American public health protection [electronic resource]

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American public health
protection

AMERICAN PUBLIC HEALTH PROTECTION

American
Public Health Protection

HENRY BIXBY HEMENWAY, A.M., M.D.

THE Li# AL PRINCIPLES OF PUBLIC HEALTH

INDIANAPOLIS

THE BOBBS-MERRILL COMPANY
PUBLISHERS

COPYRIGHT 1S16
THE BOBBS-MERRILL COMPANY

Public Health

PRESS or

BRAUNWOP^M & CO.

BOOKBINDERS «ND PRINTERS

BROOKLYN. M. Y.

RA 44 r

PUBLIC
HEALTH
LIBRARY

Dedicated to the

WOMEN OF AMERICA

Hoping Thus to Aid Them in Protecting the Lives of
Their Children

M907119

PREFACE

"How can we arouse the people to a realiza-
tion of their selfish interest in efficient public
health administration?"

"How can they be made to see that this does
not mean the enactment of many statutes and
ordinances, but the employment of specially
trained executives?"

These questions have been asked by univer-
sity professors and by officers of health in sev-
eral states. The following pages have been
written partly in answer to these appeals. The
book bears a message to every citizen: health
administration must be divorced from politics,
and recognized as a special profession.

This offering is dedicated to the Women of
America, as "the power behind the throne." In
the past they have done much to assist in secur-
ing better conditions ; but amateur sanitarians
should not themselves attempt to determine ad-
ministrative policies or legislative provisions.
In the place of trying to decide how dairies

PREFACE

should be managed they should mafe sure
that a competent health officer is employed,
and then follow his leading.

When, therefore, the women become alive to
the fact that the very lives of their children de-
pend more on the selection of competent watch-
men of health than on rules and regulations,
then fundamental changes will be made in
governmental activities. When they see the
inherent antagonism between private medical
practise and public health preservation the
women will bring such pressure to bear that
no health officer will attempt to engage in pri-
vate practise. When they comprehend that
one dollar spent in the training of sanitarians
will do more toward lessening human suffering
than ten spent in the support of hospitals, they
will use their influence to secure suitable en-
dowments for schools giving this instruction.
When they realize the intimate relationship
that exists between disease, poverty, sin, suf-
fering and death, they will also comprehend
the additional fact that the true work of the

PREFACE

Christian church will be better done if some of
the money now reverently laid upon her altars
be diverted to the support of efficient health
administration.

While the type of this book was being set,
Doctor Charles W. Stiles, of the United States
Public Health Service, gave an address before
the Indiana Sanitary and Water Supply As-
sociation at Indianapolis. He closed with the
following idea: There are annually in the
United States about 620,000 deaths from pre-
ventive disease. Most of those deaths repre-
sent infants and young people. It is difficult
to get up any sympathy really for the children
or even adults who, by their untimely deaths,
have, at the most, simply lost future possibili-
ties of activity in this world. The real sorrow
should be for those who are affected by these
deaths. Those 620,000 deaths represent 475,-
000 years of pregnancy of the mothers; it rep-
resents 600,000 years more of the care for the
nursing infant; it represents 620,000 times that
the women have been forced to undergo the

PREFACE

trials and dangers of confinement; and these
deaths make all those sufferings and trials and
cares to such degree useless. There is a popu-
lar idea in the South that men should protect
women from temporary dangers. How much
more important is it that their chivalry should
be made to extend to the prevention of unnec-
essary sickness, suif ering and death !

I wish to express my obligation to Dean C.
R. Bardeen and Professor Paul F. Clark, of
the University of Wisconsin, who read my
manuscript and made suggestions, and to the
Honorable Sir Joseph Pope, who kindly fur-
nished me with copies of the speeches of Sir
John Macdonald, from which abstracts have
been taken. H B H

CONTENTS

CHAPTER PAGE

I INTRODUCTION 1

II THE DEVELOPMENT OF PUBLIC HEALTH IN THE

UNITED STATES 21

III NATIONAL HEALTH AGENCIES 48

IV MEDICAL AND SANITARY EDUCATION COMPARED . . 83
V CHANGED SOCIAL AND ECONOMIC CONDITIONS . . . 120

VI CHANGES DUE TO ADVANCEMENT IN SCIENCE . . . 152

VII MEDICAL INSPECTION OF SCHOOLS 177

VIII ORGANIZATION OF HEALTH DEPARTMENTS .... 208

IX PREPARATION OF OFFICERS 252

INDEX . 275

AMERICAN PUBLIC HEALTH PROTECTION

American
Public Health Protection

CHAPTER I

INTRODUCTION

IT should require no argument to convince a
person that his financial status must vary with
his health, other things being equal. If his
health is good, if his muscles are strong and
his nerve supply is abundant and well trained,
he is enabled to work long and hard. If he
chances to be in only moderately good health,
if he is troubled with indigestion, for example,
he can not accomplish so much work, and it is
likely to be of inferior quality. The imper-
fectly digested food undergoes fermentive or
putrefactive changes, and the system becomes
loaded with poisons. The brain may become
directly poisoned thereby, and the symptoms
may ]be lessened certainty of action, or the pro-

2 AMERICAN PUBLIC HEALTH PROTECTION

'duction of pain; or the attention of the mind
may be distracted by the pain produced by the
gaseous distention of the intestines. Any of
these conditions decreases the man's efficiency.
With more serious illness he may be forced to
stop work entirely.

In more serious illness the loss is not meas-
ured by the patient's decrease in efficiency, for
his efficiency has dropped to a negative quan-
tity. He requires the attention of another per-
son who is thereby hindered from doing really
productive work. So the patient must pay for
the services of a doctor, a nurse and other as-
sistants, as well as for special articles of mer-
chandise needed only because of his sickness,
such as drugs and sick-room necessities. It
must also be remembered that in serious cases
of illness the loss to the family may often be
still greater, as a result of the distraction of
the attention of other members from their own
work, and from the inability of the patient to
care for business of which he alone knows the
details.

It would be a matter of economy, were it

INTRODUCTION 3

possible, for the patient to pay the doctor and
the nurse and the druggist the full amount of
their bills, and keep his health. To a degree
this course is being pursued by some to-day.
They are going to their physicians at regular
periods for physical examinations and advice.
In the past it has often happened that the first
warning of serious disease has come when an
applicant for life insurance took his physical
examination, but too frequently the warning
has been disregarded until too late. Such ex-
aminations, however, are personal matters, and
their results are almost exclusively indications
for personal hygiene. They have little bear-
ing upon the prevention of infectious diseases,
especially those scourges that invade a com-
munity almost without warning, and leave
chronic invalids and corpses where they find
happy people.

Where the same cause is liable to produce
illness in an entire community, and that cause
is external to those made ill, protection is a
community problem, and should be handled by
the agent ofjhe district interested. ^Efficiency

4 AMERICAN PUBLIC HEALTH PROTECTION

of administration here is also a financial econ-
omy, and bears a direct relationship to the
prosperity of the area. Sometimes the admin-
istration may be managed by a private corpo-
ration, and at others by governmental author-
ity. The results are similar, and if equally
efficient it does not matter greatly by whom
the efforts are exerted.

Aside from the saving of lives, and in health
of returned workmen, General Gorgas, in his
Sanitation in Panama,, estimates that the sani-
tary service on the Canal Zone saved to the
United States at least $80,000,000 in the cost
of digging the canal. Further, it is generally
recognized that it was only as a result of the
discovery of the means by which yellow fever
and malaria are spread, and the application of
that knowledge by the staff of General Gorgas
in preventing those plagues, that it was pos-
sible to complete the canal construction.

Trade from eastern Bolivia reaches the out-
side world chiefly by passing down the Ma-
deira and Amazon Rivers. Ocean-going
steamships from Liverpool and New York

INTRODUCTION 5

can sail 900 miles up the Amazon to the mouth
of the Madeira, and then 660 miles up the lat-
ter stream to Port San Antonio. There they
are stopped by rapids, but 200 miles farther
up the streams again become navigable for
long distances. Formerly freight and boats
had to be portaged many times in that 200
miles of rapids, except during high water. The
result was not only great labor and expense,
but frequent loss of cargo and life. In 1871
an attempt was made to construct a railroad
by those rapids, but so great were the obstacles,
especially in the matter of disease, that the
work was abandoned. So important did the
project seem that Bolivia made the construc-
tion of that road one of the terms in the cession
of the Acre territory to Brazil, and in 1878
another attempt was made. After construct-
ing some four miles of track, and grading a
little farther, the engineers were again driven
off by disease. However, seeing the results at
Panama, an American firm in 1909 assumed
the task, and by the aid of a sanitary depart-
ment were enabled to construct the Madeira-

6 AMERICAN PUBLIC HEALTH PROTECTION

Mamore railroad, and put it in operation. Its
value may be somewhat appreciated from the
fact that shippers were willing to pay at the
rate of $150 a ton for the transportation of
rubber over the 210 miles of its track. Here
again the successful construction of the work
was dependent upon the sanitary administra-
tion.

Adams, in his Conquest of the Tropics, tells
us that when Minor C. Keith began his rail-
road construction for the United Fruit Com-
pany in Costa Rica he lost 4,000 men by death
in the construction of his first twenty-five miles
of road. Before the United States acquire^
the Canal Zone this company realized the im-
portance of employing expert sanitarians. The
demand could not be supplied in this country,
so the company imported sanitarians from
Java and from India. It also assisted in
founding the School of Tropical Medicine
at Tulane University in New Orleans. They
were forced to do this because of their extensive
interests in tropical countries, and on account
of the inefficiency of governmental sanitation.

INTRODUCTION 7

Now when the company is about to open up
new territory it begins by sending its sanitary
corps. In 1913 it opened up a section of Hon-
duras which was denounced by the natives as
such a pesthole that it was useless to attempt
its cultivation. That year the company con-
structed 250 miles of railroad, built temporary
piers, offices and warehouses, and began the
planting of 50,000 acres of bananas, "and the
health of the thousands of men employed is
as good as that of the average farming com-
munity in the United States." That year their
hospitals in Guatemala showed a mortality of
only 2.57 per cent., and there was not a case
of quarantinable disease in any port where the
company operated, nor on any of its ships.

It must be remembered that if there be a
sick rate of fifty per cent., a company must sup-
port double the number of hands that it needs
for work. This materially increases the ex-
pense of operation. On the sugar plantations
of British Guiana, for example, it was found
that within the four years ending in 1909 there
had been 39,000 cases of hookworm treated.

8 AMERICAN PUBLIC HEALTH PROTECTION

This disease is indirectly the- cause of mortality
from other diseases, and itself causes a heavy
loss of efficiency in labor. In our own south-
ern states this infection has been a great cause
of dependency. After treatment it is found
that families who have always been more or
less dependent upon the community become
self-supporting, and even begin to acquire
property.

Whenever a large proportion of a commu-
nity is incapacitated for labor on account of
sickness, the economic production of that terri-
tory is decreased. If it be an agricultural sec-
tion, it raises less for shipment. If it sells less
to the outside world it must buy less. This
means that the transportation companies serv-
ing it do less business, and the merchants are
less flourishing. However, with less income,
the working population is directly and indi-
rectly more heavily taxed to support those who
are unable to support themselves.

It is not agricultural or tropical sections
alone which are thus punished by inefficient
protection of the community health. Before

INTRODUCTION 9

the opening of the Sanitary Canal, Chicago
had a typhoid death rate of 175 ; now it is less
than ten. This change is not the result of the
canal alone, but many other factors enter into
the case, such as supervision of the milk sup-
ply, restriction of fly infection, etc. The re-
duction in typhoid is always accompanied by
a reduction in other diseases, especially intes-
tinal infections. Did the old typhoid rate still
exist, with the increased population the city
would now lose about 3,300 more typhoid pa-
tients than it does at present. This is a disease
of early maturity, and its victims are among
the most productive workers. Each life is
therefore worth at least $3,000 on an average.
That means that the lives now saved from this
form of infection save to the community nearly
$10,000,000 a year. In addition there is the
saving of some 33,000 cases of the disease, and
the expense of the care of those cases (making
no account of the wages saved by enabling the
patients to keep at work), would amount to
from $5,000,000 to $10,000,000 more.

Similar figures might easily be found in any

10 AMERICAN PUBLIC HEALTH PROTECTION

portion of the nation, and for many different
diseases. In five weeks of 1907 there were re-
ported to the Chicago Health Department
4,048 cases of scarlet fever. According to the
rate for the previous five weeks there would
have been only 675. The increase was due to
infection received through a certain milk sup-
ply, and that same infection was evidently re-
sponsible even for much of the fever of the
previous weeks, as well as for a like epidemic
in the suburbs. That milk was shipped in from
a neighboring state. A few years ago in Stam-
ford, Connecticut, there was an epidemic of ty-
phoid fever. Of the 386 cases 352, or 91.2 per
cent., were in houses supplied by one milk
dealer, besides twelve more who were known
to have used his milk in a cafe, and four others
who had obtained milk from him indirectly,
making a total of 368, or 95.3 per cent., of
Ceases directly traced to that one supply.

While it might be possible for a wide-awake
medical practitioner in a small country com-
munity to guard his patrons from such an in-
fection, it is a manifest impossibility for the

INTRODUCTION 11

family physician practising in a metropolitan
community to render such service. It there-
fore follows that this duty must be performed
by some united effort, as through some gov-
ernmental authority. Since a portion of this
service is of local interest only, or chiefly, it
must devolve upon the local government. But
the city officer has no authority outside of his
jurisdiction. Hence other portions of the work
must be performed by state or national officers.
A man may so construct his house that it
will be fireproof, and that he may by his own
efforts protect it against housebreakers. Per-
sonal violence is open, easy to anticipate and
to guard against. Infectious diseases ap-
proach stealthily, and work their injury before
their presence is suspected. It is therefore a
practical impossibility even for a rich man effi-
ciently to protect himself and his family from
such an enemy. On the other hand, protection
of the inmates of the palace includes efficient
protection of the slums. It is among the
crowded tenements, filled with poorly nour-
ished and overworked dwellers, that infectious
I

12 AMERICAN PUBLIC HEALTH PROTECTION

fires find their tinder, and from these hovels
they sweep to the mansions.

While sickness in the family of the rich may
mean added expense, pain, suffering and dis-
arrangement of plans, in the humble homes it
threatens financial ruin. It stops wages, in-
creases expenses, sweeps away all reserve cap-
ital, and makes the self-respecting mechanic a
dependent pauper. Not seldom it leaves the
family in such a physical condition that they
will never be able to escape from the thraldom
of poverty.

Though originally public health service was
a very minor branch of governmental work, to-
day there is no department of governmental
management which exerts an influence that
more closely touches the life of every citizen.
An efficient service means increased efficiency
for the community. It means a decrease of
poverty and of crime. It means a reduction
in needless taxation for the support of crim-
inals and paupers, and for the maintenance of
hospitals. It means the saving of expenditures
for medical and nursing services for many f am-

INTRODUCTION 13

ilies. It is of vital interest therefore for every
citizen that the particular health department
supervising his home shall be as efficient as pos-
sible.

Efficiency of such service is not measured
by the number of men employed, nor by the
amount of time consumed nor of money spent.
Some years ago the executive of a certain
board of health attempted to answer criticisms
by pointing to the unusually large number of
inspectors employed, and to his own slavish
faithfulness at his work. In fact, much of the
work there done was useless, and sometimes it
was positively harmful. There was not a sin-
gle sanitarian connected with the entire board,
or any of its work.

Before the discovery in 1900 that yellow
fever was only communicated by the bite of
the stegomyia all efforts at the restriction of
the disease were disappointing. While the
board of army surgeons were pursuing their
laboratory investigations in Havana, Gorgas
was putting their ideas to test, and the result
was that Havana was cleared of yellow fever

14 AMERICAN PUBLIC HEALTH PROTECTION

and of malaria. Then Gorgas was sent to the
Canal Zone. With him there were Carter, of
the Marine Hospital Service, another eminent
pioneer investigator, and Ross, of the Navy,
who had been with Gorgas in the work at Ha-
vana. Gorgas and Carter did not use the
methods which others had used without much
effect. Criticisms arose, and a strong protest
at the "foolish squandering of money" by Gor-
gas and his associates. There was a demand
that they be recalled, and that a certain sanita-
rian of the old style be appointed. Fortu-
nately the president knew what had been ac-
complished in Cuba, and he refused to make
the desired change. Had he listened to the
demands it is probable that the present Sur-
geon-General of the American Army would
have gone to his grave discredited and prac-
tically unknown, and that the Panama Canal
would not yet be completed. There is no rea-
son for thinking that the American engineers
would have been more successful than their
French predecessors. The man selected to take
the place of Gorgas may have been a fine ad-

INTRODUCTION 15

ministrator and a competent physician, but he
did not know how to deal with either malaria
or yellow fever.

It very frequently happens that enthusiastic
amateur sanitarians, seeing partially some
phase of a subject, secure ordinances which
may actually hinder health protection. More
frequently they are carried away by adherence
to technicalities of no importance, and neglect
the "weightier matters." For example: A
certain official brought action against the
owner of a grocery on the ground that the
water-closet was in a room opening into the
store. It was in a room well lighted and per-
fectly ventilated into the outside air, and the
room was clean and thoroughly sanitary. Near
by was another grocery in which the closet had
been placed under instructions from the health
department. It was in a dark basement, away
from the outside air, and was enclosed by a
board partition which neither reached to the
floor nor to the ceiling "to provide good ven-
tilation." The first closet was in a room walled
off with a regular partition, plastered on both
sides, and with a tight-closing door.

16 AMERICAN PUBLIC HEALTH PROTECTION

It is this kind of an official who is satisfied
if a manure pit be emptied (not cleaned)
weekly, though the flies may be breeding by
the million in the manure littered around the
box, or in the bottom which is never swept.
Such an official may be very careful in observ-
ing the minute details of ordinances and reg-
ulations relative to the conduct of markets,
groceries, soda fountains, bakeries and restau-
rants, and rate down an establishment in which
there are many flies; while at the same time
he overlooks the small and inconspicuous pile
of manure by a neighboring blacksmith shop
where the flies are bred. It is a practical im-
possibility to keep flies out of a restaurant
kitchen while they are bred by the millions two
hundred feet away. The swarms around the
garbage can attract attention; but the real
danger is in the straw and manure where they
are bred, not where they eat after they have
been bred. These officers are faithful and ear-
nest, but the trouble is that they do not know
how to do efficient work.

If a citizen needs the services of a chauffeur

INTRODUCTION 17

he makes sure that his man knows about auto-
mobiles. He does not select a gardener to do
his painting, nor a clerk to manage his factory.
Strange as it may seem, however, that same
citizen assists in securing the appointment of
anybody to any kind of an office, simply be-
cause the appointee is a good fellow, or a con-
genial neighbor. More frequently he is satis-
fied with casting his ballot at the election, and
then pays no attention to the city or state gov-
ernment until the next election, or until some
trouble arises. Sometimes, without knowing
why exactly, he is loud in criticism of misman-
agement. There was great criticism of Gorgas
at Panama, but the critics have hung their
heads in shame since then.

Common business sense would suggest when
a matter concerns a citizen in every phase of
his life, when his financial status may depend
upon it, when the very existence of his family
may be closely connected with it, that he should
at least give it some consideration. He should
know something of its nature, its problems,
and of their solution. As we have stated be-

18 AMERICAN PUBLIC HEALTH PROTECTION

fore, there is no other phase of governmental
activity which so vitally touches every citizen
as does the healtk department. It is to tell
what a health department is and should be that
this little book is written. While it may seem
best occasionally to refer to the solution of
some sanitary problems, it is not intended to
give a manual on hygiene. There are plenty
of such.

There is another reason for such an outline
as this. Intelligent sanitation to-day is rad-
ically different from that of fifteen or twenty
years ago. The science of public health may
be said to have been born in 1898. It was then
that the relation of insects to infectious diseases
was first fully recognized, and the measures
taken for protection were changed. Before
that time cases of yellow fever were rigidly
isolated and often cruelly abandoned. Fences
were built around infected houses, but the dis-
ease swept on, unheeding the defenses. Now
such cases are handled without danger to the
attendants, and the disease is easily stamped
out. The last epidemic of yellow fever in New

INTRODUCTION 19

Orleans probably cost the city $20,000,000, ac-
cording to the estimate of Surgeon White who
had charge of its extermination. Yellow Jack
will never again gain a foothold in this coun-
try. Could united effort be enlisted this mal-
ady could be made as rare as the great auk.
The same is true of many other plagues which
in the past have wrought devastation, but to
attain these results the efforts must be guided
by trained sanitarians.

There is a popular idea that physicians have
the needed education. This is not true. Pub-
lic health, as we know it to-day, is practically
untaught in medical schools. The best train-
ing in the past has been given in schools of
engineering, such as the Massachusetts Insti-
tute of Technology. Now at Harvard, at the
Universities of Wisconsin, Minnesota, Ohio
and Michigan, and at Washington University
at St. Louis, courses in public health are being
given in a very imperfect way. Tkey would
be given more satisfactorily if more students
offered themselves for the course. More stu-
dents would willingly apply if they had any

20 AMERICAN PUBLIC HEALTH PROTECTION

assurance that they could put their training to
use in self-support. It is only as a result of
the recognition of the true state of the matter
by citizens generally that such a demand may
be created. As long as the citizens are satisfied
with slipshod management of health depart-
ments, and as long as health officials are ap-
pointed for political reasons, there will be no
incentive for seeking such a training. The de-
mand must be made by the citizens generally,
not by some special class who may be suspected
of self-interest at the expense of the commu-
nity.

To understand fully the present conditions
it is necessary first to trace the development
of this particular line of service, to see what
changes have already taken place, and to ap-
preciate how and where improvements may be
made.

CHAPTER II

THE DEVELOPMENT OF PUBLIC HEALTH IN THE
UNITED STATES

THOUGH the protection of the general health
of the community had long been a recognized
work of government, the formation of distinct
departments, charged especially with this duty,
has been a matter of very recent origin. Among
ancient peoples we find general sanitary laws
and regulations. The infectiousness of cer-
tain diseases was sufficiently recognized so that
their restriction by means of quarantine was a
common practise throughout the civilized
world. It is true that up to the time of the in-
troduction of yellow fever into Spain, quaran-
tine was only used against the plague, leprosy,
and, at one time in Europe, syphilis. As mat-
ters of common justice citizens were made to
realize that they must not Work injury to their
neighbors, and gradually there were evolved
certain ideas and customs for the preservation

of public health.

21

05S? ,

22 AMERICAN PUBLIC HEALTH PROTECTION

The United States derived most of its cus-
toms and legal practises from England. We
find that in early customs of England the most
efficient means of protection were found
through judicial proceedings, and without spe-
cial statutory enactments. Two methods were
especially used, civil suits for the collection of
damages, and indictments for maintaining
nuisances. Both were hased upon the old doc-
trine, "Sic utere tuo ut alienum non Icedas";
that is, a person should so make use of his own
property that it will work no injury to another.
The enforcement of these judicial determina-
tions was left to the ordinary officers of the
law. "It is on record that Shakespeare's father
was fined in 1552 for violating the bye-laws of
the Manor of Strat ford-on- A von by depositing
refuse in the street, and again in 1558 for not
keeping his gutters clean ; and in 1512 a Mayor
of Nottingham was presented at the leet court
for sundry misdemeanors such as selling her-
rings that were unfit for food and for begin-
ning a muck hill."1

1Bannington, English Public Health Administration, (1915)
p. 2.

THE DEVELOPMENT IN THE UNITED STATES 23

From early times there was no dearth of
laws pertaining to the preservation of the pub-
lic health in England, but there was no attempt
to systematize administration. In 1848 the
first distinctly Public Health Act was passed,
establishing a central board of health; but ten
years later this board was abolished. It is
always a weakness of amateur sanitarians to
multiply laws and appoint special officers to
enforce them. Just as in the United States
to-day, so then in England, there were far too
many enactments, and too many special officers
appointed, until "in all country districts there
,is one authority for every privy and another
for every pig-stye; but with regard to the
privy, one authority is expected to prevent it
being a nuisance and the other to require it to
be put to rights if it be a nuisance."2

The formation of the Local Government
Board, and the Public Health Acts of 1872,
1874 and 1875 began the establishment of real
system in the health administration. Accord-
ing to those acts, as subsequently amended, this

3 Quoted by Bannington, p. 9.

24 AMERICAN PUBLIC HEALTH PROTECTION

administration is both central and local. The
central body is known as the Local Govern-
ment Board, consisting of the president, ap-
pointed by the Crown, and certain govern-
mental officers, ex officio. As a board it is
largely a fiction. It seldom or never meets,
but it employs a staff of more or less specially
qualified aids. It is, nevertheless, a highly ef-
ficient body, and exerts a strong influence in
guiding local administration. It formulates
plans and passes upon the acts of local boards.
Under certain conditions it aids in the selection
and support of local officers.

Counties, boroughs, parishes, urban and
rural districts have local boards, varying in
authority, and often conflicting. These boards
employ local officers of health, inspectors of
nuisances, general inspectors and visitors, bac-
teriologists, veterinarians and other officers.
By the General Act it is required that officers
of health shall be legally qualified, and for
districts having a population of 50,000 or more
the officer of health must have a special pub-
lic health qualification before he is appointed.

THE DEVELOPMENT IN THE UNITED STATES 25

It is required that practically all of these of-
ficers must have passed a standard examination
in order to be qualified for appointment. The
very great weakness of the English system,
in spite of a great deal of simplification within
the past score of years, is its cumbrous machin-
ery, and the resulting conflicts in authority.
Added to this is the tremendous amount of
legislation which causes no small amount of un-
certainty as to what the law may be in a given
case. Some of these acts are general, and bind-
ing upon the entire country ; some are adoptive,
and may, or may not, be used locally; others
are merely permissive.

A great deal of liberty is permitted in local
methods, and this results in a lack of standard-
ization which is admittedly objectionable.

Another weakness, as compared with health
administration in Germany and in France, is
found in the relative lack of executive power.
More dependence is made upon the use of
court trials, where questions are decided by
.those who have no technical training. The re-
sulting delays retard efficiency. There is a

26 AMERICAN PUBLIC HEALTH PROTECTION

lack of definiteness of responsibility, and fre-
quent recourse must be made to the board of
non-experts.

Under the present laws the health authorities
of England have very wide authority, includ-
ing supervision of factories, and town plan-
ning, the maintenance of baths, and the care
of public hospitals, but they are frequently
aided, and sometimes hampered, by the activ-
ities of various voluntary associations. A great
deal of attention is paid to the question of food,
and public prosecutions are frequent. We
find, also, that civil damage suits for impure
foods, and the injury resulting, are not un-
common— such, for example, as the collection
of damages from the owner of a dairy for sick-
ness or death caused by bacterial contamina-
tion of the milk supplied.

It will be noticed, however, that practically
all of the provisions for safeguarding the pub-
lic health of England have originated since the
separation of the American Colonies from the
mother country. Previous to that parting of
the ways the only common measures, on either

THE DEVELOPMENT IN THE UNITED STATES 27

side of the Atlantic, were found in the quaran-
tine of diseased persons, and the suppression
of nuisances. While it may be true that there
is a more efficient administration in the mother
country than here, the English advantage is
found in the fundamental differences in gov-
ernmental system, and in the more general in-
sistence upon the employment of specially
qualified officers, under the skilled supervision
of the Local Government Board.

In 1647 the Massachusetts Colony put into
effect a quarantine order of the General Court,
particularly to guard against the importation
of sickness, probably yellow fever, from the
Barbados. There is evidence that the Dutch
Colony at New Amsterdam instituted a like
measure about the same time. This, it will be
noted, was simply an effort to prevent the in-
troduction of disease from outside the colony.
So, too, the first sanitary enactment of New
York was the quarantine law of 1755, provid-
ing for the quarantine of ships coining from
ports infected with smallpox, yellow fever, or
"other contagious distemper." This act im-

28 AMERICAN PUBLIC HEALTH PROTECTION

posed a fine of £500 for violation of the pro-
visions, and it further provided that the Gov-
ernor was to appoint a surgeon or physician as
inspector. From time to time the law was re-
enacted, sometimes with slight modifications,
In 1793, Philadelphia was visited by an alarm-
ing epidemic of yellow fever. More than 4,000
out of the 60,000 population died, and neigh-
boring states became alarmed. It seemed to
be clear that the New York law was sufficient
authority for the stoppage of ships coming
from Philadelphia, but it did not protect
against the coming of persons by land.

There was great difference of opinion as to
the nature of yellow fever. Some held that it
was in fact contagious; others that it was
a miasma produced by filthy surroundings.
Therefore, in 1796, a new law was passed, pro-
viding for land quarantine, and for the first
time in New York it was also provided by
general statute for the suppression of nui-
sances. It is interesting here to note that the
old contention as to the character of yellow
fever lasted for more than a century after this

THE DEVELOPMENT IN THE UNITED STATES 29

double-acting law was passed, and it was ad-
herents of a modified miasmatic theory who
sought the removal of Gorgas and his staff
after they had begun their work at Panama.

In 1635 the records of the colony of Mas-
sachusetts Bay show: "Whereas particular
townes have many things which concerne only
themselves, and the ordering of their own af-
fairs ... it is therefore ordered, that the
freemen of every towne, or the major part of
them, shall have power to ... make such
orders as may concerne the well ordering of
their own townes, not repugnant to the laws
and orders here established by the Generall
Court." In 1692, for the first time thereafter,
the General Court intermeddled with local
sanitation to the extent that it provided that
certain officers of market towns were em-
powered to assign places for slaughter-houses,
still houses, and places for the currying of
leather and the rendering of tallow; and such
trades were forbidden elsewhere than at the
places assigned. In 1797 it was provided that
a town might appoint a health committee of

SO AMERICAN PUBLIC HEALTH PROTECTION

from five to nine persons, or it might appoint
a health officer. With slight modifications
these general provisions have continued until
within very recent times. In 1799 the mayor
and aldermen of New York City were invested
with temporary authority over certain kinds of
nuisances, supposed to be instrumental in the
spread of yellow fever. This authority was
extended as to time and as to subject until
within a few years it was made general.

The events of New York and Massachusetts
were fairly illustrative of the methods in other
parts of the country. It will be noticed that
the legislation was primarily general, by the
legislative body of the state or colony, but that
the selection of officers and the enforcement
of the laws were left to local authorities. In
practical application more and more was left
to the discretion of the localities. Power was
granted to them to do certain things, but it was
seldom that the towns or cities were obligated
to take sanitary steps. Though, as we shall
see later, after a time the pendulum swung
toward centralization of administration, and

THE DEVELOPMENT IN THE UNITED STATES 31

though under our system of government all
local power must be granted by the state, the
town and city governments practically did as
they pleased.

At that time there was no semblance of sani-
tary science such as we know at present. No
one knew how these diseases were spread, and
in fact there was no means of telling with any
degree of definiteness what the diseases were.
Diagnosis was at best a matter of opinion.
Glandular tuberculosis was called scrofula,
and was commonly supposed to be related to
syphilis. Laryngeal diphtheria was called
croup, and the medical ideas relative to other
ailments were no more certain or accurate. As
with diagnosis, so also with treatment, and
particularly with the means which should be
used to prevent the spread of infections. Even
within the writer's memory good physicians
frequently carried infection from one case to
another. One went from a case of erysipelas
to three confinements, and each patient con-
tracted the infection and died. Another car-
ried the diphtheria germ to a surgical case, and

32 AMERICAN PUBLIC HEALTH PROTECTION

perhaps, as he was convinced later, he carried
the infection of scarlet fever to his own child.
The wife of a distinguished physician, one who
was ahead of his time in medical ideas, went
to the funeral of a scarlet-fever patient, and
rode in the carriage with the casket, and when
she reached her home she took her little daugh-
ter on her knees and fondled her. A few days
later my playmate was laid to rest.

