one,
location of, 17; of infants under two,
from diarrhea and enteritis, location
of, 19; from pneumonia, location of,
68; from tuberculosis, location of,
40. See Causes of Death; Prevent-
able Deaths
Decatur: pollutes Sangamon River, 75
Decker, D. O.: City and County Ad-
ministration, 76
Density of Population. See Popula-
tion
Desquamation, See Contagious Dis-
eases
ISO
INDEX
I
Diarrhea and Enteritis: death rate
by year, 35; death rates for infants
under two by ward, 21; flies and, 93;
};reat opportunity for life-saving, 3;
in infant mortality, 12, 20, 21; loca-
tion of deaths of infants under two
from, 19; privies and, 93; well and
privy elimination and reduction of, 95
Diphtheria: amounts of, 25; anti-
toxin in, 35; case fatahty by ward,
28; control of, 30; death and fatality
rates by year, 29; death rate by year,
35; fatality by ward, 30; in Spring-
field, 26; location of cases, 32; mor-
tahty by ward, 30; number of cases,
26; quarantine period, 33; release
by attending physician, ;^;^; release
by culture, 53, 34, 36; reporting of, 33
Disease, 139-141; a subtle and indus-
trious enemy, i. See Communicable
Diseases; Contagious Diseases; Pre-
ventable Diseases
Disinfection: bedside, in contagious
diseases, 34; bedside, in typhoid, 63;
of discharges in contagious diseases,
30, 31, 36; tuberculosis, 50, 51. See
Fumigation
Dispensary, 123; for tuberculosis,
49,50; for venereal diseases, 67; of
Springfield Tuberculosis Association,
44, 49
Drainage: Springfield's, 5
Drake, Dr. C, St. Clair: and inspec-
tion of dairy farms for survey, 96
Education: against venereal diseases,
68; by health department, 120; cam-
paign of, against tuberculosis, 47
Environment: and infection, 71;
man's, 71; sanitary, 71
Epidemiologist: recommendations re-
garding, 126. See Health Depart-
ment
Epidemiology: in typhoid fever, 63
Exhibits: use of by health depart-
ment, 120
Fire Risks: and water supply, 76
Flies: and diarrhea and enteritis, 20;
and diarrheal diseases, 93; and food-
handling places, 104; and food supply,
109; and garbage, 114; and infant
mortality, 20, 24; and manure, in,
112, 113; and privies, 92, 93; and
typhoid fever, 61, 92, 93
Food Inspector:
regarding, 126
recommendations
Food Supply: as part of sanitary en-
vironment, 71; central abattoir de-
sirable, 106; city employs meat in-
spector, 103; city health department
and, 108; city inspection desirable,
104; flies and, 104, 109; inspections
by state food commission, 103; in-
spection of slaughtering, 106; meat
inspection, 105, 108; privies and, 104,
106, 107; results of inspection of
various food-handling places, 103;
slaughter houses, 105; state inspec-
tors, 103; summary of situation, 108,
131; toilet and washing facilities in
food-handling places, 104
Foreign-born Whites: by ward, 9,
10; in Springfield, 7
Fumigation: in contagious diseases,
29> 31, 2>2>, 34, 36; in tuberculosis, 44.
