March 15, 1889.] 



SCIENCE. 



199 



ginnings of international co-operation for the crushing-out of 

 cholera, yellow-fever, and other epidemics, which must in the near 

 future become a beneficent reality, taking its place with arbitration, 

 in international disputes, as the most valuable victories in our 

 century. 



" The first essential of any sanitary authority," Dr. Hewitt says, 

 " is e.xecutive power, and its systematic use in the regular and 

 scrupulous performance of every-day duty, as defined in the law 

 and suggested by every- day experience. This almost self-evident 

 proposition is constantly neglected in legislation for organization, 

 and is very frequently violated by boards of health, who seem to 

 favor the popular idea that an exceptional occasion is necessary to 

 the highest exercise of their power, and infectious diseases of the 

 classical type are their selection, with a proper admixture of panic. 

 Panic is no advantage any longer, if it ever was, as a help to sani- 

 tary organization and work. Infectious diseases are not the lead- 

 ing causes of our sickness and mortality. It is only in the excep- 

 tional severity of plagues like yellow-fever, as it has prevailed in 

 Florida, for example, that infectious disease counts the most vic- 

 tims in the sickness or death roll. That epidemics prevail at all, 

 in our time and country, is somebody's fault : for, if there is one 

 thing more than another that modern hygiene ought to be able to 

 do, it is to forefend their attack, or control them if they effect a 

 lodgement ; and boards of health and health-officers have to learn 

 that the most public and pronounced activity, after the invasion of 

 infectious disease, is no substitute for the quiet, unobtrusive work 

 which, in daily faithfulness, would have detected the first case, and 

 controlled its spread. Another pressing need is a better classifica- 

 tion of causes of death, for sanitary purposes, to which should be 

 added causes of sickness and of permanent ill health from disease. 

 At present our professional nomenclature is as vague sometimes as 

 the popular one. Cholera-infantum and heart-disease are little 

 more accurate than ' too weak to live,' a common popular cause of 

 death under one year. The general divisions of the English regis- 

 trar-general's tables are the best known, but some of the subdivis- 

 ions are not satisfactory. Isolation has become so important and 

 efficient an aid in the control of many diseases, that it is time to 

 devise some changes in our customary methods which shall insure 

 more thoroughness, with the least interference with the liberty of 

 the family. It is a serious matter to restrain the bread-winning 

 power of a laboring man or of his self-supporting children ; and it 

 is a still more serious matter to shut up a suspected family, sick and 

 well, in a small house, when the removal of perhaps a single patient 

 might save the rest, or some of them. The isolation home, 

 under various names, is the ideal method of us all : but, if we had 

 one always available, people must be educated to its use. We 

 need it most for diphtheria and scarlatina. Another essential is 

 an apparatus, not too expensive or elaborate, or too heavy for easy 

 movement on wheels, for disinfecting clothing, bedding, and the 

 like, by steam. One to which steam could be supplied by the 

 boiler of a thresher-engine would serve our country districts, and 

 the same could be used where steam-boilers are available else- 

 where. It could be taken to the infected house, charged, closed, 

 and moved to the nearest available boiler, connected, disinfected, 

 and discharged of its contents, with no danger, and at trifling ex- 

 pense. Still another need in this connection is a ready way of dis-. 

 infecting the sick-room while occupied. Its essential feature should 

 be the removal of the infected air and dust, disinfecting both as 

 they escape, and the introduction of fresh air, so that quantity, 

 temperature, moisture, and movement may be as required by the 

 sick, but all to be done with the most complete protection of the 

 well. The means must be easy, comparatively inexpensive, and 

 available in the average houses of the laboring population. The 

 stove, stove-pipe, or chimney, affords the available means in such 

 houses in cold weather. In warm weather the open fire, gas, or 

 kerosene, might serve to provide the means for exhausting the foul 

 air and introducing that of the open in its place. Add to the sim- 

 plest form of apparatus (ihe open fire or stove-pipe exhaust,', clean- 

 liness, fresh air, sunlight, thorough inunclion, and boiling water for 

 infected clothing of the sick and attendants, and you have a method 

 almost everywhere practicable, which will reduce the danger from 

 such diseases to the minimum, and the mortality as well. 