With ideas so variant and uncertain it
seemed better to trust to the judgment of sev-
eral, rather than of one, in the hope that in the
multitude of counsel there might be safety. In
times of special danger these boards were ac-
corded almost unlimited power by the common
consent of the citizens. Not that they exerted
this power lawfully, but that the legality of
their action was either not questioned, or, if
questioned, it was upheld by the courts as
emergent necessity. It was thought that men
educated in medical lore knew more than others
about the laws of health. They were therefore
leaders in sanitary endeavors. Eoards of
health were by no means always composed en-

THE DEVELOPMENT IN THE UNITED STATES 33

tirely of physicians. In fact it was generally
thought better to have a majority of the board
composed of "practical" men who knew noth-
ing of either medicine or sanitation, and some-
times there was no physician in any way con-
nected with the work of the board. Boards
were given authority to make rules and regu-
lations, and under the guise of inspections the
officers of health departments were enabled
sometimes to enforce arbitrary and illegal, as
well as injudicious, orders.

It was thus that city boards of health, or
health departments, became the prey of poli-
ticians of the lower class. During the Tweed
regime in New York City the health depart-
ment became an efficient agency for the collec-
tion of blackmail, and there is strong evidence
that such a practise has occasionally occurred
even in recent years. Boards of health were
therefore largely a law. unto themselves. Be-
cause of the indefiniteness of the science there
was no efficient means for judging as to the
reasonableness of many of their laws, nor of
the effectiveness of the measures proposed.

34 AMERICAN PUBLIC HEALTH PROTECTION

Epidemics, especially those of cholera, yel-
low fever and smallpox, always resulted in re-
newed efforts at the guarding of the public
health. Judge Dillon says in his Municipal
Corporations that the police power as related
to health is one of the principal reasons for
municipal organization, and it has been stated
that the organization of the town of Chicago
was accomplished on account of the desire of
the citizens to have a local government which
might be able to cope with the cholera, follow-
ing the epidemic of 1832. That year the
cholera act of New York gave to the governor
authority "to employ suitable agents to pro-
ceed to any part of this state, or to Upper or
Lower Canada, for the purpose of procuring
information in relation to the progress of the
said disease, and the prevention or treatment
thereof, or for any other purpose he may deem
conducive to the public health." Apparently
this is the first instance of concerted govern-
mental action in this country having for its
object the investigation of the cause of dis-
ease.

THE DEVELOPMENT IN THE UNITED STATES 35

In May of 1849, under the stimulus of the
appearance of cholera, by a joint resolution
of the houses of the legislature, the governor
of Massachusetts was empowered to appoint
a commission of three to report upon a sani-
tary survey of the state, with facts and sug-
gestions. In the report which this commission
returned it was recommended that a state board
of health be established. It was not until 1869
that Massachusetts finally established the first
state board of health in America; and this
became the model after which others were later
formed. It consisted of seven members, one
being appointed by the governor each year.
Members served without pay, and were ineli-
gible for reappointment. The board elected
a secretary, who was the executive officer of
the organization. He was paid for his serv-
ices. The duties of the board were: to take
cognizance of the interests of life and health
among the citizens; to make sanitary investi-
gations and inquiries as to the sanitary condi-
tion of the people, the causes of disease, espe-
cially epidemics, the sources of mortality, the

36 AMERICAN PUBLIC HEALTH PROTECTION

effects of localities, employments, conditions
and circumstances upon public health; to
gather such information in these matters as
they deemed proper for diffusion; to advise
the government as to the location of public
institutions; to examine and report on the ef-
fect of intoxicating liquors as a beverage on
the industry, prosperity, happiness, health and
lives of citizens; and to make an annual re-
port to the legislature embodying the results
of these investigations, with suggestions for
further legislation.

It will be noticed that the board had prac-
tically no authority. Its duty was to investi-
gate and advise. Still, a mere list of its duties
shows that if the members fully complied with
the requirements it would take their entire
time. Why then should the state expect to
receive seven years' service at special work, re-
quiring a special kind of training, and ex-
pressly prohibit that its officer should receive
any compensation therefor? Yet, this plan
has been followed in a number of states. It
is a general commercial rule that one gets on

THE DEVELOPMENT IN THE UNITED STATES 37

an average about what he pays for. It is
partially because of the provision against com-
pensation for board members that no greater
advance has been made in health administra-
tion. Another result has been that sometimes
the members have at least been suspected of
capitalizing their positions.

Apparently, it was only because of the pres-
ence of local boards of health that the idea
became prevalent that health offices should be
managed by boards. Local boards, however,
had real authority, as state boards had not.
The former dealt directly with epidemics and
local conditions. The newly created state
agency in Massachusetts had no authority. It
simply acted in a clerical capacity to collect
facts, and then presented those facts to the
people, either directly or indirectly. The
state board of New York, created in 1880, was
composed of nine members, but in that organi-
zation there was an effort to coordinate other
governmental activities. The attorney gen-
eral, the superintendent of the state survey
and the health officer of the port of New York

38 AMERICAN PUBLIC HEALTH PROTECTION

were ex officio members, and three were to be
selected from the commissioners or boards of (
health of cities in the state. Soon this state
board was given real authority, and super-
vision over local boards. By the law of 1885,
it was empowered to compel the formation of
local boards of health, and in case of local neg-
lect the state board could make local appoint-
ments. Under such conditions there might be
some excuse for making a state board of health.

The state board of health in Illinois was

i

created in 1877- Like the board in Massachu-
setts it consists of seven members, who serve
without pay. The secretary, whom the board
elects, receives pay as secretary and executive,
even when a member of the board. It has de-
voted its chief attention to the enforcement of
the medical practise acts. Because the board
must examine applicants for license to prac-
tise medicine it seems very proper that this
duty should be divided between several, rather
than that the candidate should be forced to de-
pend upon the judgment of one examiner.
Still it does not appear how the interests of the

THE DEVELOPMENT IN THE UNITED STATES 39

!

state are conserved by depending upon gratu-
itous service. This board, from the time of its
creation until January, 1915, has contributed
practically nothing to our knowledge of in-
fectious diseases, and its sanitary supervision
has been uncertain. For many years past,
until the appointment of its present executive,
it has had no member with special training in
sanitation. It was composed chiefly or entirely
of physicians. The result of such an organ-
ization may be seen from its manner of han-
dling rabies, or hydrophobia. This is an in-
fectious disease, contracted by human beings
from the bite of rabid animals, usually dogs.
This disease causes annually a great loss of
cattle, sheep, horses and hogs in the United
States. According to the 1909 Mortality Re-
port of the United States Census Bureau, the
average number of human deaths in the "reg-
istration area" of the United States for the
ten years preceding was fifty-four. (Because
many states have such imperfect laws for the
registration of births and deaths, or because
of inefficient enforcement of the existing laws,

40 AMERICAN PUBLIC HEALTH PROTECTION

the records of such states are not accepted by
the Census Bureau. The area from which re-
ports are accepted is called the "registration
area.") Those fifty-four deaths are unneces-
sary, and therefore inexcusable. Deaths may
be prevented by using the special treatment
originated by Pasteur, which consists in the
injection of increasing doses, or doses of in-
creasing strength, of the virus of the disease.
The Illinois board very properly sought, and
obtained from the state, appropriations for
providing this treatment for those who were
unable to pay for it themselves. The board
then made a contract for the treatment of these
cases at a certain institution in Chicago, where
they have been well cared for. There is no crit-
icism which should be made against the board
for all of this. The members should be com-
mended.

The Illinois board is composed of physi-
cians, and they look at problems from physi-
cians' points of view. The board, having made
arrangements for the treatment of poor vic-
tims of the rabies, made no other efforts to-

THE DEVELOPMENT IN THE UNITED STATES 41

ward control of the disease. Nothing was
done to stop the spread of the malady. The
members did not seem to realize the necessity.
Prevention, not cure of disease, is the true
work of the sanitarian. Rabies has been com-
pletely exterminated from England, from
Holland, from Prussia and from other coun-
tries. All that is necessary to do is rigidly to
enforce the muzzling of all dogs for a period
of a year, and then to prevent the entrance of
other dogs until they have passed through a
period of quarantine. Because of the difficulty
of rigid enforcement of muzzling over a large
territory it might be necessary to extend the
time somewhat.

It is probably true that the state board of
health had no authority for ordering dogs in
Illinois muzzled, but it might have collected
and published the data relating to the disease
in the state, and it might have urged the legis-
lature to take action upon the matter, and have
so published the facts that the citizens through-
out the state would have assisted to stamp out
the disease. The successful treatment of ma-

42 AMERICAN PUBLIC HEALTH PROTECTION

laria or of diphtheria patients tends to restrict
the spread of the disease, for in each case the
disease is propagated from other human cases.
This is not true with reference to rabies. Prac-
tically that is spread only by dogs, and the
muzzling of dogs has been the only thing
found necessary for the eradication of the
poison from a community. While the treat-
ment and cure of a case is the aim and object
of a physician, the sanitarian does not consider
treatment of a case as a portion of his duty
unless that treatment tends to restrict the
spread of the malady. He therefore leaves
the treatment to the physician, in order to de-
vote his attention to prevention of disease.

The necessity for treatment of a case of dis-
ease is simply an open acknowledgment that
the sanitarian has failed in his special duty.

The Michigan state board of health was
formed shortly before that of Illinois. Under
the guidance of Doctor Baker it sought to se-
cure evidence of the causation of disease, espe-
cially the relationship of certain diseases to at-
mospheric conditions. Also, by means of

THE DEVELOPMENT IN THE UNITED STATES 43

sanitary conventions held in the various cities
of the state, the board spread knowledge and
interest in sanitary subjects. It was Doctor
Vaughn of that board who discovered that the
poison of cheese, ice-cream and milk, which
sometimes caused severe illness and death
within a few hours, was due to bacterial infec-
tion, not to some mineral poison which had
been introduced, either intentionally or acci-
dentally, as had formerly been supposed.

The Massachusetts board has done service
to the science of prevention by investigating
the pollution of streams in the state. In Illi-
nois this service is performed by a special com-
mission, really working through the state uni-
versity, though nominally in conjunction with
the state board of health. The state board of
Louisiana has always been active in adminis-
trative measures, and it has been given more
legislative power than most states would per-
mit. In addition, this board has equipped a
health exhibit in a railway car, or cars, and in
that way has been enabled to bring home to the
people of the state the principal facts of the

44 AMERICAN PUBLIC HEALTH PROTECTION

modern science of sanitation. While the peo-
ple are being guided through the car by one of
the assistants who explains the various things
shown, other assistants make a sanitary survey
of the town. Then lectures are given, free of
charge.

Gradually the various state boards have been
growing in importance. Many have been and
are doing excellent work. They have been col-
lecting data, aiding in sanitary education, and
making rules for the guidance of the subordi-
nate organizations. The Kentucky board has
been very active in all these fields, and its rural
clinics on the hookworm and trachoma have
been especially noticeable in the good accom-
plished.

There is a legal difference between laws and
rules. According to the American system of
government it is not generally permissible that
there should be a union of any two of the three
divisions of governmental power: executive,
legislative and judicial. The work of a health
department is essentially executive and admin-
istrative. The laws by which it works should

THE DEVELOPMENT IN THE UNITED STATES 45

be enacted by the legislature. Recognizing
this fact, and that executive organization for
efficiency demands that responsibility be defi-
nitely fixed, Pennsylvania first abandoned the
board idea and organized its state health de-
partment with a commissioner at the head.
The state is divided into districts, and the va-
rious phases of administration are guided and
watched from Harrisburg. New York has
also appointed a commissioner, and is reorgan-
izing its public health methods.

In the operation of boards of health very
much depends upon the character of the ex-
ecutive. Such men as Hurty of the Indiana
board, or Fulton of Maryland, or Bracken of
Minnesota, accomplish much. Others have
made a "big noise" and accomplished very
little. Sometimes a board, animated witK
great enthusiasm, but guided by little reali-
zation of its authority or knowledge of the
science, attempts to do things beyond its
power, and of most questionable advisability;
as when the Kansas board attempted to com-
pel all consumptives to fe segregated on trains

46 AMERICAN PUBLIC HEALTH PROTECTION

passing through the state. An antiquated and
perhaps illegal method has long been in effect
in Alabama. According to the statute the
county medical society of each county is the
board of health, and the state medical society
is the state board of health. If the system has
been at all efficient it is because of the faithful-
ness of Doctor Saunders, who has long been
the state health officer.

Although the states have been slow to drop
the board for the commissioner, cities have
done so very generally. At first the local
administration was confined to maintaining
quarantine, attending to fumigation after the
disease was over, and occasionally investigat-
ing a complaint of nuisance. Now the quar-
antine is materially modified, though it is used
for many diseases not previously considered
quarantinable. Many of our leading sanita-
rians have abandoned terminal fumigation as
worse than useless. On the other hand, the
departments are to-day watching a class of
persons who formerly did great harm without
being suspected, namely those who, without

THE DEVELOPMENT IN THE UNITED STATES 47

themselves being ill, constantly develop and
discharge certain disease germs. These car-
riers could not have been identified in the olden
time. Then, too, 'the departments to-day must
keep a watchful eye upon the production, care
and sale of many articles of food which for-
merly were left to private supervision. The
department laboratory must make examina-
tions of specimens to determine diagnosis, and
must make frequent tests of water and of food
sold in the neighborhood. It must watch the
construction and maintenance of buildings,
especially tenements and workshops. On its
own initiative, rather than on complaint of
some citizen, the officers must be constantly
looking for public nuisances and abating them.
While, therefore, the local department of
health has lost some of its independence and
authority, and while the state administration
has greatly increased in importance, the local
office has really become far more important
than it was formerly; and if headed by a thor-
oughly competent man there is no department
of city government which is of greater vital
interest to the citizens.

CHAPTER III

NATIONAL HEALTH AGENCIES

WHEN the states adopted the present Con-
stitution by which the United States was cre«-
ated in form, it was but one of the many steps
by which the nation has been developed. The
movement was one which was instigated for
commercial reasons. There was no freedom of
trade between the different states which had
united in a loose federation. There was no se-
curity for the payment of money due from the
confederation, and in many ways it was felt
that a closer bond should be created. Since
the prime motive was a unified commercial con-
trol, one of the provisions of the new document
was that the Congress should have control over
interstate and foreign commerce. However,
many of the citizens were so suspicious that
almost immediately certain amendments were
accepted by the different states, and when some

48

NATIONAL HEALTH AGENCIES 49

of the states confirmed their share in the Consti-
tution, it was only on condition that these
would be adopted.

The Ninth Amendment to the Federal Con-
stitution reads: "The enumeration in the Con-
stitution of certain rights, shall not be con-
strued to deny or disparage others retained by
the people." The Tenth Amendment says:
"The powers not delegated to the United
States by the Constitution, nor prohibited by
it to the states, are reserved to the states re-
spectively, or to the people." Since that au-
thority known technically as "police power"
is not mentioned in the Constitution, it has
generally been held that this power has been
reserved to the individual states; and it is un-
der this power that practically all govern-
mental efforts at disease restriction naturally
operate. The consequence has been that until
very recent times the national government has
taken few steps for the protection of its citizens
from morbific ills.

Two widely different contentions have
arisen from this state of affairs. Some, jeal-

50 AMERICAN PUBLIC HEALTH PROTECTION

ous for the rights of the individual states, have
affirmed that under no conditions has the na-
tional government a legal authority in disease
resistance. Others, generally ignorant of the
principles of American law, have impatiently
demanded that the Congress act in many ways,
and that national administrative offices exert
more power and authority. In the early years
the first party were by far^the stronger, but the
necessities of the progress have brought about
some changes in ideals..

No enactment, no formal agreement, no
change of residence or of cession of territory
can make a nation. A nation is the result of
natural development. Its citizenship is homo-
geneous, in that they have uniform ideals and
objects. Poland was divided between Ger-
many, Austria and Russia, but Poland the
nation continued to exist, though it had lost
its independent government. Germany forci-
bly changed the language and many of the
customs of the people, but they remained Poles
just the same, and were not Germans.

The Articles of Confederation signed by the

NATIONAL HEALTH AGENCIES 51

representatives of the colonies did not make
a nation. Neither did the Constitution. The
interests of the different sections of the coun-
try were often divergent and antagonistic.
One of the results of this condition was the war
of 1861. Slavery was abolished, and this took
away one of the bones of contention. Then
came the development of transportation, espe-
cially by railroads, and the people of Cali-
fornia were thus brought more close to the
citizens of New York than the residents of
Richmond had been to those of Rhode Island.
As far as the population is concerned, the
United States is now a real nation.

Poland is no longer a nation among the
powers of Europe because she has no govern-
ment of her own. 'A nation must have, to be
perfect in ideal, a government with supreme
authority over all its parts. There is now
one very great flaw in the title of the United
States as a nation. It is contained in those
two amendments to the Constitution. In pro-
portion as they may mean anything at all, they
restrict the authority of the national govern-

52 AMERICAN PUBLIC HEALTH PROTECTION

ment. The states are prohibited from making
treaties with outside powers, or between the
different states. That authority is granted in
the Constitution to the President, with the ap-
proval of the Senate; but the national govern-
ment has not yet found authority to enforce
the terms of such treaties upon individual
states. Acting under police power the indi-
vidual states enact conflicting laws, and the
national government has found no way in
which to prevent the condition. As a result,
a man may have several wives in different
states, with their respective families ; yet in no
state would two families have a legal claim
upon him or his property. A physician going
from one state to another has no security that
he will be permitted to practise his profession
in the new home. In proportion, therefore, as
the amendments cited have effect, in that pro-
portion the United States is still in its embryo-
logical stage as a nation.

Sir John Macdonald was a shrewd observer.
Before the inherent weakness of our Constitu-
tion was generally appreciated in this country

NATIONAL, HEALTH AGENCIES 53

he called attention thereto. In remarks made
at Quebec, October 11, 1864, during the Con-
federation Conference which was discussing
the proposed Constitution for Canada he said :
"The primary error at the formation of their
Constitution was that each state reserved to
itself all sovereign rights, save the small por-
tion delegated. We must reverse this process
by strengthening the general government and
conferring on provincial bodies only such pow-
ers as may be required for local purposes. All
sectional prejudices and interests can be legis-
lated for by local legislatures. Thus we shall
have a strong and lasting government under
which we can work out constitutional liberty as
opposed to democracy, and be able to protect
the minority by having a powerful central gov-
ernment." This comment was not unfriendly,
for in the same city on the sixth of July, 1865,
in speaking of our Constitution, he said: "I
think and believe that it is one of the most skill-
ful works which human intelligence ever cre-
ated ; it is one of the most perfect organizations
that ever governed a free people. . . .

54 AMERICAN PUBLIC HEALTH PROTECTION

JVe can now take advantage of the experience
of the last seventy-eight years, during which
that Constitution has existed, and I am
strongly of the belief that we have, in a
great measure, avoided . . .. the defects
which time and events have shown to exist in
the American Constitution." We, too, have
had the privilege of observing the operation of
the reversed system in our sister nation during
the last fifty years. Is it not time that we, also,
strike off the chain of those two amendments
which prevents the United States from being
a real nation, with full sovereign power?

It is possible, however, that the national gov-
ernment has far more power than has been
supposed, especially for the protection of the
public health. Because of the backwardness of
many states in the matter of efficient regula-
tion of the recording of births and deaths, the
writer some time ago suggested that this duty
be assumed by the national government. Good
constitutional lawyers stoutly affirmed that this
was impossible on account of those hampering
amendments. However, encouraged by in-

NATIONAL HEALTH AGENCIES 55

terest shown in Cabinet offices, where it was
said that entirely new questions had been raised
in the outline submitted, the studies were con-
tinued. As far as the writer is aware the argu-
ment, as published in the Illinois Law Review
for January, 1915, and in his Legal Princi-
ples of Public Health Administration,, has con-
vinced all of the objectors that the United
States has that power. If it has this, perhaps
it has other powers, heretofore supposed lack-
ing. When Professor Harrington, the execu-
tive of the Massachusetts board of health, in-
voked the aid of the national government to
stop the shipment of disease-producing milK
from New Hampshire and Vermont in 1907
he was informed that the national government
had no authority for such action. The same
reply was made relative to the stoppage of the
shipment of milk from Wisconsin to Illinois,
but under the commerce clause of the Consti-
tution authority was found for the passage of
the national Pure Food and Drugs Act. Un-
der this act hundreds of prosecutions have been
made successfully for fee interstate shipment

56 AMERICAN PUBLIC HEALTH PROTECTION

of milk or milk products which are not up to
the standard set by the government. By this
means the Department of Agriculture has
been enabled to exert a strong influence for
the production of safe milk.

At the present time there are several agen-
cies of the national government which have to
do with public health protection. These are:
the medical branches of the army and the
navy; the Public Health Service of the Treas-
ury Department; the Bureaus of Chemistry
and Animal Industry of the Department of
Agriculture; the Bureau of Census, of the
Department of Commerce ; the Children's Bu-
reau, of the Department of Labor, the Bureau
of Education, and the Post-Office Department.

In the past the influence of the medical stafG
of the navy has been practically nothing. It
has not added specially to our knowledge of
the laws of sanitation, nor has it exerted ad-
ministrative measures outside of its own im-
mediate scope.

In marked contradistinction, the influence
and contribution of the medical staff of the

NATIONAL HEALTH AGENCIES 57

army has been tremendous. Under military
authority this service undertook making Cuba
livable. General Wood, trained and educated
as a physician, retained his interest in medical
affairs after he entered the line. As governor
of Cuba after the Spanish War he used his in-
fluence and authority to back the efforts of
Major Gorgas. It was at that time that Sur-
geon General Sternberg appointed a board of
army surgeons, consisting of Major Reed,
Carroll, Lazear and Agramonte, to investigate
and report upon the cause of yellow fever.
Major Ross of the British army had just dem-
onstrated the connection between the anoph-
eline mosquitoes and malaria. The American
army board demonstrated that yellow fever
is only communicated through the bite of the
stegomyia mosquito ; that a yellow-fever pa-
tient can only communicate the disease to the
mosquito during the first three days of illness ;
that there must be a period of incubation last-
ing some twelve days, and thereafter for an
indefinite period, at least a couple of months,
the mosquito is able to infect other human be-

58 AMERICAN PUBLIC HEALTH PROTECTION

ings. Major Gorgas, good-naturedly though
skeptically, began to put the ideas to an im-
mediate test, and completely demonstrated
the practical utility of the discoveries. Then,
at Panama, Colonel Gorgas again demon-
strated the practicability of eradicating yel-
low fever and malaria from the tropics. As
he has remarked, the great value of the work
at Panama was not the mere performance of
the engineering feat, but it was the demonstra-
tion that the white man can live in the tropics
and remain healthy; and since the tropics are
so much more productive of food, automatic-
ally the earning capacity of the white man has
been doubled.

The glorious labors of this army board are
not, however, matters for unmixed national
pride. By making the fruits of the tropics
cheaper of production and sale, they have bene-
fited every inhabitant of this land; but as a
nation we have been willing to take the profits
without rendering to the men of science that
compensation to which they were morally en-
titled. Carroll was the first person willingly

NATIONAL HEALTH AGENCIES 59

to submit himself as a victim upon the altar
of science, to test the truth of the suspicions.
He contracted the disease, was very ill, and
in consequence developed a heart lesion which
made him a chronic invalid, finally causing his
untimely death. After his return to Washing-
ton he attempted to support himself and his
little family by making microscopic examina-
tions for other physicians, but so little money
came in that he was obliged to pawn his micro-
scope to buy bread. He died, and left his home
mortgaged, and his family with no other sup-
port than the small pension. It was brother
physicians, who in nowise profited from Car-
roll's labors, other than as all citizens were
benefited, who paid the debt upon the home
and provided for the education of the children.
Lazear contracted the fever and died immedi-
ately. Reed came home an invalid and soon
joined the silent majority. Up to the present
time the United States government has done
practically nothing to demonstrate its obliga-
tion to these martyrs of science.
For a long time before the American oc-

60 AMERICAN PUBLIC HEALTH PROTECTION

cupation the inhabitants of Porto Rico had
been troubled with tropical anemia, which was
supposed to be due to the air of the island.
It was United States army surgeons who dis-
covered that this anemia was due to the pres-
ence of a small intestinal parasite called fa-
miliarly the "hookworm." It was found that
the pathologic condition readily responded to
treatment, and a great change was made in the
condition of the population. Incited by these
results, investigations were made in our south-
ern states, especially by Stiles of the Marine
Hospital, and the campaign thus inaugurated
has raised the condition of southern peoples
beyond computation. Though the campaign
against the hookworm in the United States
was practically originated by the results in
Porto Rico, the army had no other relation-
ship to the work. Almost all of the sanitary
campaign in the Philippines, however, has been
waged by officers of the medical staff of the
army, though not always under direct army
control.

The wonderful results in Cuba and Panama

NATIONAL HEALTH AGENCIES 61

have sometimes been pointed to as evidence of
what may be accomplished under a republican
form of government. In his South America^
Sir James Bryce calls attention to the fact that
these results were not obtained under a repub-
lican rule. They were attained in spite of the
fact that the United States is a republican gov-
ernment, and they were possible only by the
abrogation of civil rule, and the establishment
of strict military government.

In 1798, Congress provided for the estab-
lishment of the Marine Hospital Service. Its
object was the care of sick and disabled sea-
men in hospitals which were established. From
time to time the duties of the service have been
increased. In the late seventies a national
board was established, but it soon died on ac-
count of lack of support. When it died its
duties also devolved upon the Marine Hospital
Service, and finally the name "Marine Hos-
pital" was dropped, and it is now known as
the "Public Health Service."

The present Public Health Service is a most
important organization. In addition to its

62 AMERICAN PUBLIC HEALTH PROTECTION

original duty of caring for sick and disabled
seamen, and incidentally making examinations
of candidates for positions in the revenue serv-
ice and other branches of the activities of the
Treasury Department, and attending to other
matters of minor importance, this service has
charge of the physical inspection of all immi-
grants coming to our shores. It is this service
which superintends all foreign and interstate
quarantine, and insular quarantine as well. In-
cidentally to this work the service collects the
data relative to infectious diseases in all parts
of the globe, publishing them each week. Its
personnel is to-day probably the best qualified
body of practical sanitarians on the earth.

The great .work which the Public Health
Service is doing is in the line of original in-
vestigations as to the nature and cause of dis-
ease. Surgeon Carter of this service had
worked out some of the preliminary problems
of yellow fever before the appointment of the
Reed board of the army. Stiles has added
much to our knowledge, and greatly assisted
in working out the problems relating to in-

NATIONAL HEALTH AGENCIES 63

testinal parasites in America. Lavinder has
been one of our best authorities on the pellagra.
McClintick gave his life as a result of his study
of the Rocky Mountain fever. McLaughlin
has done valuable work in connection with the
study of the pollution of our lakes and streams,
especially those between the United States and
Canada. Rosenau and Anderson, as direct-
ors of the laboratory, have made many valu-
able contributions to the science. They studied
the standardization of diphtheria antitoxin, the
causes of sudden death following the use of the
antitoxin, the life history of many germs and
the means for their eradication. Many others
in the service have done equally valuable,
though less conspicuous work of investigation.
The Rocky Mountain fever is spread by a
species of insect known as a tick. One of the
surgeons of the Public Health Service found
that one means of eradicating the fever was by
putting sheep to graze in the infected area.
The ticks climb from the ground to feed upon
animals. Having grown fat they breed and
fall off to lay their eggs. When, however, the

64 AMERICAN PUBLIC HEALTH PROTECTION

animal upon which they have fed has long
curly wool, like that of the sheep, the tick gets
so tangled in the hair that it can not breed, and
dies without propagating. The grazing sheep
therefore act as traps for the extermination of
the ticks.

Night soil has been frequently used for fer-
tilization of truck gardens. The possible dan-
ger of such use was investigated by this service,
and it was found that lettuce so grown some-
times showed the presence of colon bacilli upon
its leaves. Experiments were tried with fly-
blown articles of food, and it was found that
the resultant flies could and did work their way
to the surface of the ground when the food had
been buried at a depth of seventy-two inches.

When the yellow fever last infested New
Orleans, Surgeon White was in charge of the
Marine Hospital at that point. The local
commercial organizations at first denied the
presence of the disease, and threw stumbling
blocks in the way of the local administrators.
When they realized that the conflagration had
got beyond their control, White was asked

NATIONAL HEALTH AGENCIES 65

to take charge. He did so, working not under
the authority of the United States, but under
the authority of the state of Louisiana, and
sometimes without any authority other than the
necessities of the case. He performed many
acts of arbitrary nature, but he exterminated
the infection and saved greater loss for the
citizens.

It was Kinyoun of this service who discov-
ered the presence of the bubonic plague in
San Francisco, and urged energetic measures
for its extermination. The Chamber of Com-
merce made protest at Washington, and orders
were issued for his transfer to a distant point.
He resigned, and remained to keep up his
fight. The disease gained ground, and sur-
geons were sent from other parts of the coun-
try to make an investigation. Again, local
commercial interests were so unwise as to
cause the suppression of the report for a year.
Finally, when the truth could no longer be
kept secret, it was Surgeon Blue and his as-
sistants who were put in charge of the work of
elimination. In the meantime, the disease had

66 AMERICAN PUBLIC HEALTH PROTECTION

extended beyond the city limits. Ground
squirrels and other animals had become in-
fected, and the work of extermination had be-
come Herculean. From San Francisco the
disease got up into the state of Washington,
and down into Mexico. It appeared along the
coast of the Caribbean Sea, and showed itself
in Cuba, in Porto Rico, and in New Orleans.
A large portion of the state of California was
infected, and the reports just received show
that an infected ground squirrel was killed in
Contra Costa County, California, November
12, 1915, and an infected rat in New Orleans
on February 4, 1916, where another case
of human plague was reported September 8,
1915. The fire is smoldering, and the only
real service looking after the matter is the Pub-
lic Health Service of the Treasury Depart-
ment.

This infection, which has cost the country
many millions of dollars already, and which
is still taking the time and attention of a large
force of field workers, might easily have been
controlled at first by prompt and intelligent

NATIONAL HEALTH AGENCIES 67

wort. Misguided commercial interests, not
being used to the disease, objected to the un-
usual methods proposed for eradication. They
have paid heavily for their ignorance, but un-
fortunately at the same time the entire nation
has also been punished. The San Francisco
merchants denied the existence of the plague,
and protested against the cost and inconven-
ience of the measures which were advised for
the extermination. Their denial did not alter
the facts. In the same way, certain people
deny the existence of disease, as a mere error
of the mind, but their denial does not at all
comport with the daily facts of observation.
Misguided reformers protest at vaccination,
but the cold facts disprove their assertions.
Some men who have licenses to practise medi-
cine attempt to deny the proven facts of
science ; perhaps because they have let the moss
grow in their brains, and have not kept abreast
of the times; or, perhaps, because they were
always professionally ignorant, and simply
posed as physicians; and sometimes we must
believe that they deny the facts of science as a

68 AMERICAN PUBLIC HEALTH PROTECTION

money-making scheme, well knowing that their
own methods are pure confidence games. It
is such misleaders as these who manufacture
false statistics, as one of them did relative to
the results of vaccination in Japan some time
ago. It is such as these who give, for money
received, any medical testimony desired hy the
payer, and are loudest in their denunciation of
efficient public health protection. Efficient
sanitation hurts their private business.