See Disinfection
Garbage: and flies, 114; city refuse
incinerator, 114, 115; collection and
disposal necessary, 115; collection
and disposal engineering matters, 115;
exaggerated health importance of, 115
Gonorrhea: blinds children and maims
women, 66; cases treated by physi-
cians, 65. See Venereal Diseases
Griffith, Dr. B. B. (Superintendent of
health): and inspection of dairy
farms for survey, 96; and re-survey of
the well and privy situation, 86
Ground Water: pollution of, 93. See
Water Supply
Hansen, Paul: report on the PubHc
Water Supply of Springfield, 72;
report on Inspection of Streams into
which Sewage of Springfield is Dis-
charged, 82
151
INDEX
Health Department, City: adminis-
tration of antitoxin by, 35; adminis-
tration of medical relief by, 123; an-
nual report, 121; appropriation, 125,
126, 127; births returnable to, 12;
bulletin, 120; bulletin and results of
milk inspection, 102; city ph\'sician
and, 124; code, 121; "contacts'' in
contagious diseases and, 31; con-
tagious disease hospital, 127; con-
trol of communicable diseases by, 127;
control of contagious diseases by, 31;
co-operation \A'ith school authorities,
in; defects in organization, 117;
deficiencies in present service, 118;
education and publicity by, 120; epi-
demiologist needed, 119, 126, 132;
financial treatment of, 125; food in-
spection, 108, 119, 126; free clinics,
123; full-time health officer needed,
117, 126, 132; increased appropria- •
tion moit essential, 134; industrial
hygiene and, in; infant mortahty
and, 21, 24; inspection of dairy
farms for survey and,. 96; joint city
and county health department, 124;
laboratory man for, 120, 126; lec-
tures and exhibits b}^ 120; manner of
appointing health ofi&cer, 118; meag-
erly financed, 131; meat inspection,
108; meat inspector, 105; milk in-
spector needed, 119, 126, 132; neg-
lects infant mortality and tubercu-
losis, 118; new work needed, 132;
newspaper co-operation, 120; nuis-
ance abatement might be transferred
to police department, 118; per capita
expenditure for, 125; physical equip-
ment, 116; present organization, 116;
preventable diseases and, 70; pro-
posed reorganization, 127; public
health nurses needed, 118, 123, 126,
132; publicity and education by, 127;
publicity for milk inspection results,
102; recommendations regarding,
126; record keeping, 121; registra-
tion of vital statistics and, 122; re-
lease of contagious diseases b}', 34;
routine work of, 117; salaries of em-
ployes, 125; school hj'giene and, in;
should prevent epidemics, 117; stafT,
116; summar>' of recommendations
regarding, 126; summary of situa-
tion, 131; supervision of contagious
diseases by, 36; typhoid fever and,
62-64; venereal diseases and, 67-68.
127; vital statistics and, 121; well
Health Department, City {Con-
tinted)
and privy canvass and, 86. See Con-
tagions Disease Hospital
Health Education and Publicity.
See Health Department
Health History: index of, i
Health Officer: need for /uU time
55; recommendations regarding, 126.
See Health Department
Heitman, Mary J.: school nurse, 53
Hospitals: and tuberculosis, 45, 46,
48; for venereal diseases, 67; local,
for tuberculosis, 56. See Contagious
Disease Hospital
Housing: building department and
114; inspection, 114; law, 114
Illinois State Board of Health:
diagnostic laborator>% 34, 43; in-
spection of dairy farms for surv'ey
and, 96; sputum examinations by, 41
Illiterates: in wards, 9
Inanition: as a cause of death, 122;
not included among preventable
deaths, 3
Indians: in Springfield, 39
Industrial Conditions. See Potter,
Zenas L.
Industrial Hygiene: city health de-
partment and, in; inspection for,
no. See Industrial Conditions
Infant ISIortality: acute infections
and, 20; best index of, 12; birth reg-
istration and, 16; by ward, 17; causes
of, n; diarrhea and enteritis and,
20; diarrhea and enteritis in, by
ward, 21; errors in ward rates, 18;
extent of, 11; flies and, 20; from pre-
ventable causes, 20; health depart-
ment and, 21; improper care of in-
fants and, 21; infant welfare stations
and, 21, 23, 24; milk supply and, 24;
neglected by health department, 118;
opportunity for reduction of in wards,
20; pneumonias and, 20; prenatal
152
INDEX
Infant Mortality {Continued)
work against, 12; public health nurses
and, 12, 21; rate of in Springfield, 16;
recommendations for reduction of,
23; reductions possible, 21, 23;
school nurses and, 1 1 1 ; summary of
situation, 21; syphiHs in, 66
Infant Paralysis: amounts of, 25
Infant Welfare Stations. See In-
fant Mortality
Infection: modes of, 71; the environ-
ment and, 71. See Contact Injection;
Flies; Typhoid Fever
Inspector: of meat, 103, 105, 108; of
milk, loi, 126; medical, in contagious
diseases, 36. See also Sanitary In-
spector
Inspectors: in contagious diseases, 34;
in well and privy canvass, 86; of
milk and food to co-operate, 108; of
state food commission, 103
