Popular Science Monthly/Volume 46/January 1895/Twenty Five Years of Preventive Medicine

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"Who would not give a trifle to prevent
What he would give a thousand worlds to cure?"

IN 1849 the Legislature of Massachusetts appropriated five hundred dollars to be expended in a preliminary investigation of the question whether any attempt at sanitation was worth while; and in the year 1893 she expended $62,876.82, under the supervision of her State Board of Health, much of which went to accomplished biological and chemical experts, to learn exactly on what a pure water supply depends. The previous work of the board in this field had been so well done that Prof. Henry Robinson, of England, in a paper read before the Congress of Hygiene and Demography, in London, in 1891, said: "The action that has been taken by the State Board of Health of Massachusetts, to protect the purity of inland waters, deserves to be specially commended as an example of broad and wise policy, in instituting the systematic investigation by engineers, chemists, and biologists of all that bears upon the purification of sewage and on the filtration of water.… The exhaustive reports under these different heads may be stated to be far in advance of anything that has been fairly attempted in this country." No better picture of the difference in public opinion at the two dates could be found than those two contrasting amounts of money. At the first, the apathy and indifference born of ignorance reigned; at the second, we behold the immense amount of intelligent effort constantly being put forth in this country as the fruit of a quarter of a century of sanitary education.

If a man is going to give a true history of an apple tree, it will not do to begin when the tiny shoot pushes itself up through the mold; he needs to give an account of the seed itself, how produced, when planted, and of the influences that produced its germination. The seed from which the vast mass of public-health legislation and action among English-speaking peoples has sprung, was planted in England by Edwin Chadwick, between the years 1830 and 1844, when his epoch-making Report on the Health of Towns was made to Parliament. Various commissions, with him at their head, had investigated the great mortality among the troops; had looked into the condition of the children employed in factories, mines, and collieries; had studied the terrible, always-prevailing typhus; but this tremendous array of facts, culminating in the statement that the average length of human life in agricultural Wiltshire was thirty-five years, and in Liverpool only fifteen years, roused the whole nation to ask, "Why?" and "Can nothing be done to remedy it?" Chadwick was a barrister of the Inner Temple when, in 1828, a trifling incident turned his attention from the law to the subject of vital statistics, of which few worthy of the name were in existence. An able article from his pen, on What might be done to Improve the Taking of Vital Statistics, at once drew the attention of the country to him, and pointed him out as a man of unique sagacity in "extracting from masses of details the master facts, and bringing these to bear for the elucidation of a master thought." Parliament at once made use of his remarkable abilities, and, beginning with finding out the worst that could be known, inaugurated measures, largely under his guidance, for the amelioration of evils, till to-day, they and we, live in a different world. Most worthily was he knighted by the Queen, and when he died was universally recognized as the father of sanitation. One of his earliest measures was the framing of an act to procure an accurate registration of births, marriages, and deaths; and Sir John Simon says: "Before that time a perfect chaos respecting the population and mortality reigned. Since that time a mass of statistics relative to life, health, and disease has been accumulating which will exert, and is exerting, an immensely beneficial influence upon the physical and moral welfare of these realms (England and Wales), and indeed, ultimately, on every people on the face of the globe. The discoveries in astronomy have not a more palpable application to navigation and commerce, or the investigations of chemistry to manufactures, than have the statistics of health and disease to moral regeneration." But it was Chadwick's report of 1844 that waked up a slumbering nation. Fifty years after, the death rate in the whole country had been cut down from thirty-two to eighteen in the thousand. The work going on there did not escape the eyes of progressive men here. Another layman, Lemuel Shattuck, of Boston, watched the matter in its every step of development, and being touched with the same fine "enthusiasm for humanity" as Chadwick, by voice and pen strove to kindle an answering flame at home. Largely through his influence, the Legislature of Massachusetts passed an act in 1849 by which the Governor was to appoint three commissioners who were to report and prepare a plan for a sanitary survey of the State, etc. They were to be paid, for the time actually spent in the discharge of their duty, the same compensation as members of the General Court, and for travel, and could spend fifty dollars for books, which were to belong to the State Library when they were done with them, but on no account were the expenses of the commission to exceed five hundred dollars!