In the Department of Agriculture there are
many bureaus whose work relates either di-
rectly or indirectly to the health of the citizens,
but two are of especial importance. The Bu-
reau of Animal Industry has control over the
transportation of animals from one state to an-
other. It studies and restricts the spread of
animal diseases, many of which are of import-
ance to human beings. It investigates and aids
by its publications the production and market-
ing of dairy products and poultry. It seeks
to educate the farmers in the best methods for
producing and caring for their animal prod-
ucts, and it exerts a direct authority to restrict

NATIONAL HEALTH AGENCIES 69

the shipment of harmful articles. This author-
ity is most evident in the conduct of the meat
industry. A firm which desires to slaughter
animals for shipment in interstate or foreign
trade must make application to this bureau,
and must comply with the strict rules laid
down. Every portion of the interstate meat
industry is under this supervision. Upon the
filing of a proper application an inspector and
needed assistants are immediately appointed
to take charge of the slaughter-house. Every
animal must he inspected before and after
slaughter. The killing is strictly supervised,
and all diseased meat is condemned and dis-
posed of under this federal supervision. If the
slaughter-house neglects to obey instructions it
immediately loses the right to ship its products.
If, for example, the condemned carcass is held,
and an attempt made to pass it into some other
trade channel, the inspector immediately
drenches it with kerosene, and withdraws all
rights of shipment, and with his staff of as-
sistants he leaves the place.

Every slaughter-house under federal super-

70 AMERICAN PUBLIC HEALTH PROTECTION

vision must be conducted with care such as
even hospitals lacked in days within the mem-
ory of older practitioners. The "surgical clean-
liness" demanded is found in every depart-
ment, from the killing room to the final
shipment of the dressed meat or the canned
products. Microscopists examine suspicious
materials, and all materials which are not safe
are rendered harmless. About two per cent, of
all animals examined are condemned and de-
stroyed, and in addition parts of many others
are likewise destroyed.

In marked contrast with the interstate meat
industry is that which concerns the people of
the individual states. Only about one-half of
the animals slaughtered in the United States
are killed under this federal supervision. Ani-
mals which are suspicious are diverted by their
owners to local slaughter-houses. In 1907, it
was estimated that approximately 5,000,000
cattle, 8,000,000 sheep, over 10,000,000 hogs,
and 3,000,000 calves were slaughtered by
butchers without federal supervision, and a
large proportion without any supervision at

NATIONAL HEALTH AGENCIES 71

all. Added to these there were about 1,500,000
cattle, 1,000,000 sheep, and 16,500,000 hogs
which were slaughtered by farmers. Probably
at least five per cent, of these animals should
have been condemned. The federal govern-
ment is without authority in the matter of ani-
mals slaughtered for consumption in the state
where the meat is consumed. Some states and
cities have laws regulating slaughter-houses,
but the object of such state statutes or munici-
pal ordinances is frequently to prevent nui-
sance to the neighboring property. It is very
rare that these establishments have sanitary
supervision even approximating that of the
national government. A large proportion of
the slaughter-houses where cattle are killed for
home consumption are absolutely without
supervision. Many of them are positively
filthy, and very few have any provision for
laboratory examinations.

It will readily be seen that where the busi-
ness is conducted in a cheap manner it can well
afford to undersell the more reliable product.
A saving of five per cent, of meat which should

72 AMERICAN PUBLIC HEALTH PROTECTION

be condemned, a saving in expense of opera-
tion, and a saving in cost of equipment, easily
render it possible to make a better profit while
selling meat at from eight to ten per cent, be-
low the price which must be charged for the
product of the industry which is supervised by
the national officers. It therefore happens that
there is frequently manifested a local opposi-
tion to a really efficient supervision of the inter-
state business. Citizens generally do not know
the facts. Until such a time as the national
government acquires the authority to supervise
the entire industry, every state should have a
supervision of its meat industry patterned after
that of the national government.

The work of the Bureau of Chemistry is
more generally recognized. Under the guid-
ance of Doctor Wiley it attracted great pub-
licity, which was educational. Its methods dif-
fer widely from those of the Bureau of Animal
Industry. When the Bureau of Animal In-
dustry establishes a quarantine for "foot and
mouth" disease it is heralded in the public
press; but few know of the millions of animals

NATIONAL. HEALTH AGENCIES 73

which are dipped to prevent the Texas cattle
fever, or realize the efficiency of supervision in
the meat industry. This bureau seldom appeals
to the courts. On the other hand, when the Bu-
reau of Chemistry confiscates articles of mer-
chandise found on the farm, on trains, or in
commercial establishments, it must appeal to
the courts for support. The writer believes that
better results would be obtained at less expense
to the people if the Bureau were given more
power to determine questions of fact, with per-
mission for appeal to the courts as to legal in-
terpretation of the statute. Every month there
are numerous condemnations; and in a large
share of the cases the defendants simply plead
guilty and accept their fines.

The Pure Food Act was passed under the
commerce clause of the Constitution; as such
it must be considered as purely a commercial
proposition. In the plainest terms the provi-
sions of the act are that goods which enter this
country from abroad or which pass from one
state to another in trade, must be just what
they are supposed to be; and that they must

74 AMERICAN PUBLIC HEALTH PROTECTION

not contain certain poisons, unless the fact
thereof be plainly stated on the label. When a
pillar of the church in Washington was ar-
rested for selling a habit-producing drug as a
cure for headache, though in fact it was simply
dope, and did not "cure" the headache, a vigor-
ous protest was raised against the officiousness
of Doctor Wiley. He continued his prosecu-
tions against these enemies of the public health,
and the patent-medicine combine finally se-
cured a change in the administration of the
bureau.

It is amazing to look through the records of
this bureau and see the number of prosecutions
which have been made successfully. They find
wormy breakfast foods and raisins, decayed
oysters, spoiled canned goods, milk so loaded
with bacteria as to be useless for food, and other
injurious articles of kitchen merchandise. They
find that many goods are adulterated, or in-
ferior articles are falsely labeled to be sold as
the more valuable. They find many articles
falsely labeled as to composition, or as to
weight. Should the bureau let patent medi-

NATIONAL HEALTH AGENCIES 75

cines alone it would still find plenty to do, and
it would meet with little opposition; but the
bureau wishes to protect the citizens from those
harpies who prey upon others' misfortunes. An
illustration of their methods may be instructive
and interesting.

A certain firm manufactured a "Consump-
tion Cure." They had in their number a medi-
cal graduate from a state university. He was
misfortunate, crippled and "needed the
money." He made the microscopic examina-
tions, and furnished what little scientific knowl-
edge was used in the business. The other
members of the concern furnished the capital,
and transacted the business, including the con-
duct of correspondence. Their training had
been received in a grocery store. The firm ad-
vertised widely, and offered to make micro-
scopic examinations of sputum free of charge.
A specimen was received, and after due time the
sender was informed that a large number of
tubercle bacilli were found; that his case
seemed to be severe but not hopeless ; that the
"cure" sold at a dollar a bottle, but that the

76 AMERICAN PUBLIC HEALTH PROTECTION

firm would send six bottles for five dollars;
and that the doctor would advise trying the
remedy ; that it would do no harm, and it would
help if it did not cure; and that after the six
bottles had been taken another examination of
sputum would tell just how the case was pro-
gressing. The money was sent, the medicine
received, and after a time another sample was
sent. Very promptly the "doctor" reported
that the examination showed very great im-
provement, and that another half dozen bottles
would doubtless complete the cure. The sam-
ples of "sputum" sent were not sputum, but
the liquor from oysters. The "cure" was ab-
solutely useless for any purpose except to ab-
stract money from unsophisticated victims, and
it is now one of the things of the past.

As a result of the activities of the Bureau of
Chemistry very many makers of patent medi-
cines have been obliged either to change the
formula of their articles, or to alter the label,
or to discontinue the sale entirely.

Vital statistics are the bookkeeping of a
health department. In the Census Bureau of

NATIONAL HEALTH AGENCIES 77

the Department of Commerce there are col-
lected such statistics of births and deaths as
seem to be reliable. Under the wise manage-
ment of the former Chief of the Division of
Vital Statistics, Doctor Cressy L. Wilbur, the
publications of this bureau were valuable
studies of the causes of deaths and death rates.
Unfortunately, his successor has not kept his
work up to the former high standard, probably
because he has not yet become thoroughly at
home in his new chair. It is one of the mis-
fortunes of our system of government that
competent men are made to step aside to give
some one else a job.

The Post-Office Department is aiding in the
work by refusing to permit its service to be
used by those who attempt to defraud the peo-
ple by the sale of useless or harmful drugs, or
by unlawful practise of medicine.

The Children's Bureau of the Department
of Labor is the last of the national agencies
created to guard the public health. This serv-
ice has little authority, and has accomplished
little as yet. Its work must be very largely in

78 AMERICAN PUBLIC HEALTH PROTECTION

the line of investigation. The search for data,
the collection of statistics, and the careful
study of the facts discovered must take time.
Miss Julia Lathrop, the head of the bureau,
has urged the passage and enforcement of
state laws compelling the immediate registra-
tion of all births, but it will probably be some
years before anything radically new should
originate from the studies. Early impressions
may be misleading in such investigations, and
when anything shall be done it should be done
rightly.

Lastly, in the Bureau of Education there is
an effort to collect especially all data bearing
upon education. Certain diseases or infections
have a retarding influence upon the progress
of the scholar. The result is that the educa-
tion of the pupil costs more. The arrange-
ment of schoolhouses, and of the curriculum,
not only have their influence upon the health
and life of the child, but they have also much
to do with the economy of school management.
For this reason the Bureau of Education has
from time to time published and distributed

NATIONAL HEALTH AGENCIES 79

information relative to such subjects. One,
for example, is upon the hookworm; another
on physical growth and school progress ; others
are the detailed results of school inspections
by medical officers in this country and in
Europe. These publications are helpful by
their educational effect.

Mention might properly be made of the new
Harrison law which tends, incidentally, to re-
strict the sale of certain narcotic drugs, by re-
quiring the annual payment of a small license
fee by all physicians, druggists and others dis-
pensing or selling the articles named, and re-
quiring special records of all sales or dispen-
sing of the drugs. The license fee is collected
by the regular collectors of internal revenue,
and the working of the law so far has been a
definite restriction. The required registration
of persons lawfully selling or prescribing these
narcotics enables state and local officers more
effectively to restrict the vicious use of the
articles.

It is the opinion of most sanitarians that
several of these national bureaus should be com-

80 AMERICAN PUBLIC HEALTH PROTECTION

bined into one department, under the leader-
ship of a member of the Cabinet who should
be, not a physician, but a sanitarian of broad
experience, and with constructive ability. Such
a head to the department should be permanent
in fact, though not by enactment. Such a
department is far more important to the peo-
ple of the land than two or three of the present
departments, but its establishment is opposed
by certain commercial cliques who have already
found that their business has been hampered
by the light of publicity. The opponents are
especially the patent-medicine manufacturers
and commercial "doctors" whose practise de-
pends upon misleading the people. Their
principal supporter in Congress has been a
member of the Christian Science organization.
One of the strong evidences for the need of
such a department is found in the hampering
influence of the Secretary of the Treasury
when the Marine Hospital and Public Health
Bureau were first attempting to cope with the
bubonic plague in California. That hamper-
ing influence was then instigated by the com-

NATIONAL HEALTH AGENCIES 81

mercial influences of San Francisco. It seems
strange, therefore, that the people of that state,
who have suffered so severely from this mis-
guided commercial influence, should permit
their senator to continue his opposition to an
honest and scientific administration of the work
of preserving the public health. Such a change
would not in any way increase the authority
of the nation over the subjects treated, but it
would permit the harmonizing of such various
activities, and would assist in having questions
determined by those who are trained and edu-
cated in that special kind of work. Each party
in the last general election promised in its plat-
form to work toward that end, but as yet the
present administration has been false to its
promise.

Since this movement has taken more definite
form the Public Health Service has been mak-
ing rapid development. It is the contention
of the friends of that service that it should be
made independent, and that the other agencies
should be added to its force, without making
other special changes, simply raising the sur-

82 AMERICAN PUBLIC HEALTH PROTECTION

geon-general of that service to the rank of a
Cabinet officer. There are many arguments
in favor of this arrangement, though some
have thought that it would be better to make
an appointment of the head from civil life.

The army has maintained a medical school
for the training of its medical staff , and the
Public Health Service has offered its facilities
for the training of a limited number of sani-
tarians. It seems to some advisable that this
educational aid should be open to a larger num-
ber, and that state and municipal officers of
health should be expected to make frequent
use of such facilities.

NOTE. In speaking of the relationship of the mosquito to
the spread of yellow fever, mention should be made of the
fact that to Doctor Carlos Finlay, of Havana, is the credit due
for suggesting that the stegomyia mosquito was the infecting
agent. As early as 1881 he published his suspicions. Though
he was unwavering in his opinion, he was unable to prove the
fact, and he found few supporters. The Reed board simply
demonstrated the truth of Doctor Finlay's assertion.

CHAPTER IV

MEDICAL AND SANITARY EDUCATION COMPARED

IT has long been the custom in the United
States to think that any physician is competent
to give sanitary advice, and to head a, health
department, but in point of fact there is not
one practitioner of medicine in five hundred
who knows the rudiments of modern sanita-
tion. The education, training, habits of
thought and objects of work of a good physi-
cian are very different from those of an ideal
public health executive. There has been,
among physicians who have been drawn into
public health work, a jealous resistance to the
appointment of any but physicians to the
heads of such departments; but considering
the general apathy of the medical profession,
their lack of training in this line and unwilling-
ness to alter their courses of instruction in har-
mony with recent advances in sanitary science,

83

84 AMERICAN PUBLIC HEALTH PROTECTION

this jealous resistance is changing to regretful
concurrence. The best education in the past
for health executives has been given in schools
of engineering. There is less in common be-
tween the ordinary medical practitioner's work
and that of the public health worker than there
is between either and the practise of dentistry.
In the Journal of the American Medical As-
sociation for July 24, 1915, p. 321, there is an
article by Professor Milton J. Rosenau, for-
merly Director of the Hygienic Laboratory
of the Public Health Service, and now the
head of the Public Health School of Harvard
University. It begins with the following
statements:

"It may be a surprise to the readers of the
Journal to learn that hygiene is included as a
major subject in the curriculum of only three
medical schools in this country, namely, the
University of Pennsylvania, the University of
Michigan, and Harvard. The teaching of
hygiene is becoming increasingly difficult, on
account of the widening scope of the subject,
including preventive medicine, sanitary en-

MEDICAL AND SANITARY EDUCATION 85

gineering, vital statistics, epidemiology, in-
dustrial hygiene, and public health activities
generally. It has become necessary to estab-
lish special schools with graded courses to meet
the demand of training men to become public
health officers. It is slowly becoming recog-
nized that the training received for the M. D.
degree, even in our best medical schools, does
not properly fit a man to enter public health
work. Sanitation and hygiene has become a
separate profession."

In looking through the curriculum of a
leading medical school one finds that the course
of four years of study comprises approximately
4,000 hours of work. In the first year 576
hours are devoted to anatomy, and 400 to
chemistry and physiology. In the next year
128 hours are given to topographical anatomy,
144 to bacteriology, 56 to hygiene, 128 to
physiology, 112 to diagnosis, and 192 to pa-
thology. In the next year forty-eight hours
are devoted to diseases of children; and sixteen
hours are given to medical jurisprudence, but
it is taught from the standpoint of the medical
practitioner, and has no value for the public

86 AMERICAN PUBLIC HEALTH PROTECTION

health executive. The entire balance of the
course is composed of surgery and various
lines of studies in practise. The entire course
in anatomy, as far as it applies to the work of
a health officer, could be given in one hundred
hours, especially considering the time devoted
to topographical anatomy. We find then that
out of the 4,000 hours of a medical course only
1,308 have special value for the public health
worker. On the other hand, a great deal of
the course is devoted to the technical training
of the surgeon, a training which simply tends
to attract attention away from the essential
subjects for the sanitarian.

By way of contrast, the public health worker
should have a training in zoology, which would
be useless for the man practising medicine or
surgery. This training should enable the sani-
tarian to be able to recognize the difference be-
tween the culex, stegomyia and anopheline
mosquitoes, either in the egg, in the larval
stage, or in the adult insect. He must know
the habits of the different species. He must
know the habits of different varieties of flies,

MEDICAL AND SANITARY EDUCATION 87

and where they breed. He must know the
species of rats, and their habits. He must
know the life history of various disease pro-
ducing protozoa. He must have a working
knowledge of sociology, and of the science of
sanitary engineering. His laboratory train-
ing must devote much of its attention to sub-
jects of no special interest to the medical prac-
titioner. He must be able intelligently to
study vital statistics, detecting possible errors
in reports and the relationship between cause
and accidental concurrence. He must have a
general knowledge of veterinary medicine.

Epidemiology treats of the methods by
which diseases are spread. This is a science,
far more definite than the medical practitioner
can imagine. In many instances it is reduced
to mathematical exactness, of great importance
to the sanitarian. For example, a yellow-fever
patient can not infect a mosquito after the first
three days of the disease. The infected mos-
quito is harmless for the first twelve days after
he has bitten the first patient. On the other
hand, the malarial patient may infect the raos-

88 AMERICAN PUBLIC HEALTH PROTECTION

quito at any time during the progress of the
disease, and after about eight days that mos-
quito is prepared to infect other persons.
After feeding upon the patient the stegomyia
remains at the house, but the anopheles returns
to its breeding place. These distinctions have
little bearing upon the work of the medical
practitioner. He is not called until the patient
is sick, and he is paid only for guiding his
patron back to health. If the sanitarian is
successful, the medical practitioner has nothing
to do.

Aside from his knowledge of the science of
preventive medicine it is absolutely essential
that the public health executive should have a
thorough knowledge of the legal principles
of administrative law* The changes in the
science of prevention must make differences in
the methods of administration. To make the
work effective it is requisite that the official
should not attempt to do anything which is
unlawful, that he must do all that is required
by law, and that he attempt only those things
which he may carry through successfully. The

MEDICAL AND SANITARY EDUCATION 89

fact that certain practises have been permitted
in the past is no sufficient reason for thinking
that they will be permitted to continue, and the
bases of legal decisions have already been
changed. For example: A tannery in Texas
was sued for the death of a neighbor from ma-
laria. It was shown on trial that the patient
died from malaria, and that the place was kept
in a dirty condition, surrounded with flies, and
a judgment was rendered against the tannery.
On a rehearing before the Supreme Court the
verdict was reversed, on the ground that it was
not shown that there were any anopheline mos-
quitoes bred upon the premises, and it is only
by those insects that the disease can be propa-
gated.

The legal responsibility of cities and private
corporations and individuals is being more
'fully recognized for the spread of infectious
j disease. For example, Mankato, Minnesota,
.was assessed damages for typhoid fever re-
ceived through the city water supply, and milk
companies have been punished for communi-
cating disease in the milk sold. This liability

90 AMERICAN PUBLIC HEALTH PROTECTION

of the city increases the necessity for having a
competent person to keep constant guard over
the health of the city.

Science is universal, and the fact which is
true in one country is also true in another. The
result is that the man of science naturally feels
that the governmental plan which is efficient
in one land should also be effective in another.
Unless he has had a training in comparative
governments he is unprepared to meet the
legal obstructions which bar his path. So, too,
the scientific man has difficulty in comprehend-
ing the legal distinctions which are absolutely
necessary for preserving the rights and liberty
of citizens. For example, a health official was
complaining about the result of his prosecu-
tions for violations of ordinances. He said:
"No matter how carefully we work up our
cases, they are knocked out on little legal tech-
nicalities." He failed to realize that it was not
sufficient for him to find poison in an article
of food, but he must convince the court that
without reasonable doubt that poison had been
so mixed in the food by the person accused. In

MEDICAL AND SANITARY EDUCATION 91

fact, in the case then being considered he could
not prove that the food was actually purchased
in its then condition from the merchant ac-
cused. The prosecutions of this officer .occupied
his time and attention, but failed to bring re-
sults because he did not appreciate the legal
principles involved. In the place of being ef-
fective for good they simply created prejudice
against the department. The training in the
law of public health is one of the most import-
ant portions of the public health official's edu-
cation.

Not long ago some one in speaking of this
subject said that a knowledge of the law of
public health gives the health officer more
power by showing him what power he already
has, by pointing out accurately the legal
limitations upon his present power, and by
suggesting what additional powers can be ob-
tained, and by what methods. It makes it pos-
sible for him to pursue vigorously a definite,
aggressive policy, without fear of overstep-
ping his legal authority. This certainty in his

92 AMERICAN PUBLIC HEALTH PROTECTION

work will bring more satisfactory results than
he has ever known before.

This education is not even hinted at in any
medical school in America, aside from some of
those attempting to give special instruction in
those branches for the degree of Doctor of
Public Health.

Nor is it sufficient answer to say that the de-
partment has the services of an attorney at its
disposal. Relatively few attorneys are posted
upon adminstrative law, and it is absolutely
necessary that a lawyer handling such cases be
posted upon the scientific facts, and their bear-
ing upon the case in hand. This is frequently
illustrated in the experiences of every live de-
partment of health. The result is constant
vexation and disappointment for the conscien-
tious conservator of the public health. Im-
portant cases are lost, and ordinances declared
unconstitutional, because the attorney has
failed properly to grasp the significant fea-
tures. For example: In a certain case the
prosecution was being made under a city or-
dinance. If the contention of the subordinate

MEDICAL AND SANITARY EDUCATION 93

jn the health department was correct it was
simply a question as to the authority of the city
to pass the ordinance, as admittedly the facts
were as stated by the city officers making the
inspection. However, not realizing the scien-
tific basis for the ordinance, the attorney for

/

the prosecution insisted on trying the case on
the interpretation given by the inspector. For
the same reason, and not realizing that it is
necessary that there be a scientific reason for
such an ordinance, the inspector had made an
interpretation which could not stand in a high
court. The result of such a trial is to have the
ordinance declared unconstitutional, when in
fact, under an interpretation in harmony with
scientific facts, the ordinance was both reason-
able and constitutional. The test was tiresome,
occupying much time which might have been
spent more profitably, and it was foredoomed
to failure. It irritated the defendant, and
made him feel that he was being persecuted.
All this happened because there was no one
person who was able to harmonize the facts
of science and the principles of law. Every

94 AMERICAN PUBLIC HEALTH PROTECTION

case which is successfully prosecuted tends to
strengthen health administration, but adverse
decisions create distrust, prejudice and con-
tempt of departmental efforts.

The treatment of sewage and the disposal of
garbage are some of the great problems for the
modern city. Neither is exclusively a problem
for the engineer, though both may be handled
chiefly in the engineering department of the
city. There are certain points upon which the
advice of the health official must, or should, be
sought, and to give his advice intelligently it is
needful that he know something of engineer-
ing. How many physicians know the differ-
ence between a garbage reduction plant and an
incinerator? How many are prepared to ad-
vise between a mechanical and a slow sand fil-
ter for the public water supply? How many
would be prepared to act promptly and effi-
ciently should the public water supply become
temporarily polluted with sewage?

Some time ago a number of families located
a beautiful suburb, for their summer homes
especially, within easy reach of an eastern city.

MEDICAL AND SANITARY EDUCATION 95

It was found to be a particularly healthful lo-
cality, and with modern sanitary appliances in
the little city its future looked promising.
Property rose in value and the population in-
creased. Then some bright mind conceived the
idea that an electric road connecting the suburb
with the larger city would be a good invest-
ment and a help for the suburb. The line for
the road ran across a piece of low land. Before
the road was completed malaria made its ap-
pearance in the suburb. It increased in preva-
lence, and the suburb became known as a home
of malarial fevers, and the boom of its real
estate burst. When the harm had been done,
and the town had been ruined beyond recovery,,
some sanitarian made an investigation. He
found that the low ground was infested with
anopheline mosquitoes, and that the laborers
who constructed the road were old-country
Greeks, who had not been long in America.
Now it is well known that malaria is very prev-
alent in Greece, and it is very probable that
these immigrants brought the malarial infec-
tion and gave it to the suburb through the

96 AMERICAN PUBLIC HEALTH PROTECTION

agency of the mosquitoes. The ordinary phy-
sician is not prepared to deal with such a prob-
lem. He treats his patients to get them well.
He knows how to do that; and if other cases
occur in the family he advises a change of lo-
cation, and washes his hands of the perplexing
matter. If, in addition to practising medicine,
he happens to be the sanitary adviser of the
community, he generally stoutly denies that the
infection is local or common. He does not
have the least idea how to begin the investiga-
tion as to its origin.

Under exactly the same circumstances, the
wide-awake and trained public health official
immediately isolates each case from mosquito
attack, and begins a war of extermination, not
against the culex, or the stegomyia mosquitoes,
but against the anopheles, especially those
which are likely to come in contact with previ-
ous cases. To do this, he must know where to
cut grass and bushes, where to "train" streams,
where to use oil, where to fumigate, and how
to trace the insects which invade a given house.
With such treatment of the case there should

MEDICAL AND SANITARY EDUCATION 97

have been no depreciation in the value of real
estate, and the number of cases should have
been very limited.

Another evidence as to the difference of
view-point between the physician and the sani-
tarian is found in the following incident. The
head of a certain metropolitan university was
jadvised to require evidence of successful vac-
cination from all candidates for matriculation.
He was surprised at the advice — surprised be-
cause if it were necessary he thought the medi-
cal advisers of the institution should have said
so. He referred the matter to them, and they
promptly said that it was not necessary, "be-
cause the law requires all children to be vac-
cinated before they enter the grade schools, and
practically all students are vaccinated before
they come to us." The medical advisers were
the dean of the medical school and the profes-
sor of chemistry of the same school. The facts
were that there was no vaccination law in that
state, and returns from over the state showed
that relatively a small proportion of grade-
school pupils showed evidence of vaccination,

98 AMERICAN PUBLIC HEALTH PROTECTION

and that a goodly proportion of the students
in that university were not vaccinated, and that
within a short time one or two of those unvac-
cinated students contracted smallpox. If two
of the leading members of the faculty of one
of the foremost medical schools in the United
States make such an error as this, what can be
expected of an ordinary practitioner of medi-
cine?

One may frequently hear, as an argument
for not paying proper compensation for the
work of a health officer, that it is a good ad-
vertisement for a young doctor, and that it will
help him to establish a practise. No greater
error could be made. There is a statement in
the Good Book to the effect that no man "can
serve two masters: for either he will hate the
one, and love the other; or else he will hold to
the one, and despise the other." Ye can not
serve the public health and private medical
practise. That has always been true, and now
it is still more true than formerly. This fact
should be clearly appreciated by every citizen.

First, the very time when it is most neces-

MEDICAL AND SANITARY EDUCATION 99

sary for the conservator of the public health to
give the public the best of his service is also
the time when the demands of a private prac-
tise are the most urgent. If he is paid for the
private work at a higher rate than for his pub-
lic service it must mean privation for himself
and for his family if he takes the time from his
patients to destroy the practise of his brother
practitioners by preventing sickness.

Secondly, the line of thought of the doctor
who is treating his patients is very different
from that of the public health worker. One
can not travel two roads at the same time.

Thirdly, every conscientious conservator of
the public health arouses personal enmity.
Other physicians are prone to think that they
are being discriminated against, and their pa-
tients feel sure that the law is more severely
executed against themselves than against the
patients of the health officer. Then, too, his
own patients feel that they should have certain
privileges, and if these are not forthcoming the
patients object. They object still more strenu-
ously if they feel that the doctor neglects them

100 AMERICAN PUBLIC HEALTH PROTECTION

in their hour of need. If he be not engaged in
private practise many will still feel that he is
unduly severe with them. They forget that the
law demands that certain things he done, and
that the doctor is only a servant, sworn to exe-
cute the law as it stands.

No doctor engaged in private practise lias
probably ever served honestly and faithfully
as a health official and not thereby injured, or
ruined^ his private practise. It is undoubtedly
true that many doctors have increased their
private business while holding such a public
position. They may have done so honestly,
in so far that they did not use their posi-
tions to divert patients from other physicians,
though they neglected their public work when-
ever private business was urgent, and they
used their leisure time in self-advertisement
through their official positions. In other cases
they have "used the livery of heaven to serve
the devil in," making use of their positions to
undermine their fellow practitioners, or for
hunting victims for their operative or other
practise. There are some in the medical pro-

MEDICAL AND SANITARY EDUCATION 101

fession, as there are in the pulpit, who are a
disgrace to their professions. In neither case
should the profession be judged by these black
sheep. To ask a medical practitioner to serve
as a public officer of health and not pay him
amply therefor, is to put a premium upon dis-
honesty.

In this connection it is profitable to consider
the words of the Greek physician, Hippocrates,
who wrote four hundred years before the time
of Christ: "Such persons are like the figures
which are introduced in tragedies, for as they
have the shape, and dress, and personal appear-
ance of real actors, but are not truly actors,
so also physicians are many in title, but very
few in reality." This statement is true in the
United States to-day as it was in ancient
Greece, and it is very much more true of pub-
lic officers of health.

For a city to ask a medical practitioner to
be its health officer, and not give him ample
pay therefor, is practically to attempt to com-
ply with the letter of the law and evade its
spirit; to appoint an officer, and make it an ob-

102 AMERICAN PUBLIC HEALTH PROTECTION

ject for him to neglect his duties. Generally
under such circumstances the city pays the of-
fice all that the services rendered are worth.

In spite of the usual treatment of such posi-
tions in this country there is an honest hody of
workers who come nearer to the ideal of Christ
than any other body of men on earth. In
searching for the cause of disease, and means
for its eradication, many have given their lives
that others might live. There was the son of
Sir Patrick Manson who submitted to the in-
fection with malaria to prove the instrumental-
ity of the anopheles mosquito, and later died
of an accident while on an investigating ex-
pedition. There was Doctor J. Everett Button
of the Liverpool School of Tropical Medicine,
who died of relapsing fever while investigating
the African sleeping sickness. There was Doc-
tor Walter Myers of the same school who died
of yellow fever at Para, Brazil, while study-
ing that disease. In America there were
Lazear, Carroll and Reed who died as the re-
sult of their investigations on the same disease.
There was Doctor Howard Ricketts who sue-

MEDICAL AND SANITARY EDUCATION 103

cumbed to typhus just as he proved the instru-
mentality of the body louse as the carrier of
that infection. There was McClintick who
was offered up to the Rocky Mountain fever.
There have been others, willing victims for the
good of humanity.

Many physicians have willingly given of
their time and energy to solve these problems
of human life, taking it from their private
practise, often suffering privations therefor.
They have done so without compensation
oftentimes. They have done it recognizing
that their work, if successful, must diminish the
possibility of earning so much in private prac-
tise. This conduct is incomprehensible by com-
mercial minds. No other class of men on earth
have deliberately set about the destruction of
their very means of support, yet physicians
have always been the leaders in efforts to elim-
inate disease. If a preacher conducts a revival
and assists in the conversion of many souls he
thereby increases the size of his church, and
thus tends to increase the size of his salary.
The inventor who works out some great im-

104 AMERICAN PUBLIC HEALTH PROTECTION

provement in machinery thereby increases his
opportunity for accumulating property. But
the physician who demonstrates how a disease
is produced, and the means for its eradication,
thereby destroys another source of self-sup-
port. It was physicians who called attention
to the large amount of typhoid fever in Chi-
cago, and the means to be used for its reduc-
tion. As a result, in 1915, it has been estimated
that the physicians of the city -made about
2,000,000 less calls on patients sick with that
fever than they would have made at the old
rate. The sense of benefiting their fellow
men is their only reward. With the reduction
of typhoid, and as a result of the same measures
as used for that disease they also have lost the
chance to make many more professional calls,
and in consequence very many practitioners in
that city have felt most keenly the pinch of
poverty.