Isolation. See Contagious Diseases
Journal of the American Medical As-
sociation: pamphlet on Consumption
Cure Fakes, 48
Laboratory: diagnosis of the com-
municable diseases, 120; diagnosis of
diphtheria, 34; diagnosis of venereal
diseases, 67; health department, 120;
recommendations regarding, 126;
state board of health, 34, 43
Lectures: use of by health depart-
ment, 120
Life: perilous times of, 11
Life Wastage in Springfield, i, 68,
128
Lixdstrom, O. J. (State food in-
spector), 103
Locomotor Ataxia: caused by syph-
ilis, 66; deaths from, 66
Manure: accumulations noted in well
and privy canvass, 86; flies and, iii,
112; fly breeding and, 113; handling
and disposal of, iii; inspection for
Manure {Continued)
by health department, 1x2; location
of accumulations, 112; photographs
of accumulations, 113; regulations as
to handling, 112; summary of situa-
tion, 131
Marasmus: as a cause of death, 122;
not included among preventable
deaths, 3
Matron Isolation Hospital: salary
of, 125. See Health Department. Staff
McLean, Francis H.: The Charities
of Springfield, Illinois, 124
Measles: am.ounts of, 25; control of,
31; death rate by year, 29, 35; in
infant mortality, 12; patient ex-
cluded from school, 33; primary or
secondary cause of death, 122; re-
porting of cases, ^31 visitation of, 36
Meat Inspector: salary of, 125. See
Health Department
Medical Inspection of School Chil-
dren: need for, 55
Medical Poor Relief: administration
of by health department, 124
Medical Profession: birth registra-
tion and, 23; cases of tuberculosis
treated by, 41; cases of venereal dis-
eases treated by, 65; contagious dis-
eases and, 33; registration of vital
statistics and, 122; release from quar-
antine and, S3'y reporting of con-
tagious diseases and, ^s', tubercu-
losis and, 46; vote on reporting of
cases and disinfection in tuberculosis,
51
Meningitis: not included among pre-
ventable deaths, 4
MiDWivES: and birth registration, 23;
regulation of, 23
Milk Bottles: in contagious diseases,
33; in typhoid fever, 63
Milk Inspector. See Health Depart-
ment, City; Inspector; Milk Supply
Milk Supply: as part of sanitary en-
vironment, 71; dairy scores, 96, 98;
153
INDEX
Milk Supply {Continued)
food inspection and, io8; govern-
ment score card, 96; infant mortality
and, 24; improvements shown by re-
inspections, 97; inspection of farms
for survey, 96; milk inspection needed,
98, loi; over 90 per cent of farms
"bad" or worse, 98; part of pasteur-
ized, 96; pasteurization highly desir-
able, 100; production and scores ac-
cording to amount produced. 99; pro-
duction and scores according to man-
ner of sale, 100; public should pay
a fair price for clean milk, 98; pub-
licity for results of inspection, 102;
results of bacteriological examina-
tions, 100; small farmer a serious
problem, 98; sources and extent, 96;
summary of situation, loi, 131; tu-
berculosis and, 46
MoNTCLAiR, New Jersey: baby-saving
work in, 22
Morbidity Statistics: by year and
ward, 139
Mortality Statistics: by year and
ward, 139
Moving Pictures: use in tuberculosis
campaign, 47; use by health depart-
ment, 120
National Association for the Study
and Prevention of Tuberculosis,
National Board of Fire Under-
writers: Eighty-fifth Report of the
Committee on Fire Prevention, 72;
recommend new water mains, 78
"Nature's Creation": alleged cure
for tuberculosis, 48
Negroes: estimate of living cases of
tuberculosis, 41 ; estimates of popula-
tion, 39; in Springfield, 7; numbers by
ward, 10; preventable diseases and,
70; proportion of by wards, 9; tu-
berculosis and, 55; tuberculosis
death rate, 38, 39, 56, 143
Newspapers: health department pub-
licit}' and, 120; publicity for results
of milk inspection and, 102
New York City: infant welfare sta-
tion in, 22
New York State: sections of and esti-
mates of cases of tuberculosis, 40
Non-residents: deaths from tubercu-
losis, 38; deaths of, 2 '
NoRBURY, Garm: Report on Inspec-
tion of Streams into which Sewage of
Springfield is Discharged, 82
Nuisance: caused by city's sewage, 84
Nuisance Abatement: administra-
tion of, 118
Odencrantz, Louise C: Industrial
Conditions in Springfield, Illinois, 71
Old Town Branch: a sewer, 85; city's I
principal drain, 5; converted into a '
sewer, 5; pollution of Spring Creek
near, 83
Open Air Colony: a private sana-
torium, 46; amount paid by Spring-
field Tuberculosis Association for
treatment of patients, 45; tubercu-
losis patients treated at, 44 ^
Open Air Schools: in tuberculosis, 51; |
need for, 55
Ordinances: of health department,
121; relating to wells and privies, 86;
requiring sewer and water connec-
tions, 86
Palmer, Dr. George Thomas: exami-
nation of children in Palmer School,
52; sanitary survey by, 86
Palmer Public School: examination
of children in, 52; tuberculosis in, 54
Paresis: caused by syphilis, 66; deaths
from, 66
Pasteurization: and tuberculosis, 47.