The Governor appointed Lemuel Shattuck, N. P. Banks, and Jehiel Abbott as commissioners, and Mr. Shattuck formulated their conclusions in a report that to-day is one of the most interesting and instructive of sanitary documents. Sanitary science, as we now know it, had not come into being then, so that to write about it as an existent fact was considerably like "coining a vacuum"; but Mr. Shattuck condensed into it all that history can teach on hygiene from Moses down, and, as he was keenly alive to all that was going on in England, he did not fail to call attention to the great awakening on the subject there, where already two sanitary journals were established, and public meetings were being held in all parts of the country, where it was declared that "sanitation is the great idea of the age." Every consideration which it was thought could influence the legislative mind was brought to bear. The commission called attention to the fact that there had already been costly and valuable reports made on insects; the invertebrates; on fishes, reptiles, and birds; and one on trees and shrubs; and they say it would be reasonable to suppose that man was entitled to a consideration equal to either of these subjects. They cite the fact that two costly expeditions had been fitted out to search for Sir John Franklin, and ask if the preservation of the lives of many possible Franklins is not as worthy an object. They maintain that the average of human life may be much extended, its physical power augmented . . . . untimely deaths prevented, and that measures for prevention will effect infinitely more than remedies for the cure of disease. They compute the needless loss of life and the cost of avoidable sickness. They appeal to intelligent men of all classes, medical and non-medical, and quote from Simon's Report on the Condition of London: "Ignorant men may sneer at the pretensions of sanitary science. Weak and timorous men may hesitate to commit themselves to its principles, so large is their application. Selfish men may shrink from the labor of change, wicked men may turn indifferently from considering that which concerns the health and happiness of millions of their fellow-creatures, but in the great objects which it proposes to itself it transcends in importance all other sciences, and in its beneficent operation it seems to embody the spirit and to fulfill the intentions of practical Christianity." They brought the argument home, by demonstrating that at least $7,500,000 were lost annually to Massachusetts through untimely deaths and needless sickness.

The Board of Health they recommended was to consist of two doctors, one lawyer, one chemist or naturalist, and two of other occupations; and an elaborate plan of action was drawn up, covering nearly every possible combination of circumstances that such a board would be likely to encounter. Dr. Bowditch said, twenty-seven years after, "This magnificent report fell flat from the printer's hands, but when in 1869 the State Board was established it was on the lines Mr. Shattuck had drawn." He did not live to see it carried into effect, but while he lived he never ceased to strive to bring the people of his State to correct views; and now that a great majority of the States have modeled their boards on that of Massachusetts, we can see that he did not labor in vain.

Meantime not all the rest of the country was asleep, for very earnest efforts were making in New York city looking toward the establishment of a central health authority. There was need enough of it, as these facts show: twenty thousand people were living in cellars; there were spots from which typhus was never absent; there were no less than three hundred and seventeen slaughterhouses with their inevitable fat-rendering and bone-boiling concomitants below Eightieth Street; and there is a credible witness now living who saw a small child killed in Madison Street, by one of the hogs which formerly ran loose in the city. It took fifteen years of effort, on the part of a set of men whose disinterested devotion to the best interests of humanity is beyond praise, before, in 1860, they secured a Board of Health for the city. Repeated decimating invasions of yellow fever had visited New Orleans, and in 1855 the Legislature of Louisiana passed a law for the establishment of quarantine, that involved the spending of much money; its authority was vested in a State Board of Health, and its powers were much enlarged in 1867. It was, no doubt, a valuable instrument with which to repel the invasion of exotic epidemics, but bore little resemblance to the thirty-seven State Boards of Health that have since come into being. The one was a frantic effort to repel an external enemy; the others direct their main efforts to the correction of internal sanitary sins of omission and commission. These, with their vigilant watchers in every hamlet, and their multipled publications of reports, pamphlets, directions, and leaflets—the true leaves that are for the healing of the nations—constitute a bureau of information that has saved thousands and thousands of lives. While Lemuel Shattuck's splendid programme of action was calmly slumbering in the State Library the war came, and all minor issues were swallowed up in the one "Shall we have a country left?" But even this had its compensations. Dr. H. I. Bowditch truly says, "Both North and South discovered the all important advantages of cleanliness, sobriety, and strict methods of action, as opposed to the distress consequent on filth, intemperance, and chaotic rule." Dr. Bowditch himself, by the most persistent efforts, induced our military authorities to provide comfortable ambulances for the wounded, and from them has come the present ambulance system of the world—for Europe copied us in this matter.