A physician who had made a careful study
of a certain epidemic, and proved conclusively
its cause, and had materially aided in checking
its ravages, one day met one of his patrons.

MEDICAL AND SANITARY EDUCATION 105

The gentleman commended the doctor for his
"grand work," and urged him to keep it up.

"I can not afford it," the doctor replied.

"Why not? You are saving lives, and are
specially fitted for such investigations."

It was a case of milk infection, and the doc-
tor had been threatened with damage suits for
his exposure of the agency. He asked his
patron: "Supposing I knew that you were
taking that milk, what would you have ex-
p^ctedme to do?"

"Tell me," was the reply.

"Yes, and what would you have done?"

"I should have changed my source of sup-
ply," said the patron.

"Yes, and supposing I had not told you?"
asked the doctor.

"I suppose that my two children would have
taken the fever."

"And you would have employed me?"

"Certainly."

"And you would have considered yourself
lucky if my bill had not been more than twenty-
five dollars?"

106 AMERICAN PUBLIC HEALTH PROTECTION

"Certainly."

"But you think I should have told you, and
warned you?"

"Of course."

"And what compensation would you have
expected to give me for the warning?"

"Why, I should have thanked you."

"The grocer is willing to accept the twenty-
five dollars, but he does not accept thanks for
his goods."

Here is a problem in morality. Should a
doctor starve himself and his family for the
pleasure of saving the sickness of the family
who is able, but unwilling, to pay him for the
greater service, but who cheerfully pays for
the less noble work of treating the sick?

Or, put it in another way. Should a man be
expected to devote many years of study, at a
cost of thousands of dollars, and then enable
the people of his city, or county, or state, or
nation to make more money as a result of
health preserved, when the community, either
great or small, is unwilling to compensate him
for his service? Does it show good business

MEDICAL AND SANITARY EDUCATION 107

sense for a community thus to seek a special
service, and not pay at least as much as the of-
ficer could earn in some other way? Would
any business man expect to conduct his private
business on any such plan? If he refused to
pay the foreman of his manufacturing plant
which was making a good profit, would he not
find that the foreman would either neglect the
business, or else that he would collect his pay
in some other way while he still retained his
position. In ordinary business if a man is will-
ing to hold a position with a nominal salary
while his labor is yielding a good income for
the proprietor, and he may easily obtain an-
other position where he can make a good living,
is not the fact of his remaining strong evidence
that he expects to get his compensation in some
other way?

So long as public health was not a special sci-
ence requiring years of expensive study to fit
him for the place, and one person could fill the
position as well as another, there might have
been some justification in the statement that
the citizen owes something to the community;

108 AMERICAN PUBLIC HEALTH PROTECTION

but now that it is a special science which finds
small opportunity for employment outside of
official life, there is no justification in expect-
ing such an officer to sacrifice himself and his
family for the benefit of others, and that with-
out adequate compensation.

The medical practitioner has little occasion
for studying the mechanical and biological
problems of the milk production and the dairy
business, but a thorough acquaintance with
that important line of food products is an es-
sential for the health official. He must be able
to tell at a glance whether conditions are fairly
satisfactory. These questions are not bare tech-
nical theories; nor do they depend upon strict
formula* which may be printed and studied in
the office. They are matters of training which
require full time and attention. They involve
the condition of the cattle, the character of food
given, the nature of gracing land used, the
disposal of manure, even where it may be left
in the field, the nature and condition of other
animal life around the place, the manner of
milking, the method of cooling and bottling

MEDICAL AND SANITAHY EDUCATION 109

the milk, the condition of the bottling and cap-
ping machines, the operation of the pasteurizer,
the after care of the milk from the time it is
put in the bottle until it is put in the stomach
of the user. Of course, he must know the hab-
its and health of all connected with the trade.
In one instance a man was found capping bot-
tles while his hands were still rough and scal-
ing from a light attack of scarlet fever. In
another the children of a household were cough-
ing and sneezing with measles in a kitchen
where the milk was strained. Milk from tuber-
cular cows is frequently sold for children's con-
sumption unless the officers prevent it.

There is another line of study which is im-
portant for the public health official. He must
have at least a general knowledge of veterinary
medicine. This is far more important than all
that he could know of human surgery. Rabies
is a disease which is communicated to human
beings only from the lower animals, and not
one physician in a thousand knows a rabid dog
when he sees it. Tuberculosis is communicated
from cattle to men, and especially to babies.

110 AMERICAN PUBLIC HEALTH PROTECTION

Anthrax is more common among the lower ani-
mals, but its toll of human life is not unknown.
The tapeworms found in human beings are all
derived from lower animals. Glanders, a dis-
ease of horses, probably kills more human be-
ings than any one is aware of, the diagnosis in
human beings being often incorrectly made.
The Malta fever, which Sir A. E. Wright and
others of the English army have so perfectly
studied, is a disease contracted from goats. It
is now prevalent in Texas, and may at any time
make its appearance in some other locality. It
must be remembered that goats are frequently
kept especially for infant feeding. The bacil-
lus of lockjaw is frequently found in horses,
and it may be a common resident of the horse's
intestine without showing its presence by toxic
symptoms. "Lumpy- jaw," or actinimycosis is
a common ailment among cattle, and human
beings sometimes contract it from the cattle,
either directly or indirectly. As with glanders,
the disease is sufficiently rare among humans
so that physicians have difficulty in correctly

MEDICAL AND SANITARY EDUCATION 111

making a diagnosis. The cow-pox is suf-
ficiently rare in America so that it is relatively
unimportant, especially as its occurrence in the
human species is not severe, and is protective
against smallpox. Ring-worm is transmitted
from human beings to cattle, and back again,
and may possibly explain other ailments found
to be related to milk supply. Diphtheria may
be carried by domestic animals, and other dis-
eases may be shared between the human and
lower animals.

In addition to the specific diseases which
may thus be communicated from the animals,
there are other ailments which may be the re-
sult of eating meat from diseased hogs par-
ticularly. The flesh of those suffering with
hog cholera, though it may not look specially
bad to the uninitiated, contains a poison which,
when it is eaten, produces great prostration
with diarrhea. Cooking will kill bacteria, so
that if the meat has been thoroughly cooked
there is no danger that a person will contract
tuberculosis, for example, from eating the flesh

112 AMERICAN PUBLIC HEALTH PROTECTION

of a tuberculous cow; but cooking does not al-
ways kill the poison which may be the product
of a bacterium.

In all these cases the prevention of future
cases of illness may depend quite as much upon
the recognition of the disease in the cow, horse,
goat, sheep, dog, cat, pigeon, chicken, goose
or duck, as upon the correct diagnosis of the
human patient's ailment. The foot and mouth
disease of cattle is essentially a disease of the
lower animals, but it sometimes infects human
beings, and it is still a question whether or not
milk from the infected animals may not cause
human infection, even though the utmost care
be taken. However, the disease generally re-
sults in a rapid drying of the milk production.

The enumeration given by no means ex-
hausts the list of subjects with which the
health official must become at least generally
familiar, even though it be no more necessary
for him to know how to treat diseased animals
than to treat human beings. There is no know-
ing where it may be necessary for him to direct
his attention. He must be prepared to meet

MEDICAL AND SANITARY EDUCATION 113

every new situation and make the needed orig-
inal study.

Rats are great travelers. They hide in
freight cars and in the holds of ships. The rat
and the flea have formed a partnership for the
distribution of the bubonic plague. So far as
known this disease has not yet come nearer to
Chicago than New Orleans; but to-morrow it
may be discovered that the disease is already
hi the first named city. It is manifestly impos-
sible to kill every rat in the entire city immedi-
ately, but it would be necessary to begin the
task at once, examining every animal for evi-
dences of the malady. When an infected rat
has been found the location where it was caught
or killed must be taken as the center, and be-
ginning at the outside of a given radius it will
be necessary metaphorically to "rake the dis-
trict with a fine-toothed comb" to make sure
that every rat in that district has been killed.
The location where each is found must be
marked upon the tag by which it can be identi-
fied, and if another infected rodent appears its
location must be considered as a new center

114 AMERICAN PUBLIC HEALTH PROTECTION

possibly. It is easy to blow out the light of
a match. A bonfire may be more resistant.
A conflagration in which fires are burning in
many places over an entire city is exceedingly
difficult to master.

Doctor Lilian South of the Kentucky state
board office, in discussing the work of extermi-
nating the hookworm, remarked hi the presence
of the writer, that one of the greatest obstacles
with which they had met was the apathy of
school teachers who have come from northern
universities. They have not been taught the
rudiments of hygiene in their alma maters, and
they frequently come with the most erroneous
notions. The result is that they are apathetic,
or they are officiously active in the wrong di-
rection. Not long ago the health commissioner
of a large city announced a campaign against
the fly. He called a number of physicians to-
gether, and asked them to give public lectures,
especially before the school children. One of
the professors in a medical school suggested
that some of them, including himself, needed
to study the subject before they would be able

MEDICAJL AND SANITARY EDUCATION 115

to give such lectures. The commissioner,
though prominent as a surgeon, and as a for-
mer head of a medical college, was utterly un-
trained as a sanitarian. He assured the gen-
tlemen present that they were all quite well
qualified to give such talks, and he handed
around typewritten outlines of such lectures.
Those outlines were filled with the spectacular
features of the dangers of fly infection, and
of bitter denunciations of the insects, but they
told nothing definite of the manner in which
flies could, and should be exterminated. He
did not know, and while riding through that
city on the public trams one might see hun-
dreds of manure piles where the flies bred, and
those piles remained day after day, and from
one week to the next.

The fact is that the greatest aid a health ex-
ecutive may have in eliminating certain kinds
of nuisances will be found in a proper use of
the school children. But the children must be
taught, and that means that the teachers must
learn the facts in the normal schools and col-
leges. No teacher can get a certificate enti-

116 AMERICAN PUBLIC HEALTH PROTECTION

tling her to teach even in the grade schools of
North Carolina until she has passed an exam-
ination in general sanitation; and yet our
northern universities- and normal schools do not
give such courses!

There are two chief aims in a proper educa-
tion. First, the student must be trained to
think and to observe. Secondly, there are cer-
tain things which he should learn and know.
There is no line of study which more fully com-
plies with these two possibilities than does the
matter of public health ; yet when a committee
attempted to enlist an interest in such courses
in normal schools and colleges a few years ago
they were met with almost universal objection.
They were told that the schools had no money
for such instruction, and that there was no de-
mand on the part of the students for such in-
struction. No demand on the part of the stu-
dents! When, pray, did the college professorial
faculty condescend openly to be led by the
student body? No money for such instruction?
Of course not, for the colleges which should be
leaders in advanced work for the benefit of

MEDICAL AND SANITARY EDUCATION 117

humanity are so wedded to the commercial ob-
ject that they have not been able to look ahead
and comprehend what may be the needs for the
future, or their moral duty in the nation.

Those who are seeking to qualify themselves
for some money-making profession are willing
to pay for their instruction, but those who are
simply seeking a general education can not af-
ford to pay fully for instruction in a branch
which will not be their bread winner. The
form of instruction to which reference is here
made is not that which would make public
health specialists, though it might give to some
a glimpse of a future of which they now can
have no idea. What is here suggested for a
course in normal schools and literary colleges
is just the general facts of the present-day
science— such facts as will enable the student
to become a better citizen and make him an aid,
not a hindrance, in the general work of sanita-
tion. Such as will fit the grade-school teacher
to guide her pupils toward a better existence.
Such as will make people better, happier and
more prosperous.

118 AMERICAN PUBLIC HEALTH PROTECTION

One would be considered lacking in mental-
ity if he undertook to bail out a boat without
stopping up the hole through which the water
entered. Is the man any less foolish who en-
dows hospitals for the care of the sick, rather
than to endow the work of preventing sick-
ness? Hospitals are needed, but were disease
production checked, it would soon be found
that we have more hospitals than are necessary.
The graduated engineer has before him plenty
of opportunity for obtaining self-supporting
employment, and he can therefore well afford
to pay for his training. Why then should
chairs in engineering schools be endowed, if
to furnish such professorships the teaching of
public health must be neglected even to the
point of forgetfulness?

Aside from positions at the head of health
departments, there should be an opportunity
for many to be employed in minor capacities.
City and state departments of health have need
for the employment of many inspectors and
other workers. These employees should have
a special training and education. At present

MEDICAL AND SANITARY EDUCATION 119

the best that can be done in most instances is
to take those who give promise of efficiency
and train them after they are appointed. Why
may not every literary college give such in-
struction as will enable graduates to take such
positions and do intelligent work from the
first? Why may not special courses be de-
designed and special degrees given with this
in view? Just as soon as the people realize that
economy and self-interest demands trained
health workers at reasonable pay, then the day
of the political grafter and incompetent of-
ficer will have passed. Until then good health
service should not be expected.

CHAPTER V

CHANGED SOCIAL AND ECONOMIC CONDITIONS

IN a previous chapter we said that for-
merly practically all the work of public health
protection was performed by local officers.
The measures used were the most primitive
and simple. They consisted chiefly in isolat-
ing those sick with diseases recognized as
communicable, holding them in quarantine un-
til it was supposed that danger of infection
had ceased, and then fumigating the premises
or destroying bedding and clothing, generally
by fire. In addition there was some attempt
at abating things or conditions recognized as
public nuisances. Only a few diseases were
quarantinable. Diphtheria, scarlet fever, ty-
phoid fever, malaria and other maladies which
to-day are known to be transmissible from pa-
tient to patient, either directly or through the
instrumentality of insects or other species of

120

SOCIAL AND ECONOMIC CONDITIONS 121

animals, were formerly regarded as due to
some uncertain condition, generally some pe-
culiarity of the atmosphere, or of water. Small-
pox, yellow fever and cholera were the only
common diseases in America to be quarantined.

Changes in two widely dissimilar regards
have materially altered the former practises.
Scientific advances have brought a defmiteness
of procedure impossible before, and they have
not only greatly' enlarged the number of dis-
eases which are properly within the authority
of the health administrator, but they have also
demonstrated that each disease must be han-
dled in a manner peculiar to itself. Of this
we shall speak in the following chapter. Here
we must consider the results of the changes in
the social and economic fabric of the nation.

In an isolated farming community there are
few problems in public health administration.
Families are isolated so that infectious diseases
have less opportunity for spreading. It is true
that diphtheria, for example, did formerly go
through such communities, reaping rich har-
vests; but it was because the disease was not

122 AMERICAN PUBLIC HEALTH PROTECTION

suspected of being infectious. Not being so
recognized, the sick were frequently visited by
their ordinary companions, and were caressed
and fondled. Funerals were widely attended.
In one such community the following incident
came under the writer's official notice. There
had been many cases of "ulcerated sore throat,"
and several had died. Two cases came into the
writer's jurisdiction and were recognized as
diphtheria. When their bodies were taken
home for burial there were other cases in the
same family, and a nurse was engaged to as-
sist in the care. The attending physician was
also the local health official. One evening there
was a public dance in a neighboring school-
house, and the physician took the nurse directly
from the house of sickness to the dance. Up
to that time he had not regarded the local sick-
ness as "catching." It was before the days of
bacterial diagnosis, so that a definite diagnosis
was not so possible as at present. Immediately
after that dance there was an outbreak of what
the doctor recognized as diphtheria. It swept
through the entire township, and there were

SOCIAL AND ECONOMIC CONDITIONS 123

few houses which escaped its visitation, and the
harvest gathered by the grim destroyer was
far from small. When, under the instructions
of the state board of health, the infectiousness
of the disease was recognized, the natural iso-
lation assisted in immediately checking fur-
ther progress.

In a farming community, where every house
has its own well or spring, the problem of pure
water is not difficult of solution. It is true that
many wells were so placed that they received
infected drainage, but that was easy to alter
if the people could be convinced. In one in-
stance the writer asked about the water supply
and was told that it came from a "spring."
He examined, and found that a box had been
lowered into the ground close to a ditch.
Household waste, including discharges of the
body, was thrown on the surface of the ground
which sloped away toward the "spring," only
a few yards distant. When the inspector said,
"Here is where your disease comes from, and
you must fill this hole and get your water from
some other source," the housewife indignantly

124 AMERICAN PUBLIC HEALTH PROTECTION

replied that the water was clear and pure, and
that "the disease came from heaven." The
water was clear and cold, and probably did not
taste offensive. The authority assumed by the
officer was firmly enforced, and no further
trouble arose.

The disposal of nightsoil and garbage is no
great problem upon the farm. There is little
danger of receiving an infection like diph-
theria or typhoid through the milk of an iso-
lated farm, though at one time it was suspected
that scarlet fever was so produced, but such
cases were attributed to an infection received
by the cow because of drinking bad water, or
as a result of illness of the cow.

When the country gives place to city con-
ditions, some other disposal must be made of
the garbage, the nightsoil and the household
slops. Private wells must give place to a com-
mon water supply, derived from a distance,
and from a source of known purity. Privies
give place to water-closets, and ditches to sew-
ers which conduct the waste to a distance. But
sewers pollute streams, so that the sewage must

SOCIAL AND ECONOMIC CONDITIONS 125

often be purified. At first it was simply run
through settling tanks, where the gross impur-
ities were permitted to sink to the bottom, and
were then occasionally cleared out. Then came
the septic tanks, where bacteria partially di-
gested the organic material. However, it was
found that the septic tanks frequently refused
to work satisfactorily in the summer-time. The
scum was broken up by escaping gas, and the
odor which arose was very offensive. Doctor
Karl Imhoif , of the Emscher sewerage district
in Germany, invented an improved form of
tank. This takes the crude sewage, and dis-
charges water which is often clearer than that
of the stream into which it flows, and with the
number of harmful bacteria greatly reduced.
A running stream has the power of diluting
and purifying a certain amount of sewage, and
in most small country cities this Emscher tank
may be sufficient. However, after the effluent
is discharged from the tank it may sometimes
be necessary further to purify it, either by
the use of chemicals, by filtration, or perhaps
by exposing it to the purifying effect of air

126 AMERICAN PUBLIC HEALTH PROTECTION

by spraying it upon an exposed surface. Ex-
cept in very isolated sections, or when dis-
charging into a very rapid stream, falling over
rocks or dams where the water is much ex-
posed to the action of the air, it is doubtful
if sewage should ever be permitted to run into
a river without first having been passed
through an ImhofF tank.

Upon the farm the household garbage may
be fed to the chickens or pigs ; but pigs can not
be kept in town, and it is not safe to feed much
to fowls. Garbage furnishes food for flies and
rats, two pests which should not be tolerated
in town. Manure upon the farm has a definite
value, and the intelligent farmer may easily
care for it so that it will not be a nuisance. In
town the manure furnishes a fine breeding
place for flies and rats. It must be kept in
boxes or pits with Water-tight bottoms, which
must be swept out at least once a week during
the fly-breeding time. It should be made proof
against rats, and the surrounding ground be
kept clean and dry. If the ground be per-
mitted to receive the drainage from the manure

SOCIAL AND ECONOMIC CONDITIONS 127

box, that too will prove a breeding place for
flies. Stables in the country need not have
tight floors, but in town there should be no
place for rats to get under the floor, unless the
floor be high enough for the easy access of
dogs and cats, and the floor should be water
tight so that manure seepage may not so pol-
lute the ground as to furnish a possible breed-
ing place for flies. The barn should be as
nearly rat proof as possible.

Rats are expensive boarders, even in the
country. The Incorporated Society for the
Destruction of Vermin estimates the yearly
losses from rats in Great Britain and Ireland
at £15,000,000. Denmark estimates its rat
bill at about $3,000,000 a year; Germany at
200,000,000 marks; France at about $38,-
500,000; and in the Public Health Bulletin
upon the Rat and Its Relation to Public
Health we find the estimate of the amount of
property destroyed by rats in the United
States at $35,000,000 per year. The cost of
feeding a single rat with ordinary grain is from
sixty cents to two dollars per annum. Around

128 AMERICAN PUBLIC HEALTH PROTECTION

restaurants and hotels the bill includes not
only what they actually eat, but what is
spoiled.

In addition rats are known to carry the
plague, and they may also be responsible for
other infections. There is good evidence that
they may also spread diseases of other animals,
such as the foot and mduth disease of cattle.
They are unmitigated pests. It may be that
they may reside for many years in a com-
munity without causing special danger of dis-
ease; but with the advent of a single case of
plague or of the foot and mouth disease there
is no safety until every rat shall be extermi-
nated. It is far better to begin the warfare
before the epidemic has been started.

In the older days when traveling was done
by horse or wagon, or by boat of small size,
when long journeys were not common, and
took much time, the approach of disease from
a distance was easily recognized. Food con-
veying infectious disease was rare. Rats had
to travel by foot, or sometimes by boat. They
were then no great danger from the health

SOCIAL AND ECONOMIC CONDITIONS 129

standpoint. Travelers mixed with few fellow
passengers. Now all of this is changed. A
man may receive an infection in San Francisco
or London and reach New York before show-
ing signs of illness. A child may contract
diphtheria or scarlet fever from some other
case upon the cars, and the two be separated
many days before either shows clear evidence
of the malady. An infected rat might climb
into a car in Seattle and die while in transit to
Chicago, and the fleas escaping might easily
infect a new rat at the point of destination
without arousing immediate suspicion.

The farmer gets milk on his own farm. In
the small village one neighbor sells the product
of his cow to others who have ample opportu-
nity for knowing of the presence of a case of
infectious disease in his family, or of the sus-
picious condition of his cow. In the larger
village the residents are supplied from some
farm in the vicinity, and a possible infection
there would at the most expose relatively few
people. In all of these cases the dairy farm
and the consumers are under the jurisdiction

13G AMERICAN PUBLIC HEALTH PROTECTION

of a single health department, or at the most,
of adjacent health officials.

In the modern city the case is very different.
The milk from many farms, perhaps hundreds
of miles away, is gathered into a single bottling
plant. There a pailful of infected liquid may
inoculate several carloads. The time consumed
in transportation affords ample opportunity
for the multiplication of harmful bacteria. The
source of infection may be even in another
state from the place which becomes secondarily
infected. This greatly complicates the ques-
tion of authority. It shows the necessity for a,
state or national supervision of the problem
with full coordination for all local health offi-
cials. It is no longer a merely local affair, and
under the control of a single local department.

There is another point in connection with the
milk industry. In the country community the
milk reaches the consumer within a very few
hours after it leaves the cow. In fact, it may
be delivered before it has lost the animal heat.
Now it is very difficult to draw milk from the
cow and not have some bacteria in it. As a rule,

SOCIAL AND ECONOMIC CONDITIONS 131

the number of bacteria ordinarily decreases for
about four or five hours. Then they commence
to multiply, and for a time they propagate al-
most in geometrical ratio. If, then, it be de-
livered to the consumer within four hours of
milking, even with little precaution it will be
unlikely to contain many bacteria, and with
usual care the consumer may use it before the
ordinary bacteria have caused it to sour or be-
come rancid. Much of the milk of a big city
is from forty-eight to sixty hours old before
it is used, and a few bacteria may thus have
become much more numerous than it is pleas-
ant to consider. Often the milk spoils before it
can be used. This means that the care of the
milk must be much more strictly sanitary than
is necessary for the country community. It
means that all the conditions around the stable
and milk house must be of the very best. The
milkers must wash their hands after they have
thoroughly cleansed the cattle and before milk-
ing, and they should wear spotless white cloth-
ing, and in other ways exhibit "surgical
cleanliness." Incidentally it means that the

132 AMERICAN PUBLIC HEALTH PROTECTION

farmer must be paid more for his product, so
that he can afford to spend the time and invest
in the machinery necessary for the production
of good milk. The small milkman can not
afford to compete thus with the honestly con-
ducted large company. It is a fact that the
small dealers around a large city are the great-
est trouble to the health department. They
do not need many bottles, for example, and so
buy from junk dealers. Often they thus come
into possession of bottles which have been dis-
carded by other dealers, or have been picked
up by the rag pedlers and sold to the junk
men. These small dealers generally have no
education or training which fits them to ap-
preciate the distinctions in the care of their
product. They have imperfect appliances.

If milk be heated to the boiling point and
kept at that temperature long enough all bac-
teria will be killed. It is found, however, that
such milk has lost some of its food value. It
is less easily digested. It is found that such
a temperature is not necessary. Simply to
bring it to that degree of heat will kill most of

SOCIAL AND ECONOMIC CONDITIONS 133

the disease-producing bacteria, but the more
approved system is to heat it to 140 degrees,
and hold it there for twenty minutes. This is
pasteurization. Commercial pasteurization con-
sists in simply bringing it to the desired tem-
perature and immediately cooling it. This
method has proved quite uncertain. One small
dairy, endorsed by several good physicians who
were not educated in public health methods, was
supplying a hospital with "pasteurized" milk,
but inspection showed that the process consisted
in setting a can on the stove and occasionally
stirring the contents with a stick, or a not too
clean ladle. The result of this method was that
some portions of the contents would be over
heated, and others under heated. The milkman
was honest and willing, but he simply did not
know any better, and he could not afford to in-
vest in a proper machine. Cans from that dairy
were seen at the railway station, waiting to be
returned to the farms. They were unsealed,
and covered with flies. The very presence of
the flies showed that the cans had not been sat-
isfactorily cleaned. Those cans came unsealed

134 AMERICAN PUBLIC HEALTH PROTECTION

by the cars, and sometimes a thirsty baggage
man would dip therein the cup which he kept
handy. Such are some of the conditions which
occupy the attention of the modern defender
of the city health.

The relative number of bacteria in milk is
not of itself a reliable indication of the safety
of the article. Some bacteria are highly dan-
gerous, while others are harmless. The presence
of the lactic acid bacilli may be a good indica-
tion, even though the number be great. Their
presence is necessary in the making of butter,
and they tend to prevent the growth of putre-
factive bacteria. On the other hand, the pres-
ence of the colon bacillus is evidence of dan-
gerous contamination, while a single germ of
diphtheria or of the tyrotoxicon producer is
sufficient to make the use of the article alarm-
ing. Of course, it must be remembered that
not all the bacteria are isolated in an examina-
tion, and the presence of one of a certain kind
is pretty sure proof that many of its friends
and relatives are not far away. However, an
exhaustive search for the different germs is a

SOCIAL AND ECONOMIC CONDITIONS 135

practical impossibility as a routine practise.
The presence of many bacteria shows relative
carelessness in the handling of the article, while
fewness of bacteria indicates care and caution.
It is ordinarily the careless operator who gets
dangerous infection of his milk.

Formerly the health officer waited until some
case of infection developed in his community;
or perhaps he instituted a blind quarantine
against an entire section. To-day the health
official anticipates the danger, and thus inter-
feres as little as possible with commerce. He
attempts to keep posted as to conditions on the
farm, and if there be a case of infectious disease
present he intensifies his watchfulness. He not
only sees to it that the patient is so isolated that
there is no probability of infecting the milk, but
he keeps especial watch over the places where
that milk is delivered. In view of the fact that
the place of production is far removed from
the place of consumption, some cooperation
should be arranged between the officials watch-
ing over the respective territories. If an officer
in a dairy district finds a case of scarlet fever or

136 AMERICAN PUBLIC HEALTH PROTECTION

diphtheria upon a milk farm he should at once,
in addition to taking the needed local precau-
tions, notify the central office of the state, and
also notify the offices in the territory to which
the milk is sent. To do this effectively it is
necessary that he have on file the list of sta-
tions to which the output of the local bottling
plant is sent. Such a process, in the place of
interfering with trade, is a safeguard. The
buyers feel that they are being treated "on the
square," and assist in "watchful waiting" of
a good kind. When, however, as sometimes
happens, the local authorities connive with the
producers to keep quiet and run the risk, they
are running a tremendous hazard, which must
soon be better recognized by the courts. They
are like the captain who overloads his boat. He
may do it thousands of times without being
caught, but when caught, and many deaths oc-
cur, the business is ruined. Even state officials
have been known to connive at such rascality,
and to assist the producer to get his condemned
milk to the market in some other way. Some
politicians do not want to have honest and com-

SOCIAL AND ECONOMIC CONDITIONS 137

petent health officials, though they may make a
big ado and spend much of the public funds,
especially in prosecuting minor offenders.

Experience demonstrates that it is not safe
to depend alone upon inspections of the dairy
district. A check test must he had, and in
practise that check test is now the percentage
of bacteria. Formerly the quality of milk was
judged entirely by the chemical composition —
by the amount of cream and water. Now, while
the old tests are made, they are considered of
less sanitary importance. Both the chemical
and bacterial tests require the use of a labora-
tory, properly equipped. Because the office is
so equipped it is called upon to make other
tests. The fact that water is added to milk
does not make it harmful, unless the water con-
tain injurious substances. Oleomargerine was
unknown to our grandfathers. It may be far
safer to use than dairy butter, but its sale as
butter is a fraud. Lard adulterated with cot-
tonseed oil is a commercial deception. Spoiled
tomato pulp, treated chemically and sold as
ketchup, may be both an imposture and a dan-

138 AMERICAN PUBLIC HEALTH PROTECTION

ger to the public health. The same is true
relative to meat which has been preserved with
chemicals. These tests naturally fall to the
health laboratory, and it would surprise most
people to know how many cases of such trickery
are discovered, though since the national Pure
Food Law went into effect there has been a
manifest improvement.

There is a tendency to make the health office
the scapegoat of governmental activities. At
the best, an honest official meets with many
enmities and condemnations, and it seems a pity
that he should be loaded with other matters
which only take his time and attention, and in-
tensify opposition to him and his work. Any
man who attempts to "put something over"
and gets caught feels a resentment against his
captor. Really the fact that grocers and mar-
ket men frequently sell short weight is no con-
cern of the health department ; but in the course
of tests made the department frequently detects
these shortages. Under such circumstances
when they have reported the fact to the city
government they have been told, "It is your

SOCIAL AND ECONOMIC CONDITIONS 139

duty to bring prosecution." Generally it is not
the specific duty of the health department to
bear the brunt of such action, and it never
should be expected, though the office may rea-
sonably assist by giving evidence. To turn this
work over completely to the health department
is as unfair as certain practises on the Canal
Zone. The hospitals of the Sanitary Depart-
ment acquired a favorable reputation through
Central and South America, and very many
patients came to receive treatment. They were
encouraged to come, and were charged a dollar
or two a day; but while the Sanitary Depart-
ment had to bear the expense and the anxiety
of the cases, and its servants were obliged thus
to use their time, in order to make the relative
accounts of the two departments show as much
as possible in favor of the Engineering Depart-
ment, all moneys thus paid in were credited to
the Engineering branch of the service. Like-
wise, because the only competent embalmers
were in the Sanitary Service, when the presi-
dent of the republic of Panama died the Sani-
tary Department was called upon to embalm

140 AMERICAN PUBLIC HEALTH PROTECTION

the body; and though the family paid consid-
erably more than a hundred dollars for the
operation, it was credited to the Engineering
and Construction Division.