" The very large mortality from non-infectious disease, under 



five years of age, is, in the light of our present knowledge, no lon- 

 ger tolerable ; and boards of health should move now, and positively, 

 for its material reduction. By the last census this mortality was 

 43.7 per 1,000 of living population for the whole country, while in 

 thirty-one registration cities it was 88.4 per 1,000. The mortality 

 under five years to total of all ages was given as 39.8. The deaths 

 under one year were, for the whole population, 120.9 in 1,000 living, 

 while for the cities it was 267.5. This does not tell the whole 

 story, as the statistics are estimated to fall from 15 to 30 per cent 

 below the facts. We have no means of accurately estimating the 

 sickness rate which accompanies this mortality, but may assume 

 that it is enormous. 



"Another subject of increasing importance, and which ought to 

 receive the immediate attention of the State boards, is the sanitary 

 relation of certain diseases of animals as communicable to man, 

 notably tuberculosis, trichinosis, and glanders; and the increasing 

 possibility that diphtheria and scarlatina may belong to the same 

 class. The relations of the diseases of the cow to the influence of 

 milk as food are attracting wide-spread attention, and, as affecting 

 a very important infant food, deserve an attentive study with refer- 

 ence to sanitary control. On this subject, popular and certain pro- 

 fessional opinion has, as usual, gone to extremes. From the use 

 and even advocacy of distillery-milk, some have come to refuse the 

 purest supply except after boiling, and their foolishness has been 

 an acceptable and pecuniary advantage to the manufacturers of the 

 proposed ' substitutes for cow's milk ' which fill our markets and are 

 tried on our children. The importance of the subject has resulted 

 in making the control of infectious diseases of domestic animals 

 one of the duties of the State and local boards of health, as in Min- 

 nesota, where the experiment has proven eminently successful and 

 satisfactory. 



" For the Nation and the States, the most urgent lesson is 

 organization and efficient co-operation : for this last experience [of 

 the epidemic of yellow-fever in Florida] but adds another to the 

 accumulated evidence of the near past, that no State or province on 

 this continent can afford to be any longer without a board of 

 health officered by experienced men, who have the confidence of 

 the people and governments they serve ; supplied with unquestioned 

 legal authority and sufficient money ; and provided with every 

 recognized means for dealing directly, and to the best advantage, 

 with any disease of men or domestic animals threatening, or 

 actually invading, the State. It must also, and for the same reason, 

 have authority and funds to act with similar authorities of other 

 States, in mutual co operation, for State and national defence. It 

 will not do to forget the established fact, that epidemics are now to 

 be looked upon as evidences of the failure of public health, in or- 

 ganization or administration. That they occur, or spread, is pre- 

 sumptive evidence, when properly qualified authorities exist, that 

 they neglected to take the needed measures, or were unable to take 

 them. I see no escape from this conclusion, except it be shown, in 

 any case, that prevention or control was beyond the resources of 

 our art. 



" A central State authority, organized and equipped as proposed, 

 will find itself unable to do efficient preventive or restrictive work 

 without thoroughly organized local sanitary authorities in every 

 township, village, and city; and, further, each local board should 

 have the same powers, and proportionate means, as the State board, 

 in the locality it serves. Enforcing the common law, and inde- 

 pendent in all purely local administration, the local authorities 

 should be a unit for common purposes, under the State board, 

 of which the control of infectious diseases is a conceded example. 



" There are now in the United States thirty-one State boards of 

 health. The first was organized in 1S69, and others as well, be- 

 fore any attempt at national organization was made. Some of 

 these boards are fully equipped with legal powers and funds for 

 the work we have found laid out for them. The rest, with varying 

 degrees of speed, are coming on to the higher level necessary for 

 efficiency, and all are growing in usefulness and experience. 



" State boards of health are established and recognized forces 

 to-day ; and any national organization attempted must, to be suc- 

 cessful, be a development from them in form and function, for the 

 purpose of carrying over to the nation, as a whole, the sanitary 

 succor which the best of the State boards afford to the populations 