The putting to sleep of Lemuel Shattuck's noble report by apathetic legislators did not prevent progressive minds from pursuing the subject, and there was a knot of men in Boston who kept up interest in the work by stated meetings among themselves, and occasional public meetings, at one of which Edward Everett delivered one of his most brilliant addresses; but when they ascended Beacon Hill and took the practical steps of asking for the organization of a State Board of Health, it was sure to be defeated by the rural legislator from "way back," typified by the one who said, "Them boards don't do no good, and they cost a sight o' money." Just before the war the prospect became hopeful, and then came the imperative "Halt!" to all the lines of forward-marching progress. During the four-long, bitter years of contest the whole land had taken a lesson in the value of organized action, and as soon as we had caught our breath the march was resumed with a quickened step. Meantime England had made great strides in practical sanitation, and it had begun to be stoutly held that some of the most destructive diseases are not the visitations of an angry God for the moral derelictions of people, but are the direct and palpable outcome of the neglect of sanitary laws. Especially was it believed in England that typhoid fever, the decimating scourge of young manhood and young womanhood, can be averted; and on this side the water Dr. Bowditch had instituted an inquiry looking to discovering the preventable causes of consumption. The results, printed only for private circulation, made a great impression in medical circles—for bacteriology with its tubercle bacillus had not been even heard of. The phrases Preventive or State medicine had begun to be used, when, in 1869, a remarkable concatenation of circumstances, consisting of two distinct lines of action, resulted in the establishment of the Massachusetts Board of Health. Repeated repulses at the State House had completely disheartened the advocates of State medicine in Boston, but unexpected help was coming to their aid from the extreme western part of the State. Those familiar with the annals of sanitation will recall a fearful visitation known as the Maplewood Fever, which occurred in the year 1864 in Pittsfield, at the Young Ladies' Institute, in which out of seventy-seven pupils fifty-one had typhoid fever of a virulent type, and thirteen died—as the result of purely local causes, the direct result of ignorant sanitary neglect. The outbreak occurred in August, and in September, at the instance of Thomas F. Plunkett (husband of the writer), three of the professors, who had come to give their annual courses of lectures in the Berkshire Medical College, undertook a searching investigation. They were A. B. Palmer and C. L. Ford, of the University of Michigan, and Pliny Earle, Superintendent of the Northampton Insane Asylum, and after several months their fearless and exhaustive report was published in the Boston Medical and Surgical Journal and in pamphlet form. It created a profound sensation; but lest the proprietor of that school should be thought a "sinner above all others," it should be recalled that these were days prehistoric to sanitation, and that a bulky volume might be made up of the stories of epidemics caused by unsanitary conditions connected with schools and colleges. The man who had instigated the investigation was no enemy, but had been friend, trustee, and patron of the school from its foundation, but he was of the fiat-justitia-ruat-cœlum type, and the findings of the report, which proved that on those beautiful grounds, and only there, save in the case of day pupils who had been subjected to the same poison, was there any typhoid fever, sank deep into his heart. We quote one of the closing sentences: "To whatever extent the ignorance of sanitary laws may shield the violator from moral responsibility, it will not abate the physical penalty of such violation. This will fall with the same force upon the unconscious, the ignorant, the helpless, and morally innocent, as upon the intelligent, the powerful, and the wicked. . . . To prevent the poison of typhoid fever, when taken into the system, from producing its legitimate effects, except by natural agencies, would require as positive a miracle as to restore a severed head, or arrest the course of the heavenly bodies. Instead of closing our eyes and soothing our minds by casting the responsibility of a great calamity upon Providence, we should look to the physical conditions producing it, and see if these conditions are remediable." Some people thought these declarations of the preventability of disease by human agency bordered on the blasphemous, but the thought was "in the air." Dr. Budd, of Bristol, in England, had traced epidemics of typhoid directly to infected drinking water; and Dr. Austin Flint's classical study of the outbreak near Buffalo, N. Y., convinced medical men of its preventability, as well as here and there a progressive layman, but they all saw that only organized, concerted effort, fortified by law, could effect this exemption. Mr. Plunkett was chosen to the Legislature in 1868, and made some tentative efforts looking to a State Board, but the time was not auspicious. He was again a member in 1869, and in a faction fight in the dominant party had been able to render the candidate who was finally seated as Speaker an important service, and naturally the gentleman so seated was "willing to oblige," etc. Among the members were three physicians, and some other broad-minded progressive men; and rather late in the session, the motion was made to appoint a

committee to inquire into the expediency of establishing a Board of Health. The man who made the motion was placed at its head, and the kindly disposed Speaker desired him to name his associates; he designated those to whom the cause would appeal. Word was sent to Dr. Bowditch and his fellow-sanitarians to come and present their reasons. A bill was drawn, but its champion did not care to have it discussed till late in the session, when many of the timid obstructionists would have hied themselves to their rural farms; and when speaking in its advocacy, he ignored the wails of the bereaved fathers and mothers of the Maplewood pupils, and based his plea entirely on economic grounds, saying that by the aid of law preventable diseases might be checked; that it had been shown that typhoid fever was a preventable disease. He called attention to the fact that it generally attacked persons in the productive age, and that scarcely one of the three hundred and thirty-five towns in the State but had at least one annual victim. He said a man of twenty-one represented an investment of ten thousand dollars; that it had cost at least five hundred dollars each year of somebody's money—public or private—to feed, clothe, shelter, and educate him; and thus the State sustained an annual loss of five million three hundred and fifty thousand dollars.

It seems humiliating that the issues of life and death should be made to hinge on a pocket argument, but it was effective, and the law establishing a State Board of Health was enacted June 21, 1869. The members were to be appointed by the Governor and Council. The act was not twenty-four hours old before an application from an unprogressive doctor-constituent came to its champion for a position. The Governor said, "I suppose you have some friends you would like to see on the board?" "No," was the answer, "only I think it goes without saying who should be at its head—Dr. H. I. Bowditch, who has worked disinterestedly for so many years toward this consummation; for the rest, all I ask is that you will not make it worthless by appointing a set of nobodies, on account of their political opinions." The Governor rose to the occasion; the pace he set has never been lost, and in the twenty-five years of its existence many of the ablest men in the Commonwealth have lent their powers to make it a success. The action of the member from the "western county" may be compared to that of the man who turns the jet and applies the match, thus setting the already waiting illuminant alight a small but very indispensable operation. There are now thirty-six State Boards patterned very closely after this, under whose guidance a whole army of sanitarians is at work.