These changes in social and economic con-
ditions have brought into greater prominence
certain principles of law, or have brought new
applications. It is an old principle found in
Blackstone which recognizes the fact that one
may not poison a stream to the detriment of
those below. Still, it has long been the practise
of cities to get rid of their sewage by turning
it into a convenient river. People sometimes
have imagined that such a practise secures for
the city a right so to do ; but as cities increase in
size, and as they become more closely situated,
such use of streams becomes dangerous. There
are many recent decisions holding that no pre-
vious use of a stream for the discharge of its
sewage gives to it a right to continue such use ;
and if such right be admitted, still the fact that
when it was a village or a small city it emptied
its waste into the stream, by no means gives a
similar right to the large city. Further, though

SOCIAL, AND ECONOMIC CONDITIONS 141

damages may be awarded in an action, that
does not preclude the enforced abatement of
the nuisance. On the other hand, there are
cases in which it has been very rightly held that
a district may not be enjoined from discharg-
ing its sewage into a stream, simply because it
is sewage, when in fact the stream is made more
pure in consequence. When the sewage has
been properly treated it is not a nuisance ; and
what that proper treatment is, and when it
should be instituted, must be a matter for ex-
pert decision. For the city discharging its
sewage, and for the city lower down the stream,
their respective health departments must be
looked to for guidance.

While the principles upon which these de-
cisions rest are old, in former times they would
not be taken to apply to the action of munici-
palities. They were only enforced against pri-
vate individuals or private companies. Now,
however, we find the courts asserting in no un-
certain tone that a city has no more right to
pollute a stream, than has a private individual.
To change a city's sewage system under legal

142 AMERICAN PUBLIC HEALTH PROTECTION

pressure may be a very serious financial prob-
lem ; but it may be accomplished gradually. It
is the health department of the city which must
generally be expected to watch conditions and
anticipate such possible trouble, even though
the sewers be in the care of a Public Works
office. The two should work in harmony to-
gether, but ordinarily the health office is the
only one which has a laboratory equipped for
such studies.

The changes in social conditions not only
necessitate a change in city work, but they also
necessitate greater caution on the part of the
city administration. When cities were small
and not numerous it was an easy matter to get
a good and safe water supply. Now such a
supply must be constantly watched to preserve
its purity, and the department must be pre-
pared within a few hours to institute protective
operations. The watching must be done by
the health department, and must be done in-
telligently. Until very recently there have
been no suits to determine the liability of a city
for providing water which spreads typhoid

SOCIAL AND ECONOMIC CONDITIONS 143

fever. The maintenance of a system of water
supply is a commercial venture, and for negli-
gence in connection therewith the municipality
is liable, even though it may not make a profit.1
A city is therefore liable for damages for sick-
ness and death caused by such infection.2 Nor
is it sufficient excuse that the conditions are un-
usual, as from some break in a sewer, a flood
which could be guarded against, an unusual
change in the wind, causing the water of a lake
to take an unusual current, carrying sewage to
the water intake. It is the duty of the city to
anticipate such conditions and protect itself
from them.

The writer's attention was recently called to
a very peculiar case of water pollution, which
illustrates both the importance of changed eco-
nomic conditions and the necessity for efficient
health administration. In a corner of a city
most distant from the pumping station, com-
plaint was repeatedly made that the public wa-
ter was so offensive that even the horses and

1 Pearl v. Inhabitants of Town of Revere, 107 N. E. 417.
"Milnes v. Huddersfield, L. R. 10 Q. B. Div. 124; Keever v.
Mankato, 113 Minn. 55.

144 AMERICAN PUBLIC HEALTH PROTECTION

cattle there kept refused to drink it. Such
complaints did not come from other sections,
and general tests of the supply showed it to be
free from contamination. In that section, how-
ever, the water was apparently contaminated
with manure. Investigation developed the fol-
lowing conditions. There were in that outly-
ing section several large greenhouses devoted*
especially to the growing of market truck. In
three there were tanks connected with the city
water system. It was a custom of the pro-
prietors to use these tanks for making solutions
of fertilizers, and then, having shut off the city
pressure at the meters, either by natural pres-
sure, or by the use of power pumps, to force
the solutions through the pipes which were or-
dinarily used in watering the plants. Owing
to the great distance from the city pumping
station, and the natural elevation of the land
above that of most of the city, the city pressure
is lower in that section of the city, and during
temporary fluctuations it may sometimes be re;-
duced almost to zero. Under such conditions
if the greenhouse-man fails effectually to shut

SOCIAL AND ECONOMIC CONDITIONS 145

off connection with the city mains before start-
ing his manure pumps he may easily force his
solution into the city mains. Incidentally we
may remark that this practise of spraying
growing lettuce with liquid manure introduces
another danger — the contamination of the let-
tuce ; and even after thorough washing such let-
tuce may have an unpleasant taste, and be the
carrier of colon or other bacteria.

The mayor of a certain city expressed regret
that the city was not able to increase the com-
pensation of a medical officer of health suf-
ficiently to employ his full time; and im-
mediately thereafter, being obsessed with the
idea of the "commission form of government,"
but not grasping its real meaning, that same
mayor forced the passage of a new ordinance,
creating a new office, and placed a former po-
lice officer in charge of the health department,
although the new appointee was totally lacking
in any education or training which would fit
him for such a position; and every "improve-
ment" which he instituted was ill advised. Ob-
jection is frequently made on financial grounds

146 AMERICAN PUBLIC HEALTH PROTECTION

by city officers to the maintenance of a proper
health department, in charge of a trained sani-
tarian; or to the building and equipment of a
needed filtration plant for the water supply;
or the construction of suitable systems for the
care of the sewage ; or for the disposal of gar-
bage. It matters not to them whether or not
the expenditure will save to the citizens more
than they cost, in sickness and funerals avoided.
The average city father wants to make a good
financial showing, and he is "willing to take
the risk." The owners of the Eastland wanted
to make a good financial showing and they
"took the risk." 'Government inspectors
wanted to encourage the steamship business,
and they "took the risk." Is the city official
any less guilty when for financial reasons he
fails to take the needed precautions for the
preservation of the citizen's health ? In Keever
v. Mankato the court was asked not to find
against the city as such judgments, if en-
couraged, would bankrupt every city. If cities
do not heed the warning given in the few cases
already decided, should they not be bank-

SOCIAL, AND ECONOMIC CONDITIONS 147

rupted? While these conditions are officially
in charge of the elected officers of the cities, the
real responsibility rests upon the individual
citizens. They must eventually pay the bills,
and it is for them ultimately to decide whether
they prefer to pay their taxes for judgments
and poor public service, or for good service
entirely.

These suits for damages for the distribution
of such disease germs in the water supply, or
for the pollution of streams, etc., will be more
common in the future than in the past, for they
are the natural outcome of the increasing pop-
ulation, and consequent necessity for greater
caution.

Good roads are desirable, but they are no
more needed than good health in the com-
munity. Money spent in buildings and public
parks makes a good advertisement for a city,
but a reputation for healthf ulness is worth quite
as much. Of course, public parks are among
the health measures of a city, but what we here
referred to is the expenditure in raising fine
flowers, in landscape gardening, and the main-

148 AMERICAN PUBLIC HEALTH PROTECTION

tenance of fountains and zoological collections.
Embossed letter heads for all the offices are very
nice cards for the city administration; but if
they are obtained at the expense of efficiency
in a health department they might better be
dispensed with. The health department has
been neglected too long. It has been stuck
away in some uncomfortable corner, without
proper equipment of men, or of laboratory ap-
paratus, or of library. In a city whose annual
appropriation bill is about $415,000, the writer
has found the employees in the health depart-
ment forced to wear overcoats while working
in the offices in the winter, and one day he
found the contents of the laboratory actually
frozen, though complaint had been made for
several weeks of the condition of the office.
And yet, that particular office is probably
much better provided for than most health de-
partments in cities of a similar size.

Although vital statistics are the bookkeep-
ing of the health department, and although the
records are very commonly and properly bept
in that office, still the chief use of the individual

SOCIAL AND ECONOMIC CONDITIONS 149

records is legal and commercial. The tran-
script of a death record may be needed for life
insurance, proof of title to property, or for
legal evidence in a variety of other cases, per-
haps long years after the record was made.
This use is more common now than formerly,
but not on account of special changes. On
the other hand, there are very many new needs
for certificates of birth, and the demand for
that kind of evidence for old purposes is more
common. Such certificates have always been
useful in proving right to property — proof of
heirship, and many American-born children
have lost their title, especially to property in
Europe, through lack of such documentary
evidence. There is an increasing demand for
such certificates as a proof of right to enter
school. The great increase in legislation rela-
tive to child labor has made it often impossible
for a boy, or a girl, who is unable to produce a
copy of the legal birth record, to get a chance
to work, no matter how much it may be needed.
In fact, some of the laws require the filing of
such copies of birth recor3.

150 AMERICAN PUBLIC HEALTH PROTECTION

This matter of individual records is here
mentioned because in many states there is no
satisfactory law governing the recording of
births and deaths. The result is that the matter
is neglected. Records of deaths are more likely
to be made than those of births. Most phy-
sicians do not appreciate the necessities of the
case, and for one reason or another they simply
neglect it. It is the legal duty of the physician
to make the record, but it is the moral duty of
the parent to see that the record is made. An
Indiana young lady was only able to prove
her age, and her consequent right to certain
property, because a neighbor happened to re-
member that a calf was born to a blooded cow
on the same day that this baby girl first saw
the light. The cow was of enough commercial
value so that its birth was recorded in the farm
book, but no record of the girl's birth could
be found. In another instance a well-to-do me-
chanic died, leaving his wife and child with
small means. Soon after this they were re-
joiced to learn that the little girl had inherited
sufficient property in the old country to care

SOCIAL AND ECONOMIC CONDITIONS 151

for both. Unfortunately there was no official
record of the child's birth, and the attending
physician had died so that the record could not
be legally made, and the inheritance was lost.

While it is the duty of the attending physi-
cian to make the record of birth, and it is
the duty frequently of the health office to re-
ceive and record such certificate, it is the duty
of every parent to make sure that the legal
record is completed as to the birth of each
child. Legally, until such record is made the
physician has not completed his care of the
case, and is therefore not entitled to his fee.
This matter is here mentioned because many do
not appreciate the necessities of the matter un-
til it is too late.

CHAPTER VI

CHANGES DUE TO ADVANCEMENT IN SCIENCE

In the older time few diseases were recog-
nized as being communicable from one patient
to another, either directly or indirectly. Those
which were so regarded were all handled in the
same manner in the work of protecting the
community. The case was isolated, and no one
from the outside was permitted to approach.
Fences were often built around the house, and
a guard was stationed to enforce quarantine.
If it were necessary to furnish provisions, they
were brought to the doorstep and there left,
and after the messenger had departed some one
from the house came out and got them. It was
supposed in each case that clothing, or any
thing which had' been in the room with the
patient would convey the infection. Diagnosis
was not definite, but was a matter of judgment,
based upon the combination of symptoms. We

153

CHANGES DUE TO ADVANCEMENT IN SCIENCE 153

now know that very many cases which were
formerly called malaria were unquestionably
typhoid fever. Diphtheria and membranous
croup, now known to be due to the same bacil-
lus, were then considered distinct diseases, and
even after the diphtheria was recognized as in-
fectious, the croup was not so considered.

Some diseases, like yellow fever, were the
subjects of much discussion. Some authorities
considered that fever infectious, while others
very stoutly insisted that it was due to unfavor-
able surroundings. We now know that both
were right, though neither was right in their
exact suppositions.

The first great advancement was made when
it was discovered that many diseases were the
product of specific germs. Some rashly claimed
that all diseases were caused by microscopic
plants called bacteria. The specific bacteria
were so definite in character that a diagnosis
could be made from them. Later it was learned
that the diagnosis could be often made much
more accurately and surely, in many cases at
least, by certain tests of the blood of the patient.

154 AMERICAN PUBLIC HEALTH PROTECTION

It was learned that the symptoms were gen-
erally caused by a poison produced by the
germ, rather than by any direct effect of the
germ itself. Then it was found that an anti-
toxin could be produced, which when injected
into the patient neutralized the poison, and thus
tended to cure the patient. That same anti-
toxin introduced into a healthy person pro-
duced an immunity to the disease, and as a
routine practise the use of antitoxin was de-
pended upon to protect all who had been
exposed to the disease. Now it is known that
not every person is susceptible to the disease,
and in the case of diphtheria, for example, a
definite test has been found to determine this
point. In that way the use of antitoxin as a
prophylactic has been materially decreased.
This is important, for it has also been discov-
ered that the use of the antitoxin may render
the patient unduly sensitive to future injec-
tions of serum from the same species of animal.
Antitoxin is always secured in the serum of an-
other animal, generally from the horse. Fur-
ther, it has been learned that the virulent germs

CHANGES DUE TO ADVANCEMENT IN SCIENCE 155

may be present in an immune person, without
any symptoms being present. The antitoxin
may cure the disease without killing the germs.
Finally, the immunity of a person is to specific
diseases; he may be immune to the effects of
diphtheria, and still be very susceptible to
typhoid fever.

It is very apparent that since every patient
is a possible source of infection for others, the
danger to the healthy members of a community
is in direct proportion to the number of the
sick; and every person cured therefore by so
much protects the community. However, it is
not distinctly the province of the health de-
partment to treat the sick, especially when they
have their own physicians. It is a duty of the
guardian of the health to keep watch of the
treatment. It is the province of the health
official, not of the attending physician, to de-
termine when the case is officially well and safe
to be given freedom. This fact often causes
friction, either between the attending physician
and the department, or between the depart-
ment and the family. There is a very decided

156 AMERICAN PUBLIC HEALTH PROTECTION

difference between the recovery from the dis-
ease, and the official recovery, when the patient
may be given unrestricted liberty. Thus it has
been found that many weeks after recovery
from diphtheria the patient may still be a
potent source of infection for others ; and some
typhoid patients remain carriers of the disease,
and sources of epidemics, for many years.

Some years ago in Washington it was found
that there was a sudden increase in typhoid
fever. Investigation showed that the epidemic
was connected especially with two milk depots.
Both received their supply from the same farm.
Inspection showed that every thing on the
farm was above suspicion, except — The farm
was owned by a widow who had typhoid fever
seven years previously, and upon testing her she
was found to be a typhoid carrier. Near the
house was a clean and well-kept privy, but it
was not fly proof, and flies were traced from
that pit to the milk cans which were exposed
to the sun and air after being scalded. This
was the source of the disease. This instance
illustrates three forms of disease carriers. The

CHANGES DUE TO ADVANCEMENT IN SCIENCE 157

woman was constantly producing the disease
germs, and flies acted as mechanical carriers;
the milk served as a culture medium, in which
the few bacteria left by the flies in the cans
became millions before the milk was used.

The bacteria' escape from patients in dif-
ferent ways, and herein lies a distinction in the
form of quarantine to be used. The germs of
diphtheria are in the expired air, and in the
discharges from the nose and throat. The ba-
cilli from the typhoid case are chiefly found in
the discharges from the bowels and kidneys.
A typhoid case is not properly isolated unless
all discharges are thoroughly disinfected.

The immunity induced in a patient by injec-
tions of antitoxin is temporary, and as has been
intimated it may not always be entirely safe.
Typhoid bacilli, carefully grown in the labora-
tory, isolated and killed, when injected into a
healthy person induce an immunity to that dis-
ease which lasts for some years. This is safe
and effective, and as a result of its use typhoid
fever has been practically eliminated from the
army. . Its use in the case of every individual

158 AMERICAN PUBLIC HEALTH PROTECTION

exposed to infection, or likely to be exposed,
is a strong aid for the health department.

The bacillus of the bubonic plague is carried
by the flea to the rat, and the rat becomes in-
fected, and so infects other fleas. Thus the
disease is spread among the rodents, and in
time it comes back to some human beings.
From the rat it also is communicated to ground
squirrels and other animals. When a case of
the plague occurs, quarantine consists in first
isolating the patient, and killing all insects
found on the premises, generally by the use of
a thorough fumigation with sulphur fumes. In
addition, beginning at a little distance and
with that case as a center, from all directions
the entire territory must be searched for pos-
sible sources of infection. Every rat must be
caught and examined, taking care that no fleas
can escape. If the search began at the patient
the rats might escape to infect others.

Whenever a case of infectious disease is dis-
covered it is the duty of the health department
to make an immediate and thorough search to
discover the source of the infection, and the

CHANGES DUE TO ADVANCEMENT IN SCIENCE 159

steps to be taken will be largely determined by
the results obtained. This search for the source
of infection is not to satisfy curiosity, nor to
furnish a scientific record, but to enable the
department to act intelligently. Still, some
health officers have made those investigations
after the epidemic has spent its force, and ap-
parently more as a matter of record than any-
thing else. This is not ideal service, though
nevertheless to be commended. However, in-
vestigations made after the epidemic yield less
satisfactory results than at earlier dates.

Bacteria are not the only causes of disease.
Microscopic animals — protozoa — are the mor-
bific imps for many ailments. Some have been
studied very carefully under the microscope,
and their life history is fairly well known. Otji-
ers are so small that they can not be seen, except
possibly by the ultramicroscope, a relatively
new invention. They are judged to be proto-
zoal in nature from the fact of resemblance in
manner of reproduction to those which have
been studied.

The plasmodium of malaria is reproduced in

160 AMERICAN PUBLIC HEALTH PROTECTION

two ways. In human blood it usually multi-
plies by asexual means. The little plastid gains
entrance into a blood cell and there grows fat.
When it has reached maturity it forms within
itself several new plastids, and then bursts, set-
ting them free. As the mature plasmodium is
in a blood cell, when it ruptures it also breaks
down the blood cell, and the little plastids float
about in the watery serum. Each mature cell
produces from six to twenty plastids, but many
of them die without doing harm. Since the
conditions under which all are living are the
same, and the time for maturing is practically
uniform, it follows that in each generation all
the descendants of a single ancestor come to
maturity at the same time. Ross finds that
when the number of cells maturing amount to
150,000,000 in a man weighing 142 pounds,
the time of rupture is marked by a chill of the
patient, followed by fever. Thus, considering
that the cells multiply tenfold in each genera-
tion, if 1,000 cells of the tertiary species, matur-
ing every second day, be injected, the chill will
appear about the twelfth day. The period be-

CHANGES DUE TO ADVANCEMENT IN SCIENCE 161

tween the inoculation and the chill is called
the period of incubation. Thereafter, every
second day there is a chill, followed by the fe-
ver, as long as the reproduction of the plasmo-
dia continues sufficiently. So many blood cells
are destroyed that the patient loses his healthy
color, and becomes pale and anemic. This form
of reproduction is called sporulation.

Some of the spores develop sexual characters,
and when taken into the body of an anopheles
mosquito they mate and begin sexual reproduc-
tion. This gestation requires about eight days.
The anopheles mosquito likes to live around
clear water, containing grasses and algae. Its
natural food is the juices of plants. The male
mosquito can not bite, but the female is armed
with a lancet. When she has reached her
growth she needs a drink of blood before she
can develop her eggs. She accordingly seeks
some animal, and after gorging herself hastens
back to the water to lay her eggs. When she
wants to lay some more eggs she returns to get
another drink of blood.

It will thus be readily seen that the chance

162 AMERICAN PUBLIC HEALTH PROTECTION

of spreading the infection of malaria is based
upon certain mathematical data. There must
first be in the community some person contain-
ing the sexual forms of the plasmodium in his
blood. The danger is greater the larger the
number of infected individuals. The danger
varies with the relative number of mosquitoes
as compared with the population. These points
determine the chance that the patient will be
bitten. Then after receiving the infection that
individual mosquito must live a week and there-
after bite another person who is not immune.
These chances are decreased with the increase
of distance from the breeding places to the
people. The presence of bushes and high grass
between the breeding places and the people,
in which the mosquitoes may rest in their flight,
increases the danger. The danger is lessened
by the reduction of the relative number of
germs in the source of infection.

Protective measures against the disease con-
sist in treating the sick, to reduce the number
of plasmodia; feeding quinine to the well, to
make their blood unfavorable for the develop-

CHANGES DUE TO ADVANCEMENT IN SCIENCE 163

ment of the germs ; keeping mosquitoes away
from the patient, and killing all of the insects
that have found access to him; destroying the
breeding places of the insects; clearing away
their places of secretion, such as grass and
bushes. The method used for the extermina-
tion of the insects varies very greatly accord-
ing to circumstances.

In the absence of the anopheles there is ab-
solutely no possibility of the spread of malarial
infection so far as has been discovered. Under
such circumstances, the health official need do
nothing more than await developments. He
should, however, even in the absence of the ma-
larial infection, know the kind of insects in his
vicinity, and their usual breeding locations. In
a malarial region, on the contrary, it is im-
portant that he keep constant watch of the
malarial index of the jurisdiction, and that he
wage a constant warfare both against the
germs and against the mosquitoes.

The following diagram, modified from one
designed by Doctor Carter, of the Public
Health Service, shows at a glance the various

164 AMERICAN PUBLIC HEALTH PROTECTION

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CHANGES DUE TO ADVANCEMENT IN SCIENCE 165

measures which are used for the restriction of
malaria, and, with slight changes, those which
are applicable against yellow fever. Anoph-
eles mosquitoes breed in ponds, whereas the
stegomyia insects are likely to use cans and
other receptacles around the house. Against
yellow fever, therefore, it is especially neces-
sary to clear the yard of tin cans, broken crock-
ery and such small receptacles for water, and
to screen cisterns.

There is so much to be discovered in regard
to the transmission of disease that the live
health officer must watch developments all over
the globe. A disease not known to exist in the
hemisphere may at any time be imported in
the body of some globe trotter without arous-
ing suspicion. Perhaps he may be nearly im-
mune, but others may yield readily to the new
infection. Moreover, the methods used in a
foreign disease may be instructive in the hand-
ling of some other near at hand. The sleeping
sickness of Africa has developed some interest-
ing facts.

The central portion of Africa, practically

166 AMERICAN PUBLIC HEALTH PROTECTION

from coast to coast, has been scourged by the
ravages of the sleeping sickness. Whole dis-
tricts have been depopulated by its ravages, and
the inhabitants have been driven from others
to prevent their destruction. This disease is
produced by a protozoon called a trypanosome.
It is carried from patient tp victim by the
tse-tse fly. If the fly bites a patient afflicted
with the disease, and thus becomes itself in-
fected, it may directly communicate the disease
to another person by biting within about forty-
eight hours. Then for some seventeen days
it is unable to communicate the disease. Then
again it becomes an infective agent, and con-
tinues such for about two months. In the
first forty-eight hours it is a carrier of the in-
fection just as the fly carries typhoid, or the
flea transports the bacillus of the plague. Then
comes the inert period when the trypanosome
is undergoing sexual reproduction, as the ma-
larial and yellow-fever germs develop in the
bodies of mosquitoes. There is much evidence
that this trypanosome is also developed in
many other kinds of animals, being very fatal

CHANGES DUE TO ADVANCEMENT IN SCIENCE 167

for horses. This makes the work of extermina-
tion very difficult. Still, the smaller the num-
ber of human patients the less will be the dan-
ger of the spread of the infection. It is found
that normally about ninety per cent, of the
cases die. However, by injections of an arsen-
ical compound known as atoxyl the trypano-
somes are frequently killed, and eighty per
cent, of the cases recover. It is found that if the
atoxyl be not given in sufficient doses to kill the
trypanosomes at once, those little animals de-
velop an immunity to the action of the drug.
It therefore follows that if the treatment be
used skilfully and successfully the danger of
the spread of infection is decreased ; but if it be
used in too small doses a race of immune pro-
tozoa is developed which are more resistant, not
only to the atoxyl, but to all arsenical com-
pounds.

A very important part of the health officer's
duty lies in the extermination of disease car-
rying pests. The development of the science
of public health has changed the legal applica-
tion of old forms. Formerly a manure pile was

168 AMERICAN PUBLIC HEALTH PROTECTION

considered a nuisance if it were large, or if it
were sufficiently near so that it could be
smelled. Now we know that the effluvia aris-
ing from the pile are not injurious to health,
but the manure piles are the breeders of flies
and rats. Flies and rats are carriers of disease,
so that the manure pile is a nuisance in propor-
tion as it develops these pests. A newly-
hatched fly can fly five or six hundred feet, and
with the aid of the wind it may go much far-
ther. Whereas formerly a pile of manure was
only a private nuisance, and within a very lim-
ited distance, now it must often be recognized
as a public nuisance, and at any point within
six hundred feet.

When the principal objection to a manure
pile was its effluvia, it was a nuisance largely in
proportion to its size, for the larger it was, and
the more rapidly it accumulated, the more did
it develop fermentative action producing the
heat and gases. However, in a rapidly increas-
ing pile the outside is too fresh for the develop-
ment of the larvae of the fly, and the interior
of the pile is so hot that it burns and kills

CHANGES DUE TO ADVANCEMENT IN SCIENCE 169

them. The prolific fly breeding pile is one
often which one must search to find, one which
takes a month in which to accumulate a bushel-
basketful. The little pile is therefore a great
nuisance, though it may not offend either sight
or nostril.

The development in the science of public
health has thus increased the number of dis-
eases to which some form of quarantine is ap-
plicable ; it has greatly increased the different
ways in which the functions of health protection
must be exerted; and it has changed the ap-
plication of legal principles. That is to-day re-
garded as a public nuisance often times, which
before would either have been no nuisance, or
would at most be only a private nuisance. New
facts are being constantly discovered, and every
epidemic must be carefully studied. The me-
chanical observer of prescribed rules is of little
value in public health work. The ideal officer
must be level-headed and original. He must
also be an enthusiastic student, and must not
be misled by superficialities. Sometimes he
must work through authority; sometimes by

170 AMERICAN PUBLIC HEALTH PROTECTION

education and cooperation. A pond had been
created by the erection of a dam and a dyke.
Complaint was made that it bred mosquitoes,
but the superior powers of the city government
refused to act, or authorize action, because they
did not wish to offend the owner of the land on
which the pond was located. Examination,
however, showed that the real nuisance was not
on that land. Water had seeped through the
dyke on to some railroad property which was
covered with elderberry bushes. Though the
railway corporation was in no way responsible
for the production of this breeding place of
the pests, the matter was explained to the road-
master, and the next day a gang of men cleared
away the bushes and filled in with a couple of
train loads of gravel.

The discovery of the relationship of rats and
flies to infection has intensified the importance
of properly caring for the garbage of a city or
village. It must be kept in closed metal or
stone receptacles, protected from both rats and
flies. Garbage cans may be easily injured or
stolen, so that in some places it is a custom to

CHANGES DUE TO ADVANCEMENT IN SCIENCE 171

construct the receptacles of concrete, with a
tight-fitting top which dogs can not remove,
and with a door at the bottom through which
they may be cleaned.

Dogs, cats, fowls and pigeons must always
be remembered as possible carriers of infection,
and treated accordingly. Under the old ideas
of the fathers the work of health protection was
very slight as compared with the present; but
it was also ineffective. Now many diseases
which have defied the art of man for centuries
are rapidly becoming extinct, as the result of
making practical application of the facts de-
veloped in modern sanitary science. Most of
these results have been attained quietly, and
with little attraction of attention until the end
has been attained. Often, especially by poli-
ticians and would-be sanitarians, those accom-
plishing results have been denounced, and their
methods derided. "He laughs best who laughs
last."

With the scientific advances certain old prac-
tises and ideas have either been abandoned or
greatly altered. In the place of isolating a yel-

172 AMERICAN PUBLIC HEALTH PROTECTION

low fever patient from his friends, and build-
ing a fence around the house, now he is at once
enclosed in mosquito-proof netting, and all
stegomyia mosquitoes within the house are most
carefully captured or killed. After three days
the quarantine may be relaxed, though the war-
fare against that species of mosquito must keep
up for the balance of the season.

Probably fumigation may be much more ef-
ficient against some infections than for others,
but there are many (and the number is increas-
ing) sanitarians who regard fumigation as a
deceptive prop. Experiments show that the
bacteria are more likely to be on the floor than
on the ceiling, and practically the number
found on the side wall increases as the examina-
tion progresses toward the floor. Bacteria or
their spores, protected perhaps in a crust of
dried sputum, and hiding in a crack of the floor,
are very difficult to kill by fumigation. The
antisepticizing will be much more efficient by
making use of a hot caustic soda solution with
a scrubbing brush. It is entirely useless to de-
pend upon domestic fumigation. The amount

CHANGES DUE TO ADVANCEMENT IN SCIENCE 173

of sulphur or of formaldehyde used is almost
without exception far too small to be effective.
It is probable that the most valuable action
of fumigation is the extermination of insects
which may carry the infection, and the destruc-
tion of mice, rats and other pests. While it
seems probable that the formaldehyde vapor is
most efficient against bacteria, as an insecticide
it is inefficient. It simply makes the flies and
other insects drunk. They may be swept up,
and destroyed, but if the room be left too long
without opening it to sweep up the insects they
will probably be found in their usual health.

For the extermination of the vermin, burn-
ing sulphur fumes is most efficient, and in
the inspection service of the United States sul-
phur dioxid is the one thing upon which de-
pendence is placed for the killing of rats in
the hold of a vessel. It is often claimed by
ship owners that such fumigation is not neces-
sary on account of the presence of an efficient
rat killing cat. Some time ago one such ship
was sealed and fumigated, and when she was
opened dead rats were found in every part of

174 AMERICAN PUBLIC HEALTH PROTECTION

the ship. By the irony of fate, in the cabin
they found the excellent ratter who had by some
accident been left, and with her there were
twenty-four dead rats.

Formerly we heard much about the deadly
character of sewer gas. The plumbers suc-
ceeded in having all kinds of plumbing or-
dinances passed, which greatly increased the
cost of work, without benefiting any but the
members of that guild. Some time ago, under
the auspices of the Massachusetts State Board
of Health, and of the American Engineering
Society, most careful tests were made, and no
detrimental gases were found to come from
sewers. Bacteria fall, they do not rise. This
has been known since the days of Tyndall.
What does sometimes happen is that the traps
become breeding places for mosquitoes, and
the more complicated the plumbing, the more
likely is this to occur. In consequence, it is
doubtful if some of these ordinances regulating
the plumbing houses would to-day stand the
test of the court. Unless an ordinance be
based upon fact it is arbitrary, and without such

CHANGES DUE TO ADVANCEMENT IN SCIENCE 175

foundation it would lack one essential feature
of legality, namely, reasonableness.

It was formerly customary in some places
to require that the house sewage or at least the
kitchen waste, be run through a tank before
being connected with the sewer. This tank,
catch-basin, or cesspool, was ordinarily a form
of settling or septic tank. Sewage entered it,
and the more solid particles dropped to the
bottom, where the bacteria could digest them.
A heavy scum collected on top. Now we know
that such cesspools need constant watching by
competent observers. They may work effi-
ciently for many years without being touched.
When, however, they are cleaned, it takes time
to get a new crop of bacteria developed suffi-
ciently to do the work. A septic tank when
first cleaned does not do what it is expected
to do; but as long as it is working efficiently
it should be let alone. Yet, these same unself-
ish plumbers secured ordinances requiring the
frequent cleaning of cesspools. Cesspools
should never Toe cleaned unless under the
supervision of the health department.

176 AMERICAN PUBLIC HEALTH PROTECTION

There is another strong objection to the in-
dividual cesspool. Not only are there so many
in a city, under such ordinance, that they can
not be properly watched, but the expense of
construction and maintenance is enormous.
With only a fraction of the total cost of the in-
dividual cesspools, a much more efficient Im-
hoff tank could be constructed to take care
of all sewage in a trunk sewer, where with
comparative ease it could be watched and kept
in operation. The cost to the people is less, and
the efficiency is increased. The danger of sewer
gas is an exploded bubble.