See Milk Supply
Pneumonia : among old persons not in-
cluded among preventable deaths, 3;
death rate, 35, 68; in infant mortal-
ity, 12, 20; location of deaths of
residents under 55 years of age, 69;
154
INDEX
Pneumonia {Continued)
opportunity for prevention, 2; pri-
mary or secondary cause of death,
122
Police Department: and nuisance
abatement, 118
Pollution: of ground water and wells,
93; of Sangamon River, 73; of
streams by Springfield's sewage, 83
Population: density by enumeration
district, 9; densities by ward, 8;
diflferent character of in wards, 9;
distribution of, 8; estimates of whites
and Negroes by year, 39; foreign-
born whites in, 7; growth of, 7;
Negroes in, 7; net and gross densities
by ward, 9; not served with city
water by ward, 78; of wards not
served by sewers, 83; statistics by
ward, 144
Potter, Zenas L.: Industrial Condi-
tions in Springfield. Illinois, 71
Poverty: and tuberculosis, 37, 52
Premature Birth: not included among
preventable deaths, 3. See Births
Prenatal Work. See Infant Mor-
tality
Preventable Deaths: causes not in-
cluded, 3; number of, 4; proportion
of all deaths, 3; specific questions
relating to, 4; summary of situation,
68, 128
Preventable Diseases: and health
department, 70; and pubhc health
nurses, 70; in wards, 133; summary
of the situation, 68; underlying
causes of, 70
Privies: as part of sanitary environ-
ment; 71; carriers and, 93; changes in
number of, by ward, between 1910
and 1914, 87; condemnation of, 83,
94; distribution of, 88; diarrheal
diseases and, 93; districts showing in-
creases and decreases, 1910-1914, 88;
flies and, 92, 93; food-handling places
and, 104; food supply and, 106, 107;
in 1910, 86; infant mortality and, 24;
location of (insert), 92, 93; made sani-
tar}', 95; mostly unnecessary, 89;
Privies {Continued)
number of by ward, 89; numbers in
1910 and 1914, 87; ordinance relat-
ing to, 86; per 1,000 population by
ward, 89, 90, 91; pollute the ground
water, 92; present situation discred-
itable, 88; recommendations to rem-
edy situation, 94; summary of situa-
tion, 129; typhoid fever and, 60, 61,
93; unnecessary by ward, 91; why
dangerous. 92; with both sewer and
city water available, 91; with sewer
available by ward, 91
Public Health Nurses: and physical
examination of pupils, no; and pre-
ventable diseases, 70; in infant mor-
tahty, 12, 21, 23, 24; in supervision
of contagious diseases, 36; in tu-
berculosis, 44, 50; in typhoid, 64;
in venereal diseases, 67; needed by
health department, 118, 123; recom-
mendations regarding, 126; school
nurses and infant hygiene work, in
Puerperal Septicemia: not included
among preventable deaths, 3
Quarantine. See Contagious Diseases;
Diphtheria; Scarlet Fever
Railroads: establishing lines of divi-
sion, 5; in Springfield, 5; influence liv-
ing conditions, 5
Record Keeping: of health depart-
ment, 121
Red Cross Seal Campaign: and tu-
berculosis, 47
Redemption Home: and syphilis, 66
Registration of \'ital Statistics.