"Its banner bears the single line,
'Our duty is to save.'"

The board had to blaze out a new path into regions hitherto unoccupied. At its first meeting Dr. Bowditch said: "I know of no higher office in the State than that which we now hold, viz., that of inaugurating the idea of State medicine in Massachusetts, Upon our high or low appreciation of the position, and of the duties resulting from that position, and upon our wise or foolish performance of these duties, depends the success of the object aimed at. Our work is for the far future as well as for the present. . . . I wish to impress upon you the essential dignity of the offices we now hold, and that we should assume them with minds loyal to the truth. . . . State medicine ranks among the most important matters now discussed by the highest intellects and the humanest hearts in Great Britain. . . . The chief object of the physician is to cure; the far higher aim of State medicine is, by its thorough and scientific investigation of the hidden causes of diseases that are constantly at work in an ignorant and debased community, to prevent the very origination of such diseases." He quoted Simon's "platform," that the sole object of State medicine is "the improvement in human health, and the lengthening out of human life of each individual man and woman." He also cited Dr. Farr's: "The primary object of public medicine is to prevent disease, but it also surrounds the sick with conditions most favorable to recovery, and diminishes the death-roll of the people. But supposing every condition most favorable for the operation of State medicine, we should still see grave defects in many persons; shortcomings in others; in many, organic degeneracies; in many, criminal depravities. How, out of the existing seed, to raise races of men to divine perfection is the final problem of public medicine. Public hygiene is a want, as much as air and public roads and waters are public necessities, and as such, must be cared for and paid for by the community."

The high ideal was nobly lived up to, and in a sort of manifesto addressed to the Municipal Boards of Health, nominally existing in all the towns of the State, they say: "We believe that all citizens have an inherent right to the enjoyment of pure and uncontaminated air and water and soil; that this right should be regarded as belonging to the whole community; and that no one should be allowed to trespass upon it by his carelessness or his avarice, or even by his ignorance. . . . These propositions are recognized in existing statutes, but they are not enforced, and the reason of that is, that the public mind is not sufficiently aware of the dangerous elements around us, does not understand the connection between filth and disease, and is not convinced that undrained land is not wholesome to live upon." The board at once set about collecting the mortality statistics in the principal cities and towns of the State, and addressed themselves to investigating the corruption of springs, wells, reservoirs, and aqueducts, the sale of dangerous drugs, the sale of "swill milk" and watered milk, the sale of unwholesome meat, the condition of tenement and lodging houses, but say that "local and private interests have, it is thought, often been strong enough to paralyze the action of local health authorities"—an opinion that was violently confirmed a few years after, when they found themselves involved in a lawsuit with a powerful firm who were corrupting the water supply of a town with offal. It rendered a report to the Legislature of 1870, when it had been at work only six months, and had little of achievement to relate; but in the lofty ideals it holds up, and its catalogue of reasonable hopes for the future, though only a pamphlet of fifty-eight pages, it remains to this day a good sanitary bible for the earnest disciple. It would be amusing if it were not painful to see how gingerly it walked, claiming only "advisory" powers, it was by no means firm in the saddle and dreaded lest some "watchdog of the treasury" should land it on the ground. In the second year, an investigation was begun of the possibilities of improvement in tenement houses, which it is not too much to say has led up to the immense improvement in that class of dwellings throughout the United States; and in the third year it was directed by an act of the Legislature on April 6, 1873, to "consider the general subject of the disposition of the sewage of towns and cities and to report to the next Legislature their views, with such information as they can obtain upon the subject, from our own or other lands." This was the beginning of the accurate study of a subject that has a personal interest for every man, woman, and child. It has been prosecuted uninterruptedly since, and at the end of nearly two decades, in 1890, it put forth its monumental and authoritative three-volume report, one of which relates to the general work of the board, one to Purification of Sewage and Water, and one to Examination of Water Supplies. Dr. Bowditch had said in 1869, "Public health has so wide a field that help is needed from all—from the chemist, the engineer, the naturalist, and from the humblest citizen as well as the highest statesman." He didn't mention the bacteriologist, because that interesting personage did not exist. He was beginning to be evolved in Pasteur, who was studying the "parasitic diseases of silkworms," and in Tyndall, who was earnestly probing the truth or falsity of the doctrine of "spontaneous generation," but, as we now know many of him, he was non est. No less than four chemists par excellence, one civil engineer, and one professed biologist, outside the regular corps of medical and other contributors, help to make this a work that puts this country in advance of all Europe, and which will find a place in all scientific libraries.

Typhoid Fever in Michigan in 1890. The figures represent the number of persons per 10,000 inhabitants. They were compiled from the State Board's "Vital Statistics" obtained from the reports of local Health Officers.

In 1876 Dr. Bowditch made an address at Philadelphia on the then status of preventive medicine, in which he prophesied a grand future for it, and said, "The touchstone which tests the earnestness of any individual or community in reference to any subject is a willingness to spend money in the furtherance of it," and the five hundred dollars that was to be spent in 1849, in finding out whether the State had best do anything toward public hygiene, and the $62,876.82 that was spent in 1893 for expert work by her trained corps of sanitarians, are capital indices of the contrasting condition of public opinion at the two periods.