CHAPTER VII

MEDICAL INSPECTION OF SCHOOLS

THERE is room for much difference of opin-
ion whether the medical inspection of schools
should be under the auspices of the department
of health, or wholly under the control of the
school management. Both departments are in-
terested in the matter, and clearly the effect
of such inspection should be an improvement
in the health of the community. There may
be a difference in the work which it is sought
to accomplish, and this would go far toward
deciding who should do it. Whoever does
the work, there should be hearty cooperation
between the two organizations. Although the
present movement originated in the work of
health departments, and although very much
of the service rendered has been strictly health
department work, still it is the opinion of the
writer that the work is essentially educational,

177

178 AMERICAN PUBLIC HEALTH PROTECTION

and that it should be provided and controlled
by the school management. He believes that
in this way more good can be accomplished,
and with less serious objection.

School inspection as a routine procedure is
a relatively new matter. For many years it
has been the custom in many sections to make
occasional inspections to detect the presence of
cases of infectious disease during epidemics.
Scholars have been sent from school to get cer-
tificates of health, generally from the family
physician, when for some reason the suspicions
of the teacher ha3 been excited. During an
epidemic of smallpox, or even the presence of
a single case in a village, it has been the prac-
tise in many places to send physicians to the
school to inspect for evidence of vaccination,
and to perform that operation on those not thus
protected. While generally these occasional
visits of a medical school inspector have been
instituted by the health department, sometimes
the school board has taken these steps for its
own protection.

According to the laws of some states it has

MEDICAL INSPECTION OF SCHOOLS 179

been the duty of either local health authorities
or the state board of health to inspect school
houses, and to examine and approve plans for
new buildings. Authority has sometimes been
given to the health authorities to condemn a
school building on sanitary grounds, and by
the laws of some states it is definitely required
that certain provisions be made for the health
of the children. The right to condemn a school
building on sanitary grounds does not include
the right to cause its destruction. It simply
prevents its use as a school until the sanitary
provisions be complied with.1 Even if not used
as a school the building might be used for some
other lawful purpose, and the medical or health
officials have no authority to compel its destruc-
tion.

The medical inspection of schools as at pres-
ent practised in the United States is very dif-
ferent from either of these former forms of
inspection, though including them. Gulick
states that only about four per cent, of the cases
needing attention were excluded on account of

1 Coal Creek Township v. Lewandowski, 84 Ind. 346.

180 AMERICAN PUBLIC HEALTH PROTECTION

infectious diseases. Almost all the attention in
good medical inspection of schools is devoted to
other matters, though in point of time inspec-
tion for such diseases is put first.

Experience has demonstrated that when a
child has been absent from school, especially on
account of infectious disease, it is unsafe to per-
mit that child to return until the case has been
properly investigated by the school doctor, or
the school nurse. It is not safe to permit teach-
ers to accept the certificates of the attending
physician. While out of courtesy a medical
inspector may thus accept a practitioner's cer-
tificate, it should be distinctly understood by
both the physician and the family interested
that it is a matter of courtesy, and not a matter
of right, unless the law so distinctly states. The
reasons are that all must be treated alike, and
to guard against the unprincipled or careless
physician the rule must be made to include all.
What is needed is that the responsible official
shall be satisfied that the case is safe. On ac-
count of their relations with the families, phy-
sicians frequently feel obliged to give the pa-

MEDICAL INSPECTION OF SCHOOLS 181

tient the benefit of a doubt. Certificates are
given of recovery from diphtheria while the
child is still producing the bacteria; and certif-
icates of recovery from scarlet fever sometimes
find their way to the school while there is still
flaking of the skin of the hands, or while there
is still an abnormal discharge from the nose.
The writer has found certificates of vaccination
given after simply scarifying the skin and ap-
plying some cold water. The certificate of vac-
cination should distinctly state that the opera-
tion was followed by the typical evidence of
infection with cowpox.

Every time that a scholar is absent from
school he interferes with the normal course of
instruction for others. The more irregular the
pupils are, the less progress can the classes
make. The irregular scholar is thus retarding
and harming the other members of the class.
It is the duty of the school board to make these
losses as slight as possible. It is necessary for
scholars to be brought close together, and they
are at the age when they are most susceptible
to disease. In the interest, therefore, of school

182 AMERICAN PUBLIC HEALTH PROTECTION

efficiency it is expedient that the danger of in-
fectious diseases be reduced as much as pos-
sible. Many scholars are unable to keep up
with the more advanced pupils, not because of
lack of mentality, but because their mental op-
erations are hampered by physical conditions
which are susceptible of improvement or cor-
rection. Others need to be segregated in order
to keep them with those of their own class.
They will thus advance more rapidly them-
selves, and will not retard the average progress.
It is clear that the longer a school class takes
in making the course, the greater will be the
expense to the school district. For these and
other reasons, not necessary here to amplify, it
seems that the medical inspection of schools is
essentially a problem of school management.
If a case of infectious disease be found by
the examiner it is his duty to the school to ex-
clude the patient, and to take such other meas-
ures to defend the school from that source as
seem necessary. It is his duty to the commun-
ity, just as it is the duty of every physician, to
report these cases to the department of health

MEDICAL INSPECTION OF SCHOOLS 183

There is no other item connected with the med-
ical inspection of schools which is distinctly the
province of the health office. Further, the em-
ployment by the board of education, or by the
school trustees of a medical inspector of health
does not in any way interfere with the inspec-
tion by the health office whenever, and so far as,
seems necessary. These additional examina-
tions may be made as a check upon the work of
the school, or in cases of special danger, or of
a perplexing epidemic. It may have happened
in the past that incompetent medical examiners
have been appointed by school boards, just as
in the case of health departments. In case of
an accidental difference in the findings by ex-
aminers of the two departments there should be
a frank interchange of ideas, each giving due
regard to the right of the other to his opinion.
There should be no contest, or "fight" between
the two. If, on the other hand, it proves that
there is a distinct incompetence on the part of
an examiner, justice demands that the facts be
brought to the attention of the proper officers.
In Europe the distinctive relation of school

184 AMERICAN PUBLIC HEALTH PROTECTION

inspection to the educational work of the school
has heen generally recognized. In 1842 it was
ordered in Paris that, "All public schools
should be visited by a physician who, in addi-
tion to inspecting the buildings, should also in-
spect the general health of the children." At
present in Paris the school physician is ap-
pointed for a term of three years. In addition
to examination of such pupils as may be spe-
cially recommended to him by the teachers, and
investigation of cases absent on account of sick-
ness, he is to make examinations as to the light,
heat, ventilation and other sanitary conditions
of the school buildings. Once a month he ex-
amines the pupils' eyes, ears and teeth, and if
defects are found the matter is called to the at-
tention of the parents. Sometimes the school
provides glasses, clothing and other necessities
for those who are needing them but are unable
to provide them.

In Switzerland it has been the custom to have
such examinations of schools and school build-
ings for some time, and especial attention has
there been given to the effect of school work

MEDICAL INSPECTION OF SCHOOLS 185

upon the eyesight. Periodic examinations of
vision have been made and records kept. The
teeth are also frequently inspected, and in case
the parents are unable to give proper treatment
this is provided, at least in part, by the school.
In Germany the duties of the school physi-
cian include the following items: examina-
tion of all pupils as they enter the school; in
case of physical abnormalities he may recom-
mend special instruction; he investigates cases
of absence from school, and in infectious dis-
eases gives special instructions, or advice to the
head master of the school ; he is expected to ad-
vise the school board when he finds the health
of the children unfavorably affected by the un-
hygienic conditions of a school ; he is to report
at stated times for the purpose of advising with
the head master about certain individual cases ;
and the school physician has control over the
classrooms without reference to hours of in-
struction. All the medical officers of the schools
meet together regularly under the presidency
of a member of the school board to discuss mat-
ters relative to school hygiene,

186 AMERICAN PUBLIC HEALTH PROTECTION

In the United Kingdom also it is the custom
of school boards to provide such medical offi-
cers. It was not a matter of growth, but of sud-
den interest. It was noticed in the Boer War
that there had been a degeneration of Eng-
lishmen. In 1907 a law was passed by Parlia-
ment, which went into effect January, 1908,
making the medical inspection of schools com-
pulsory, and specifically imposing the duty of
complying therewith upon the educational au-
thorities. The present system is very complete.

"As interpreted by the Central Board of Ed-
ucation, the aim of the English Education Act
is not primarily the medical inspection of .chil-
dren, but their physical and mental improve-
ment. The subject of school hygiene is related
in every possible way to the public health work,
and is viewed as an integral factor in the health
of the nation. Doctors, teachers, and nurses
work together in the closest cooperation. The
aim is not merely to improve the health of the
children who are weakly or ailing, but in the
broadest sense to conserve the health of all chil-
dren by adapting and modifying the system of
education so as to make it fit their needs and

MEDICAL INSPECTION OP SCHOOLS 181

capacities. No other nation, unless it be Japan,
has adopted a school medical service with a
more rational conception of its true purpose.
In her school medical clinics England has
boldly undertaken the free medical treatment
of her ailing children, heedless of the criti-
cisms of the medical profession. Her school
physicians are as a rule full-time officers,
highly trained and well paid."2

In Sweden all public secondary schools (cor-
responding to the use of that term in Germany,
not in the United States) , had medical officers
on their staffs as early as 1868. Though in
some cities and rural districts there is a medical
service like that required of secondary schools
by the general government, that condition is
not general in the kingdom. In Denmark
some schools maintain such inspection, but
not as a compliance with law or general cus-
tom. In Norway there is compulsory medical
inspection of secondary schools, and the law is
permissive as to the establishment of such in-
spection in elementary schools. Canada, Aus~

__? Health Work in the Schools, Hoag and Terman, p. 286.

138 AMERICAN PUBLIC HEALTH PROTECTION

tralia, Argentina, Chile, South Africa and
many other countries have instituted such in-
spection of schools. We are told that the
school conditions of Ireland are deplorable.
One-eighth of the elementary schools are with-
out any toilet facilities. One-third of the
schools of Belfast have no playgrounds. The
mortality of children of school age is enormous.
Again considering the financial side of the
problem, what is the use in half educating a
lot of children who never reach an age which
pays the community for the money spent?

In marked contradistinction from the condi-
tion in Ireland, we find that the educational
system of Japan is one of the most carefully
planned and managed in the world. The na-
tion considers that the health of the school child
is one of its most valued resources. If during
the age of growth and development there are
unfavorable conditions, which retard, stunt or
pervert the child's development, mentally and
physically, the result will be shown in mental
and physical lowering of standard for the na-
tion ; but by care during these formative years

MEDICAL INSPECTION OF SCHOOLS 189

the national standard of existence may be ele-
vated. It is far more important to prevent
misfortunes than it is to treat them, or support
them, after they have been created. By keep-
ing records of the child's height, weight, chest
circumference, general nutrition, and of all
forms of defectiveness, Japan is collecting
most valuable material for study, and her lead-
ers are already making use of this data.

When it is remembered that in the United
States the public school is the only govern-
mental department having to do with the
lives of children directly, and that nine out
of every ten children are subject to this con-
trol, extending roughly from the age of six
to fourteen, one may appreciate the tremen-
dous influence which may here be exerted
for the improvement of the rising genera-
tion. Further, a large proportion of the
scholars are the children of foreign-born par-
ents, often from the most lowly ranks of so-
ciety. In the schools these scions of different
races and nations are brought in contact with
those of native parentage, and the result is a

190 AMERICAN PUBLIC HEALTH PROTECTION

constantly changing new race, with new stan-
dards. With very slight help this period of
new blending may be made especially favorable
for improvement. Without intelligent super-
vision the introduction of much foreign- ma-
terial may weaken the strength of the original
stock. For example : Reference has been made
to the condition of schools in Ireland. Chil-
dren from families coming out of the unfavor-
able environment mentioned — for there are fine
schools also in the island — do not appreciate
the need of certain precautions. Their laxity
tends to spread to their fellows, and unfavor-
able results follow. It was one of those mothers
from the Emerald Isle who patiently listened to
the doctor's directions relative to the care of
her daughter. The next day, in answer to his
questions, she told him that everything had
been done exactly as directed. He knew that
if all had been done as ordered the patient
would have no more trouble. Five days later
he was surprised to find conditions puzzling,
and shortly thereafter the patient was uncon-
scious, and rapidly approaching the brink of

MEDICAL INSPECTION OF SCHOOLS 191

the river. Then he learned, when it was almost
too late, that the motherly soul, who had buried
many children, laughed at his directions, say-
ing that such precautions were unnecessary.
"They never do so in Ireland." No? Look
at the death rate there! Especially note the
high mortality from tuberculosis among the
Irish school children!

It may be that many persons may not ap-
preciate the remark of this good motherly
Irish woman — "They never do so in Ireland."
One of the frequently repeated objections to all
new efforts in the line of saving life and health
and particularly with regard to school inspec-
tion, is that such things are unnecessary.
"They never used to do so in my day, and I am
here all right." Yes, but how many have
fallen by the way?

In an address before the Medical Society of
Kings County in February, 1915, Honorable
George McAneny, President of the Board of
Aldermen, of the city of New York, gave some
interesting data relative to the results of health
protection, from which we take the following:

192 AMERICAN PUBLIC HEALTH PROTECTION

In 1866, the city had a death rate of 35 per
thousand; in 1914, it was 13.3, and still re-
ducing.

In 1868-1877, there were 154 deaths each
year from diphtheria to 100,000 of population;
in 1913 the rate was 32, a reduction of 80 per
cent. The figures for scarlet fever were 91 per
100,000 in the period 1868-77; in 1908-1912
only 18, also 80 per cent, reduction.

There are, in proportion to the population,
700,000 fewer serious cases of illness in the
city, than there would have been according to
the annual rate of 1880.

It is not for a moment implied that this dif-
ference is due to the medical inspection of
schools which is now practised, though that is
materially helping. The reduction in mortal-
ity and morbidity may be justly attributed to
the things which "they did not do in my time,"
but are done now.

In 1890, according to Burks,3 San Antonio
established a so-called system of medical in-
spection of schools. Two years later in New,

9 Health and the School, p. 128.

MEDICAL INSPECTION OF SCHOOLS 193

York City Doctor Moreau Morse was ap-
pointed Medical Inspector of Schools — prob-
ably the first such appointment in the United
States. This appointment was made under the
direction of the department of health. The first
regular system of medical inspection of schools
seems to have been established by the health
department of Boston, Massachusetts, in 1894.
Since that time the idea has spread, until in 1913
it was estimated that more than 800 cities had
established similar inspection. Several states
have passed laws requiring such inspection;
others are permissive only. In many instances
the system has been inaugurated without spe-
cial authorization in law, but under general
provisions. In some jurisdictions the system
has been under the control of the health de-
partment; in others it has been wholly under
the supervision of the educational boards. In
several the examination has been begun and
continued by the medical society. In a few
cases it has been maintained partially or en-
tirely by private volunteers, or by such or-
ganizations as Women's Clubs. In glancing

194 AMERICAN PUBLIC HEALTH PROTECTION

through a list of Gulick's "Medical Inspection
of Schools" one notices that only a minority in
1908 were under the care of educational boards.
"What is worth doing at all is worth doing
well," and "the laborer is worthy of his hire."
While voluntary inspection of schools might
sometimes be started by non-governmental
bodies, or by individuals, there are several ob-
jections to such work, except in very tempor-
ary experiments. It may occasionally be best
to make such an examination to settle some
special question, or to demonstrate to the com-
munity the results which may be attained by
such examinations regularly made. On the
other hand, parents and others are suspicious
of the prying impertinence of such volunteers.
Strong objection is frequently made, and the
suspicion has sometimes been apparently jus-
tified that such examinations have been made
the "feeders" for the private practise of the
examiner or his friend. Besides this, such
gratuitous service often breeds a sort of les-
sened respect for the entire profession to which
he belongs. What business is it of Doctor A.

MEDICAL INSPECTION OP SCHOOLS 195

if one of the regular patients of Doctor B. has
adenoids? Why should the members of the
Woman's Club be so inquisitive relative to the
physical condition of Dennis McSweeney's or
Sambo Brown's children? That is the way the
victims feel, and it makes no difference how
disinterested the examiners, or their sponsors,
may be.

Neither should the examinations be made
by the department of health. Their training
and manner of thought would come far from
fulfilling all the important points. This seems
to be the almost universal opinion of disinter-
ested students of the subject, in spite of the
proportion of places in this country where the
health department does control the matter. It
takes a person of peculiar nature and educa-
tion to be a good medical examiner of schools.
It is better if he be fitted also by experience as
a teacher. Professor Dresslar of the National
Bureau of Education thus sums up the neces-
sities of his qualifications.4

"The school physician must be an expert

* School Hygiene, p. 331.

196 AMERICAN PUBLIC HEALTH PROTECTION

diagnostician, for his work is to detect disease,
not to treat it. He should be a man of refine-
ment, culture and tact, that he may win the
confidence of the children who shall come to
him to look upon him as a friend. He must
know how to exercise firmness in dealing with
parents who do not understand the necessity,
or appreciate the value, of his work. He must
have a psychological, as well as physiological
and anatomical, knowledge of children. He
must be a man of patience, a man who is deep-
ly conscious of his mission — the correction of
defects, the prevention of illness, and the alle-
viation of suffering, thus adding to the sum
total of the world's peace and happiness."

Dresslar, who is not a physician, but who
has had an unusual opportunity for studying
the problems connected with the medical in-
spection of schools, gives it as his opinion that
"there should be no connection with the Board
of Health, except that the medical inspectors
would report contagious diseases to that board
which by virtue of existing laws assumes con-
trol of such cases." Hoag and Gulick, who
are physicians, are quite as emphatic as to the,

MEDICAL INSPECTION OF SCHOOLS 197

Jhadvisability of having the work under the
health office. Experience has demonstrated
this fact, and where the work was begun by
the health department it is now under the man-
agement of the board of education in a large
percentage of the cases. Occasionally the ex-
pense and authority have been divided between
the two offices.

It is not the province of the school physician
to treat these cases, says Dresslar, and we are
inclined to agree with him. For that very
reason the examiner should not be in general
practise. Even if he carefully recommends
the family to consult the family physician, if
the examiner be also engaged in practise there
is almost a surety that friction will arise, and
he will be unjustly suspected of using his posi-
tion to build up a private practise. In fact,
some physicians, generally of the commercial
class, very frankly advise that young physi-
cians be permitted to serve thus, practically
without pay, and in lieu of other compensation
that they be permitted to build up a private
practise.

198 AMERICAN PUBLIC HEALTH PROTECTION

If they be not permitted to engage in gen-
eral practise, it follows that they should be en-
gaged and paid for full time. To accomplish1
this in some of the smaller districts it would
be necessary that several districts unite to em-
ploy one good examiner, as is the custom in
England. Sometimes the work of medical in-
spector might very properly be combined with
teaching of sanitation, hygiene and physiology.
The lessons in sanitation given to the child, il-
lustrated in the daily work of the examiner,
will go far toward changing the habits of the
parents.

In addition to work directly connected with
the infectious diseases, the examiner keeps track
of the condition of the nose, throat, teeth, scalp,
eyes, ears and finger-nails. Adenoids are very
common. They not only cause deafness in
many cases, but the mental operation is made
more difficult and sluggish by their presence.
Many children who are backward immediately
change after the operation. In some parts,
particularly through the South, it is necessary;

MEDICAL INSPECTION OF SCHOOLS 199

also to examine for intestinal parasites. This
work, however, has been generally done by the
ordinary health agencies, and as a separate un-
dertaking. Special studies pertaining to school
work are sometimes made. For example, Bur-
gerstein quotes the studies made by Key of
Stockholm upon the influence of outside work
upon the amount of sickness.5 He found that
those who were required to do the most work
outside of schools were those who were most
likely to be sick. This extra work apparently
referred chiefly to studies, such, for example,
as music. Here in this country the relation-
ship of play to study and health has been the
subject of much investigation, and as a result
the importance of play is now recognized as
never before.

The importance of play brings up another
use of the school physician. While the average
scholar is benefited, not harmed, by vigorous
exercises, it sometimes happens that a heart is
overstrained, or other injury is done by exercise

8 School Hygiene, p. 125.

200 AMERICAN PUBLIC HEALTH PROTECTION

beyond that which the child should attempt.
Supervision of this element is an important
duty.

In order to carry the hygienic instruction
home when necessary, to keep track of the
home surroundings, and to see that the parents
fully appreciate the defect cards sent home
by the examiner, many schools, and now an
increasing number, employ a school nurse.
Practically the nursing staff among the foreign
element of a city like New York is a school
extension department.

In many places there has also been estab-
lished the school clinic, where those who are
unable to pay for service may have the atten-
tion of physicians and dentists. Hoag is strong
is his advocacy of the clinic, but there may be
some question as to the advisability of its use
as a routine matter. It is an institution which
may be very easily abused, and it may arouse
opposition where there would be none with-
out it.

While school clinics may be found generally
useful, they are especially to be advised, in the

MEDICAL INSPECTION OF SCHOOLS 201

poorer sections of cities, where the parents,
particularly foreign-born individuals who have
grown up under unfavorable conditions, are
prone to neglect the early stages of abnormali-
ties among the children. The clinic has also
proven especially advisable in connection with
college life, where many young people, away
from home surroundings and parental watch-
fulness, are exposed to many kinds of danger
to health. Stimulated by an epidemic of ty-
phoid fever among its students, the University
of Wisconsin established a school clinic some
years ago in order to keep a closer and more
intelligent oversight of the health of its com-
munity. Students are encouraged to come to
the clinic, where they may obtain the best of
professional advice and instruction without cost
to themselves. Here all students are examined
at the time of matriculation, and record is made
of conditions found and history. On the basis
of this examination the students are divided
into classes, and receive physical supervision,
including advice as to work, in proportion to
the def ectiveness discovered, The necessity for

202 AMERICAN PUBLIC HEALTH PROTECTION

this supervision arises out of the educational
work of the university, and the methods used
have direct relationship to education in train-
ing and in result.

The medical inspection of schools has now
proved its usefulness. It is often opposed
through ignorance or prejudice. Its object is
simply to enable the scholars to get the most
out of their school experience, and to train
them to efficient citizenship, and to prevent
untimely deaths. The work should be recog-
nized as educational.

Medical inspection of schools has been op-
posed by two principal organizations: the
"League for Medical Freedom" and the Chris-
tian Scientists. The "League for Medical
Freedom" is an organization which was
formed apparently by the patent-medicine in-
terests in order to defeat the Owen Bill, which
aimed at the creation of a national Depart-
ment of Health. It was thoroughly commercial
in its nature, and untruthful in its arguments.
Like its other statements this "League" was in
error in affirming that this movement for medi-

MEDICAL INSPECTION OF SCHOOLS 203

cal examination of schools was an effort of "the
medical trust" to get control. The real anx-
iety of the "League" apparently was because
it feared that with healthy children, trained in
the principles of hygienic living, there would
be less demand for the services of commercial
men calling themselves "doctors," or for pat-
ent medicines.

So far as the writer knows there has been no
organized opposition by the Christian Sci-
entist Church, but many individuals, acting
upon mistaken notions, prejudiced perhaps by
some incident not covered by the real move-
ment, or instigated by some false statement
originated by some interested person or organ-
ization like that just mentioned, have objected
to this inspection ; and in one case such persons
have carried the legal contest to a supreme
court. In the supreme court of Minnesota the
authority of the schools to initiate medical in-
spection of schools, as a reasonable and proper
part of their educational character was upheld
in Stoltertberg v. Brown.6 In South Dakota

•112 Minn. 370, 128 N. W. 294.

204 AMERICAN PUBLIC HEALTH PROTECTION

a board of education provided that a scholar
seeking admission must present a certificate of
examination from a physician of their own
choosing, and at the expense of the family, or
by a physician furnished and paid by the school
district. This was objected to as an interfer-
ence with religious liberty, and as in con-
flict with the laws compelling school attend-
ance. The court upheld the law, saying that
it in no way interferes with religious liberty,
and that no question of sect should enter into
the work of the school. That physical culture,
athletics and vocal culture are not required
taught by statute does not make their provi-
sion invalid, since there is nothing in the statute
prohibiting such additional instruction. On
the same basis, medical inspection of schools,
not being prohibited, and being properly a
part of the educational work of the school is
allowable. The examination does not exclude
any person, unless he excludes himself, by fail-
ing to produce the certificate; or in case of a
disease dangerous to the health of the other

MEDICAL INSPECTION OF SCHOOLS 205

scholars. The court therefore upheld the ac-
tion of the board.7

The failure of a pupil to make the normal
advance in his work increases the cost of edu-
cation for the district. It is therefore a duty
of the school management to investigate
whether the failure be due to the teacher, the
school surroundings, to the inherent capacity
of the child, or to some environmental influence
upon the child. It is therefore a reasonable
part of its duty to investigate the child's habits
out of school, and it has even been thought by
many, and actually practised to some extent,
that if evidence shows that the child is un-
derfed, by reason of the negligence or poverty
of the parents, the school should also provide
meals. Surely some governmental body should
have the authority to insare the proper nutri-
tion for the growing child, who in the future
will become a prop or a burden for society.

On the other hand, while the authority of a
health department may be recognized over the

T Streich v. Board of Educatbn, 14? N. W. 779.

206 AMERICAN PUBLIC HEALTH PROTECTION

subject of infectious diseases, and though fur-
ther studies by that department might be tol-
erated by the community, it is very doubtful
whether the courts would conclude that the de-
partment of health has the authority to delve
into private affairs such as attendance at the
"movies," amount of breakfast eaten before
school, increase in height of child as compared
with increase of chest circumference, and oc-
ular or aural defects which lessen the child's
ability to keep up in his classes. Such studies
are essentially in line with the problems of
school management, but are only distantly re-
lated to the work of preventing sickness. On
fundamental legal principles, then, it seems
that the medical inspection of schools might far
better be left to the department of education.
Because this work is essentially a study
which is of value in direct variation with the
number of accurate observations, it should be
uniform in character, and under the general
supervision of the state department of educa-
tion, with which the United States Bureau of
Education would willingly cooperate. Japan

MEDICAL INSPECTION OF SCHOOLS 207

is collecting its data from the entire kingdom,
and it is doing so because her leading men
have decided that it is a necessity.

No false pride of a parent should stand in
the way of his child's benefit. The object of
the examination is to inculcate health, not dis-
ease. Every citizen should therefore assist in
the work, insisting that it be done honestly by
those whose nature and education fit. them to
do it in a scientific manner.

CHAPTER VIII

ORGANIZATION OF HEALTH DEPARTMENTS

ALTHOUGH Mr. Eaton, in his Government
of Municipalities1 gives a somewhat lengthy
discussion to show that health administration
should be in the hands of a board of health, he
does not indicate great familiarity either with
the legal or practical aspects of the problem,
and his ground is quite the opposite to that
taken by most recent students of governmental
methods, and his arguments are even contra-
dicted in his own book. It is true that, simply
because that has been the American custom in
the past, most laymen and physicians think that
the board system should be continued. Since
this matter is generally decided by persons
who have not enjoyed the privilege of a careful
training in the principles of governmental
practise, it seems best to devote some space to
the consideration of this subject.

1P. 407.

208

ORGANIZATION OP HEALTH DEPARTMENTS 209

Mr. Eaton argues that where the authority
resides in one man there is too great an oppor-
tunity for oppression and partiality in admin-
istration; and there is need for multiplicity of
council to obtain the best results in formulat-
ing regulations and ordinances. On the con-
trary, to get the advantage of numbers in a
board it must have some degree of legislative
power. This it does not, and should not have.
The rules passed by a board do not them-
selves bar any abuse of power by the executive
or his agents. On the other hand, the more
boards that are permitted even a modified leg-
islative power, the less prominent will the
deliberations of each become. Mr. Eaton him-
self says:2 "In most American cities the ordi-
nance making power is distributed between
limited councils, boards and single officers.
Much conflict, confusion, and needless litiga-
tion are the inevitable result, as there would
be concerning the laws if there were several
law-making bodies in the same state.'* This
is of itself sufficient to condemn the suggestion

1 Op. cit. p. 262.

210 AMERICAN PUBLIC HEALTH PROTECTION

that an administrative body should be a
"board," in order to get the advantage of mul-
tiplicity of ideas, and a division of responsi-
bility.

An illustration of needless and useless litiga-
tion because of apparent conflict between the
ordinance of the city and a regulation made by
a board of health is found in the case of People
ex rel. Knoblauch v. Warden of City Prison.8

What is true of municipal government in
this regard, is also true of state administration.
President Goodnow says:4 "The experience of
the world is against the administrative ar-
rangements of the states of the American
tJnion;" and the English student, Percy Ash-
ley, says of the American state governmental
system:5 "The state executives are ill organ-
ized and weak."

A prime essential for executive efficiency is
found in the idea of oneness. Chief Justice
Story has given the subject a somewhat
lengthy consideration relative to national ad-

8 153 N. Y. Sup. 463.

^Principles of Administrative Law, p. 133.

8 Local and Central Government, p. 327.

ORGANIZATION OF HEALTH DEPARTMENTS 211

ministration in his work on the Constitution.
He says :6

"That unity is conducive to energy will
scarcely be disputed. Decision, activity, se-
crecy, and despatch will generally characterize
the proceedings of one man in a much more
eminent degree than the proceedings of a
greater number ; and in proportion as the num-
ber is increased, these qualities will be dimin-
ished." "This unity may be destroyed in two
ways: First, by vesting the power in two or
more magistrates of equal dignity; secondly,
by vesting it ostensibly in one man, subject,
however, in whole or in part, to the control and
advice of the council."7 Although discussions
are beneficial in legislation, after a law has
been enacted there is no longer occasion for
discussion. It is only the duty of the executive
to administer the law as enacted. "No favor-
able circumstances palliate or atone for the
disadvantages of dissension in the executive
department. The evils here are pure and un-

6 Op. cit. sec. 1420.
TSec. 1421.

212 AMERICAN PUBLIC HEALTH PROTECTION

mixed. They embarrass and weaken every
plan to which they relate, from the first step
to the final conclusion. They constantly coun-
teract the most important ingredients in the
executive character — vigor, expedition, and
certainty of action."8 "But the multiplication
of voices in the business of the executive ren-
ders it difficult to fix the responsibility of either
kind; for it is perpetually shifted from one to
the other. It often becomes impossible, amidst
mutual accusations, to determine upon whom
the blame ought to rest."8

Mr. Justice Miller tells us:10 "The nearer
we approach to individual responsibility in the
executive, the nearer will it come to perfec-
fection." President Goodnow sums up the
argument, particularly as regards municipal
administration, in the following words:11 "The
desirability of single-headed departments has
come to be regarded as unquestionable, and it

8 Sec. 1424.

9 Sec. 1425.

10 Lectures on the Constitution, p. 94.
u Municipal Government, p. 225.

ORGANIZATION OF HEALTH DEPARTMENTS 213

is almost heretical at the present time to ex-
press the conviction that the board form is
preferable."

All that we have heretofore said in support
of the single-headed executive rather than the
board is of general application; but when it
comes to a matter requiring a special, or tech-
nical, education and training, as in health ad-
ministration, the case is much stronger. This
is especially true when the department has the
supervision of so important a matter as the
health, and so prosperity of the community.
In the earlier times, when the science of health
protection was in such a crude and chaotic
state, it was not possible to have such enact-
ments as may now guide administration. The
science was indefinite, and the application was
individual. There might then have been some
justification for a board of health. No one
was competent to be an executive of health,
and the members of a board were equally in-
competent from a scientific point of view. This
is no longer true. It is true that competent

214 AMERICAN PUBLIC HEALTH PROTECTION

executives of health are uncommon, but they
will he more common when the country fully
recognizes the facts.