See Vital Statistics
Reporting of Cases: and the health
department, 63; and the medical
profession, 63; of tuberculosis, 50, 51;
of venereal diseases, 67. See Conta-
gious Diseases; Diphtheria; Measles;
Scarlet Fever; Tuberculosis; Typhoid
Fever; Whooping Cough
Residents: deaths of, 2
Return Cases: in typhoid, 62
155
INDEX
Rickets: not caused by pasteuriza-
ti'^n, loo
Salaries: of health department em-
ployes, 125
Saxgamox Couxty: and tuberculosis,
46, 55; co-operation with city in
health work, 124
Saxgamox River, 5; and Springfield
waterworks, 72; drainage area above
the city water works, 73; polluted,
73, 75
Saxitary Coxditioxs IX Sprixgfield:
food supply, 131; manure, 131; maps
illustrating, 130; milk supply, 131;
miscellaneous, no; privies, 129;
refuse disposal, 131; sewerage and
sewage disposal, 129; summar}^ of,
129; water supply, 129; wells, 129
Saxitary Inspector: and contagious
diseases, 32; and t>'phoid, 63; salary
of, 125. See Health Department;
Inspector
Scarlet Fever: amounts of, 25; case
fataHty by ward, 28; control of, 30;
death and fatality rates by year, 29;
death rate by year, 35; in Springfield,
26; location of cases, 27; number of
cases, 26; quarantine period, 33;
release from quarantine, 33; report-
ing of cases, 7,2>
School Hygiene: administration of,
hi; health authorities and, iii;
in Springfield, iii; physical exami-
nation of pupils, no; school authori-
ties and, in; vaccination, in
School Nurse: and examination of
pupils in Palmer School, 53
Schools. See Ayres, Leonard P.
Scores. See Milk Supply
Secondary Cases: in typhoid, 62
Secretary of City Health Depart-
ment: salary of, 125
Sewage Disposal: an engineering prob-
lem, 84; and sewer plan, 84; dangers
from stream pollution, 84; data re-
garding sewer outlets, 84; location of
outlets, 83; outlets one, two, and
Sewage Disposal {Continued)
eight, 85; present disposal, 83; re-
ports by State Water Survey, 82;
sewage discharged into Spring Creek,
83; sewage discharged into Sugar
Creek, 83; State Water Survey in-
spection of streams shows serious
pollution, 83; scope of investigation,
82; summary of situation, 129; treat-
ment works needed, 84. See Sewer-
age
Seaverage: an engineering problem,
84; and method of disposal, 84; as
part of sanitary environment, 71;
"combined" type, 82; cost of and
use of, 86; estimates of ward popula-
tions not served, 83; extension of the
system needed, 83; inadequacies in
distribution, 82; location of built-up
areas without, 79; location of out-
lets, 83; ordinance requiring connec-
tion, 86; scope of investigation, 82;
summary of situation, 129; thorough
survey needed, 83. See Sewage Dis-
posal
Slaughter Houses: central abattoir
desirable, 106; inspection of , 105
Smallpox: and vaccination, in; how
spreads, 120; location of cases, 119
SoRGATZ, Dr. G. F.: state bacteriolo-
gist, 41, 42
Sprixg Creek: carries city's drainage,
5; receives sewage, 2>y, sewer outlets
reaching, 84
Springfield: area of by ward, 145; as
a sanitary environment, 71; drain-
age, 5; fundamental facts regarding,
5; growth of population in, 7; lite
wastage in, i; Negroes in, 7; rail-
roads, 5
Sprixgfield Hospital, The:
berculosis, 45
and tu-
Sprixgfield Tuberculosis Associa-
tion: activities of, 44; and hospital
care, 46; and increase in nursing
service, 50; and open-air schools, 52;
change in policy needed, 45; dis-
pensary, 49; reorganization of, 55;
report of the treasurer, 44; what re-
port should include, 45
IS6
INDEX
Springfield Water Works. See
Water Supply
Sputum Examinations: made at St-
John's Hospital, 43; made in the
bacteriological laboratory of the Illi-
nois state board of health, 42
State Food Commissioner: places in-
spection results at disposal of survey,
103
St. John's Hospital: and tuberculosis,
45; sputum examinations at, 43
State Board of Health.