Knowledge and light can not be fenced in or shut out, and the example set in the early home of the Puritans saw its first answering spark on the Pacific coast. It was only two decades since the irruption of the Forty-niners when California, in 1870, established her State Board, "in order to remain on the level of other intelligent people in other States." Her influential citizens had gone from the East as grown men, and some of them had been disciples of Lemuel Shattuck in Boston. Some of our young States have made astonishing advances, because not hampered with a set of conservative obstructionists, and when once started on the track of progress have shown a fruitful activity quite overshadowing the action of older communities. In the very next year Minnesota established a State Board, and thus a nucleus for the growing work of preventive medicine was planted on the four borders of the land, that at New Orleans being the most palpable and obvious, as the quarantining and disinfecting and fumigating of yellow fever, is a much more perceptible process than the noiseless but sure elimination of malarial fever from Maryland by extensive sanitary underdraining.

Two of the men who had investigated the Maplewood fever were professors in the medical college at Ann Arbor. They were indefatigable in efforts to influence the Legislature, and did not rest till Michigan had a State Board of Health, with Dr. Henry B. Baker as its secretary—an enthusiastic knight of sanitary science, possessed of a phenomenal ingenuity in popularizing its study among the million, and in making its work valuable. The work it has done in reducing the death-rate from scarlatina, diphtheria, and smallpox is a true nineteenth-century miracle.

Maryland and the District of Columbia followed in 1874, Mississippi in 1875, and Tennessee in 1877. It required eight years to get ten boards, and when we scan the legislation that gave them being, and see how little money was given them to work with—scarcely enough to pay necessary postage on the letters that must pass before any rapport could be established between the central authority and the separate municipalities—it is apparent that the public mind was far from convinced as to their utility, and the public heart was by no means "fired" with zeal to aid their work. A pathetic story attaches to the North Carolina Board. Dr. Thomas F. Wood—one of those patient, self-sacrificing men whose worth is never half known till they are dead had labored unremittingly through the columns of a medical journal that he conducted for a State Board. At last the

Lives saved by Public Health work, by comparison of death-rate in Michigan before and after the establishment of the State Board of Health. Compiled from the Vital Statistics gathered by local Health Officers, and showing at a glance the value of enforced sanitation. Lives saved from scarlet fever in seventeen years—7,265.

Legislature yielded to his importunate zeal. He devoted the entire earnings of his journal to sustaining it for four years of "anxiety and hardship"; but the blood of the martyrs has been the most fertilizing material that has ever been expended on this crooked old earth, and before his lamented death in the prime of life in 1892, he saw his State with a thoroughly organized health service in every corner.

Lack of space forbids a detailed statement of the work which at the close of the first decade had gained such a momentum that thirty-seven boards in as many States have been formed, young Oklahoma—bent on having every improvement that can attract immigration—bringing up the rear. Most of them are composed entirely of physicians. No commendations are too strong for these true knights of science, who, in the spirit of "truth for truth's sake," have labored unceasingly and unselfishly to promote preventive medicine.

The modern State Health Board is a highly organized educational machine, in each State employing experts to investigate the mistakes and errors, the needs and advantages of the region. At the first menace of invasion by cholera, yellow fever, or smallpox the State is at once transformed into a camp of instruction, through the myriads of pamphlets and leaflets that fly on the wings of every outgoing train to the farthest hamlet or lumber camp or mine, in many tongues—a true pentecostal dispensation of saving light and knowledge. It is twenty-five years since the first one drew its first timid breath. State medicine is now rapidly growing and will be a giant. Its twenty-fifth birthday seemed a good milestone at which to pause and, in mercantile parlance, "take account of stock." A circular letter was sent out to all the secretaries as follows:

1. When was your State Board established?
2. To the reform of what sanitary errors or abuses did it address itself?
3. What obstacles did it encounter?
4. What positive results has it effected?
5. By what methods does it promote sanitary and hygienic reforms?

From all but three, careful, painstaking, and most courteous answers have been received, often accompanied by documents of inestimable value, both as presenting a graphic picture of sanitation to-day in the localities whence they come, and as a mine of sanitary information.[1]

The most glaring of all sanitary errors a quarter of a century ago was ignorance of the danger that lurks in an impure water supply, and the early efforts of most of the boards was directed to the protection of inland waters from pollution, and to inducing people in the older sections of the country whose ancient wells proved incomparable disease-breeders, to provide themselves with "piped"—i. e., protected—water wherever obtainable from an uncontaminated source. The legislative appropriations of money made it possible for the frontier and coast States to put in force efficient quarantine against those incursions of infectious disease that every now and again will strive to enter, in the person of the irrepressible immigrant. The newer, far western States have been the stamping-ground of quacks of every type, and the place where men with credentials bought from some "diploma mill" have passed as physicians, and where others, honest enough, have established themselves as doctors after acquiring so little of medical knowledge that an eastern man would not trust them with the care of a favorite cat. All those States have made a uniform push for registration of physicians, and in those where there are medical colleges, for a longer and more thorough course of medical education. The early boards had to make headway against prejudice and vested abuses, but they labored to enlighten and educate the people, and they reached a turn of the tide at about the end of the first decade, so that those that have been formed since were able at once to set about positive measures for good, and did not have to waste strength on combating obstacles. The history of the health boards supplies a beautiful example of the evolution of a sustaining public opinion—certainly "at the top" among the educated.