John Stuart Mill was wise when he said:12
"No progress at all can be made toward ob-
taining a skilled democracy, unless the democ-
racy are willing that the work which requires
skill should be done by those who possess it."

It is manifestly impossible to appoint a
board of sanitarians of equal ability; yet the
members have equal authority and equal ir-
responsibility. The strength of a chain is
measured by that of its weakest link. Every
member of a board below the best man for this
special work, no matter how competent he may
be in other lines of professional or business ac-
tivity, is so much dead weight upon the admin-
istration. His presence may be positively an-
tagonistic to good work, on account of his
lack of special education and experience. It
is an almost universal rule that the ignorant
man does not appreciate the depth of his ig-
norance, but overrates his ability. He may

^Representative Government, Everyman's Ed., p. 248.

ORGANIZATION OF HEALTH DEPARTMENTS 215

even help to force the board into some ultra
vires tort, for which the competent man who
has been overruled will be held legally equally
liable.

Whereas, in Prussia and in France the pro-
fessional administrator is only subject to the
general and financial control, in England "The
unprofessional administrators are supreme;
they are the authorities, and the salaried ex-
perts are merely their agents and servants."18
Still, in practise the English health specialists
have more power and influence in shaping ad-
ministrative measures than have similar officers
in the United States. The English official class
are better posted upon the necessities of good
government, whereas in the United States
they are more proficient in "politics."

The services of a competent specialist should
not be expected unless he be paid a reasonable
compensation; that means, a compensation
commensurate with the responsibilities of the
position, and with the time and expense requi-
site for obtaining his fitness. The first point is

M Ashley, Local and Cent. Gov., p. 13,

216 AMERICAN PUBLIC HEALTH PROTECTION

generally recognized in America, and the
politician class take advantage of it to secure
for themselves the best paying berths, without
regard to qualifications. It thus frequently
happens in American administration that the
really competent, or less incompetent, health
official is made subordinate to the mere political
appointee. The first question to be asked rel-
ative to the fitness of a candidate for appoint-
ment to a health department should be, not is
he a good physician, nor does he belong to the
party in power, nor is he a getter of votes, nor
does he have elective influence; but, does he
know the modern science of public health pro-
tection.

It is a very unfortunate thing that the medi-
cal profession should so frequently imagine
that any competent bacteriologist is also a com-
petent public health administrator. The con-
trary may be the fact. The expert laboratory
specialist frequently takes too narrow a view
of his position. The administrator in a large
office has no time for laboratory work himself;

ORGANIZATION OF HEALTH DEPARTMENTS 217

and to no small degree the same is true of
smaller offices. It is necessary that the execu-
tive head should have a good knowledge of the
methods and results of bacteriologic investiga-
tion, just as he should know the general facts
of sanitary engineering; but a thorough ac-
quaintance with the subject of administrative
law is more important for the chief than either
engineering or bacteriology.

There is also a tendency in American gov-
ernmental practise unduly to multiply execu-
tive bodies. The result is necessarily conflict
of authority, division of responsibility, and
unsatisfactory and expensive administration.
With every new suggestion as to subject, some
amateur enthusiast rushes forward to have a
new commission appointed to make the investi-
gation, or to attend to its administration.
Sometimes this work is arranged by regular
governmental agencies, as when the legislature
establishes a commission to investigate the in-
dustrial diseases. Sometimes voluntary organ-
isations are formed actually to do the work.

218 AMERICAN PUBLIC HEALTH PROTECTION

The formation of antituberculosis societies is
of itself a demonstration of the utter ineffi-
ciency of the ordinary health departments.

Many of these commissions are expected to
work without pay. A competent member of
the Illinois commission for the investigation
of industrial diseases was forced to resign from
the commission in order that she might receive
a salary while actually doing the work. Of
what possible advantage can a board of non-
experts be, who devote only a portion of their
time to an investigation, and who must judge
of the matter at second-hand? Why should
such intermediaries interfere between the ex-
pert, or trained observer, and the people?
What man would expect to place the trained
manager of his factory under the control and
dictation of a committee who are without the
same degree of training?

Definiteness of duty, and therefore a liEe
definiteness of responsibility, are essential ele-
ments in the work of a good and efficient execu-
tive. This individualness of responsibility
practically means that the chief should have

ORGANIZATION OP HEALTH DEPARTMENTS 219

the appointing power over all his subordinates.
This further means that he should have the
power to remove such officers as he can appoint.
Incidentally, we may here remark that though
the principle of civil service is undoubtedly
correct, in its practical operation it may often
protect inefficiency. A man may pass a good
general examination, and still not be efficient,
and when he chances to begin his service under
a general officer who is himself inefficient the
subordinate becomes rooted in his place. So
long as he commits no definite breach of law
or rules, it is practically impossible to oust
him. On the other hand, the position as health
official should be absolutely removed from pol-
itics, and a competent executive should be re-
tained as long as possible.

According to the laws of some states a candi-
date is not eligible for appointment to office
unless he shall have been a resident of the
jurisdiction for a year previous to his appoint-
ment. Though such a law may be advisable
relative to elective offices, and though it may
also be desirable relative to positions which 3o

220 AMERICAN PUBLIC HEALTH PROTECTION

not require special or technical education and
training, it is a positive and serious handicap
to efficiency in public health service. There is
no advantage in such a law, except to the in-
competent office-seeker. It is a disadvantage
to the community, for many times it is impos-
sible to find a competent official in the juris-
diction. It is a disadvantage to the competent
man, for it practically prevents his rising
higher than he starts.

Were there no limitation in appointment of
health officers as to previous residence, it would
be quite possible for the young man to start as
an inspector in a metropolitan department.
Having gained experience he might be either
directly appointed as the head official in a
small city, or he might be so appointed after
taking another course in the school. In the
small health department he would gain another
point of view, and other training. There would
be a strong incentive for him to do good and
efficient work in the hope that he might thus
gain a promotion to a larger position. The
community would gain in that it first would

ORGANIZATION OF HEALTH DEPARTMENTS 221

have the benefit of his previous training; and
secondly, through his increased efficiency as a
result of his ambitions. On the other hand,
the larger community would not run the risk
of appointing an untried and inexperienced
administrator. The present law, requiring a
year's previous residence before appointment,
is an injustice to all concerned, and should be
immediately so changed as to make an excep-
tion in the case of such positions as require a
special or technical education and training.
This point is the more important in the case
of health officials inasmuch as the education
needed is one for which there is practically no
demand outside of governmental service.

The head of a health department should be
a whole-time paid officer, thoroughly trained
in the duties of his office. Such a man is worth
to the community all that he is paid. It will
often be found impossible for a small village to
pay such an officer. That should not mean
that the village should get part-time service
from some doctor in private practise; nor that
it should entrust its affairs to a board of phy-

222 AMERICAN PUBLIC HEALTH PROTECTION

sicians who divide between themselves the re-
sponsibility. The following incident from the
writer's personal observation will show the in-
advisable result of such action.

In a little city in the eastern part of Illinois
there was a board of health composed of three
of the leading physicians. They were men
who were as much alive to their responsibil-
ities of office as one is likely to find. An epi-
demic of typhoid fever occurred. Investiga-
tion showed that a young man had come home
to his mother's farm from an Indiana city and
developed typhoid fever. His mother was a
widow, dependent for her support upon the
conduct of a small milk trade. The expense of
the boy's sickness made it all the more neces-
sary that she keep her trade. She also felt
obliged to economize by doing as much of the
work as possible, caring for her boy in the
meantime. The attending physician was one
of the board of health. He tried to watch over
the possibility of the spread of disease, but be-
ing employed by the family he did not feel
that he should take the first steps toward a

ORGANIZATION OP HEALTH DEPARTMENTS 223

more vigorous quarantine. On the other hand,
the other two members hesitated to act because
they knew that friends of the widow would
charge that they were actuated by jealousy,
because they had not been employed. They
accordingly kept quiet, and waited. In the
meantime case after case developed, and every
one was among the patrons of the widow milk
dealer. At last, stirred by the alarm of the
citizens, they insisted upon the quarantine and
the epidemic was stopped.

In the county where the above incident oc-
curred there were several small villages, in ad-
dition to the county seat, which was the city
mentioned. No one of these communities was
itself able to employ a whole-time health offi-
cial. On the other hand, the county would have
saved money for its citizens had it appointed a
health officer and an assistant, and those two
could have administered the affairs of the en-
tire county very satisfactorily. Together they
could have shared the labors of microscopic ex-
aminations, and other laboratory work, have
kept the records, and attended to such inspec-

224 AMERICAN PUBLIC HEALTH PROTECTION

tions and other routine work as seemed ad-
visable. There was no necessity for either of
them to go outside of their legal jurisdiction,
as there might be where the milk supply, for
example, comes from outside territory. It
would probably be inadvisable for such an of-
fice to make many analyses of foods, such as
may be more frequently needed in the vicinity
of a large city. On the other hand, in such an
office, when it had been working for a reason-
able time, there should be on file data relative
to every well or other source of water supply
in the county, data as to sewage and garbage
disposal, data as to the number and character
of animals on every farm in the county, popu-
lation of each district, location of each school,
and telephone connections over the county, so
that by reference to the map the officer could
tell at a glance where to call up by telephone
some person to give information relative to con-
ditions. State departments might well coop-
erate with such a county office, making water
analysis, and furnishing temporary service of
special inspectors. This office should receive

ORGANIZATION OP HEALTH DEPARTMENTS 225

all reports as to infectious diseases, and records
of births and deaths. It should also keep track
of cases of infectious diseases in domestic ani-
mals.

Veterinarians are ordinarily appointed by
the state. There should be a veterinarian in the
vicinity, and such a man would probably find
it to his decided advantage to cooperate with
such a county health office. It would be equal-
ly helpful to the health office to make such an
arrangement. In some more thinly populated
sections it might even be advisable to make
the veterinarian the assistant in the health of-
fice.

In connection with the public health school of
Harvard, and the United States Public Health
Service, Professor Phelps some time ago tried
an experiment in a more thickly populated por-
tion of Massachusetts, in which several villages
were united into one health department. This
worked very satisfactorily, and enabled the
employment of several persons, each for some
specific portion of the work, and all done un-
der Professor Phelps' direction. A similar

226 AMERICAN PUBLIC HEALTH PROTECTION

plan has given satisfaction at La Salle, Illi-
nois. To overcome legal objections in such a
case it might be necessary that A be appointed
the health officer of M, B of N, C of O, and
so on, with the understanding that they are to
work together, and pool the issues. Thus, un-
der such an arrangement A would make the
laboratory tests for N and O, as well as M ; B
would make inspections of dairies, etc., in M
and O; and C would keep the records for all
the villages.

The head of the department should be a
whole-time officer, but his assistants need not
be such. It is far better to have the entire time
of one good man in a given line, ordinarily,
than to have half time from two or three in
the same line of work. This is especially true
of physicians. As has been said before, a phy-
sician who spends part of his time in general
or special practise is morally certain to bring
upon the department, sooner or later, suspicions
of intrigue. On the other hand, there is often
a decided advantage in employing part of the
time of a competent bacteriologist or inspector.

ORGANIZATION OF HEALTH DEPARTMENTS 227

In a small office such a part-time assistant may
easily do all that is desired in that line. He
may be engaged also in teaching in the local
high school or college. By such an arrange-
ment both the high school and the health de-
partment may be able to obtain the services of
a better man than they would otherwise feel
able to pay. Students might be employed for
inspection work, especially those who are
studying in health schools. That which espe-
cially lends itself to this form of service is that
while the inspection work is the most urgent in
the summer-time, when the school is not in
session, the heavy work of the school occurs
in that portion of the year when ordinarily
the work of a health department should be the
lightest. Further, such practical work gives
point to the work in the school, and enables the
student to grasp the fundamentals as he would
not otherwise be able to do. Not only so, but
the student inspector brings to the small health
office the latest ideas from the school, and the
returning student inspectors naturally compare
the conditions and results in the different ter-

228 AMERICAN PUBLIC HEALTH PROTECTION

ritories in which they have been working. Stu-
dents thus recently made a most thorough san-
itary survey of Logansport and Noblesville in
Indiana.

One of the natural results of such arrange-
ments would be that certain health departj
ments would acquire a certain accredited stand-
ing, so that service there would be recognized
in the school work; just as certain hospitals
have received accredited standings among
medical schools.

In the metropolitan health departments the
organization must be much more complex. In
addition to the commissioner and his assistant,
there must be many heads of sections, as of lab-
oratory, statistics, infectious diseases, tenement
inspection, garbage disposal, etc. Perhaps un-
der each section head there may be several sub-
heads, and under them the individual inspectors
or other workers. Each inspector should have
a definite territory for which he is responsible
to his subchief . In that way responsibility may
be at once traced in either direction. The re-
sponsibility is determined by subject between

ORGANIZATION OF HEALTH DEPARTMENTS 229

sections, and by location to the responsible in-
dividual. Sometimes a subject may involve
two or more sections, in which each must be
held responsible. For example, though it may
be the duty of one man to look after the dis-
posal of manure, andj of another to inspect
dairies, as a part of his work relating to dairies
the second should also inspect the barn, and if
he finds that the manure there is breeding flies
he should at once report to his chief, who will
communicate the complaint to the chief in
charge of manure disposal.

Such an organization also provides for ap-
peal. There should always be some opportu-
nity for appeal, and if the department has made
suitable provisions therefor, appeal outside of
the department to the courts could only cover
a question of law. Decisions within a properly
organized executive department are not sub-
ject to review by the courts. When, however,
there is question as to whether the legal forms
have been complied with, there is appeal to the
courts. If it shall appear that the officer has
exceeded his authority, and injury has re-

230 AMERICAN PUBLIC HEALTH PROTECTION

suited therefrom, the courts will hold the in-
dividual officer legally responsible. The law
does not presume that its servants will act il-
legally, and if the officer does so, though he
may have the office claimed, yet in the special
act in which he does the wrong he will be pre-
sumed to be a private wrongdoer. When,
however, in a matter in which the law gives him
discretion, he makes an error in that discretion-
ary decision, he will not ordinarily be held liable
for injury resulting from his act.

All of these things show the necessity for
appeal within the department, and for a
knowledge of the law which may guide the
department head.

The work of a department of health is at the
best uncertain and irregular. If the office be
manned only for the ordinary amount of ser-
vice, there will be times when it is unable to
cope with the problems promptly. Slack time
may be used for routine work and completing
studies of special subjects, but it is desirable
that some means be found for greatly increas-
ing the force at command on short notice. This

ORGANIZATION OF HEALTH DEPARTMENTS 231

additional force may only be needed for a week
or two, or it may be occupied for some months.
There are two solutions of this problem. The
arrangement previously suggested between the
department and a neighboring school where in-
spectors may spend part of their time is one.
Another may be found in the relationship be-
tween the local and state departments. This
will be mentioned later. Sometimes the stress
may be relieved by transferring some of the
force temporarily from one section to another.
There is this advantage in such a makeshift,
that thus a worker becomes more familiar with
the methods of other sections, and also gains
a broader view of his own work.

The guardianship of public health is no
longer merely a local matter, largely individual
in its decisions. There is need for the highest
technical education in many lines, and different
sections of the country and varying lines of en-
terprise are most closely concerned in the health
administration. Take, for example, the milk
industry. The supply of a city like Washing-
ton, New York, Boston, Chicago, St. Louis or

232 AMERICAN PUBLIC HEALTH PROTECTION

Philadelphia, is received from several states.
Even when a metropolitan supply is received
only from the one state in which the city is lo-
cated, it comes from several counties, often
widely separated. It is impossible to tell from
examination whether or not a certain sample of
milk is safe in most cases. Examinations take
time, and serious harm might easily result be-
fore the conditions may be discovered, even
when the tests finally show that there is a dan-
gerous infection. It is not to be presumed
that milk will be actually spoiled when it is
delivered to the customer. If it were, the cus-
tomer would seriously object, and the dealer
would soon lose his patron if the incident were
frequently repeated. On the other hand, if
the conduct of the farm be sanitary the milk
will be safe, and the chemical and bacteriolog-
ical examinations of the supply need not be so
frequent, nor so searching, but the results of the
service will be far more effective. But inspec-
tion of farms widely separated takes much time,
and the city inspector has no legal authority to
order immediate changes made when he finds

ORGANIZATION OF HEALTH DEPARTMENTS 233

dangerous conditions. It is true that he may
withhold the privileges of trade with his own
city; but then the farmer will often ship his
product to some other market, or will find
another route by which the infected milk may
reach the same market. A certain company
had bottling plants in different counties. That
from county X went to A, while from Y it
went partially to B and C. The X territory
was found infected with a communicable dis-
ease which was epidemic in A, and which in A
seemed to be very strictly limited to the pa-
trons of this one dairy. Milk from X was re-
fused admission to A, and in its place came a
carload from Y. The officer at B knew that
his supply had been coming from Y, so that
when he discovered a sudden outbreak of the
disease in his city he at once hastened to Y
for an inspection. A and B were on quite dif-
ferent lines of rail, so that he never suspected
the fact, but it was a fact nevertheless, that the
infected carload from X had been taking the
place of his better supply from Y. In another
instance, when typhoid was found at the farm

234 AMERICAN PUBLIC HEALTH PROTECTION

of a producer, and many cases of infection had
been traced to that one supply, the milk from
that farm was refused in market D. Shortly
thereafter, in tracing another outbreak of the
typhoid it was found that this farmer had sim-
ply driven to a station on another road, and,
using another name, had been shipping to an-
other dealer. In the first instance, lack of au-
tKority over conditions had simply shifted the
injury from A to B. In the second it had occa-
sioned doing the same work twice by the D
health department.

The foregoing incidents illustrate the diver-
sity of territory interested in a single proposi-
tion. The same trade shows how a problem
may need the study of the veterinarian, the
chemist, the bacteriologist, the epidemiologist,
the general inspector of dairies and other spe-
cialists. Further, when milk is refused in the
milk trade it may be diverted to the creamery
for butter production, or for the making of
cheese.

Bruck, in Germany, found that butter may
retain typhoid bacilli for twenty-seven days,

ORGANIZATION OF HEALTH DEPARTMENTS 235

and Washburn, as quoted in the government
bulletin on Milk and Its Relations to Public
Health, found that butter may retain the liv-
ing typhoid bacteria as long as sixty days or
more. While in the course of the repeated
washings most of the bacteria would be re-
moved, still here is one possible source of infec-
tion. Milk makes a very satisfactory medium
in which the typhoid bacillus multiplies. The
buttermilk is not washed, nor otherwise me-
chanically purified, so that if the milk was orig-
inally infected the buttermilk will retain the
infection for a time at least. The time required
for the ripening of cheese makes it unlikely
that it would retain this infection. Rosenau
says,14 "Nevertheless fresh cheese, such as cot-
tage cheese, may contain the infection." He
does not say that the infection has been found
in such cheese, and the writer knows of no such
evidence.

Ice-cream may also be an active carrier of
typhoid infection. Both butter and cheese have
been found to contain living tubercle bacilli.

14 The Milk Question, p. 114.

236 AMERICAN PUBLIC HEALTH PROTECTION

In a series of tests made by Schroeder he found
infection with tubercle bacilli in a majority of
the butter samples examined. Mohler, of the
Department of Agriculture, found viable tu-
bercle bacilli in butter after one hundred and
fifty-three days. Cheese infection with the tu-
bercle bacillus is less frequent because of the
longer time required in ripening, but such in-
fection has been found.

Since dairy products such as butter .and
cheese lend themselves to wide distribution, and
they may be transporters of infectious germs,
it follows that it is important for the resident
of Providence, R. I., or of Washington, of
Philadelphia or New York, that the manufac-
ture of milk products be carefully supervised
by health agencies even in the little country
village of Wisconsin, or Iowa.

Efficiency of health administration then
means that so far as it may be possible all the
different agencies for the safeguarding of the
public health should be systematized and or-
ganized. It means that the organization be of
such a nature that it will be possible without

ORGANIZATION OF HEALTH DEPARTMENTS 237

delay to get definite information relative to
the various health questions which may be
asked, from any section of the country. This
necessity may be partially recognized in the
following incident. There was a sudden out-
break of typhoid fever in an Illinois city. The
only common point between the cases, as far as
could be determined, was that each patient had
eaten celery which had been purchased by the
local grocers from a commission firm in Chi-
cago. Thence it was traced to a Michigan
town, but the Illinois official was informed
that there was no typhoid there. However, he
learned later that there were cases and deaths
from typhoid fever on the celery marshes of
that town. The local health official was appar-
ently afraid that a statement of the truth
might interfere with an important branch of
the town's industry; and he regarded the mat-
ter as of no one else's business. Perhaps a few
damage cases in such conditions would open
the eyes of the official and his friends, and thus
serve to safeguard the public weal.

Of all the branches of governmental activity,

238 AMERICAN PUBLIC HEALTH PROTECTION

the health department is the one which most
needs to be executed without fear or favor.
The practising physician is incapacitated from
such service because of his interest in his pa-
trons' families. The member of the little city
board, who did not want to be too strict with
the widow who sold typhoid fever in milk,
knew that with more strict quarantine he would
be obliged to wait for a long time for pay for
his professional services. The health officer of
the Michigan town probably had patrons on
the celery marshes, so that he did not want to
hurt the business.

Legally speaking, a municipality has a dual
character. In so far as its affairs are strictly
communal within its limits, as in the mainte-
nance of a public water supply, or in the grant-
ing of a local franchise to a gas company, it is
a local corporation, and entitled to do as it
pleases within certain general restrictions. In
other matters it is simply the local guardian
of strictly governmental affairs, to which the
state has assigned certain governmental duties
as the representative of the state.

ORGANIZATION OF HEALTH DEPARTMENTS 239

The work of a health department is essen-
tially state duty, and in that sense a health offi-
cer is a state officer. That fact protects him in
the performance of his duty. A city may be
sued for its conduct of the water business, but
a suit against a city for its work in the preser-
vation of the public health would not stand in
court. This has been the repeated decision of
the courts in all parts of the country. A state
can not be sued in tort, and this protects also
its subordinate agents. So, unless an officer
exceed his lawful authority, he will be pro-
tected from being assessed damages, even
though as a result of his error some individual
suffer injury. This is not true relative to the
officer who is essentially an officer of the cor-
poration. These matters have been the sub-
ject of legal decisions in the past.

If the officer be essentially a state officer,
even though he be appointed and paid by the
city, he is also subject to state regulation in the
conduct of his office. It has been held that po-
lice officers of cities may be appointed under
the state regulations. Health officers are es-

240 AMERICAN PUBLIC HEALTH PROTECTION

sentially police officers, and under this general
authority of the state according to the present
law in the state of New York, if a local gov-
erning body neglect to appoint a health officer,
the state department may make such appoint-
ment. If the state may make such appoint-
ments at one time it may do so at another. It
has the power, therefore, to make such local
appointments at all times, and the duty to pro-
vide suitable compensation may be assessed
upon the local jurisdiction. There may be
some question as to the advisability of always
making such appointments by state officers,
especially until the state has shown an appreci-
ation of the necessities of the case by selecting
trained specialists, rather than politicians. Still
the legal right should be recognized, and in
case of a real state department of health, with
a makeshift local office, the right of the state
should be exercised.

Whether appointed by the state or by the lo-
cal governing body, the local health depart-
ment should be recognized as a part of the
machinery of the state, and there should be a

ORGANIZATION OF HEALTH DEPARTMENTS 241

general supervision exercised by the state ex-
ecutive, and the local office must recognize its
duty, not only to the local interests, but quite
as much to the community as a whole. As to
authority in health matters each state is the
unit, and the nation must work at present al-
most entirely in an advisory capacity. It must
depend upon the cooperation of the different
states. In the states there is not only the moral
force which produces cooperation between dif-
ferent districts, but there is the absolute author-
ity of the state to compel such cooperation. In
other words, a local health officer has no special
obligations to the residents of his district, but
he has a responsibility for the proper care of
the territory, and that responsibility is to the
people of the entire commonwealth.

This responsibility of the health officer to
the entire commonwealth, and not to the people
of his special jurisdiction, is another reason
why there should be the greatest freedom of
choice, and that officer should not necessarily
be selected from the immediate neighborhood.
In fact, it may very often happen that an offi-

242 AMERICAN PUBLIC HEALTH PROTECTION

cer from another jurisdiction may be more de-
sirable for that very reason. He is less likely
to be biased by personal interests, and he is
more likely to appreciate defects. One who
has always been accustomed to see certain
things gets so used to the sight that he does
not appreciate the defects as he would were he
to visit the scene for the first time. In the same
way, a man brought up in one community, or
who has always lived in that one neighborhood
during his active career, becomes hidebound
in his brain. He does not readily get new
ideas, and in consequence he falls far below his
possibility in execution of his duty. Even to
move him to a new location breaks his old man-
ner of conduct, and enables him to make ad-
vances which he could not make at the old
home. The gain to the community is still
greater, for the man from away brings with
him new ideas, and sees all the local problems
from a new point of view. Custom is inertia
which must be overcome. If the new ideas are
mere notions he will find them difficult of ap-
plication, though in another place the custom,

ORGANIZATION OF HEALTH DEPARTMENTS 243

has given them life. Thus the officer from
away may have a test for his former methods
and practises which would have been impos-
sible in his former home.

To overcome some of these difficulties we
might well copy some of the English cus-
toms. There the appointment of local officers
of health is made by the boards of the juris-
dictions, but the central authority, the Local
. Government Board, pays one-half of the sal-
ary of such a local officer under certain condi-
tions. It requires that he shall not bevengaged
in private business, and that he be of a certain
prescribed standing as to technical training.
No officers of health partially supported by the
Local Government Board may be appointed or
removed without the approval of the central
board. In some districts such local officers of
health are also employed to make the school
inspections, or to conduct the governmental
laboratory for making chemical or bacterial
examinations.

The commercial and transportational condi-
tions of the present day demand that every inch

244 AMERICAN PUBLIC HEALTH PROTECTION

of territory in the United States be covered
by some well organized health service. There
should be some uniformity and defmiteness of
responsibility so that at any time, and with
the least possible delay, information may be
sent or obtained from distant sections. Some
time ago the writer was seeking certain infor-
mation from the different cities and villages
of the state relative to a single public health
problem. He found that in some localities
there was no special health service; in others
there were boards of health, composed mostly
or entirely of unprofessional people, and with-
out special training or education; in others
there were boards consisting of physicians, and
each referred the question to his brothers for
solution; in some there was a commissioner of
health, and he was not always educated in any
professional line. It is only a few years ago
since the great city of Chicago had for its com-
missoner of health a certain ward politician
who was without any special training or edu-
cation which fitted him for the place.

A medical book agent chanced one day to

ORGANIZATION OF HEALTH DEPARTMENTS 245

meet a politician with whom he was well ac-
quainted, and the following conversation is said
to have occurred: "Why don't you apply for
the position as executive of the state health de-
partment?" The book agent laughed at his
friend's felicity, but on being convinced of his
earnestness answered :

"I could not possibly get the recommenda-
tion of the medical profession."

"The governor wants to make a change, and
you could easily get the place."

"I could not get the backing of the doctors,
and if I tried they would jump on me and sim-
ply make me look ridiculous."

"Don't tell them a word about it. They
don't count, at least before they begin to work,
and after you are appointed they will say noth-
ing. You go home and find J (naming a cer-
tain ward politician) and get him to take you
to P (naming one of the political bosses) , and
get P to write a letter to the governor, asking
for your appointment. Then come right back
and I will take you to the governor."

The medical book agent did as he was bid,

246 AMERICAN PUBLIC HEALTH PROTECTION

and within less than forty-eight hours he re-
ceived his commission as the health executive
of the state. This incident is given simply to
show that until the importance of the health
positions is generally appreciated by the citi-
zens they will be used, in many cases at least,
as means whereby political favors can be re-
paid, or for personal aggrandizement.

All of the various agencies pertaining to the
preservation of the public health in a state
should be grouped under one appointive head.
Appointive, for the people are not competent
to select by election the most competent man
for such a position. The more officers to be
elected at an election the less discrimination
will be used in casting the ballot. This has
proved an almost universal rule. The people
may select a good governor, and they should
place upon him the duty of selecting his sub-
ordinates.

There is need in such a state department of
health for the services of a state veterinarian
and his assistants. They should compose one
of the divisions of the general office of health,

ORGANIZATION OF HEALTH DEPARTMENTS 247

and be neither a separate organization, nor, as
at present in Illinois, subordinate to a commer-
cial department of a state government. There
should be also a division in charge of food in-
spection generally, and another to watch over
the dairy business. There should be a division
for the investigation of industrial conditions
and diseases, and one for the investigation of
lodging houses and tenement buildings. There
must be a division of infectious diseases, in the
charge of an epidemiologist with good train-
ing and executive ability. There must be a di-
vision of laboratories, which will be engaged
in making the chemical and bacteriologic ex-
aminations. There should be a division of zo-
ology, which should be prepared to make a sur-
vey of any section, and give needed advice for
the eradication of pests which are injurious to
health. In the southern states, at least, this will
prove one of the most important divisions, and
will be obliged to watch the production of
mosquitoes and the hookworm particularly.
There must be a division of vital statistics,
which will keep accurate data relative to births

248 AMERICAN PUBLIC HEALTH PROTECTION

and deaths, and of the occurrence of infectious
disease. Every local office should report to
this division weekly as to the number of cases
of infectious disease present, and in case of the
appearance of an epidemic there should be a
telegraphic report, so that at any time the state
executive may be able to report as to the pres-
ence of such cases in any section of the state,
with some degree of definite certainty. There
should be a division of publication, and the
reports and papers issued should be efficient
means for the education of the people of the
state. In many states it will be necessary to
have a division on license, which will attend
to the examinations for all licenses relating to
health preservation, such as for physicians and
surgeons, dentists, pharmacists, nurses, veteri-
narians, and perhaps barbers. The licenses
should in each case be issued by the state com-
missioner of health, not by the examining
board, and there should be a chance for re-
jected applicants to appeal within the depart-
ment, making the decision of the commissioner
final. There should also be a provision for the

ORGANIZATION OF HEALTH DEPARTMENTS 249

trial of license holders, before a license can be
revoked and withdrawn. There should also be
a division of correspondence, and one of rec-
ords. There should also be connected with the
department a sanitary engineer. This posi-
tion will be of increasing importance in the fu-
ture, and it may prove to be one of the large
divisions. This division should pass upon all
plans for the change of systems of water sup-
ply or of sewerage. No sewer should be per-
mitted to empty into any stream or lake used
for water supply in any of its parts, unless the
plans for such sewer shall have been approved
by the sanitary engineer of the department,
and upon suitable evidence that the sewage will
have been so purified as to work no injury to
other communities.

The above enumeration of the divisions of
state departmental work is not exclusive, for
in many jurisdictions other divisions may seem
advisable. It will, however, give some slight
indication of the magnitude and importance of
the subject. Probably, too, it will be found
necessary to have a division of subordinate ju-

250 AMERICAN PUBLIC HEALTH PROTECTION

risdictions, with a chief who will be directly re-
sponsible for the localized work. The state
should be, as Pennsylvania is to-day, divided
into sectional divisions, with a subchief for
each section. With such an organization much
unnecessary duplication of work will be
avoided. In the place of having dairy inspect-
ors from several cities to make the dairy inspec-
tions and records, this should all be done by
the state department, and such definite records
kept that any municipality may at once get its
desired information.

Though at present the national government
has only a limited authority, according to the
legal interpretations of the past, the organiza-
tion of a national Department of Health, with
its head seated in the Cabinet, may be made on
similar lines to that of the individual states.