Stale Board of Health
See Illinois
State of Illinois: growth of popula-
tion in, 7; sputum examinations in,
42
State Water Survey: analyses of city
water, 75; analyses of Springfield
well water, 94; data regarding sewer
outlets, 84; inspection of streams
receiving sewage, 83; report on
Streams Into Which Sewage of
Springfield is Discharged, 82; report
on the Public Water Supply of
Springfield, 72
Statistical Methods, 139
Statistics: of population by ward, 144
Stromquist, W. G.: report on the
Public Water Supply of Springfield,
72
Sugar Creek: carries city's drainage,
5; receives sewage, 83; sewer outlets
reaching, 84
Summary and Conclusions: causes of
life wastage, 134; city health depart-
ment, 131; increased health depart-
ment appropriation most important,
134; life wastage in Springfield, 128;
public health is purchasable, 135;
public health problem centers in east
wards, 128; recommendations to
meet situation, 134; sanitary con-
ditions in Springfield, 129; Spring-
field's public health problem, 133
Superintendent of Health: salary
of, 125. See Health Department, Sta^
Syphilis, 3; cases treated by physicians,
65; causes paresis and locomotor
ataxia, 66; certification of as a cause
of death, 66; death rate from, 65;
deaths from, 66, 67; effects of, 66;
in infant mortality, 12. See Venereal
Diseases
Topography: of Springfield, 5
Tuberculosis: an adequate campaign,
46; and children, 46, 52; and pov-
erty, 37, 52; and Sangamon County,
55; anti-spitting ordinance, 44, 51;
basis for campaign against, 37; bo-
vine, 46; campaign of education, 45,
47; cases treated by Springfield
physicians, 41; death rate, 38, 39,
56, 143; diagnosis of, 43, 52; dis-
infection in, 50, 51; dispensary main-
tained by local a sociation, 44;
distribution of literature regarding,
47; educational campaign of local
association, 44; examination of chil-
dren in Palmer School, 52; existing
agen ies for the control of, 43; ex-
tent of, 38; fake cures, 48; forms of
disease included in study, 39; free
dispensary service, 49, 50; fumiga-
tion in, 44; hospitals, 45-49, 56;
hospital required for Springfield, 45,
49; in Palmer School, 54; in Spring-
field, 37; institutional provision for
cases of, 48; lectures in churches, 47;
location of deaths from, 40; main
points considered in local situation,
37; many cases never recognized, 52;
medical inspection of school children
and, 55; medical profession and, 46;
moving-picture reels, 47; munici-
pality and, 44; neglected by health
department, 118; number of living
cases, 40; nursing service in, 50;
open-air schools, 51; open-air schools
and, 55; opportunity for prevention,
2; patients treated at Open Air
Colony, 44; provision for at county
almshouse, 46; Red Cross seal cam-
paign, 47; reporting of cases, 50, 51;
responsibility for control of, 37;
sputum examinations, 41-43; strikes
in middle life, 4; visiting nurse em-
ployed by local associations, 44;
where the responsibility lies, 55;
wide prevalence of, 43. See Open
Air Colony; Springfield Tuberculosis
Association; Tuberculin Test
157
INDEX
Tuberculin Test: not used in exami-
nation of children in Palmer School,
52
Typhoid Fever: a preventable disease,
58; carriers in, 93; case fatality by
ward, 59; city water supply and, 59;
contact infection in, 61; contagious-
ness of, 61; death and fatality rates
by year, 58; death rate, 35, 59; dis-
charges in, 61; disinfection of dis-
charges, 63; epidemiology, 63; flies
and, 92; health department and, 62;
milkman and, 63; opportunity for
prevention, 3; privies and, 92, 93;
public health nurses in, 64; recom-
mendations for improvement in
health department supervision, 64;
recommendations to reduce, 62; re-
porting of cases, 61, 63; return cases
of, 62; sanitary inspectors and, 63;
secondary cases, 62; summary of
situation, 64; supervision by health
department, 63; wells and privies and,
60, 61; well and privy elimination
and reduction of, 95
V^accination: and school hygiene, iii