To the query, "What obstacles did it encounter?" there comes up one uniform chorus of groans over the apathy, indifference, and ignorance of the populace, and in some cases hostility from the medical profession itself, of whom better things might have been expected. If they tremble lest the world shall educate and sanitate itself into such perfect health that there will be no demand for their services, they can dismiss their foolish fears, for the more intelligent a man becomes in the structure of this "harp of a thousand strings," and the delicate adjustments on which its harmony depends, the less willing will he be to trust to an ignoramus when it gets out of tune. A long history might be made up of actual instances where greed of money has attempted to block the onward progress of sanitation. In Pennsylvania, added to indifference and ignorance, "was the direct and persistent opposition of manufacturers of every kind, the prosecution of whose business led them to dispose of their waste, no matter of how offensive a character, in the least expensive way, that is, by dumping it into the public streams." In Rhode Island there was "the usual and expected objection to the prevention of the sale of glandered and other diseased animals." In Maryland the obstacles were "ignorance, selfishness, obstinacy, old habits and customs, and the difficulty of obtaining such legislation as was necessary to sustain the authority of the board in suppressing nuisances." In Missouri it was "the opposition of all the unclean and dishonest who are practicing or pretending to practice medicine, and of the ignorant people outside of the profession who seem to be anxious to be humbugged and defrauded." In Michigan it was "the inertia due to the general ignorance of the people on sanitary subjects, and the sentiment of economy prompting to opposition on account of the cost; in North Carolina, "apathy, indifference, in some cases positive hostility, when the demand was made for money or for work that was inconvenient"; in Iowa, "ignorance of the masses." "Ignorance," "lack of funds," runs with tiresome iteration through many, for, though there are ample legal powers, there must be money to aid in their enforcement. One writer puts the difficulty very delicately as "civilization imperfectly developed"; while the Connecticut secretary comes down to details thus: "The obstacles in the way have been the unsuitableness of the persons who, ex officio, constituted the local boards of health, the paralysis of these boards resulting from long years of inaction and torpidity, and the settled conviction on the part of the majority of the old communities, that the habits and customs of their ancestors were good enough." The Rhode Island man goes still deeper into the psychological mysteries of the matter thus: "From the early instructions and habits of our first settler, Roger Williams, we have all been led to believe that we severally and individually are a law unto ourselves, and as soon as any new law or change is ordered, even by the representatives of the individual, it becomes at once our duty to oppose it"; and the secretary of Tennessee says, "Those obstacles usually encountered by missionaries in any field, who come to teach the new gospel that 'thou art thy brother's keeper.'"

The third question was, "What positive results has your Board achieved?" Before going into details, we would say the first great collective beneficial result of sanitation is in the moral realm—the successful propagation of the idea that a man has no more right to poison the water which his neighbor must drink, or the air he must breathe, than he has to put strychnine in his food—either is potential murder, and is coming to be so regarded; and the next touches the sphere of the affections, as it has saved thousands and thousands of lives, as a long catalogue of diminished death-rates testifies. At the World's Fair Dr. Abbott had prepared a series of sanitary maps of Massachusetts, exhibiting the comparative ravages of the communicable diseases. The towns most deeply stricken by them were colored a bright carmine, and, by different patterns of cross-hatchings, the greater or lesser prevalence was indicated by lighter and lighter shadings, till at last one or two happy localities were left a pure white. In the map of Typhoid Fever one was instantly struck with the deeper dye of the rural districts, while for a radius of a hundred miles around Boston hardly a town showed more than a mild pink, and the general effect changed the whole aspect of that half of the State. The reason is not far to seek. The perpetual exhortations to "get pure water" have so moved the people that perhaps there is more "piped" water in that section than in any other equal area in the United States, a fact that takes on fresh significance when we consider that there is a population of two hundred and seventy-five persons to the square mile, and that parts of it have been lived in more than two centuries and a half. Such conditions call for much more vigilant supervision than "out west," where one person to the square mile lives on fresh, uncontaminated soil. That lighter shading means that to-day thousands of young men and women are "breathing this sweet air of life" who, but for the action that led up to it, and all it means, would be filling untimely graves.

The whole subject of vaccination, revaccination, and the establishment of vaccine stations where pure, active, and fresh bovine lymph is produced, has been so frequently and thoroughly discussed and acted upon by the several boards, that it is strange that any intelligent person should allow himself or his family to remain for a day unvaccinated. Still, in Minnesota seventy per cent of the school children are not vaccinated, and the knowledge of this fact so moved the State Board, that they at once established a station for the production of a safe virus. In Massachusetts, in the epidemic of 1872, there were five thousand six hundred and six cases of it, and in one year since there were but two. Self-interest has protected the State from the evil result of the incursion of unvaccinated French Canadians, for they are not allowed to go to work in the factories till after they show the vaccination certificate. In Rhode Island general gratuitous vaccination and the compulsory vaccination of school children have reduced the mortality to one twentieth of what it was, though this is a manufacturing State, subject to the irruption of hordes of the unvaccinated.