In the practical working of such a depart-
ment it will often be found that the same item
of information touches several divisions. For
example: The divisions having the oversight
of local departments, epidemiology and dairies
are each interested in the matter of infectious

ORGANIZATION OP HEALTH DEPARTMENTS 251

disease prevalence. We have indicated that
local officers should make those reports weekly,
and sometimes by telegraph. Such reports
would regularly find their way weekly to the
division of publication, from the division of vi-
tal statistics, and proof-sheets could be distrib-
uted through the central office within a few
minutes after copy is submitted to the printer.
In case of an epidemic, the manifold copy could
quickly be given to the divisions specially in-
terested. If it be in a dairy district the chief
of the division should have on file information
as to the field supplied from the infected terri-
tory, and he could, and should, at once com-
municate the information to the subchief of
the field service having that territory directly
in charge. This does not mean that there
should be instituted a quarantine upon this
milk, but that the local officials may be upon
their guard to detect the infection without de-
lay. In other words, with such an organization
it would be possible to anticipate and prevent
serious trouble, with the least possible disturb-
ance of the normal trade.

CHAPTER

PREPARATION OF OFFICERS

WITH the development of the modern sci-
ence of public health there is coming naturally
a readjustment of former conditions. Changes
are being made in the conduct of commercial
affairs, for definite and reasonable methods are
taking the place of the former empiricism.
Public health administration is becoming rec-
ognized as the aid and defender of commerce,
not as its occasional enemy. Old principles of
law find new and broader application. While
the work of the practising physician is being
greatly decreased, that of the veterinarian is
being widened and dignified. The blacksmith
or livery stable loafer, each of whom formerly
was frequently consulted about equine ail-
ments, have lost their prestige, and in the place
of the old "hoss-doctor" we now find a profes-
sion whose education is far in advance even of

252

PREPARATION OF OFFICERS 253

the average medical graduate of a few years
ago. This point is important from the public
health standpoint, for the veterinarians, as
such, play a very influential part in the safe-
guarding of the community health — quite as
much as that taken by physicians. Entomol-
ogy, which only a few years ago was simply
the pastime of boys, and the occupation of a
few professors, has become a profession in it-
self, and a* most interesting and fascinating
one it is.

The great change has been the opening of
a vast field of governmental work, much of
which is entirely new in character, and for
which no previous arrangements were made. It
has been like the explosion of a shell. As a
group of boys stand around while one of their
number lights the fuse attached to an immense
firecracker, risking their lives in their enthusi-
asm, and then run aside to see the effect of their
act, so we may imagine Ross, Kitasato, Reed,
Carter, Gorgas and the others, though widely
separated upon the globe, mentally surround-
ing the little light showing in the fuse of tha

254 AMERICAN PUBLIC HEALTH PROTECTION

idea — disease carriers. This idea is the key to
modern sanitary science.

One result of the suddenness of the scientific
change has been that an enormous work has
been abruptly thrust upon the service, without
competent workers. Incompetence and igno-
rance on the part of the field force must neces-
sarily result in unsatisfactory work. It is
therefore of importance to the people of the na-
tion that provision be made to remedy the pres-
ent deficiency. How can it be accomplished?

When college authorities have been ap-
proached with the suggestion that even the
elements of the science of public health be
taught in their institutions, they have generally
replied that they have no funds at disposal for
such work, and that there is no demand on the
part of students for such courses. As to the
students' demands, they are not likely to ask
for courses radically different from those which
have previously been given at the institution.
Neither will they be insistent for the education
until they see a future career behind it. The
first point then must be to make it evident to

PREPARATION OF OFFICERS 255

the student that the field offers him a career in
exact ratio to his degree of preparation.

One of the tried governmental methods for
fostering prosperity has been the favoring of
infant industries. Germany and the United
States have enabled manufacturing enterprises
to get on their feet by means of a protective
tariff. Communities foster new endeavors by
furnishing capital, or by temporarily granting
special privileges. In the same way a course
in public health could be made attractive by the
conferring of a degree, say of Bachelor of Sci-
ence in Public Health, upon the completion of
a curriculum practically equivalent to the
ordinary bachelor's study. Give the Master's
degree for additional study. Give, as is now
being done in some institutions, the Doctor's
degree for still more advanced study. For the
present, at least, it would also seem advisable
to give credit for work done in absentia. By
law it might be well to require, not the degree,
but an education equivalent to the degree of
B. S. in P. H., or Master, or Doctor, for re-
spective grades of health appointments. If

256 AMERICAN PUBLIC HEALTH PROTECTION

so, it would also be necessary to provide some
examining board to determine this fitness.

Such courses could not be well given in many
institutions. The variety of subjects is so great,
and it touches so many schools of the univer-
sity, that few educational plants could under-
take such instruction without a heavy expense.
This is particularly true relative to the ad-
vanced grades of work. Such advanced grades
must have access to schools of agriculture, of
engineering, of veterinary medicine and of
law, quite as much as to schools of medicine
and to hospitals. It is probably true that if the
preliminary work were started in some schools
an opportunity would soon be found for exten-
sion into the higher grades. It may not al-
ways be necessary that there be a school of
veterinary medicine in connection with the in-
stitution. Special courses by competent veteri-
narians could be arranged. The same is true of
other branches ; but for the most perfect results
the students must be brought in close contact
with the best of work in the special fields.

It is the opinion of many that at least the

PREPARATION OP OFFICERS 257

rudiments of public health should be taught in
every college of literature and arts, and in
every normal school, as a portion of the regular
courses.

Unfortunately, a serious obstacle for the col-
lege in such endeavors is found in the question
of finance. There is to-day no other "infant
industry" in educational lines which is nearly
so worthy of endowment as public health. The
courses given to-day, even at the best of schools,
are admittedly very far below the real necessi-
ties of the case. Perhaps a mistake has been
made in beginning to build the structure at
the top. There are several schools offering the
degree of Doctor of Public Health, but so
far as the writer knows, there is no institution
which has arranged courses leading to lower
degrees in the same service. There are, it is
true, courses arranged for certificates, or for
Master of Science in Public Health, but so
far as the writer knows it is prerequisite in
each that the recipient be already a holder of
the degree in Medicine. There seems to be no
provision for the education of those who are

258 AMERICAN PUBLIC HEALTH PROTECTION

to search for the breeding places of flies and
mosquitoes, or as to sanitary conditions in the
milk industry. It is quite as necessary to have
trained inspectors as it is to have trained di-
rectors. In only one line has there been a pre-
vious recognition of the special nature of prob-
lems, and sanitary engineering has taken its
position as a distinct profession. The present
imperfection of course is due partially to the
fact that courses are at best tentative. The sub-
ject is so new that there is as yet no general
agreement as to what is most to be desired.
Secondly, the courses must be managed largely
as an avocation, rather than as the special voca-
tion, of the teachers. This is due to lack of
special endowment for such instruction, and in
consequence the professor must steal from his
endowed work in order to devote attention to
that which is much the more necessary.

Is it not possible that our educational insti-
tutions are too much impregnated with com-
mercialism? There has been a claim in the past
that learning unfitted the student for business,
and now special courses are prepared for the

PREPARATION OP OFFICERS 259

commercial student. However, recognizing
fully the unpopularity of the statement, the
writer can not resist the temptation to enter a
hearty protest against the commercializing of
education in the way that is being done to-day.
Science and literature, while they have their
practical value, have a sphere in themselves,
and independent of the present commercial
utility. Studies which a few years ago were of
minor importance are to-day exceedingly use-
ful. Consider, for example, the great impor-
tance to-day of the study of the life habits of
insects. The tendency, then, toward the selec-
tion of courses of study purely for their present
economic utility is commercial, rather than edu-
cational, unless the courses may have a high
cultural value in themselves. Courses pertain-
ing to public health have such cultural values
in a marked degree, and their utility adds to
the interest. For example : It is quite as inter-
esting and educational to study the develop-
ment and habits of a mosquito as it is to study
the structure of the bird's lung, and the results
are to-day more applicable to daily life.

260 AMERICAN PUBLIC HEALTH PROTECTION

One of the most interesting1 passages in Gor-
gas' Sanitation in Panama is that in which
he tells how he was called from his home one
morning in Cuba at four o'clock, and hastened
to the hospital, because a mosquito had her
wing caught in the mesh covering the jar in
which "her ladyship" resided. They had pre-
viously sent to the United States to get an oil
stove with which to keep "her ladyship" com-
fortable. When Gorgas reached the hospital
he found that Doctors Juan Guiteras and Ross
had also been summoned from the city, and
doctors and nurses from the hospital were
working over the patient. She had been re-
leased from the gauze, but she was so exhausted
that she lay upon a bed of cotton. The oil stove
was started. A number of the most important
physicians from Havana dropped in and sat
mournfully around the room, making occa-
sional suggestions to the staff. Surrounded by
more professional talent than any but a few
human beings, and after five hours of effort at
reviving her, "her ladyship" finally gave an
expiring feeble kick and was still. That mos-

PREPARATION OF OFFICERS 261

quito was the only known living insect infected
with the yellow-fever germ which was being
studied and upon which depended the work of
the next few months. The results had a tre-
mendous commercial influence; but commer-
cial motives had little to do with the enthusiasm
of the scientists. Carroll and Lazear gave their
lives in that investigation. Is it not "up to" the
commercial interests of the United States
richly to endow a few chairs for teaching pub-
lic health in our universities, dedicating them
to the memory of that board of army surgeons
who put the world under such a debt by their
discoveries?

It is not necessary to discuss here what should
be the subjects taught, nor how much of time
should be devoted to each study. We only sug-
gest that the studies would be given a practical
turn, and would be of greater benefit to the
community and to the student, if they be asso-
ciated with regular work under experienced
health officials. In that way the community
would the more quickly reap the benefit of the
college work, and the college would be able

262 AMERICAN PUBLIC HEALTH PROTECTION

sooner to get its orientation relative to the new
field. At present the courses are so long as to
be discouraging. That is, a physician who has
devoted some attention to this line of work
finds that he must give up his practise and de-
vote two years of study before he can get aca-
demic recognition for anything.

The present condition of the work requires
that the laboratory and other school facilities
shall be used during the winter by the regular
students. Post-graduate courses in medicine
may conveniently be given during the summer
months, when the physician's practise is light
and when the laboratories are not crowded.
The summer-time is a busy one in health ad-
ministration, though infectious diseases may
be more common during the winter months.
Many health officers would like to take short
special courses from time to time, during their
winter vacations especially. While track may
be kept of such work, and after some years
sufficient credit be thus accumulated for a de-
gree, in most cases such special work would
have no such object in view. This occasional

PREPARATION OF OFFICERS 263

month in school would enable the officer to keep
up with scientific advances, and occasionally
work out some special problem. It seems also
that there should be a concerted effort intended
to stimulate original study outside of school,
giving credits and honors for work especially
meritorious.

There is another educational need for the
men in the field that is already being met in
some jurisdictions. All of the workers in small
districts, and the leading men from larger
areas, should have frequent meetings under the
guidance of their leader. At these meetings
local problems should be thrashed out, and
every member expected to contribute some
original study in connection with the work.

Until more satisfactory conditions arise, have
not our state universities a moral obligation
regularly and systematically to aid in the work
of educating our guardians of health? How
can it be done ? Not by offering special courses
for the summer months. That is the busy time
for health officers. It seems perfectly feasible,
however, to establish for eacli year a special

264 AMERICAN PUBLIC HEALTH PROTECTION

course of one week, and invite all who wish to
attend. The course should not be the same each
year. During that one week the special school
could listen to two or three lectures a day, and
receive laboratory training, especially in ento-
mology. The regular faculty should be willing
thus to contribute, and sometimes some special
lecturer might be secured from the outside.
Regular college students should have access to
these lectures, and the results should be bene-
ficial both to the university and to the 'special
students. A very moderate fee might be re-
quired, and courses of study might be prepared
for work at home, granting certain credits to
those who later passed a test examination upon
the sub j ects. At the University of Illinois there
is now regularly held a meeting of the state
municipal league, composed especially of city
officers. These meetings are recognized as ben-
eficial to all who attend. There city govern-
mental problems are discussed, for the same
questions arise in many places. College pro-
fessors contribute with lectures and demonstra-
tions, For example: At the 1915 meeting

PREPARATION OF OFFICERS 265

Professor Brooks gave a most instructive lec-
ture upon street lighting, demonstrating his
points with models or with regular appliances.
So in a health officers' school the zoologist could
give a short course on insect pests, and the pro-
fessor of dairying could give instruction in that
branch, which would save the studious inspector
months of uncertain groping after knowledge.

Another important educational aid may be
found in the United States Public Health
Service. While it would perhaps be too much
to expect that service to be thrown open for the
education of any who might wish to use its
facilities, still it would be desirable if more of
the better class of men took occasional advan-
tage of the laboratory facilities and the instruc-
tion in that service. Such use of the service
would tend more perfectly to coordinate the
work in the different states and should give a
more advanced view of the administrative prob-
lems than would be possible in college work.

At Harvard and at the University of Wis-
consin at the present time the course in public
health includes practical surveys in the field.

266 AMERICAN PUBLIC HEALTH PROTECTION

In neither is that work strictly governmental.
In both it is solely under the control and guid-
ance of the college authorities. The writer is
inclined to think that this method is a mistake.
The man who is recognized as a student may
be considered as a meddling intruder by the
people, while doing exactly the same work as
an employee of the city or state he would be
given respect and assistance. While such co-
ordination between the school and govern-
mental bodies might at times be difficult to
maintain, still experience shows that it is
possible. Students have been doing similar
work while still under the guidance of the
teacher. This is made easier when the head of
the department is also upon the teaching force
of the school. He may be only a lecturer, or
he may be really the responsible head of the
special school of public health. Such arrange-
ments are particularly to be desired now while
the schools are necessarily small and weak.

As a rule, little assistance can be reasonably
expected from medical schools. They are
neither equipped with laboratory facilities nor

PREPARATION OP OFFICERS 267

with men fitted for this special line of instruc-
tion. The laboratory of the literary college
much more closely meets many of the require-
ments. Medical men as a rule have no rea-
sonable appreciation either of what the public
health work is, nor of the means needed in its
execution. Some of them are positively an-
tagonistic, either from mistaken ideas as to the
real facts, or from self-interest, though they
may not openly show their opposition. They
feel that the public health guardians are too
freely invading private rights.

The degree of Doctor of Public Health
should never be considered as an additional
degree in medicine. The fact that a doctor
of medicine later takes a course in a law school
and there receives the degree of Bachelor of
Laws does not make the second course and de-
gree an addendum to those in medicine. The
two are distinct, and must be so regarded.

There are two important movements within
the medical circles which directly concern the
people generally, though the people have not
been consulted. The first pertains to medical

268 AMERICAN PUBLIC HEALTH PROTECTION

education. The field of medical science has be-
come so great that it is becoming a practical
impossibility in the ordinary medical course to
give the student proficiency in all. In con-
sequence it has been suggested that the course
be so arranged as to give a general view of
the whole subject, and that specialties be made
major subjects, from which the student may
select his special work. Another suggestion
in the same line is that the specialties be only
taught in post-graduate work extending over
from one to two years ; and that none be per-
mitted to practise the specialty unless he has
taken these additional years of study and train-
ing. The first part of the proposition is not
objectionable, but time devoted to a study does
not create competence. Many men, without
the additional time in school, have become emi-
nent in special lines of work. This is true of
the very men who are to-day advocating that
their work be capitalized by preventing com-
petition unless the student shall have given up
his practise and spent further time in the med-
ical school.

PREPARATION OF OFFICERS 269

The second movement is concerned in the
formation of a new society, or "College," to
which certain members of the profession may
be elected after passing a satisfactory exami-
nation, having presented certain credentials.
This part is unobjectionable; but here again,
recent developments have indicated a tendency
to restrict, by legal enactment, the perform-
ance of major surgical operations by those not
members of this "College." Already we are
told by those in touch with the conditions in
country communities, there is a retrograde
effect upon the standing of the country prac-
titioners by virtue of the more elevated stand-
ard of medical education. Formerly many of
our most distinguished men have been country
doctors and surgeons. McDowell, who per-
formed the first successful ovariotomy, was a
Kentucky country surgeon. Many country
boys, with plenty of determination, but with
little cash, have gone back to the country when
they have received their degrees, and there
have been powers for good. Ian MacLaren
has drawn a fine picture of such an one in his

270 AMERICAN PUBLIC HEALTH PROTECTION

Doctor of the Old School — MacLure. Now
with the raising of the standard so that so much
more time and money are required for the ob-
taining of a degree, the successful candidate
is less inclined to take the smaller income of
the country doctor. He leaves that field for
those who have obtained their licenses by less
expensive routes, while he remains in the city,
there hoping the more quickly to obtain inter-
est on his investment, and eventually a chance
at big fees. These new suggestions for addi-
tional time, or special society membership,
neither insure greater competence, nor are
likely to be for the good of the nation as a
whole.

Public health, then, is a new profession, as
well as a new science. An education in a col-
lege of liberal arts, or of law, or of medicine,
would each and all of them be good prepara-
tion for this profession, but it is not an addi-
tional degree in either. There is no other pro-
fession which to-day presents a more alluring
opportunity — not for the commercially in-
clined, but for the real lover of science and

PREPARATION OF OFFICERS 271

of humanity. There is none other which af-
fords such frequent chance for doing good.
There is none which more perfectly epitomizes
the essence of the Christian religion. It wields
its sword in the defense of innocent children;
it wards off the thrusts which are made at the
heart of the poor; it strengthens the weak; and
it offers the refreshing sip of cold water to the
parched throat, with assurance that it contains
no poison-producing germ. But, just as the
knight of old sometimes received the fatal blow
intended for the women and children at his
back, so the modern knight sometimes falls a
victim to the darts and arrows of the disease
which he is fending from those dependent upon
him. When this happens, he dies as he has
lived — unselfishly, and for the good of his fel-
low men.

THE END

INDEX

INDEX

Actinomycosis, 110.

Adams, Frederick U., quoted, 6.

Administration of public health, 208 et aeq.

American colonies, 26.

Cooperative, 225.

County, 22S.

England, 23 et seq., 215, 248.

France, 25, 215.

Germany, 25.

Illinois, 218.

Municipal, 239.

Pennsylvania, 250.

Philippines and Porto Rico, 60.

Prussia, 25, 215.

United States, 27 et seq., 215 et seq.
Advertising value of public health, 147.
Agramonte, Dr. A., 57.
Anderson, Dr. John F., 63.
Anthrax, 110.
Antitoxins, 154.
Antituberculosis societies, 218.
Antityphoid vaccine, 157.
Appeals in executive departments, 229.
Ashley, Percy, quoted, 210.

Bacillus, see BACTERIA.
Bacteria, 130, 134, 153.

In milk and dairy products, 10, 109, 156, 222, 231, 234.

Killed by heat, 111, 134.

Of plague, 158.
Baker, Dr. Henry B., 42.
Baths in England, 26.
Bergerstein, Leo, quoted, 199.
Birth and death records,

Commercial value of, 148.

Duty of physicians and parents, 148.

General importance of, 150.

Jurisdiction over, 54.
Blue, Dr. Rupert, 65.
Boards of health,

Condemned, 208, 222.

State, 32.

275

276 INDEX

Boards of health — Continued.

Alabama, 46.

Illinois, 88, 43.

Kansas, 45.

Louisiana, 43.

Massachusetts, 35, 43.

Michigan, 42.

New York, 37.
Used for blackmail, 83.
Bolivia, 4.

Bracken, Dr. Henry M., 45.
British Guiana, hookworm In, 7.
Bruck, quoted, 234.
Bryce, Sir James, quoted, 61.
Burks, F. W. and J. D., quoted, 192. '
Butter,

Tubercle bacilli In, 235.
Typhoid bacilli in, 234.

Carriers of disease, 156.
Carroll, Dr. James, 57.

First victim in yellow fever experiment, 68.

Martyr to public health, 102, 261.
Carter, Dr. Henry R.f 253.

At Panama, 14.

Chart for malarial treatment, 163.

Yellow fever studies, 62.
Celery, typhoid from, 237.
Census Bureau, 76.
Cesspools, 175.

Cheese, disease bacteria in, 235.
Chicago,

Example of health commissioner, 244.

Sanitary canal, 9.

Sanitation a motive for organization, 34.

Typhoid at, 9.
Cholera, 34, 35.
Christian Science, 80.

And medical inspection of schools, 202, 203.
Commerce, unpaid debt to sanitary science, 261.
Commissioner of Health, see also ORGANIZATION OF HEALTH
DEPABTMENT.

At Chicago, 244.

Pennsylvania, 45.

New York, 45.

Compensation for health service, 104, 215.
Consumption, see TUBERCULOSIS.
"Consumption Cure," 75.
Costa Rica, sanitation in, 6.

INDEX $77

Croup, membranous, 31.
Cuba, see HAVANA.
Plague in, 66.

Dillon, Judge John H., quoted, 84.
Diphtheria and croup, 31.

Spread by animals, 111.

Quarantine of, 120, 122.
Disinfection, 172.

"Doctor of Public Health," 92, 255, 257, 267.
Domestic animals spread disease, 109, 171.
Dresslar, Fletcher B., quoted, 195, 196, 197.
Dutton, Dr. Everett, martyr, 102.

Eaton, Dorman B., quoted, 209.
Economic changes and health protection, 121 et seq.
Economic importance of sanitation, 13, 95.
Education in public health, see also PUBLIC HEALTH EDUCA«
TION and MEDICAL INSPECTION OF SCHOOLS.

Degrees in, 92, 255, 257, 267.

Not additional medical, 262, 267.

Of officers, 252 et seq.

Should be endowed, 255.

Special courses in, 262.
Efficiency depends upon health,

Community, 3.

Personal, 1.

Efficiency of service, 13.
Epidemiology, 87.
Erysipelas, 31.

Factories in England, 26.

Finlay, Dr. Carlos, originator of mosquito theory, 82.

Fleas and plague, 158, 168, 170.

Flies,

Habits, 16, 126, 168.

Typhoid carriers, 156.
Food analysis, 47.
Fulton, Dr. John A., 45.
Fumigation, 172.

Garbage, disposal of, 94, 124, 170.

Germ theory, 153.

Glanders, 110.

Goats and Malta fever, 110.

Goodnow, Frank J., quoted, 210, 212.

GoBgas, General William C., 253.

At Havana, 13, 57, 58, 260.

At Panama, 14-17.

Quoted, 4.

278 INDEX

Greece, Malaria In, 95.

Physicians in ancient, 101. .
Ground squirrels and plague, 66.
Guatemala, sanitation in, 7.
Guiteras, Dr. Juan, 260.
Gulick, Dr. Luther H., quoted, 179, 194, 195.

Harrington, Dr. Charles W., 55.

Harrison Law, 79.

Havana, yellow fever at, 13, 260.

Health of rich depends on that of poor, 12.

"Her Ladyship," 260.

Hippocrates quoted, 101.

Hoag, Dr. Ernest B., 196.

Honduras, sanitation in, 7.

Hookworm,

British Guiana, 7.

Kentucky work, 114.

Porto Rico, 60.

Southern states, 8, 60, 247.
Hurty, Dr. John N., 45.

Ice-cream, germs in, 235.

Imhoff, Dr. Karl, 125.

Imhoff tank, 125.

Immunity, 155, 157.

Industrial Disease Commission, Illinois, 218.

Kansas, attempt to segregate traveling consumptives, 45.
Kinyoun, Dr. Joseph James, 65.
Kitasato, Dr. Sh., 253.

Lard, adulterated, 137.
Lathrop, Julia A., 78.
Lavinder, Dr. C. H.
Lazear, Dr. Jesse W., 57.

Martyr, 102, 261.

"League for Medical Freedom," 75, 202.
Legal principles, importance of, 90.
Leprosy, 21.

Local Government Board, England, 23, 243.
Louisiana State Board of Health, 43.
Louse, body, and typhus fever, 102.

McAneny, George, quoted, 191.
McClintick, Dr. T. B., 63.

Martyr, 102.

Macdonald, Sir John, quoted, 52.
McDowell, Dr. Ephraim, 269.

INDEX 279

MacLaren, Ian, 269.
McLoughlin, Dr. A. J., 63.
Madeira-Mamore" railroad, 4-6.
Malaria,

Due to anopheles, 57, 58, 89, 161.

Economic results of, 94.

In Greece, 95.

Plasmodia of, 159.

Quarantinable, 120.
Malta fever, 110. \

Mankato, assessed damages for impure water, 89, 146.
Manson, Dr. P. Thorborn, martyr, 102.
Manure pits, 16.

Breed rats and flies, 126.

Nuisance, 167, 168.
Marine Hospital Service, 61.
Martyrs to public health, 102.
Massachusetts state board of health, 35.

Examination of sewer gas, 174.
Meat industry, 69.
Measles, 109.

Medical and sanitary education compared, 83 et seq., 97.
Medical certificates in schools, 180.
Medical inspection of schools, 175 et seq.

Argentina, 188.

Australia, 188.

Boston, 193.

Canada, 187.

Chile, 188.

Denmark, 187.

England, 186.

Germany, 185.

Ireland, 188, 190.

Japan, 188.

Legal decisions relative to, 203.

Minnesota, 203.

New York, 192.

Norway, 187.

Paris, 184.

Problem of education, 196, 206.

San Antonio, 192.

South Africa, 188.

South Dakota, 203.

Switzerland, 184.
Milk supply,

Carrier of disease, 10, 109, 156, 222.

Changed economic conditions, 129 et seq.

Inspection, 108, 231.

State supervision of, 249.

280 INDEX

Milk supply — Continued.

Tuberculosis, 109.

Typhoid from, 10, 156, 222.
Mill, John Stuart, quoted, 214.
Miller, Justice Samuel Freeman, quoted, 212. "?
Mohler, Dr. John R., 236.
Morse, Dr. Moreau, 196.
Mosquitoes,

Anopheles and malaria, 57, 58, 89, 102, 161.
Economic relation of, 95.

Habits of, 86, 87, 161, 170.

Stegomyia and yellow fever, 13, 57, 87, 102, 153, 260.
Myers, Dr. Walter, martyr, 102.

National health agencies, 48 et seq.

Army, 56.

Bureau of Census, 76.

Bureau of Children, 77.

Bureau of Education, 78.

Department of Agriculture,

Bureau of Animal Industry, 68.
Bureau of Chemistry, 72.

Marine*Hospital, 61.

Navy, 56.

Post-Office Department, 77.

Public Health Service, 61.
National health authority and power, 49.
New Orleans,

Plague in, 66, 113.

School of Tropical Medicine, 6.

Yellow fever in, 18, 64.
Nightsoil,

As fertilizer, 64.

Care of, 124.
Nuisance, 115, 141, 167, 168, 169.

Oleomargarine, 137.

Organization of health departments, 208 et seq. .

All-time health officer, 221, 223.

Multiplicity in, 217.

Municipal department, 239.

Pennsylvania system, 250.

State department, 246.

Panama Canal,

Sanitation at, 4, 58.

Sanitary versus engineering divisions, 139.

Saving in cost of, by sanitation, 4.
Pellagra, 63.

INDEX 281

Pennsylvania, Commissioner of Health, 45.

Phelps, Prof. E. B., 225.

Plague,

Cuba, 66.

New Orleans, 66, 113.

Porto Rico, 66.

San Francisco, 65, 113.

Spread by rats and fleas, 158, 170.
Plasmodia of malaria, 159.
Pollution of lakes and streams, 63.

By sewers, 140.
Porto Rico,

Hookworm in, 60.

Plague in, 66.

Poverty, a result of disease, 12.
Protozoa and disease, 159.
Public health,

Administration, see ADMINISTRATION OP PUBLIC
HEALTH.

Advertising value of, 147.

Change in methods, 18.

Depends upon citizens, 17.

Economic importance of, 1 et seq.

Education,

Common schools, 117.
In North Carolina, 116.
Schools teaching, 19.
Status of, 84.
Value of, 116, 259.
Pure Food Act, 73.

Control of milk industry under, 138. 1*>

Quarantine,

Methods, 152, 171.

New diseases under, 120.

Old diseases under, 21.

Rabies, 39, 109.

Exterminated from England, et cetera., 41.
Rats,

Breeding of, 126.

Loss from, 127.

Spread plague, 66, 113, 158 et seq., 168, 170.
Reed, Dr. Walter A., 57, 62.

Martyr, 102, 253.

Ricketts, Dr. Howard T., martyr, 102.
Rocky Mountain spotted fever, 63, 103.
Rosenau, Dr. Milton J., 63.

Quoted, 84, 235.

282 INDEX

Ross, Dr. John W. (U. S. N.), 14, 260.
Ross, Dr. Ronald (British Army), 57, 253.

San Antonio, medical inspection of schools, 192.
San Francisco, plague in, 65, 80, 113.
Sanitarians, imported from India and Java, 6.
Sanitary canal, Chicago, 9.
Sanitary engineer, 87.
Sanitary martyrs, 102.
Sanitation, see PUBLIC HEALTH.
Saunders, Dr., 46.
Scarlet fever,

Carelessness, 32.

Milk infection, 104, 109.

Quarantinable, 120.
School clinics, 200.
School of Tropical Medicine,

Liverpool, 102.

Tulane, New Orleans, 6.
Schools,

Medical inspection in, 175.

Teaching public health, 19, 116.
Schroeder, investigations on dairy products, 236.
Scrofula, 31.
Septic tanks, 125, 175.
Sewage,

Pollution of streams, 140.

State supervision, 249.

Treatment, 94, 124.
Sewer gas, 174.

Shakespeare's father fined, 22.
Slaughter-houses, 29, 69 et seq.
Sleeping sickness, 102, 165.
Smallpox, 27, 34, 178.
Sociology and sanitation, 87.
South, Dr. Lilian, quoted, 114.
Sternberg, General George M., 57.
Stiles, Dr. Charles W., 60, 62.
Story, Chief Justice Joseph, quoted, 210.
Syphilis,

Confused with tuberculosis, 31.

Quarantined, 21.

Ticks,

Carriers of fever, 63.

Sheep as traps of, 64.
Tomato pulp, 137.
Town planning in England, 26.
Trypanosome, 166,

INDEX 283

Tuberculosis,

Germs in butter and cheese, 235.

Kansas attempt to segregate travelers, 45.

Spread in milk, 109.
Typhoid fever,

At Chicago, 9.

At Stamford, Conn., 10.

At Washington, 156.

Carriers, 156.

Celery, 237.

Dairy products, 234.

Milk, 10, 156, 222.

Or malaria? 153.

Quarantinable, 120.

Water supplies, 89, 146.

When properly isolated, 157.
Typhus fever, agency of body-louse, 102.

United Fruit Company, sanitation by, 6.

Vaccination,

In Japan, 68.

In schools, 97, 178.
Veterinarian, 225, 246.
Veterinary profession, 252.
Vital statistics, 76, 87, 148.

Washburn, quoted, 235.
Washington, typhoid at, 156.
Water-closet, 15, 124.
Water supplies,

Changes in, 123, 142.

Pollution of, 89, 143 et seq.

State supervision, 249.

Typhoid in, 89.
White, Dr. John H., 19, 64.
Wilbur, Dr. Cressy L., 77.
Wiley, Dr. Harvey, 72.
Wright, Sir A. E., 110.

Yellow fever, 13, 87, 153, 166.
At Havana, 13, 57, 260.
At New Orleans, 19, 64.
At Para, Brazil, 102.
Board appointed, 57.
Quarantine of, 21, 27, 28, 153, 171.

Zoology, necessity for study of, 86, 247.

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