Van Blarcom, Dixon: field secretar}^
National Association for the Study
and Prevention of Tuberculosis, 37
Venereal Diseases: cases of, 65;
cases treated by physicians, 65 ; " con-
spiracy of silence" concerning, 67;
dispensary for, 67; education against,
68; free laboratory diagnosis, 67;
health department and, 67, 68; hos-
pital care for, 67; importance neg-
lected, 65; indigent cases to be treated
free, 67; probably commonest com-
municable diseases, 66; public health
nurses and, 67; recommendations re-
garding, 127; reporting of cases, 67;
serious indirect effects of, 66; should
be prevented. 68; what can be done,
67. See Chancroid; Gonorrhea; Sy-
philis
ViNiNG, Mrs. Eleanor: supervising
nurse, 53
Vital Statistics: and health depart-
ment and medical profession, 122;
certification of death unsatisfactory,
121-122
Ward: birth rates, 15; case fatality in
diphtheria and scarlet fever by, 28;
changes in number of wells and priv-
ies, 1910-1914, 87; contagious dis-
ease mortality by, 26; death and
fatality rates typhoid fever, 59;
death rates of children under two
from diarrhea and enteritis, 21;
death rates from pneumonia, 68;
death rate from tuberculosis, 38;
deaths from syphiHs by, 67; density
of population by, 8; foreign-born
whites by, 10; infant mortality by,
18; life wastage by, 128; lines, 5;
map, 6; morbidity statistics, 139;
mortality from contagious diseases of
children, 28; mortality statistics,
139; Negroes by, 10; number of
wells and privies by, 89; opportunity
for reduction of infant mortahty by,
20; populations not served by city
water, 78; populations not served by
sewers, 83; population statistics, 144;
preventable diseases by, 70; pre-
ventable mortality by, 133; sanitary
conditions, 129; social statistics, 9,
132; unnecessary privies by, 91;
unnecessary wells by, 90; wells and
privies per 1,000 population by, 90, 91
Ward Five: contagious diseases, 27;
illiterates, 9; infant mortahty, 19, 23;
low birth rate, 15; preponderance of
wells over privies, 89; sanitary con-
ditions, 129; sewers, 82; typhoid
fever, 59; unregistered births, 15;
wells and privies, 89
Ward Four: case fatality from diph-
theria, 28; contagious diseases, 27;
illiterates, 9; infant mortality, 18,
20; preponderance of wells over
privies, 89; sanitary conditions, 129;
tv-phoid fever, 59; unregistered
births, 15; wells and privies, 88, 89
Ward One: birth rates, 9; children of
school age, 9; contagious diseases,
27; four- fifths of population rely on
wells and privies, 89; illiterates, 9;
infant mortality, 19, 20, 23; life
wastage, 128; Negroes and foreign-
born whites, 9; preventable diseases,
70; sanitary conditions, 129; un-
necessary wells and privies, 90;
water mains, 78, 79; wells and priv-
ies, 88, 89
158
INDEX
Ward Seven: contagious diseases, 82;
infant mortality, 19, 23; low birth
rate, 15; sanitary conditions, 129; so-
cial statistics, 10; wells and privies, 89
Ward Six: birth rate, 9; children of
school age, 9; contagious diseases,
27; ilUterates, 9; infant mortahty,
19,20,23; life wastage, 128; Negroes
and foreign-born whites, 9; pre-
ventable diseases, 70; sanitary con-
ditions, 129; sj'philis, 66; unneces-
sary wells and privies, 90, 91; water
mains, 78, 79; wells and privies, 88,
89
Ward Three: case fatality from diph-
theria, 28; contagious diseases, 27;
infant mortality, 19, 23; sewers, 82;
water mains, 78; wells and privies,
88, 89
Ward Two: case fatality from diph-
theria, 28; contagious diseases, 27;
infant mortality, 18, 20; sewers, 82;
wells and privies, 89
Water Supply: analyses of city water,
75; and disease, 72; as part of sani-
tary environment, 71; bacteriologi-
cal examinations of, 146; coal work-
ings and, 77; compulsory connection,
79; cost of and use of, 86; develop-
ment of Springfield water works, 72;
direct connection established with
river, 72; distribution system, 77;
distribution throughout the city, 76;
estimates of ward populations not
served, 78; extension of mains, 79;