Mortality from Smallpox in Rhode Island before and after General Gratuitous Vaccination and Compulsory Vaccination of School Children.

Five-year Periods. Popula­tion. Mortality from smallpox.
1863–'67 184,965 44
1868–'72 217,353 48
1873–'77 258,239 46
Five-year Periods. Popula­tion. Mortality from smallpox.
1878–'82 276,531 7
Or a proportion to population of 5 deaths after to 100 before.
1883–'87 304,284 3
1888–'92 345,506 4

Deaths from Smallpox in Massachusetts, by Decades.

Ten-year Periods. Deaths.
1863–'72 2,375
1873–'82 922
1883–'92 51
Previously to 1872 there had been an almost universal neglect of vaccination, and the idea of compulsory vaccination had not come into people's minds. The great epidemic of 1872, which swept around the world and destroyed thousands of lives, had the effect of rousing people to the value and practice of vaccination. Still, the factory towns, which were ever receiving fresh relays of the unvaccinated from Canada—especially the paper-mill towns, with rags from all over the world—would every now and again have an outbreak. At last stringent laws were passed at the instigation of the Board of Health for the vaccination of school children, and self interest accomplished the work in factories with such obvious good results that now a stringent State law aids in producing the result shown in the smallest of the three lines.

There is no need to recite how the States whose situation exposes them to cholera and yellow fever have, through their boards, provided themselves with all the means of enforcing necessary quarantine, and with the best disinfecting apparatus known to science, the mere possession of which has put old-fashioned panics to flight. Alas for Georgia! She stands forth a dismal foil to the above, and a dark object lesson. When yellow fever smote her second commercial town in 1893, her former State Board had been abolished and there was no organized authority. The Brunswick epidemic ought to silence the rivalries among doctors that led to the abolition of the board. Nashville, Tenn., in 1878, made enlightened preparations under the leadership of Dr. J. D. Plunket,[2] and, though there were twenty-four cases, either coming from other places or originating there, they were restricted, cared for in a hospital made ready, and the business of the city went on with no interruption; but there was concentrated authority at the center of things.

The large southern and western States—each of which is a sort of empire—have organized their work largely by counties, each of which has a board that reports to the central State Board, and they are doing a valuable work in the collection and collation of vital statistics—a work in which our country lags far behind European lands. Should our Congress see fit to create the Bureau of Public Health within the Department of the Interior, now asked for by the New York Academy of Medicine, and all sensible sanitary bodies everywhere, it would be bringing our country into step with other progressive peoples. Dr. Abbott, of Massachusetts, made a plea before the Sanitary Congress at Chicago for a national registration. Is not a numbering of the people, and an account of their sicknesses and deaths, of as much importance as the acreage of wheat or corn, and the number of acres that have been destroyed by weevils or fungi? It would seem that a central authority can better fence out those contagious diseases that pay no attention to State lines, than one diffused among a number of organizations, even though each one has its inalienable State rights.

The scientific and safe sanitation of the Columbian Fair grounds in Chicago, and the direct reduction of the typhoid-fever rate there from the hour when water from the contaminated intakes was shut off, and the new four-mile tunnel began to be used, is a distinct triumph of the science of sanitation.

The thirty-seven boards have very different phases of sanitary and hygienic errors brought to their attention, and naturally each attacks the evil that is most importunate in his section, and the result is that there is no detail of the house—its site, its material, construction, plumbing, heating, lighting, or ventilation—that is not exhaustively discussed by some competent mind; nothing pertaining to the hygiene of the individual escapes them, from protecting the newly born from blindness, up through all the perils of youth, middle life, and age, till at last he finds sanitary sepulture at the hands of a funeral director who has been carefully taught by his State board how to conduct the entombment of those who have died of the most virulent infections with perfect safety to the living. The frauds and adulterations in foods and drugs are exposed, health resorts, prisons, hospitals, and public buildings are inspected, the poor are provided with sanitary homes—in short, the people are watched over and defended from the cradle to the grave. The steady lengthening of human life shows that their intelligent efforts are not wasted. The annual reports are an incomparable means of mutual education, for no new method of investigation or illustration appears in one that is not availed of by the others. The mere titles of the different topics to which study has been directed would fill several pages of this magazine.

The last query was, "By what methods does it promote sanitary and hygienic reforms?" The comprehensive reply deduced from the thirty-seven letters is "the education of the people" through reports, circulars, pamphlets, and leaflets, accompanied by most ingenious and instructive maps, charts, and graphic diagrams. While one of the most potent means of convincing and moving men is the human voice, with a clear brain, an enthusiastic soul, and a worthy cause behind it, the most lasting and universal is a judicious diffusion of printer's ink. Most of the boards keep on hand, circulars, giving plain directions how to care for and limit the spread of contagious diseases—a work made easier since bacteriology became the definite science that it now is. In one sanitary convention complaint was made that these tracts in large numbers remained piled up in the offices of the board. But there comes a moment when they achieve their destiny. Let a case of scarlatina break out, as soon as the telegraph can order, and the mail bring these documents, people are conning them for a way of escape, and that locality will never again be as densely ignorant as it was. The State of Pennsylvania sends out twenty-three different ones, and some of them printed in many tongues, for the benefit of her polyglot people; and there are few of the States that have not established similar fountains to send forth a fertilizing irrigation of knowledge. In the States of Michigan and Pennsylvania conventions held in localities that need them have been found of the greatest value. The first holds four a year, and already forty-eight separate localities have experienced this quickening visitation. In Ohio the State Board holds joint conventions now with the school teachers, and again with the "funeral directors." The Maine Board prints a monthly journal, and sends it to school teachers, clergymen, and heads of local boards. Maryland tries to send tracts to every family. In the larger and more sparsely settled western States the central board gets into very close and vital relations with local boards, and as a consequence two States, Tennessee and Indiana, report, "We no longer have epidemics of diphtheria, since we have learned to limit and counteract it." In Minnesota sixteen hundred and thirty local boards reported to the central authority in 1892, which proves that at least sixteen hundred and thirty persons are not asleep. The secretary wrote three thousand one hundred and fifty-three letters on subjects ranging from glanders and leprosy to vital statistics.

Says the secretary of Kentucky, "The growth of sanitary work in public confidence has been very marked, especially in the last three or four years."

The capital of our country presents a very perfect object lesson of what thorough sanitation is; it formerly was bad, as bad could be.

Progressive physicians early perceived the trend of preventive medicine, and also the advantage of a free interchange of ideas, and have now been formed into the American Public Health Association twenty-one years, through which Mexico, Canada, and the United States form a sanitary solidarity.

In 1879 the Sanitary Council of the Mississippi Valley was formed, and the struggle that the Nestor of sanitarians. Dr. J. H. Ranch, and Dr. Holt, had with the authorities of Louisiana to prevent concealment and dissimulation makes a lively and interesting story; but for twelve years there has been practically no yellow fever in New Orleans (since 1880), and the commercial value of the services of that council are immense, while there is no measuring the confidence inspired in millions of minds, that they will surely keep the fever or the cholera out.

Incidentally the new profession of sanitary engineer has come into being, and an immense amount of sanitary literature has accumulated. What of the future? The best sign of the times we have kept for the last: women are actually becoming interested in practical sanitation, and large classes of them have paid money to be instructed in it in Boston lately. The movement of these public bodies is important but extraneous; this feminine interest is vital and interstitial, and under woman's influence we look to see the physical life made doubly worth the living.

A hundred years ago to-day Jenner alone knew the secret of the means by which smallpox was to be virtually banished. Now hundreds of people know the precise conditions under which a successful crusade of extermination against consumption can be conducted. Is it too much to hope that fifty years will see it driven out from among civilized peoples?

Prof. Cyrus Thomas, who has made special studies of the subject for several years, has reached the conclusion that ancient Mexican civilization originated with the Malays of the South Pacific islands, and believes that he has established a connection between the languages of those tribes and that of the Mayas, showing it to be a direct offshoot from them.
  1. The names of the gentlemen thus kindly favoring me, and of the States to which they belong, are as follow: Alabama, Jerome Cochrane, M. D.; Arkansas, D. W. Holman; California, J. R. Lane, M. D.; Connecticut, Prof. C. A. Lindsley, M. D.; Delaware, F. B. Frazer; District of Columbia, W. C. Woodward, M. D.; Florida, Joseph Y. Porter, M. D.; Illinois, J. W. Scott; Indiana, C. N. Metcalf, M. D.; Iowa, J. F. Kennedy, M. D.; Kansas, M. O'Brien, M. D.; Kentucky, J. N. McCorraac, M. D.; Louisiana, W. R. Harman, M. D.; Maine, A. S. Young, M. D.; Maryland, James A. Stewart, M. D.; Massachusetts, G. W. Abbott, M. D.; Michigan, Henry B. Baker, M. D.; Minnesota, C. N. Hewitt, M. D.; Mississippi, Wirt Johnson, M. D.; Missouri, R. C. Atkinson, M. D.; New Hampshire, Irving A. Watson, M. D.; New Jersey, W. D. Mitchell, M. D.; New York, J. S. Barnes, M. D.; Rhode Island, Gardner T. Swarts; South Carolina, H. D. Frazer, M. D.; North Carolina, Richard M. Lewis, M. D.; North Dakota, F. H. De Vaux, M. D.; Ohio, C. O. Probst, M. D.; Oklahoma, J. O. Overton, M. D.; Pennsylvania, Benjamin Lee, M. D.; Tennessee, J. Berrien Lindsley, M. D.; Washington, G. S. Armstrong, M. D.; West Virginia, N. D. Baker; Wisconsin, U. O. B. Wingate, M. D.
  2. No connection of the writer, and spells his name differently.