filtration projects, 73; fire risks, 76;
force mains inadequate, 78; funds
needed by water department, 80;
ground water, 72; has improved, 75;
inducement to connect, 79; infiltra-
tion gallery constructed, 72; large
well constructed, 72; location of
Water Supply (Continued)
built-up areas without, 79; need
for further development, 75; ordi-
nance requiring connection, 86; pres-
ent water-gathering equipment, 74;
pumping equipment, 76, 77; re])ort
of National Board of Fire Under-
writers, 72; report of State Water
Survey, 72; river intake should be
eliminated, 75; Sangamon River and,
72; size of mains, 76; summary of
situation, 80, 129; test wells, 76;
tubular wells, 72, 74; turbidity, 77;
typhoid fever and, 59; unpurified
river water used, 73; yield of well
units, 75, See Sangamon River
Wells: analyses of water from, 94;
apparent and actual change in num-
ber, 87; as part of sanitary environ-
ment, 71; at places where city water
is available by ward, 90; changes in
number of, by ward, between 1910
and 1914, 87; condemnation of, 79,
94; distribution of wells, 88; dis-
tricts showing increases and de-
creases, 1910-1914, 88; in 1910, 86; in-
fant mortahty and, 24; location of (in-
sert), 86, 87; mostly unnecessary, 89;
numbers in 1910 and 1914, 87; num-
ber of by ward, 89; number unneces-
sary by ward, 90; ordinance relating
to, 86; per 1,000 population by ward,
89, 91; pollution of, 93; present sit-
uation discreditable, 88; recommen-
dations to remedy situation, 94;
summary of situation, 1 29; suspicious
in cities, 93; typhoid fever and, 60,
61; why dangerous, 92
Whooping Cough: amounts of, 25;
control of, 30; death rates by year,
29, 35; in infant mortahty, 12; pa-
tient excluded from school, ^:^; re-
porting of, S3] visitation of, 36
159
Pamphlet Publications of the Department of
Surveys and Exhibits, Russell Sage
Foundation, New York City
SE I THE SOCIAL SURVEY. Paul U. Kellogg. Shelby
M. Harrison, ct al. 52 pp. (Out of print.)
SE 2 • THE NEVVBURGH SURVEY. 104 pp. (Out of print.)
SE 2c THE RELATION OF THE SOCIAL SURVEY TO
THE PUBLIC HEALTH AUTHORITIES. Franz
Schneider, Jr. 2 pp. 2 cts.
THE TOPEKA IMPROVEMENT SURVEY; in four
part^:
SE 3 Public Health. 98 pp. 25 cts.
SE 4 Dellnquency and Corrections. 64 pp. 15 cts.
SE 5 Municipal Administration. 43 pp. 15 cts.
SE 6 Industrial Conditions. 56 pp. 15 cts.
THE SPRINGFIELD (ILL.) SURVEY; in ten parts:
SE 7 Public Schools. 152 pp. 25 cts.
SE 8 Care of Mental Defectives, etc. 46 pp. 15 cts.
SE 9 Recreation. 133 pp. 25 cts.
SE 10 Housing. 24 pp. 15 cts.
SE II The Charities OF Springfield. 185 pp. 25 cts.
SE 12 Industrial Conditions. 173 pp. 25 cts.
SE 13 City and County Administration. 158 pp. 25 cts.
SE 14 Public Health of Springfield. 159 pp. 25 cts.
SE 15 Correctional System. 185 pp. 25 cts.
SE 16 Springfield: The Survey Summed Up.
SE 17 THE DISPROPORTION OF TAXATION IN PITTS-
BURGH: Summary of findings of taxation inves-
tigation of the Pittsburgh Survey. Shelby M.
Harrlson. 15 pp. (Out of print.)
SE 18 AN EFFECTIVE EXHIBITION OF A COMMUN-
ITY SURVEY: A brief description of the Spring-
field Survey Exhibition (reprint from the American
City). 6 pp. 5 cts.
A SURVEY OF THE PUBLIC HEALTH SITU-
ATION, ITHACA, N. Y. Franz Schneider, Jr.
34 PP- 20 cts.
DEPARTMENT OF SURVEYS AND EXHIBITS,
RUSSELL SAGE FOUNDATION. Activities
and Publications. 11 pp. Free.
SURVEY OF THE ACTIVITIES OF MUNICIPAL
HEALTH DEPARTMENTS IN THE UNITED
STATES. Franz Schneider, Jr. 21pp. 20 cts.
BIBLIOGRAPHY OF THE SOCIAL SURVEY. 16 pp. sets.
COMMUNITY ACTION THROUGH SURVEYS.
Shelby M. Harrison. 30 pp. 10 cts.
RELATIVE VALUES IN PUBLIC HEALTH WORK.
Franz Schneider, Jr. 10 pp. 10 cts.
METHODS OF INVESTIGATION IN SOCIAL AND
HEALTH PROBLEMS. D. B. Armstrong,
Franz Schneider, Jr., Louis I. Dublin. 24 pp. 20 cts.
SE
19
SE
20
SE
21
SE
22
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23
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24
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